Asthma

Triggers are the things that can cause your asthma symptoms. Each person has their own set of asthma triggers. Over time you can figure out what your asthma triggers are and take steps to reduce your exposure.

There are two types of asthma triggers:

• Allergens
• Irritants

Allergens only affect you if you are allergic to them. Irritants can bother anyone with asthma.

Allergens

When you breathe in one of your allergens, your immune (defence) system is ready to react to it in order to remove it. It is this allergic reaction that causes inflammation, swelling, extra mucus, and a tightening of your airways (bronchoconstriction). This blocks the flow of air into and out of your lungs and causes your symptoms.

The most common allergens include:

• Dust mites
• Pet allergens
• Pollen
• Mould
• Cockroach

Although food is not a common trigger of asthma, additives such as sulphites may trigger asthma symptoms in some people.

Irritants

There are many possible irritants where people live, work, or go to school that can trigger asthma symptoms. You may notice that you get asthma symptoms from some of the following irritants.

Indoor Irritants

Most people are aware of the risks from outdoor air pollution. However, indoor air pollution is often worse than outdoor air. We also generally spend a lot more time indoors than outdoors.

The following are common indoor irritants that can trigger asthma symptoms.

• Tobacco and Wood Smoke
• Strong Odours and Toxic Chemicals
• A cold or the flu often leads to asthma symptoms.

Outdoor irritants

There are many outdoor irritants that can cause asthma symptoms. They include:

• Air pollution from vehicles, factories, power plants, etc.
• Cold air
• Hot, humid weather
• Smoke from wood burning, backyard burning, and forest fires

Air Quality Health Index (AQHI)

Current air pollution levels and forecast maximums can be found at www.airqualityontario.com. The Air Quality Health Index (AQHI) reports on the health risks associated with air pollution at a given time.

The AQHI measures these three air pollutants that are known to be harmful:

• Ozone (O3)
• Particulate matter 2.5 microns (PM2.5) in diameter and less (1 micron is 1/1000 of a mm)
• Nitrogen dioxide (NO2)

The AQHI provides the combined overall general health risk from these three pollutants. Follow the AQHI reports and forecasts, and take steps to reduce your exposure. Adjust your outdoor activity accordingly.

Follow the recommended steps to take based on the AQHI levels and whether or not you are in an “at risk” group (e.g., asthma).

Sign up for air quality alert notifications through Air Quality Ontario.

Medication triggers

Certain medications can trigger asthma symptoms in some people. Let your health-care providers know about all of the medications you take – including non-prescription and herbal treatments. Check with your health-care provider before you take any new medication.

The following medications may cause asthma symptoms in some people:

• Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, naproxen—these are often used for cold/flu symptom relief and to relieve pain (e.g., for arthritis, headache, and muscle pain). If one NSAID triggers your asthma symptoms, other NSAIDs will also likely trigger your asthma symptoms
• Beta blockers used to treat high blood pressure, angina, glaucoma, and sometimes tremor
• ACE inhibitors (for high blood pressure and heart disease) can cause a dry cough

If you know that you react to a certain medication, here are some ways to protect yourself:

• If you take a medication and develop asthma symptoms, stop taking that medication and tell your health-care provider and pharmacist right away—ask them for advice on which medications to avoid
• Work with your health-care provider to find an alternate medication that you do not react to
• If you need to avoid certain medications, always check medication labels
• Managing your asthma

Exercise

Regular exercise is a very important part of a healthy lifestyle. If you manage your asthma well, you should be able to exercise. Most people who manage their asthma well should not need to take a reliever inhaler (usually a blue inhaler) before exercising. If you need to take your reliever inhaler more than three times a week (including before exercise) see your health-care provider to find out how to get your asthma under control.

