Asthma in Teens and Adults by Paul Lehnert

Overview

Is this topic for you?
This topic provides information about asthma in teens and adults. If you are looking for information about asthma in children age 12 and younger, see the topic Asthma in Children.

What is asthma?
Asthma makes it difficult for you to breathe. This can happen only every now and then, or in more severe cases, every day. Asthma may also last throughout your life (a chronic disease), but you can control it through treatment with medications.

Asthma makes it difficult to breathe because it can cause inflammation in your bronchial tubes, which carry air to the lungs. The inflammation usually starts slowly, but over time it can make the muscles that line the bronchial tubes get tight (bronchospasm). This can cause a blocking or narrowing of your airways, making it difficult to breathe. This is known as an acute asthma episode (also called an attack, flare-up, or exacerbation).

Acute asthma episodes can happen rarely or often and be mild or severe. Most often, you can take care of symptoms at home by using an asthma action plan, which is a written plan that tells you which medicines you need to use and when you should call a health professional. If you have a severe acute episode, you may need urgent care. These acute asthma episodes can even cause death, but that is rare.

Even if you have few acute asthma episodes, you still have inflammation in your airways that needs treatment. If the inflammation is not controlled, asthma could lead to permanent changes in the bronchial tubes and harm your lungs.

Although there is no cure for asthma, with treatment you can control your symptoms and prevent further damage to your lungs.

What causes asthma?
We don't know what causes asthma. But here are some of the things that can cause the inflammation in your airways that can lead to asthma and acute asthma episodes:

Asthma may run in families (inherited).
In some people, immune system cells release chemicals that cause inflammation in response to certain substances (allergens) that cause allergic reactions. Studies show that exposure to allergens such as dust mites, cockroaches, and animal dander may influence asthma’s development. 1 Asthma is much more common in people with allergies, though not all those with allergies get asthma.
Some experts believe that there are more cases of asthma because of pollution and less exposure to certain types of bacteria or infections. 2 As a result, children's immune systems may develop in a way that makes it more likely they will also develop allergies and asthma.
What are the symptoms?
Symptoms of asthma can be mild or severe. You may have no symptoms; severe, daily symptoms; or something in between. How often you have symptoms can also change. Symptoms of asthma may include:

Wheezing, which is a loud or soft whistling noise that occurs when the airways narrow.
Coughing.
Chest tightness.
Shortness of breath, which is rapid, shallow breathing or having a hard time breathing.
Trouble sleeping.
Tiring quickly during exercise.
Many people have symptoms that become worse at night (nocturnal asthma).

How is asthma diagnosed?
No one test can diagnose asthma. Your health professional will diagnose asthma using spirometry, as well as your medical history, a physical exam, and lab tests.

Spirometry measures how quickly you can move air in and out of your lungs and how much air you move. The test can help your health professional decide whether asthma is causing your airflow to decrease and by how much. The test can also show how well your lungs work when you're not having asthma symptoms and measure how well your lungs respond to treatment with medication.

While taking your medical history, your health professional will ask about your symptoms and when they occur. A physical exam will not find signs of asthma unless you are having symptoms. Your health professional will listen to your chest for signs of reduced airflow in the bronchial tubes and will look for signs of sinus problems or allergies.

A chest X-ray may be done to see whether another disease is causing your symptoms. Blood tests may show that you have allergies that could cause asthma episodes. If your health professional thinks you may have asthma related to allergies, skin testing may be done to identify them.

You will need routine checkups with your health professional to keep track of your asthma and decide on treatment.

How is it treated?
You can treat asthma with medications, especially inhaled corticosteroids, which prevent or control airway inflammation, and beta2-agonists, which make the airways larger (dilate). You usually work with your health professional to form a daily treatment plan and an asthma action plan. These plans help you to:

Control airway inflammation and prevent asthma episodes.
Identify and treat early symptoms of episodes.
Avoid things that make symptoms worse, such as cigarette smoke or allergens (triggers).
Know when emergency help is needed.
Health Tools
Health tools help you make wise health decisions or take action to improve your health.

Decision Points focus on key medical care decisions that are important to many health problems.
Should I take allergy shots (immunotherapy) for allergic rhinitis and allergic asthma?

