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Asthma is a common chronic lung disease that can make it difficult to breathe. Although there is no cure for asthma, those with the condition can live healthy, active lives if their asthma is under control.

Steve’s Story

Steve is a 32-year-old who has a history of frequent asthma symptoms. He relied on an albuterol inhaler for relief but tried to avoid it as he understood it was for “emergency relief.” Last year, he was seen in the emergency room for uncontrolled asthma possibly related to the common cold. Subsequently, his symptoms persisted and he had stopped regular exercise. He also had missed work at least once every two months.

Steve also had trouble sleeping several times a month. He even hesitated going out with friends because laughing caused asthma. Ultimately, he consulted a physician who prescribed a steroid inhaler. The albuterol was continued.

Steve felt better after a few weeks. He had fewer attacks at night and could exercise, although frequently had to stop because of his symptoms. He continued to use the albuterol inhaler in the mornings, and occasionally for symptom relief. As he felt better, he began to decrease use of the steroid inhaler. He just didn’t like the idea of taking steroids. Overall, Steve was content with his asthma control. It was, after all, much better than when he was only taking albuterol.

What do you think of Steve’s treatment? Does his improvement mean that therapy was successful?

As an asthma specialist, I hear stories similar to Steve’s almost daily. Most asthmatics believe that some improvement with therapy is all they can expect. They also withhold use of albuterol, which they believe should primarily be used for emergency relief.

I love seeing patients like Steve, because I know that within a few weeks their lives can be turned around.

Treating Two Components is Key

Appropriate asthma therapy is extremely effective, with major advances seen in the last few decades. Most people with asthma can achieve near total resolution, or at least dramatic improvement in symptoms. As a result, their quality of life also improves. The good news is that therapy is relatively simple and safe.

There are two primary components of asthma. The first is spasm of the muscles that surround the airway, resulting in narrowing of the airways, and leading to chest tightness, wheezing and shortness of breath. Short-term relief is accomplished by taking an inhaler, usually albuterol. This class of drug, called a short-acting beta agonist, results in relaxation of the bronchial muscles and improvement in breathing. Improvement begins after a few minutes and usually lasts up to four hours.

The second and more important aspect of asthma is inflammation. You can think of inflammation as being similar to a burn on your skin. There is swelling, increased secretions and irritation, with the skin perhaps sloughing off. A similar reaction occurs in the lung and is often present in asthmatics even when they feel well. Treatment of inflammation includes removal of environmental allergens, and treatment of sinus disease or gastroesophageal reflux. The hallmark of treatment, however, is low-dose inhaled steroids.

Steroids to the Rescue

These steroids are not the same as those you hear about athletes using. Their function is to decrease inflammation and return the lung to a more normal state. As a result, the airway becomes healthier and the tendency for muscle spasm decreases. Steroids are given through an inhaler at microgram doses straight to the lungs. This is a thousand times less than may be given by mouth for a severe asthmatic episode, which is in milligrams (one milligram is a thousand micrograms).

A person with well-controlled asthma can return to a normal life. In more active asthma, a long-acting beta agonist (12 +hours) is added to the inhaled steroid, which results in more rapid and better control and stability. This is called dual therapy. There are now many dual therapy inhalers on the market, which are taken either once or twice a day.

Lifestyle Regained

Steve ultimately saw an asthma specialist, who performed pulmonary function tests. Although he felt well that day, the tests showed moderate obstruction. This is common, as the longer asthma is active, the more likely it is that the patient does not sense their level of obstruction.

Because of his ongoing symptoms and the pulmonary function results, he was prescribed dual therapy. Within a week, Steve was back to bicycling, sleeping better and had improved overall energy (even mild active asthma is fatiguing). He was taught to use the albuterol prior to exercise and for symptom relief. Soon however, he discovered that it wasn’t needed much at all, as he was experiencing no significant symptoms. Dual therapy was continued.

Here are the ‘take home’ messages of this case study:

• Asthma is a combination of inflammation and muscle spasm in the lung.
• Treatment targets both processes and involves a combination of avoidance of triggers (such as dander/dusts/pets), treatment of underlying conditions such as hay fever and reflux, and medications.
• Control can be achieved in the vast majority of patients, allowing a normal lifestyle.
• The goal of treatment is to have no or limited symptoms on the least amount of medication. Oftentimes, medication use is needed on a daily basis to maintain control.

Charles McDonald, MD, is a pulmonologist in San Francisco who has more than 49 years of experience in the field pulmonary diseases. He graduated from University of Utah School of Medicine and is affiliated with California Pacific Medical Center – Van Ness Campus.

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