If you've been diagnosed with severe asthma, you likely know that managing it and maintaining control are the two most important things you can do. You and your doctor collaborate on your treatment plan, and you keep him informed about your symptoms — you're a team.
In a telephone interview, HealthCentral asked Dr. Nathan Lott, D.O., at Columbus Internal Medicine in Columbus, Ohio, about the questions he hears most frequently from patients. Dr. Lott is board certified in internal medicine, critical care, and pulmonology.
HealthCenral: What do you mean by controller and rescue inhaler?
Dr. Lott: I set up a treatment plan at the beginning so we both understand what we're doing. Treatments are in two broad categories: A controller helps improve control of symptoms so you don't require a rescue inhaler nearly as frequently as you might otherwise. These include long-acting beta agonists and corticosteroid inhalers.
A rescue inhaler is used to acutely relieve dyspnea or shortness of breath and is a short-acting beta agonist. I grade patients' symptoms using the Asthma Control Test (ACT). It gives me a measurable, reproducible way of determining how well asthma is controlled. If I find they have a significant problem with control, we will step up therapy to include more control and try to improve the patient's baseline level.
HC: How long am I going to be on this inhaler?
Dr. Lott: Really, it depends on you. Patients with asthma have inflammation and using inhalers helps to get inflammation under control. Current guidelines advise to manage disease with the least amount of medication possible to maintain control. It's important to use the inhaler as prescribed, with consistent follow-up with your physician. Usually after six to 12 months, we determine when you've reached a certain level of control. Once that's obtained, we can start to wean inhaler use down to the minimum amount necessary to maintain control for you to carry on normal daily activities.
HC: Someone told me having a dog or cat might make my asthma worse. Do I have to give up my pet?
Dr. Lott: This partly depends upon allergy testing to evaluate the response of your body to pet dander that could be the true allergic component. Some people with allergies develop bronchoconstriction as a secondary consequence of allergic reactions. This can induce bronchial spasms, like those seen with asthma.
If testing indicates an allergy to the pet, I tell my patients: "You have a choice to keep your pet and try to manage symptom with medical therapy such as inhalers, oral medications, or some infusion (intravenous) medications. But you shouldn't be surprised at not having the control you would ultimately like."
Occasional sneezing or itchy eyes are one thing. In patients with allergic asthma who have a severe reaction such as airway swelling that could potentially cause death — that would also leave no one to take care of the pet. Everyone wants to avoid animals turned in needlessly at a shelter, so patients who give up their pet should work hard to find a new and appropriate home for it, with a family member, friend, or with a reputable rescue.
HC: If steroids make us gain weight, why do I need to use this steroid inhaler?
Dr. Lott: Inhaled steroids aren't systemically absorbed outside of the lining of the lungs. There is no systemic impact on the body at a cellular level, since they're only inhaled.
HC: How do I use this spacer device? Does it really help?
Dr. Lott: A spacer device is traditionally used with wet inhalers, and connects to the mouthpiece. Medication is delivered as a mist squirted out of the device from brands that include Symbicort and Dulera. Rescue inhalers are also wet inhalers, and these include ProAir HFA, Ventolin HFA, and Proventil HFA.
Droplets are different sizes. Large droplets really don't travel far when squirted, while smaller droplets contain submerged medication. Using these types of inhalers without a spacer can result in a significant deposit of medication on the tongue or back of the throat due to the way the medication is ejected from the device. That means you're getting less into your lungs.
A spacer allows you to puff medication into the spacer, and improves efficient delivery of medication into the lungs, meaning less waste. When you puff into the spacer and inhale afterwards, you inhale all suspended droplets that are not too heavy. That means more efficient distribution into the lungs. This also decreases, to some extent, the risk of thrush, which is a yeast infection in the back of the throat.
HC: Which of these inhalers is the best?
Dr. Lott: The best in class is the one you respond to. All medications prescribed for treatment of asthma have an FDA (Food and Drug Administration) indication for managing patients with asthma. None of them is superior to all of the others.
HC: I'm pregnant and I don't want to harm my baby. What can I use that's safe during pregnancy?
Dr. Lott: Expectant mothers understandably worry about the impact of anything they take upon the developing fetus. When it comes to use of inhaled steroids and beta agonists, there's no credible evidence of fetal abnormalities occurring in pregnant patients. Pregnant women have an increased risk of adverse effects if asthma is not controlled during the course of pregnancy, and especially if they don't pursue treatment for it. Look at risk versus benefit: There is far more benefit gained from treating severe asthma than there are risks from using the inhalers in pregnancy.
HC: How often can I use my rescue inhaler?
Dr. Lott: A rescue inhaler was designed for acute relief of dyspnea or a sensation of shortness of breath, often mitigated with broncho spasms.
If you find you need your rescue inhaler consistently for management of symptoms that aren't controlled, speak to your physician. You may step therapy up to another level to achieve better control. The goal of managing asthma is that it should not impact you on a daily basis or cause you to fear that you can't breathe and do normal daily activities.
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Intrinsic Vs. Extrinsic Asthma
At Home Tests for Asthma Control