Let’s Talk About Asthma Diagnosis and Treatment
If there’s any good news about having asthma, it’s that treatment for this condition is highly effective—but it can take a little time to figure out what works.
An asthma diagnosis can feel like a literal punch in the chest, leaving you gasping for breath and grasping for answers. The good news: Your life with asthma can look a whole lot like your life before asthma, thanks to a bevy of highly effective treatments from everyday maintenance meds to quick-relief inhalers and state-of-the art biologics. Rest assured, there’s a treatment plan tailored to your unique needs and symptoms out there and we’re going to help you find it. Take a deep breath—and let’s get to it.
Our Pro Panel
We went to some of the nation’s top experts on asthma to bring you the most up-to-date information possible:
Albert J. Polito, M.D.
Chief of the Division of Pulmonary Medicine and Medical Director
The Lung Center at Mercy Medical Center
Leonard B. Bacharier, M.D.
Professor of Pediatrics, Allergy/Immunology/Pulmonary Medicine
David R. Stukus, M.D.
Associate Professor of Pediatrics in the Division of Allergy and Immunology
Nationwide Children’s Hospital
Most likely yes, although the specific meds and doses may evolve over time. If your asthma is well-controlled, you may need less medication than when you were first diagnosed, for example. It’s also not unusual for childhood asthma symptoms to wane or even disappear during adolescence and young adulthood, but then return later in life. Women who have asthma may also find that their symptoms improve or worsen during pregnancy and menopause.
Only very rarely and it’s really more of a procedure than actual surgery. In cases of severe uncontrolled asthma with evidence of longstanding irreversible changes to the airways, a procedure known as bronchial thermoplasty may be done. It involves inserting a tube known as a bronchoscope through the nose or mouth down into the lungs. Then thermal energy is delivered into the airways to reduce the swelling and thickness of the smooth muscles that are constricting them.
At the root of all asthma symptoms is inflammation, which causes the swelling and narrowing of the airways. Long-term controller meds work over an extended period of time to help keep that inflammation down and prevent symptoms. They also help stop your airways from being so twitchy or sensitive, which means they are less likely to overreact when you’re around one of your triggers or have a respiratory illness.
Not to worry! The corticosteroids used to treat asthma are not the same as the synthetic anabolic steroids used to build body mass and strength. Corticosteroids work like the natural hormone cortisol, which is made by the adrenal gland to slow or stop the inflammation process. Because they’re inhaled, they only reach the lungs and not the rest of your body, so there are also fewer side effects than when taken orally.
What Is Asthma Again?
There’s a solid chance that you have some working knowledge about asthma, since one in every 13 people in the U.S. have this very common lung condition that causes breathing problems. To be clear though, asthma today looks nothing like those kids sidelined in gym class when you were growing up. Effective asthma treatments have given people with this condition their lives back. Once you get asthma under control, you should be able to do pretty much everything you love.
To get to that point, however, it helps to understand what’s happening in your body with asthma. Asthma affects the airways leading into your lungs, known as bronchial tubes. If you have asthma, these lower airways are always inflamed; they swell and produce excess mucus. This narrows the opening, making it difficult for air to travel in and out of the lungs, leading to symptoms including:
Chest tightening, pain, or pressure
Shortness of breath
Trouble sleeping due to symptoms
Most cases of asthma are diagnosed in childhood, but it’s possible to develop it at any age. What causes someone to develop it is still a bit of a mystery: As prevalent as asthma is, experts still can’t fully explain its origin. Genetics clearly plays a role because asthma can run in families, but you can still develop it without a family history. Environmental triggers factor in, too—things you come in contact with that lead to an asthma attack (a.k.a. asthma episode or asthma flare up). But not everyone with asthma has every trigger, or a family history, leaving researchers still puzzled about a definite cause for the condition.
Regardless, if you are experiencing symptoms the seem like they could be caused by asthma, step one is to see your doctor for a diagnosis.