Actionsets are designed to help people take an active role in managing a health condition.
How to measure peak expiratory flow
Identifying asthma triggers
Using a metered-dose inhaler (MDI)
Using daily asthma treatment and action plans

Frequently Asked Questions
Learning about asthma:
What is asthma?
What causes asthma?
Can I prevent asthma or asthma episodes?
What are the symptoms of asthma?
What happens in asthma?
What increases my risk of asthma?
How is the severity of asthma classified?
What is occupational asthma?
What is exercise-induced asthma?
Who is affected?

Being diagnosed:
Who can diagnose asthma?
How is asthma diagnosed?
How is asthma monitored?

Getting treatment:
How is asthma treated?
What medications will I need to take?
What other treatments might be recommended?
What is a daily asthma treatment plan?
What is an asthma action plan?
Should I take allergy shots (immunotherapy) for asthma?

Living with asthma:
How can I manage asthma at home?
How often will I need to see my health professional?
When should I call my health professional?
What devices are available to deliver asthma medication?
How do I control asthma caused by exercise?
How does asthma affect a pregnancy?
What is an asthma diary?
How do I use daily asthma treatment and action plans?
How can I monitor my breathing?
How do I know what triggers my asthma?
How do I use a metered-dose inhaler?


Cause
The cause of asthma is unknown. Health experts believe that inherited, environmental, and immune system factors combine to cause inflammation of the bronchial tubes, which carry air to the lungs. This can lead to asthma and acute asthma episodes.

Asthma may run in families (inherited). If this is the case in your family, you may be more likely than other people to develop long-lasting (chronic) inflammation in the bronchial tubes.
In some people, immune system cells release chemicals that cause inflammation in response to certain substances (allergens) that cause allergic reactions. Studies show that exposure to allergens such as dust mites, cockroaches, and animal dander may influence asthma’s development. 1 Asthma is much more common in people with allergies, though not all those with allergies develop asthma.
Environmental factors and today's germ-conscious lifestyle may play a role in the development of asthma. Some experts believe that there are more cases of asthma because of pollution and less exposure to certain types of bacteria or infections. 2 As a result, children's immune systems may develop in a way that makes it more likely they will also develop allergies and asthma.
Asthma in adults also can be related to work (occupational asthma). Being around animals, plastic resin, wood dust, grain dust, insecticides, and metals can cause asthma, usually because your immune system reacts to the material. Some people continue to have asthma symptoms even after they are no longer exposed to what caused the symptoms.

Symptoms
Symptoms of asthma can be mild or severe. You may have no symptoms; severe, daily symptoms; or something in between. How often you have symptoms can also change. Symptoms of asthma may include:

Wheezing, which is a whistling noise of varying loudness that occurs when the airways of the lungs (bronchial tubes) narrow.
Coughing, which is the only symptom for some people. The cough usually is dry (does not bring up mucus) and occurs mostly at night.
Chest tightness.
Shortness of breath, which is rapid, shallow breathing or difficulty breathing.
Sleep disturbance.
Tiring quickly during exercise.
An acute asthma episode occurs when your symptoms suddenly increase. Factors that can lead to or worsen an acute asthma episode include:

Having a cold or another type of respiratory illness, especially one caused by a virus, such as influenza.
Exercising (exercise-induced asthma), especially if the air is cold and dry.
Exposure to triggers, such as cigarette smoke, air pollution, dust mites, or animal dander.
Being around chemicals or other substances at work (occupational asthma).
Changes in hormones, such as during the start of a woman's menstrual blood flow or pregnancy.
Taking medications, such as aspirin (aspirin-induced asthma) or nonsteroidal anti-inflammatory drugs.
Many people have symptoms that become worse at night (nocturnal asthma). In all people, lung function changes throughout the day and night. In people with asthma, this often is very noticeable, especially at night, and nighttime cough and shortness of breath frequently occur. In general, waking at night because of shortness of breath or cough indicates poorly controlled asthma.

Symptoms are used to classify asthma by severity. They are also used along with peak expiratory flow to help define the green, yellow, and red zones of your asthma action plan. You use this to decide on treatment during an acute asthma episode.

Other conditions with symptoms similar to asthma include heart failure, chronic obstructive pulmonary disease (COPD), and vocal cord dysfunction.

What Happens
Asthma often begins during childhood or the teen years and may last throughout your life. It can increase your risk of complications from lung and airway infections, such as bronchitis and pneumonia.

At times, the inflammation found in asthma causes a narrowing of your airways and mucus production, resulting in asthma symptoms such as shortness of breath.