Benefits of regular exercise include:

• Helps you to maintain a normal weight
• Reduces your risk of:
• Osteoporosis
• Heart disease
• Diabetes
• Some cancers
• Improved mental health
• Better able to do your normal daily activities
• Prevent falls as you get older
• Longer life

Here are some tips that can help you stay active:

• Do not start exercising if you have any asthma symptoms
• Warm up by starting at a slower pace—increase the pace slowly
• If you need to take a reliever inhaler before exercising, it should be taken about 10-15 minutes before the activity
• If you develop asthma symptoms while exercising, stop immediately—use your reliever inhaler and do not start again unless your symptoms are completely gone.
• Consider exercising indoors when outdoor conditions may trigger your asthma (e.g., when there is high air pollution or pollen levels, cold air, or hot humid air)
• When exercising in cold weather, cover your nose and mouth with a scarf or cold weather mask
• If symptoms continue, your asthma may not be under control—work with your health-care provider to improve your asthma management

During an asthma flare-up, your airways can get so blocked that your lungs may not be able to provide enough oxygen to your body or remove enough carbon dioxide. This can be dangerous if left untreated. Whether your asthma is mild, moderate or severe, it needs to be taken seriously and managed properly.

WHAT TO DO WHEN YOUR ASTHMA GETS OUT OF CONTROL

• Mild Asthma Attack
• Continuous Coughing
• Trouble Breathing
• Chest Tightness
• Wheezing (whistling sound in chest)
• Person may also be restless, irritable and/or very tired

STEP 1: Immediately use fast-acting reliever inhaler (usually a blue inhaler). Use a spacer if provided.

STEP 2: Check symptoms. Only return to normal activity when all symptoms are gone. If symptoms get worse or do not improve within 10 minutes, this is an emergency – follow steps below.

ASTHMA EMERGENCY

If any of the following occur:

• Breathing is difficult and fast
• Cannot speak in full sentences
• Lips or nail beds are blue or gray
• Skin on neck or chest sucked in with each breath
• Person may also be anxious, restless and/or very tired

STEP 1: Immediately use fast-acting reliever inhaler (usually a blue inhaler). Use a spacer if provided. CALL 911 for an ambulance.

STEP 2: If symptoms continue, use reliever inhaler every 5-15 minutes until medical help arrives.

While waiting for medical help to arrive:

• Have person sit up with arms resting on a table (do not have person lie down unless it is an anaphylactic reaction).
• Do not have person breathe into a bag.
• Stay calm, reassure the person, and stay by his/her side.
• Notify emergency contact if known.

After you’ve had a worsening of your asthma or an asthma attack, make an appointment with your health-care provider. There may be a need to adjust the doses of your medications. You can also discuss possible reasons why your asthma got out of control and find ways to prevent this in the future.

Different people have different asthma symptoms, which can change over time or depending on the situation. Common asthma signs and symptoms include:

• Feeling short of breath (at rest or when exercising)
• Chest tightness
• Coughing
• Wheezing

These symptoms can also be caused by other conditions. If you have these symptoms or if you think you might have asthma, see your doctor for a proper diagnosis.

ASTHMA SYMPTOMS – CHILDHOOD VS. ADULT? 

Childhood asthma symptoms are generally similar to adult asthma symptoms. However, determining asthma symptoms in children can be a bit more difficult. Adult asthma symptoms are easier to determine since an adult can tell you how they are feeling plus they know their body better. Although you can see and hear the coughing and shortness of breath (laboured breathing, faster breath rate) in younger children, they may not be able to let you know how they are feeling. Plus young children are not able to do a breathing test called spirometry.

• Not being able to keep up with other children while running around
• Having a hard time catching their breath or breathing faster than other children who are doing the same thing
• Looks like they have a cold, which could actually be asthma
• Coughing, especially at night
• Coughing so hard that they vomit
• You may hear wheezing (high pitched whistling sound)
• If you notice any of these typical childhood asthma symptoms, see your doctor to find out if it is due to asthma.

ASTHMA SYMPTOMS – ACUTE VS. CHRONIC 

In medical related matters, “acute” simply means short term, and “chronic” means long term. Although asthma is a chronic disorder, since it usually lasts a long time (often a lifetime), you can have both chronic and acute asthma symptoms. If someone does not properly manage their asthma, they can have regular chronic symptoms for many weeks, months, or even years. For example, they could experience a regular cough that lasts a long time if not managed properly.

Then on top of the regular chronic cough, they may also sometimes experience an acute asthma worsening that leads to a symptom such as shortness of breath. This could perhaps be due to getting a cold, or exposure to pollen or air pollution.