How Is Asthma Diagnosed?
For doctors who treat asthma, making a diagnosis is not complicated. Often they can recognize it just based on listening to you describe your asthma symptoms. There are some pulmonary (lung) function tests that can help complete the picture as well. These are a few diagnostic tools your doctor may use.
Your Personal and Medical History
Be prepared to answer a lot of questions about chronic conditions in your family, medicines you might be taking, your lifestyle, work environment, and of course, your symptoms—both current and previous. Jotting down some notes before your appointment can help you remember details.
A Physical Exam
Your doctor will look at your ears, eyes, nose, throat, skin, chest, and lungs. An x-ray of your lungs or sinuses may also be needed—not so much to diagnose asthma, which wouldn’t be visible, but to determine if there is something else going on that might be causing your symptoms.
Pulmonary Function Tests
These noninvasive tests measure your breathing and are usually done before and after you inhale a bronchodilator, a medication that opens your airways. The “normal” results vary from person to person, so the doctor will compare your test to the average amount of air inhaled and exhaled by someone who is the same age, height, race, and gender. Pulmonary function tests may not reveal much if you aren’t experiencing symptoms at the time, but they can still provide other important info, such as how well your medications are working.
There are a few ways to conduct pulmonary function tests, including:
Spirometry: Your doctor will use this test to help confirm your diagnosis, then later at checkups to track changes and medication effectiveness. You’ll take a deep breath, then blow air out of your lungs and into a mouthpiece as fast and hard as you can. This measures how much air you can inhale and exhale, as well how fast you can exhale. If the results show reduced lung function, you’ll be given an inhaled medication known as a bronchodilator to open your airways. Then, after the medicine has had a chance to work, you’ll repeat the test to see if your lung function has improved.
Fractional exhaled nitric oxide (FeNO) tests: This test measures the amount of nitric oxide in your breath, a marker for airway inflammation. You’ll blow into a handheld device for about 10 seconds at a steady pace and get immediate results. While this test alone does not confirm an asthma diagnosis, it can be used as another piece of supporting evidence. FeNO tests can also help identify the type of asthma (certain types are linked to high levels of nitric oxide), as well as track inflammation over time, and determine if your treatment plan is effective.
Peak flow tests: This portable handheld device measures how well air is moving in and out of your lungs at any given time. It’s easy to use—you just blow a quick blast of air into the mouthpiece and get a reading on a built-in scale. It may be used as part of your diagnosis; afterward, you’ll use one daily at home to help you keep your asthma under control. Peak flow meters are so sensitive that they can measure narrowing in the airways hours or days before symptoms occur.
Also known as provocation or trigger tests, these tests may be performed if your symptoms and other tests don’t convincingly establish a diagnosis of asthma, or if your doctor is trying to determine which asthma triggers you react to. There are a few subtypes:
Methacholine challenge: You’ll breathe in increasing doses of methacholine, a drug that will make your airways tighten up at low doses if you have asthma. Then you’ll be given spirometry tests to see if your lung function has changed. A 20% drop in breathing ability means a diagnosis of asthma should be considered.
Irritant challenge: Your doctor will expose you to specific airborne asthma triggers such as perfume or smoke, then you’ll take a breathing test to see how you respond.
Exercise challenge: You will run on a treadmill while your oxygen and heart rate are monitored to determine if exercise triggers your symptoms.
After your diagnosis, your asthma will be classified into one of four categories that reflect the severity of your disease to help determine your treatment plan. The first is
mild intermittent, which means you have mild symptoms up to two days a week and up to two nights a month. Mild persistent means you have symptoms more than twice a week, but no more than once in a single day. Moderate persistent applies to symptoms once a day and more than one night a week. The most challenging cases are classified as severe persistent—symptoms throughout the day on most days and frequently at night.
