This is Asthma

This is my asthma explanation. The progression of a flare looks like a list in my head, so that’s how I explain it to friends and family. Maybe it will make sense to you, too, although I’ve included some medical links below if you prefer the more technical breakdown.

This is Normal Breathing

1. You breathe air in.

2. Air heads down your windpipe into the right and left bronchial tubes, or the tubes that connect the windpipe to the lungs.

3. While the air travels through these clear and open airways, mucus traps dirt, bacteria, and other stuff you don’t want in your lungs.

4. Finally, the air passes through tinier bronchioles at the end of the airways, inside the lungs. (see photo) And at the very end of the bronchioles, alveoli are tiny sacs that grab oxygen out and pass it into the blood and exchange carbon dioxide in return (the exhale).

33787_lungs.jpg
(An actual pair of plasticized lungs. All those tiny branchlike structures are bronchioles.)

This is Breathing with Asthma

1. You have inflamed and swollen airways all the time. No one knows why, although there are some risk factors.

2. Swelling narrows the airways and makes them more sensitive.

3. You breathe in, and various triggers like allergens or airborne irritants make those inflamed bronchial tubes start spasming and producing more mucus than they should. This is an asthma flare.

4. Since swelling already narrowed the airways, the extra mucus and spasms don’t help.

5. You therefore cannot exhale as much air as you need to.

6. The “dead air” stays trapped in the bottom of your lungs, forcing you to breathe shallowly with just the top of your lungs. You cannot take deep breaths without intervention, and that’s where the inhaler comes in.

If you say asthma, most people will free-associate the word wheeze, and that’s the whistling sound air can make as it tries to travel through narrow, spasming airways during a flare. But wheezing, is not the number-one asthma symptom. Coughing is. Many asthmatics–including my daughter–never wheeze at all, but they will cough and cough and cough without stopping as their lungs try to force the air out.

Treatment for most asthmatics means taking preventative medicines to keep the inflammation down so that flares are less frequent and less severe, avoiding triggers for the same reason, and using an emergency inhaler for any flares that do occur.

The Steroid Question

Let’s talk steroids.

But first, let’s talk preventative medicine. Persistent asthma–that’s any case of asthma that generates weekly symptoms without treatment, even if the symptoms are mild and infrequent–usually motivates a doctor to prescribe maintenance meds. Flares are a whole lot easier to prevent than to treat because they can spiral out of control very fast. And spending all your time chasing down flares, worrying they’ll turn severe enough to require an ER visit, is no way to live.

Believe me, AG’s been there. It’s scary and it’s dangerous and the best part? It’s usually avoidable, since most asthma usually responds well to treatment.

Part of that treatment means avoiding asthma triggers, part of it can include taking antihistamines if allergies are the main trigger, part of it involves carrying a quick-relief inhaler, and part of it usually includes preventative inhaled steroids.

No parent likes the idea of giving steroids to children.
And I imagine no adult asthmatics like the thought of taking steroids, either. Who wouldn’t prefer good health without medication? But that’s just it — the idea of making my kid take steroids for asthma maintenance was far different from the reality of the benefits on her health and the real–as opposed to what I imagined–side effects.

Because:

Inhaled maintenance corticosteroids are NOT the same thing as anabolic steroids.
Let’s get that idea out of the way, too, because it formed a large portion of my mental block when AG was younger. Anabolic steroids are the ones you read about in the papers during pro-athlete scandals, the ones with horrible side effects like sterility, aggression, liver damage, masculinization of women, and even death. They are a synthetic version of the male sex hormone, and they work on protein and muscle.

Corticosteroids are synthetic versions of natural hormones that regulate things like the body’s stress and inflammation responses. Unlike anabolic steroids, these have nothing to do with sex and don’t affect the liver. The other difference here is that athletes who abuse anabolic steroids inject them or take them orally, and maintenance corticosteroids for asthma are inhaled directly into the lungs. (Except when severe flares warrant a oral dosage, but we’ll get to that.)

Inhaling the corticosteroids sends them directly to the bronchial and lung tissue where they need to go, and very little enters the bloodstream. So inhaled steroids don’t affect other organs to the extent that oral ones do.

But Why Steroids?
Remember how all asthma patients have swollen, inflamed airways and no one knows why? I always picture this part as a light switch when I’m thinking about my daughter. Somehow, her hyper-reactive switch got turned *on,* and there’s no way I can turn it *off.* Figuring out how to flip that switch would be the cure.

If I can’t turn the switch off, what I can do is beat down that bronchial inflammation that results. As I understand the process, inhaling corticosteroids can do this because that’s what the natural ones in her body do–they help balance out and regulate the healthy inflammatory response.

I think of it this way: if AG has problems with extra inflammation, then she needs extra amounts of the corticosteroids that reduce it. Bombarding the exact location–her airways–with a low level of steroids does the trick and minimizes the side effects. Then when she does encounter triggers, her flares aren’t made worse by swollen and irritated tissue.

Another reason why inhaled steroids aren’t as bad as they first sound? Doctors prescribe the lowest possible dose to maintain asthma control and can tailor the frequency of use for each patient. My daughter, for example, is lucky enough to use the lowest dosage (44 mcg) controller inhaler and doesn’t use it all during the summer.