When someone has asthma, it is very important to keep it well controlled so that there are no chronic asthma symptoms. You can’t avoid all asthma symptoms all the time, but in general the symptoms should be uncommon and mild.

It is also very important to monitor your asthma so that you notice when there are acute asthma symptoms starting and can take the necessary measures to get it under control before it leads to an asthma attack. A written asthma action plan from your doctor can be very helpful in guiding your treatment decisions.

For more information please Call us at 1-888-344-LUNG (5864) Monday to Friday between 8:30am-4:30pm or email us your question anytime at info@lunghealth.ca.

If you think you might have asthma, it is important to get a proper diagnosis. Once asthma is diagnosed, it is possible to manage it well so that you can live a full active life. There are many people who have asthma but do not know they have it. The diagnosis of asthma is based on many factors including:

• Medical history
• Physical examination
• Test results, such as a lung function test

MEDICAL HISTORY 

• Your medical history includes any past and current health issues that could be related to your asthma. Your health-care provider will ask you about:
• Your medical history and your family medical history (e.g., allergies, eczema, hay fever)

WHAT SYMPTOMS YOU HAVE HAD AND FOR HOW LONG? 

• Have you had a cough? Shortness of breath? Chest tightness? Wheeze?
• Do you have these symptoms at night or in the early morning hours?
• Do you get symptoms when you exercise, have a cold, or are exposed to cold air?

PHYSICAL EXAMINATION

A physical exam includes checking for signs that you might have asthma. Your health-care provider will:

• Examine your chest and breathing rate
• Use a stethoscope to listen to your lungs for unusual sounds while you breathe
• Examine your nasal passages for signs of allergies
• Examine your skin for signs of eczema

LUNG FUNCTION TESTS

Lung function tests (breathing tests) such as spirometry are an important part of diagnosing asthma.

• Spirometry testing involves taking in a deep breath and breathing out as hard and long as you can into a tube. Once all your air has been exhaled, you then inhale as fast and deep as you can until your lungs are totally full. This test measures important flows and volumes and compares them to normal values.
• Spirometry testing is often done before and after using a reliever inhaler (bronchodilator) to see if there is a change in your lung function
• People under six years of age are not usually able to do a spirometry test

If your spirometry test results are normal but your health-care provider still thinks you might have asthma, you may be sent for further testing. A “challenge test” using either methacholine or histamine can also help diagnose asthma.

ALLERGY TESTING

Your health-care provider may refer you to an allergist for an allergy assessment. This may include an allergy skin test that tests you for reactions to specific allergens (e.g., pets, dust mites, pollen, mould). This can help you find out what allergens may be causing your asthma symptoms.

An allergy skin test involves placing drops of allergens on your forearm or back and making small scratches in the skin where the drops are located. The amount of redness and swelling caused by these allergens will help to show if you have any allergies.

TRIAL OF ASTHMA MEDICATIONS

Your health-care provider may prescribe asthma medications for you to take to see if they improve your asthma symptoms. If asthma medications improve your symptoms, this increases the likelihood that you have asthma.

OTHER TESTS

• Chest x-rays are not very useful in the diagnosis of asthma, but they may help rule out other reasons for your symptoms.
• A blood test or sputum (phlegm, mucus) test may sometimes be ordered. Diagnosing Asthma in Young Children

DIAGNOSING ASTHMA IN A YOUNG CHILD CAN BE MORE CHALLENGING BECAUSE:

• Children under six years of age are not generally able to do a lung function test
• Symptoms such as cough and wheeze are fairly common in very young children who do not have asthma

However, a diagnosis of asthma can be made in a young child. Your health-care provider will assess:

• What symptoms does the child have?
• When do the symptoms occur (e.g., seasonal, during colds)?
• Is there a history of allergies or asthma in the family?
• Does the child have any signs of allergies (e.g., congested nose, eczema)
• Do the symptoms improve when taking asthma medications?

For more information please Call us at 1-888-344-LUNG (5864) Monday to Friday between 8:30am-4:30pm or email us your question anytime at info@lunghealth.ca.