Control is a word you’ll hear a lot in your asthma care: Good asthma control allows you to do the things you want and means you seldom need to use your rescue inhaler, a fast-acting treatment for asthma attacks. Uncontrolled asthma is life-limiting and potentially life-threatening, putting you at much greater risk for a serious asthma attack. Good asthma control can only be achieved, however, through the right medications. There will be a learning curve at first as you and your doctor figure out which meds you’ll need and how often.
You’ll also experiment with how to take the medicine. Most asthma medicines are inhaled so they go straight to the airways, which means you need a delivery device. Usually that will be an inhaler, a small handheld device also called known a puffer. There are two types of inhalers: metered dose inhalers deliver the medicine in a mist or spray, while dry powder inhalers deliver the medication in a fine powder. You’ll want to practice using your inhaler in front of your doctor or nurse to make sure you are doing it correctly.
If you find it tricky to use, you have two other options. The first is a spacer, which attaches to the inhaler and holds the medicine in place so you can breathe it in easier. Another option is a nebulizer, an air-compressor device that turns liquid medicine into a fine mist that you inhale via a facemask.
So what exactly are those medications that you are inhaling? Let’s take a closer look.
Long-Term Asthma Control Medicines
You’ll need at least one of the medications in this category and possibly several to get your condition under control and reduce the likelihood of flares. Long-term control medicines need to be taken every day, usually first thing in the morning and last thing at night. These are some of the most common options your doctor may prescribe:
These anti-inflammatory meds are the most effective and commonly used daily medicines for preventing and reducing airway swelling and reducing mucus. You may need to use them for several months to experience full benefit. Side effects are uncommon but do include mouth and throat irritation or yeast infections (thrush). Using a spacer and rinsing your mouth with water afterwards can help. They may also delay growth slightly in children. Inhaled corticosteroids include: Alvesco (ciclesonide), Arnuity Ellipta (fluticasone furoate), Asmanex (mometasone), Flovent (fluticasone propionate) and Pulmicort (budesonide).
Inhaled Long-Acting Beta Agonists (LABAs)
These bronchodilator medications are used to control moderate to severe asthma and to prevent nighttime symptoms. They open airways and reduce swelling by relaxing the smooth muscles. They have been linked to severe asthma attacks, however, so they must be taken in combination with an inhaled corticosteroid on a regular schedule. LABAs include formoterol, salmeterol, and vilanterol.
Combination Inhaled Medicines
This drug category features both a corticosteroid and LABA in one convenient dose and includes Advair (fluticasone and salmeterol), Breo (fluticasone furoate and vilanterol), Dulera (mometasone and formoterol), Symbicort (budesonide and formoterol, and Trelegy (fluticasone, umeclidinium, and vilanterol).
These powerful medicines are made from natural components (sugars, proteins, and cells) found in living sources (mammals, plants, and bacteria). They work by targeting a cell or protein in your body to prevent airway inflammation. They’re given by injection or infusion every two to eight weeks, and when taken in conjunction with other asthma meds, can help people with severe asthma that has been difficult to control.
Biologics are generally safe, but depending on the specific drug, can have side effects like redness, pain, and swelling at the injection or infusion site, headaches, fatigue, and nausea. Rarely, they have been linked to anaphylaxis, a life-threatening allergic reaction. Biologics include Cinqair (reslizumab), Dupixent (dupilumab), Fasenra (benralizumab), Nucala (mepolizumab), and Xolair (omalizumab).
Leukotrienes are immune system chemicals that cause asthma symptoms. By blocking their effects, these meds reduce airway swelling and relax the smooth muscles surrounding the airways. They are taken in pill or liquid form. Very rarely, leukotriene modifiers have been linked to psychological reactions, such as agitation, aggression, and depression. This category includes Accolate (zafirlukast), Singulair (montelukast), and Zyflo (zileuton).
This generic, inhaled non-steroid prevents airways from swelling when they come in contact with a trigger. It has few, if any, side effects and is safe to use for long periods of time.