The airways narrow when they overreact to certain substances. These are known as asthma triggers and may include:

Substances you are allergic to (allergens, such as dust mites or animal dander). Allergens cause long-term (chronic) inflammation and may cause asthma symptoms.
Environmental factors, such as smoke or cold air. Environmental factors may lead to a tightening of the muscles that line the bronchial tubes (bronchospasm), which can trigger asthma symptoms.
What triggers asthma symptoms varies from person to person. When asthma is triggered by an allergen, it is known as allergic asthma.

When asthma symptoms suddenly occur, it is known as an acute asthma episode (also called an attack, flare-up, or exacerbation). Acute asthma episodes can occur rarely or frequently and be mild to severe. Generally, you can take care of symptoms at home with an asthma action plan, although a severe acute episode may require emergency treatment and on rare occasions can be fatal.

Asthma is classified as mild intermittent, mild persistent, moderate persistent, and severe persistent. People with:

Mild intermittent, mild persistent, and, frequently, moderate persistent asthma often have symptoms only after being around a trigger.
Mild intermittent asthma usually need medications only during an acute asthma episode.
Mild persistent or moderate persistent asthma need to take medications daily to control the long-term inflammation in their airways.
Severe persistent asthma have symptoms almost all of the time. Their symptoms need to be treated daily. These people are at increased risk for severe, life-threatening asthma episodes known as status asthmaticus.
Asthma—even mild asthma—may result in changes to the airway system (airway remodeling) and may speed up and worsen the natural decrease in lung function that occurs as we age. 3 Asthma may also influence your risk of developing chronic obstructive pulmonary disease (COPD). Childhood asthma may make you more sensitive to cigarette smoke and thus more likely to develop COPD. 4

Sometimes asthma does not respond to treatment because people are not taking their medications, not taking them correctly, not avoiding triggers, and otherwise not following their daily treatment plan or asthma action plan. Follow your asthma plans so you can prevent worsening asthma and an increased risk of death.

Asthma during pregnancy
Asthma can affect your pregnancy. It may occur for the first time during pregnancy, or it may change during pregnancy: about one-third of pregnant women with asthma experience worse asthma during pregnancy, one-third remain the same, and one-third improve. 5

When asthma is properly controlled, a pregnant woman with asthma can have a normal pregnancy with little or no increased risk to herself or her fetus. However, if the asthma is not well controlled, there are risks to the pregnant woman and her fetus. The management of asthma in pregnant women and nonpregnant women is basically the same, although pregnant women may need to take different medications and need to monitor their fetus's health as well as their own.

What Increases Your Risk
Many factors may increase your risk of developing asthma. Some of these are not within your control; others you can control. The major risk factors for developing asthma as an adult are chronic wheezing when you were a child and cigarette smoking. 6

Asthma risk factors that you cannot control
The following risk factors are not within your control:

Gender. In young adults, women have asthma more often than men.
Inherited tendency (genetic predisposition) to overreaction of the bronchial tubes. People who inherit a tendency of the bronchial tubes (which carry air to the lungs) to overreact often develop asthma.
A history of allergy. If you have an allergy, you are more likely than others to develop asthma. Most children and many adults with asthma have atopic dermatitis, allergic rhinitis, or both. Studies indicate that 40% to 50% of children with atopic dermatitis develop asthma. Having atopic dermatitis as a child may also increase your risk of having more severe and persistent asthma as an adult than someone who did not have the condition. 7
A family history of allergies and asthma. People who have an allergy and asthma usually have a family history of allergies or asthma.
Rhinitis. Adults who have inflamed nasal passages (rhinitis) have a higher-than-average risk of developing asthma.
Asthma risk factors that you can control
You may be able to change some factors to reduce your or your child's risk of developing asthma. These include:

Cigarette smoking. About half of all new cases of asthma in adults older than 40 occur in people who smoke cigarettes and have other lung disease, such as chronic bronchitis or emphysema. 8
Cigarette smoking during pregnancy. Women who smoke during pregnancy increase the risk of wheezing—a symptom of asthma—in their babies. Babies whose mothers smoked during pregnancy also have worse lung function than those whose mothers did not smoke.
Workplace exposure to irritants. Occupational asthma may develop after exposure to a specific inhaled irritant or allergen in the workplace. Such substances also can make symptoms worse in people with existing asthma.
Dust mites. Exposure to dust mites is a risk factor in the development of asthma. 9
Cockroaches. In one study, children who had a high level of cockroach droppings in their home were 4 times more likely to have a new diagnosis of asthma than children whose homes had a low level. 9
The evidence concerning breast-feeding and the risk of a child developing asthma is conflicting. One study has found that exclusively feeding a child breast milk in the first 9 months of life may reduce the child's risk of developing asthma. 10 However, other studies indicate no protective effect and that breast-feeding may increase the risk for developing asthma. 11

The effect of pets in the home is controversial. Some research indicates that owning cats or dogs may increase your child's risk of developing asthma. 9 However, other research indicates that exposure to pets early in life may decrease your child's risk of developing asthma. 12 Generally, if you already have asthma and allergies to pets, having a pet in the home will make your asthma worse.