What About the Side Effects?
Even inhaled corticosteroids have some, of course, but they’re minimal. The main one is throat irritation or thrush, which are avoidable by rinsing after using the inhaler. While not definitive, a few studies seem to indicate a slightly higher risk for cataracts in patients over 40 who use steroid inhalers and the risk of some bone loss in adults after long-term use.

Here’s the irony, though. Sometimes a parent (read: me) is terrified of inhaled corticosteroids without really knowing much about them, keeps her young child from using them despite moderate to severe persistent asthma not responding well to bronchodilators alone, and her kid (read: AG) ends up on oral corticosteroids instead. Those side effects are far, far more severe if used frequently because they enter the bloodstream.

Just about every asthma patient will end up needing a short burst of oral steroids to get over a particularly severe flare at least once, and these 5-day, infrequent courses mainly just result in a stomachache, weight gain from fluid, and mood swings. But using oral steroids often, like with severe asthma or with under-treated persistent asthma, can cause side effects from glaucoma and cataracts to osteoporosis and adrenal gland problems.

For me, the trade-off is clear. I can keep AG on daily inhaled steroids, or I can watch her flare constantly and end up on the more severe oral steroids several times every fall, winter, and spring. Because she will, no question.

Don’t be afraid of steroid inhalers if your child’s doctor prescribes one.
They don’t guarantee an existence free of life-threatening flares, but they sure can decrease the possibility. They changed my child’s life, and mine.

Common Inhaled Steroids
(Brand names in parentheses)

Beclomethasone (Beclovent, Qvar, Vanceril)
Budesonide (Pulmicort)
Fluticasone (Flovent)
Flunisolide (Aerobid, Aerobid-M)
Mometasone furoate (Asmanex)
Triamcinolone (Azmacort)

More on asthma and steroids:

National Jewish: Steroid Pills & Syrups
Asthma Society of Canada: All About Inhaled Steroids
Partners Asthma Center: Asthma & Inhaled Steroids

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Corticosteroids aren’t the only asthma maintenance meds, either. They’re just the most common, and they carry the best risk-benefit profile. There are a few other options, mostly prescribed for more severe and/or persistent asthma when inhaled steroids won’t do the job by themselves.

Leukotriene Inhibitors

These oral meds block leukotrienes, or chemicals that produce allergic inflammation. Singulair’s (montelukast) the most common, but Accolate (zafirlukast) and Zyflo (zileuton) are options, too. The FDA approved Singulair as an asthma preventative in 1998 and, two years later it approved low dosages for infants under age two. Singulair is very popular as a maintenance medicine, both in conjunction with a corticosteroid or on its own. In fact, some asthma patients have been able to decrease their use of corticosteroids while on Singulair.

Recently, though, it’s come under scrutiny for a possible link to suicides, mood swings, and suicidal behavior. In any case, many patients experience little or no side effects while others don’t seem able to tolerate it. Like any medicine, it will depend on the patient.
(Read more about the Singulair controversy here and here.

Long-Acting Beta-Agonists

They’re just what they sound like, bronchodilators that relax the smooth muscles around the bronchial tubes to open airways the way albuterol does, only they take more time to do it. Albuterol, on the other hand, takes around 5 to 20 minutes for immediate relief.

So long-acting beta-agonists (LABA’s) will not stop an asthma flare. Although they are bronchodilators, their longer action means they work as maintenance meds rather than relievers. Serevent (salmeterol), Advair, and Foradil are approved for children over the age of 4 and adults, but doctors only prescribe them for moderate to severe persistent asthma that isn’t responding well to other controller meds. LABA’s are an *add-on* treatment, and doctors like inhaled corticosteroids and/or leukotriene modifiers best for prevention.

As with all beta agonists, LABA’s can cause rapid heartbeat, shakiness, and dizziness. A very small number of patients may experience adverse reactions, hospitalizations, and even death, explaining these prescriptions’ black box warnings. In fact, the FDA recently reviewed the pediatric use of LABA’s and recommended stronger black box language about their risk, although they’re unquestionably lifesaving medications for many asthmatics.
(Read more about the decision here.)

Monoclonal Antibodies

Xolair (omalizumab) is the newest maintenance option in the asthma arsenal. It’s a shot that blocks IgE (immunoglobulin E), the substance that causes allergies. It’s an add-on treatment for persistent allergic asthma sufferers aged 12 and older whose symptoms are not under good control even with corticosteroids. Xolair’s been approved since 2003, and short term side effects include swelling/irritation at the injection site, increased viral and respiratory infections and sinusitis, sore throats, and headaches.

Xolair also carries a black box warning, since 0.2% of patients have experienced anaphylaxis after an injection. Plus, during development, researchers noted a very slight increase in breast, skin, and prostate cancers after long-term Xolair use. The connection between the two is unclear.
(Read more here.

Any questions? Always ask your doctor first.

More Information
What is Asthma? (National Jewish)
Childhood Asthma: An Overview (American Lung Association)
Adult Onset of Asthma (Asthma and Allergy Foundation of America)