Shelby Gottschalk loves to sing. Last July, the 21-year-old from Fort Myers, Florida, came to the realization that it was just too hard to harmonize along with the car radio without a lot of effort — and without pain. Her asthma symptoms had been getting steadily worse, and in September, she joined the 5 to 10 percent of asthma patients in the United States diagnosed with severe asthma.
Gottschalk underwent a chest x-ray, two computed tomography (CT) scans, and pulmonary function testing. "I found out my lung function was only sixty percent of normal capacity," she says.
Nights are the worst, she says, when she's lying down and feels "like I'm drowning in mucus. Exercise makes it worse. I cough for an hour every morning."
In a telephone interview with HealthCentral, Gottschalk said her treatments have included inhaled steroids and a nebulizer. "I'm lucky I haven't had to go to the ER. I have an action plan and I use it."
She can't really exercise and misses her Zumba dancing, so she stretches. She's looking forward to going to pulmonary rehabilitation soon.
Severe or not?
According to the Severe Asthma Foundation, "the severity of your asthma is mainly determined by how often you have symptoms, your breathing test results, the type and amount of medications you use daily, and how often you have to use your rescue inhaler."
Diagnosing severe asthma means first making sure it is severe asthma, says Mitchell H. Grayson, M.D., chief of the Division of Allergy and Immunology for Nationwide Children's Hospital and professor of pediatrics at The Ohio State University. He is also on the board of directors for Asthma and Allergy Foundation of America (AAFA) and chair of their Medical Scientific Council.
"It could be uncontrolled asthma because you're not using medications properly," he told HealthCentral in a telephone interview. "Maybe you're also not being treated efficiently, and that's where partnership becomes so important."
Close monitoring by the physician and patient, along with good patient compliance, really are the keys to controlling severe asthma. They're also the keys to living a more normal life, says Dr. Grayson. Severity and symptoms change and so must treatment. A written control plan is highly recommended, as is awareness and monitoring of asthma triggers and any other medical conditions that impact asthma severity.
"Don't be afraid to speak up and tell your doctor all your symptoms," Gottschalk says. "If you're confused, just ask. Get copies of all your paperwork, keep it organized, and if something comes up, pull out that paper and say, 'Look at this.' Doctors won't always have all that at their fingertips."
Understand treatment options
Its crucial for patients to understand the specific uses of each medication. Dr. Grayson wants patients to understand the difference between a rescue or short-acting bronchodilator (such as Albuterol to relieve bronchospasms) and the long term inhaler medications that they are likely also using. Severe asthma patients may not be receptive to their current regimens, possibly misusing inhalers and other medications leading to less optimal control of symptoms and exacerbations.
When it comes to medications, the AAFA explains that short-term medicines include:
- Short-acting beta agonists: This "first-choice" option works quickly to relax airway muscles and reduce swelling.
- Anticholinergics: They act slightly slower, but relax airways and reduce mucus production.
- Combo medications: These contain each of the above in one single inhaler.
Long-term control medications include:
- Inhaled corticosteroids: They reduce airway swelling and mucus.
- Inhaled long-acting beta agonists: These open airways by relaxing muscles. They should never be used alone, but in combination with an inhaled corticosteroid.
- Combination inhaled medicines: Again, these work by using both of the above.
- Omalizumab (anti-IgE): This injection stops reactions to allergic triggers.
- Leukotriene modifiers: Pills or granules reduce airway swelling.
- Theophylline: This oral medication opens airways.
- Oral corticosteroids: They are prescribed when other medications aren't effective.
Patients may also be asked to use a peak flow meter at home to monitor peak expiratory flow rate — how fast a person can exhale. Work with your doctor to ensure you use this device correctly.
What's new with treatment?
Patients with severe asthma can look forward to new and better personalized medicine options, thanks to a focus on phenotyping, says Dr. Grayson. In fact, a 2016 paper in Current Opinion in Pulmonary Medicine concluded that "stratification of asthma subtypes into phenotypes and endotypes should move the field forward in terms of more effective and personalized treatment."
"'Asthma' is a catch-all phrase, where there are different diseases or phenotypes within 'the bucket of asthma,'" he says. More targeted therapies will play a major role in treatment of different types of asthma, and will include, but aren't limited to, anti-interleukins which are all biologics, as is anti-lgE.
Anti-interleukins are proteins made by immune cells that drive an inflammatory process or inflammation, Dr. Grayson says. "This inflammation is a hallmark of asthma, although which interleukin or interleukins cause a given patient’s disease is what the medical field is trying to determine."
The role of biologics, which are made from living organisms, will increase as science focuses on precision medicine.
"Compare these advances to using steroids, which are broadly used, but don't work as well in everyone, and which do potentially have more side effects," he says.
"Currently, there is not enough evidence to support the use of any complementary approaches for asthma," notes the National Center for Complementary and Integrative Health. It calls conventional medical treatments "very effective."
The agency found little evidence for effectiveness of acupuncture and breathing exercises, also known as retraining lungs. It is, however, funding research in:
- Mindfulness meditation to manage symptoms
- Vitamin E, borage oil and Ginkgo biloba to reduce lung inflammation
- Sublingual, under-the-tongue, immunotherapy to increase tolerance to allergic asthma triggers
Get support for your asthma
There's plenty of reliable information for you here at HealthCentral, and from these respected organizations:
Allergy and Asthma Network
American Lung Association
American Academy of Allergy, Asthma and Immunology
Asthma and Allergy Foundation of America
National Heart, Lung, and Blood Institute
Severe Asthma Foundation
Childhood Respiratory Infections May Raise Asthma Risk
You play such a major role in taking care of your severe asthma, but you have plenty of help along the way. Take advantage of it to be the best you can be.