Risk factors that may make asthma worse (triggers)
Triggers that may make asthma worse and may lead to acute asthma episodes include:

Infections, such as severe upper respiratory infections (URI), sinusitis, and influenza (flu). URIs cause more than half of the asthma episodes in adults. 13
Allergens, such as dust mites or mold. 9, 14
When to Call a Doctor
If you have been diagnosed with asthma and have an asthma action plan, do the following.

Call 911 or other emergency services immediately if you are having severe asthma symptoms (in the red zone of your asthma action plan) and you have followed the plan, but:

You are having severe difficulty breathing.
20 to 30 minutes after taking the extra medication, you do not feel better and/or your peak expiratory flow (PEF) is still less than 50% of your personal best measurement.
Call your health professional immediately if you:

Are in the red zone, and 6 hours after taking the extra medication the following are true:
You still require inhaler medication every 1 to 3 hours.
Your PEF is below 70% of your personal best measurement.
Are in the yellow zone of the asthma action plan and continue to have a PEF below 70% of the personal best measurement in spite of home treatment using your asthma action plan.
Have mild asthma symptoms that get worse, and you feel there is nothing else you can do at home.
Are having a first episode of asthma symptoms, and your symptoms include wheezing, chest tightness, and moderate difficulty breathing.
Are coughing up green, dark brown, or bloody mucus.
Call your health professional if you:

Have asthma symptoms, you do not have an asthma action plan, and your symptoms are mild (chest tightness, cough, and slight shortness of breath or tiring easily during exercise).
Are having symptoms in the yellow zone almost every day, but your inhaler medication is controlling your symptoms.
Have asthma and your PEF has been getting worse for 2 to 3 days.
If you have not been diagnosed with asthma but have mild asthma symptoms, call your health professional and make an appointment for an evaluation.

If your teenager has symptoms of asthma, it is important to see a health professional; a large portion of teens with frequent wheezing may have asthma but are not diagnosed with the disease. Teens who have asthma but are less likely to be diagnosed include: 15

Girls, especially teenage girls.
Smokers, or teens who are exposed to household cigarette smoke.
Those with low socioeconomic status.
Those who have allergies.
African Americans, Native Americans, or Mexican Americans.
Watchful Waiting
Watchful waiting is a period of time during which you and your health professional observe your symptoms or condition without using medical treatment. Self-treatment is not appropriate if you have asthma symptoms. See your health professional, even if you are taking nonprescription medications and they relieve your symptoms.

If you have been getting treatment for 1 to 3 months but are not improving, ask your health professional whether you need to see an asthma specialist.

Watchful waiting may be appropriate if you follow your asthma daily treatment and action plans and stay within the green zone. Watch the symptoms and continue to avoid asthma triggers.

Who to See
Health professionals who can diagnose and treat asthma include:

Pediatricians.
Family medicine physicians.
Nurse practitioners.
Physician assistants.
Internists.
You may need to see a specialist (allergist or pulmonologist) if you have:

Unusual symptoms, or there are problems deciding whether you have asthma.
Other medical conditions that make it hard to treat asthma.
Need for additional education or difficulty following your daily asthma treatment and action plans.
Not met the goals of treatment after 3 to 6 months of therapy.
Had a life-threatening asthma episode.
Other reasons to see a specialist include:

Having severe persistent asthma.
Needing to take continuous oral corticosteroid medications or high-dose inhaled corticosteroids or having had more than two treatments with oral corticosteroids in 1 year.
Having asthma because of your workplace (occupational asthma).
Needing skin testing for allergy.
Thinking about starting treatment with allergy shots (immunotherapy).
Exams and Tests
Diagnosis of asthma is based on your medical history, a physical examination, and lung function tests. If you developed asthma in adulthood, your health professional will ask about your job to determine whether you have occupational asthma.

Lung function tests can diagnose asthma, determine its severity, and check for complications.