Medications are usually needed for asthma, even if it’s mild asthma. New asthma medications are continually being discovered and there are several effective asthma drugs in the market that help get asthma under control.

There are two types of asthma medications: controllers and relievers.

Asthma Controllers

These are usually taken every day, even if you feel well. They help prevent asthma symptoms and asthma attacks. However, they do NOT help quickly during an asthma attack. Types of controller medications are listed below:

1. Inhaled steroids (corticosteroids)

Controller medications are daily inhalers that control the inflammation in the airways of your lungs. This type of medication is generally the most effective for controlling asthma long term. Examples include Alvesco, Arnuity, Flovent, Pulmicort, and Qvar.

Possible side effects of inhaled steroids:

• Hoarseness and sore throat
• Thrush or yeast infection – looks like a whitish layer on your tongue. You can help prevent thrush by rinsing your mouth after taking the medication and by using a spacer when using a metered dose inhaler.

Your doctor will adjust your dose so you get the best asthma control using the least amount of medication. For a full list of side effects, see your doctor or pharmacist. In most cases, inhaled corticosteroids have few side effects with the dose needed to control asthma.

2. Long-acting bronchodilators

These inhalers open up your lungs by relaxing the tiny bands of muscle that surround the airways. Since they can take longer to work than the reliever medications, they are not to be used to quickly relieve symptoms, such as during an asthma attack. Examples include Foradil, Onbrez, Oxeze, and Serevent.

Possible side effects of long-acting bronchodilators:

• Increased heart rate
• Anxiety
• Tremors (shaking) in the hand

3. Leukotriene-receptor antagonists

Leukotriene-receptor antagonists are daily pills that help control inflammation in the airways. For people with mild asthma, doctors may prescribe leukotriene receptor antagonists alone, however they are generally not as effective as low dose inhaled corticosteroids. Doctors may also prescribe leukotriene receptor antagonists to people who are already taking inhaled corticosteroids to help further reduce symptoms or to help reduce the dose of corticosteroid. Examples include Singulair and Accolate.

Possible side effects of leukotriene-receptor antagonists:

• Headache
• Dizziness
• Heartburn
• Upset stomach

For a full list of side effects, see your doctor or pharmacist. In general, side effects from leukotriene receptor antagonists are uncommon.

4. Combination medications

Combination medications have two medications in one inhaler: an inhaled steroid and a long-acting bronchodilator. They are used when inhaled steroids alone do not fully control your symptoms. Examples include Advair (Flovent + Serevent), Breo (Fluticasone + Vilanterol), Symbicort (Pulmicort + Oxeze), and Zenhale (Mometasone + Formoterol).

5. Biologics

Biological medications, often called biologics, are a relatively new type of medication for asthma. Compared to most medications that are made using chemical reactions, biologics are made using living systems (e.g., bacterial/viral cells, plant or animal cells). An example of a common biologic is the flu vaccine, which is usually grown in chicken eggs.

Biologics are designed to inhibit certain components of the immune system that trigger inflammation—and it is inflammation in the airways that cause a lot of the asthma symptoms.

Biologics for treating asthma now include Xolair® (available since 2005), Cinqair™, Nucala™ and Fasenra®.

Xolair®

Medication class: IgE-neutralizing antibody (Anti-IgE)

Immunoglobulin E (IgE) is a type of protein that our bodies naturally make in small amounts. In allergic asthma the IgE increases abnormally, causing swelling and tightening of the airways. Anti-IgE therapy reduces the ability of IgE to cause symptoms.

If you are following all the correct steps in managing your asthma but are still having a hard time getting your asthma under control, then your health-care provider may decide to send you for Xolair® injections. Xolair® may be prescribed to reduce the symptoms of asthma due to allergic triggers for individuals aged 12 and older.

If you are sent for Xolair® injections, you will receive them every two to four weeks. You need to continue using all of your asthma medication as prescribed by your health-care provider.

Possible side effects should be explained to you by your health-care provider.

Cinqair™, Nucala™

Medication class: Interleukin-5 (IL-5) inhibitor

Cinqair™ is given by intravenous infusion every four weeks.

Nucala™ is given by subcutaneous injection every four weeks.