This bronchodilator tablet, capsule, or liquid is used for mild asthma and nighttime asthma symptoms. It helps open the airways by relaxing the smooth muscles and decreases the lungs’ response to irritants. Potential side effects are insomnia and gastroesophageal reflux (GERD). Brand names include Theo-24, TheoDur, and Uniphyl.
If other medications aren’t keeping serious asthma under control, you may be prescribed an oral corticosteroid such as prednisone or methylprednisolone in pill or liquid form for a few weeks. They have a systemic effect—meaning they impact your whole body—and can cause serious side effects like cataracts, osteoporosis, high blood pressure, and delayed growth in children when taken over a long period of time.
Also known as emergency or rescue meds, this category is used as needed to stop an in-progress asthma attack within minutes. Some people with exercise-induced asthma also find it beneficial to use a rescue inhaler before working out or playing sports.
Short-Acting Beta Agonists
These inhaled meds, also known as bronchodilators, are usually the first choice for quick relief of asthma symptoms. They work by targeting a receptor called the beta-2 receptor in the airways. The drug activates the beta-2 receptor which relaxes the airway muscles, making it easier to breathe. They may cause jitteriness and heart palpitations, however. Options include and include Asthmanefrin and Primatene Mist (epinephrine); ProAir and Ventolin (albuterol); and Xopenex (levalbuterol).
Also known as long-acting muscarinic antagonists (LAMAs), these drugs are inhaled to reduce mucus and help open your airways but will take longer to work than your rescue inhaler so should not be used in place of one. Side effects like dry mouth, sore throat, increased heart rate, and muscle contractions are possible. They include Atrovent (ipratropium) and Spiriva (tiotropium).
Combination Quick-Relief Medicines
These inhaled drugs feature both a short-acting beta-agonist and an anticholinergic and are sold as Combivent (ipratropium and albuterol) and DuoNeb (ipratropium and albuterol).
Your Asthma Action Plan
Having the asthma medications best suited to your symptoms is the first part of the equation. You’re also going to need to know when to use them. An asthma action plan will help you assess your symptoms, decide which medications to use, and know what to do in an emergency.
You’ll also need a peak flow meter, an inexpensive handheld device you can use at home to gauge how well air is flowing in and out of your lungs. Your doctor will help you determine what your personal best peak flow meter reading is—the highest number you can achieve over a two- to three-week period when your asthma is under good control. Then you’ll use your current reading each day to help determine if you’re moving from a green (well-controlled) into a yellow (caution) or red (emergency) zone. Your action plan will list the symptoms that characterize each zone as well as the medications you should take at that time.
If all this sounds like a lot of work, try not to panic. It’s a matter of getting into a routine, understanding what meds to use when, and aggressively jumping on them at the first sign of trouble. Once you’ve accomplished that, you’ll likely experience fewer asthma symptoms and have less to worry about. That’s the beauty of asthma control—your disease is no longer controlling you!
Asthma Statistics: Asthma and Allergy Foundation of America. (2021.) “Asthma Facts and Figures.” https://www.aafa.org/asthma-facts/
Asthma Diagnosis: American Lung Association. (2020.) “How Is Asthma Diagnosed?” https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/diagnosing-treating-asthma/how-is-asthma-diagnosed
Pulmonary Function Tests: Respiratory Care. (2012.) “What Is the Best Pulmonary Diagnostic Test for Wheezing Patients with Normal Spirometry?” http://rc.rcjournal.com/content/57/1/39
Asthma Medications: American Academy of Allergy, Asthma and Immunology. (n.d.) “AAAAI Allergy and Asthma Drug Guide.” https://www.aaaai.org/Tools-for-the-Public/Drug-Guide
Asthma Management: Allergies and Asthma Foundation of America. (2019.) “Your Guide to Managing Asthma.” https://www.aafa.org/media/1751/your-guide-to-managing-asthma.pdf