Spirometry is the most common test used to diagnose asthma. It measures how quickly you can move air in and out of the lungs and how much air is moved. The test helps your health professional decide whether airflow is decreased because of inflammation in the bronchial tubes and whether the tubes can return to their usual size in a short time after using medication. Doctors also recommend the test at least every 1 to 2 years after asthma treatment has begun.
Testing of daytime changes in peak expiratory flow (PEF) is done over 1 to 2 weeks. This test is needed when you have symptoms off and on but have normal spirometry test results.
An exercise or inhalation challenge may be used if the spirometry test results have been normal or near normal but asthma is still suspected. These tests measure how quickly you can breathe in and out after exercise or after using a medication. An inhalation challenge also may be done using a specific irritant or allergen if your health professional suspects occupational asthma.
A newer test to monitor asthma is the NIOX nitric oxide test system. This test measures nitric oxide in exhaled air; a decrease in nitric oxide suggests that treatment may be reducing inflammation caused by asthma.

Regular checkups
You need to monitor your condition and have regular checkups to keep asthma under control and to review and possibly update your daily treatment and action plans. The frequency of checkups depends on how your asthma is classified. Checkups are recommended:

About every 6 to 12 months for people with mild intermittent or mild persistent asthma that has been under control for at least 3 months.
Every 3 to 4 months for those with moderate persistent asthma.
Every 1 to 2 months for people with uncontrolled or severe persistent asthma.
During checkups, your health professional will ask whether your symptoms and peak expiratory flow have held steady, improved, or become worse, and about asthma episodes during exercise or at night. You track this information in an asthma diary. You may be asked to bring your peak expiratory flow meter to an appointment so your health professional can see how you use it. Based on the results, your asthma category may change, and your health professional may change the medications you use or how much medication you use.

Tests for other diseases
Asthma sometimes is hard to diagnose because symptoms vary widely from person to person and within each person over time. Symptoms may be the same as those of other conditions, such as influenza or other viral respiratory infections or vocal cord dysfunction. Tests done to determine whether diseases other than asthma are causing your symptoms include the following.

Additional lung function tests may be needed if other lung diseases, such as chronic obstructive pulmonary disease (COPD), are suspected.
An electrocardiogram (EKG, ECG) measures the electrical signals that control the rhythm of your heartbeat. This test might be done to rule out serious conditions with similar symptoms, such as chronic heart failure.
A bronchoscopy involves using a flexible scope called a bronchoscope to examine the airways. Occasionally airway problems such as tumors or foreign bodies will create symptoms that mimic those of asthma. The test might be done if you have unequal wheezing in the lungs or a poor response to asthma therapy. Biopsies of the airways can be done to look for changes characteristic of asthma.
A chest X-ray may be used to see whether other lung diseases, such as fibrous tissue caused by chronic inflammation (pulmonary fibrosis), are causing symptoms.
A sweat test, which measures the amount of salt in sweat, may be used to see whether cystic fibrosis is causing symptoms.
Tests to identify triggers
If you have persistent asthma and take medication every day, your health professional may ask about your exposure to substances (allergens) that cause an allergic reaction. For more information about the following tests, see the topic Allergic Rhinitis.

Allergy tests include:

Skin tests. The skin on the back or arms is pricked with one or more small doses of allergens that might cause an allergy. The amount of swelling and redness at the sites of the skin pricks is measured to see which allergens cause a reaction. Skin tests are quick, simple, and relatively safe. Skin tests are necessary if you are interested in allergy shots (immunotherapy).
Radioallergosorbent test (RAST). A blood sample is taken from a vein and tested for immunoglobulin E (IgE) antibodies, which are produced in response to particular allergens. RAST may be done instead of or along with a skin test. Enzyme-linked immunosorbent assay (ELISA) is another test that measures IgE antibodies.
Other tests may be done to see whether other conditions such as sinusitis, nasal polyps, or gastroesophageal reflux disease (GERD) are present.

Treatment Overview
Although asthma cannot be cured, you can manage the symptoms with medications, especially inhaled corticosteroids and beta2-agonists. You usually work with your health professional to develop a management plan consisting of a daily treatment plan and an asthma action plan. These plans help you meet treatment goals:

Minimize long-term lung damage by treating the underlying inflammation to the lungs.
Decrease the severity, frequency, and duration of acute asthma episodes by avoiding triggers.
Treat acute episodes as they occur.
Have a full quality of life—the ability to participate in all of your daily activities, including work, school, exercise, and recreation—by preventing and managing symptoms.
Emergency treatment
If you have a severe asthma episode (the red zone of your asthma action plan), use medication based on your action plan and talk with a health professional immediately about what to do next. This is especially important if your peak expiratory flow (PEF) does not return to the green zone or stays within the yellow zone after taking medication. You may have to go to the hospital or an emergency room for treatment. Be sure to tell the emergency staff if you are pregnant.