IL-5 inhibitors are sometimes prescribed for the maintenance treatment of severe asthma in patients aged 18 years or older. It may be added when someone’s asthma is not under control despite using medium to high doses of inhaled corticosteroids plus another controller medication.

IL-5 inhibitors are only effective for people who have a certain level of eosinophil, a type of white blood cell in your blood. Your health-care provider will check your blood eosinophil level before prescribing the medication.

Possible side effects should be explained to you by your health-care provider.

Fasenra®

Medication class: Anti-eosinophil (anti-interleukin-5 receptor alpha monoclonal antibody)

Fasenra is used in addition to other asthma medicines for the maintenance treatment of adult patients with severe eosinophilic asthma, whose asthma is not controlled with their current asthma medicines. Severe eosinophilic asthma is a type of asthma where patients have increased eosinophils in the blood or lungs. Eosinophils are a type of white blood cell that are associated with inflammation of the airways that can cause your asthma to get worse or can increase the number of asthma attacks.

Fasenra works by reducing the number of eosinophils in the blood and lungs and helps reduce the number of asthma attacks that you experience.

Fasenra is given to you as an injection just under the skin (subcutaneously) by a healthcare professional. The injection is given every 4 weeks for the first 3 injections, and then every 8 weeks thereafter.

Possible side effects should be explained to you by your health-care provider.

Asthma Relievers (Fast-acting Bronchodilators)

These are usually only taken when needed for quick relief or for an asthma attack. They help open up your lungs by relaxing the muscles that surround the airways.

Reliever medications are sometimes called “rescue” medications or “quick relief” medications, since they start working quickly (usually within a few minutes). This is the inhaler you use when you have an asthma attack. It is also used for less severe symptoms, or before you exercise. These medications are not useful for long-term control of asthma since they do not control the inflammation in your lungs. If you need this medication more than three times a week, see your doctor. Examples include Ventolin, Salbutamol, Bricanyl, and Airomir.

Possible side effects of reliever medications:

• Trembling
• Nervousness
• Flushing
• Increased heart rate

1. Spacer (Holding chamber)

This is a plastic device that is used with pressurized inhalers (the kind that spray the medication out) to better deliver medication to your lungs. It makes it easier to coordinate inhaling the medication from the inhaler. You get more medication in your lungs and less in your mouth and throat.

2. Corticosteroid Pills

Sometimes, the swelling in people’s airways is severe – this may be because they have a chest infection or for some other reason. In cases of severe airway swelling, the doctor may prescribe corticosteroid pills to reduce the swelling, redness, and mucus in the airways. Corticosteroid pills basically do the same thing as inhaled corticosteroids, but they are more powerful. Doctors often prescribe these pills for a short time to get the swelling under control. Examples of corticosteroid pills include Prednisone, Prednisolone (PediaPred®), and Dexamethasone (Decadron®).

For a full list of side effects, see your doctor or pharmacist. In the short term (e.g., 7-10 days) side effects of corticosteroid pills may include:

• Increased appetite
• Mood changes
• Water retention
• Hyperactivity in children

In the long-term (prescriptions that last many weeks or months) side effects of corticosteroid pills may include:

• Increased appetite
• Weight gain
• Stomach irritation
• Bone thinning

Dependency: your body can go into withdrawal if you stop taking prednisone all of a sudden. Your doctor may ask you to taper off your dose slowly.

Where to Learn More

Your doctor, pharmacist, or Certified Respiratory Educator can:

• Explain how each of your asthma medications work
• Discuss any concerns about potential side effects
• Show you how to use your medication inhalation advice

Ontario residents can reach our Certified Respiratory Educators through our toll-free Lung Health Information Line at 1-888-344-LUNG (5864).

Click here to learn how to use your inhaler.

Asthma Action Plan

An Asthma Action Plan is a set of written instructions from your doctor that shows you what medicines you need to take, when you should take them, and how you should adjust them if your asthma starts to get out of control. It’s based on the traffic light system:

GREEN means your asthma is under control

YELLOW means your asthma is getting out of control

RED is an emergency.

Download an Adult Asthma Action Plan or Pediatric Asthma Action Plan, and fill it out with the help of your healthcare provider.