At the hospital, you will probably receive inhaled beta2-agonists and corticosteroids. You may be given oxygen therapy to help you breathe. Your lung function and condition will be assessed. Depending on your response, further treatment in the emergency room or a stay in the hospital may be necessary.

Some people are at increased risk of death from asthma, such as people who have been admitted to an intensive care unit for asthma or who have needed a breathing tube (intubation) for asthma. These people need to seek medical care early when they have symptoms.

Medical checkups
You need to monitor your asthma and have regular checkups to keep it under control and to ensure correct treatment. The frequency of checkups depends on how your asthma is classified. Checkups are recommended:

About every 6 to 12 months for people with mild intermittent or mild persistent asthma that has been under control for at least 3 months.
Every 3 to 4 months for those with moderate persistent asthma.
Every 1 to 2 months for people with uncontrolled or severe persistent asthma.
Every month if you are pregnant.
During checkups, your health professional will ask whether your symptoms and peak expiratory flow have held steady, improved, or become worse, and about asthma episodes during exercise or at night. You track this information in an asthma diary. You may be asked to bring your peak expiratory flow meter to an appointment so your health professional can see how you use it.

Initial treatment
There are many components to managing asthma. After your diagnosis, your health professional may only discuss the components you need to know immediately. These include:

Oral or injected corticosteroids (systemic corticosteroids). These medications may be used to get your asthma under control before you start taking daily medication. In the future, you also may take oral or injected corticosteroids to treat any sudden and severe symptoms, such as shortness of breath (acute asthma episodes). Oral corticosteroids are used more than injected corticosteroids. Systemic corticosteroids include prednisone and dexamethasone.
Inhaled corticosteroids. These are the preferred medications for long-term treatment of asthma. They reduce the inflammation of your airways, and you take them every day to keep asthma under control and to prevent asthma episodes. Inhaled corticosteroids include beclomethasone dipropionate, triamcinolone acetonide, fluticasone propionate, budesonide, and flunisolide.
Short-acting beta2-agonists. These medications are used for acute asthma episodes. They relax the airways, allowing you to breathe easier. Short-acting beta2-agonists include albuterol and pirbuterol.
Basic education about asthma. The more you know about asthma, the more likely it is you will control symptoms and reduce the risk of acute asthma episodes. Studies show that adults who learn about asthma reduce their risk of hospital admissions, unscheduled visits to their health professional, and lost time from work. 16 Keep in mind that even severe asthma can be controlled, and cases where the condition cannot be controlled are unusual.
Instruction on how to use a metered-dose inhaler (MDI). An MDI delivers inhaled medications directly to the lungs. If you use your inhaler correctly, you can control your symptoms and avoid acute asthma episodes that can send you to the emergency room. Most health professionals recommend using a spacer with an MDI. For more information, see:
Using a metered-dose inhaler.
Your short-term goal is to control your current symptoms. Long-term, your goal is to prevent symptoms so that asthma does not impact your daily activities.

Special considerations in treating asthma include:

Managing asthma during pregnancy. If a woman had asthma before becoming pregnant, her symptoms may become better or worse during pregnancy. Pregnant women whose asthma is not well controlled may be at risk for a number of complications.
Managing asthma in older adults. Older adults tend to have worse asthma symptoms and a higher risk of death from asthma than younger people. They may also have one or more other health conditions or take other medications that can make asthma symptoms worse.
Managing exercise-induced asthma. Exercise often causes an acute asthma episode. Steps you can take to reduce the risk of this include using medication immediately before exercising.
Managing asthma before surgery. People with moderate to severe asthma are at higher risk of developing problems during and after surgery than people who do not have asthma.
Ongoing treatment
After your initial treatment for asthma, it is important to learn more about the condition and develop an overall plan to manage the disease. You and your health professional will work together to do this. Because asthma develops from a complex interaction of genetics, environmental factors, and the reaction of the immune system, no one management plan is effective for everyone.

Asthma management consists of:

A daily asthma treatment plan. A daily asthma treatment plan outlines in writing how to treat inflammation in your lungs. The plan helps you prevent or slow the development of the long-term effects of asthma and tells you which medications to take every day. A daily treatment plan may include an asthma diary where you record your peak expiratory flow (PEF), symptoms, triggers, and quick-relief medication used for acute asthma episodes. This valuable tool helps you and your health professional manage your asthma. A daily asthma treatment plan is often combined with an asthma action plan.
An asthma action plan. An asthma action plan contains directions to treat acute asthma episodes at home. It helps you identify triggers that can be changed or avoided, be aware of your symptoms, and know how to make quick decisions about medication and treatment. See an example of an asthma action plan (What is a PDF document?). For more information, see:
Using daily asthma treatment and action plans.
Monitoring peak expiratory flow. It is easy to underestimate the severity of your symptoms. You may not notice them until your lungs are functioning at 50% of your personal best peak expiratory flow (PEF). Measuring PEF is a way to keep track of asthma symptoms at home; it can help you know when your lung function is becoming worse before it drops to a dangerously low level. You can do this with a peak flow meter. For more information, see:
Monitoring peak flow.
A plan to deal with factors that can make asthma worse (triggers). Being around triggers increases symptoms. Try to avoid situations that expose you to irritants (such as smoke or air pollution) or to substances (such as animal dander) to which you may be allergic. If substances at work (occupational asthma) are causing your asthma or making it worse, you may have to change jobs. See information on:
Identifying asthma triggers.
A plan to treat other health problems. If you also have other health problems, such as inflammation and infection of the sinuses (sinusitis) or gastroesophageal reflux disease (GERD), you will need treatment for those conditions.
Using your prescribed medications correctly. Your health professional may adjust your medications depending on how well your asthma is controlled. Medications include:
Inhaled corticosteroids. These are the preferred medications for long-term treatment of asthma. Inhaled corticosteroids include beclomethasone dipropionate, triamcinolone acetonide, fluticasone propionate, budesonide, and flunisolide.
Long-acting beta2-agonists (such as salmeterol and formoterol), which are sometimes used along with inhaled corticosteroids.
Oral or injected corticosteroids (systemic corticosteroids) to treat any sudden and severe symptoms, such as shortness of breath (acute asthma episodes). Oral corticosteroids are used more than injected corticosteroids. Systemic corticosteroids include prednisone and dexamethasone.
Quick-relief medication, such as short-acting beta2-agonists and anticholinergics (ipratropium) for acute asthma episodes. If you are using quick-relief medication more than 2 times a week, you probably need long-term treatment. Overuse of quick-relief medication can be harmful.
Education. Continue to learn about asthma. This questionnaire can help you determine what you already know about asthma and what you may need to discuss with your health professional.
If you have persistent asthma and react to allergens, you may need to have skin testing for allergies. Allergy shots (immunotherapy) may in rare cases be helpful. For more information, see:

Should I take allergy shots (immunotherapy) for asthma?
You can expect to live a normal life if you control symptoms by following your daily treatment and action plans. If asthma symptoms are not controlled, the disease may progress, permanently damaging the bronchial tubes that carry air to the lungs.

Special considerations in treating asthma include:

Managing asthma during pregnancy. If a woman had asthma before becoming pregnant, her symptoms may become better or worse during pregnancy. Pregnant women whose asthma is not well controlled may be at risk for a number of complications.
Managing asthma in older adults. Older adults tend to have worse asthma symptoms and a higher risk of death from asthma than younger people. They may also have one or more other health conditions or be taking other medications that can make asthma symptoms worse.
Managing exercise-induced asthma. Exercise often causes an acute asthma episode. Steps you can take to reduce the risk of this include using medication immediately before exercising.
Managing asthma before surgery. People with moderate to severe asthma are at higher risk of developing problems during and after surgery than people who do not have asthma.
Treatment if the condition gets worse
If your asthma is not improving:

Talk to your health professional to determine whether you have a condition with symptoms similar to asthma, such as sinusitis.
Review your asthma diary to see if you have a new or previously unidentified trigger, such as animal dander. Talk to your health professional about how best to avoid triggers.
Review your medications, to be sure you are using the right ones and using them correctly.
Review your asthma plans, to be sure they are suitable for your condition.
If your medication is not working to control airway inflammation, your health professional will first check to see whether you are using the inhaler correctly. If you are using it correctly, your health professional may increase the dosage, switch to another medication, or add a medication to the existing treatment.

Your health professional may suggest you try other medications. These include:

Mast cell stabilizers, such as cromolyn sodium or nedocromil.
Theophylline, such as Theo-Dur, Slo-bid, Uniphyl, or Uni-Dur.
Leukotriene pathway modifiers, such as zafirlukast, zileuton, or montelukast sodium.
If your asthma does not improve with treatment, you may require more intensive treatment, including larger doses of corticosteroids or other medications. An asthma specialist generally prescribes these medications.

If you have persistent asthma and react to allergens, you may need to have skin testing for allergies. Allergy shots (immunotherapy) may in rare cases be helpful. For more information, see:

Should I take allergy shots (immunotherapy) for asthma?
What to think about
If you have been diagnosed with asthma, it is important that you treat it. You may feel good most of the time—so much so that you find it hard to believe you have a long-lasting condition. But all asthma—even mild asthma—may result in changes to your airways that speed up and worsen the natural decrease in lung function that occurs as we age. 3

Prevention
While there is no certain way to prevent asthma, you can take steps to reduce airway inflammation and the likelihood of acute asthma episodes.

The evidence concerning breast-feeding and the risk of a child developing asthma is conflicting. One study has found that feeding an infant breast milk exclusively in the first 9 months of life may reduce the child's risk of developing asthma. 10 However, other studies indicate no protective effect and that breast-feeding may increase the risk for developing asthma. 11

Preventing asthma episodes
The main focus of prevention is on reducing the number, length, and severity of asthma episodes. By avoiding triggers, you may be able to prevent or reduce the severity of symptoms. For more information on identifying your triggers, see:

Identifying asthma triggers.
Following is information about specific triggers. If you know that any of these cause your symptoms to become worse, you should avoid or limit your exposure to them.

Irritants in the air
Common irritants in the air, such as tobacco smoke and air pollution, can trigger asthma episodes in some people.

Controlling tobacco smoke is important because it is a major cause of asthma symptoms in children and adults. If you have asthma, try to avoid being around others who are smoking, and ask people not to smoke in your house.

Pregnant women who smoke cigarettes during pregnancy increase the risk of wheezing in their newborn babies.
Exposing young children to secondhand tobacco smoke increases the likelihood that they will develop asthma and increases the severity of symptoms if they already have the disease.
Consider staying inside when air pollution levels are high. Other irritants in the air (such as fumes from gas, oil, or kerosene or wood-burning stoves) can sometimes irritate the bronchial tubes, which carry air to the lungs. Avoiding these may decrease your asthma symptoms.

Allergens
If you are allergic to certain substances (allergens), you may decrease your asthma symptoms by limiting exposure to them. However, experts have not been able to determine who will benefit, how much someone may benefit, and whether the benefits of avoiding an allergen are worth the cost. 17

To help reduce your exposure to allergens:

Control cockroaches, especially if you live in an inner-city area or the southern part of the United States.
Control dust mites. House dust mites have been linked with the development of asthma in children. 1
Control animal dander and pet allergens. Taking steps such as keeping your pet out of your bedroom and dusting and vacuuming often may help your asthma.
Control indoor mold, especially if you live in an area with high humidity.
It also may be necessary to avoid exposure to other types of triggers that cause asthma symptoms.

Control your exposure to pollens in the air. Check your local weather report or newspaper for pollen counts in your area.
Avoid exercising outdoors in cold weather. The air may irritate your airways. If you are outdoors in cold weather, wear a scarf around your face and breathe through your nose.
Avoid foods that may cause asthma symptoms. Some people have symptoms after eating processed potatoes, shrimp, nuts, and dried fruit, or after drinking beer or wine. These foods and liquids contain sulfites, which may cause asthma symptoms.
Avoid taking aspirin, ibuprofen, or other similar medications if they increase asthma symptoms. Consider using acetaminophen (Tylenol) instead. (Do not give aspirin to anyone younger than 20 because of the risk of Reye's syndrome.)
People with asthma and their family members should have an annual flu shot (influenza vaccine).

Living With Asthma
You can control the impact asthma has on your life by following your asthma plans consistently. A management plan can reduce inflammation to prevent long-term damage to your lungs and decrease the severity, frequency, and duration of acute asthma episodes. Following your plan may be difficult because of its many different factors.

To help yourself remain consistent in following your asthma plans:

Educate yourself about asthma. By doing so, you can learn to control symptoms and reduce the risk of developing acute asthma episodes. Studies show that adults who learn about asthma reduce their risk of hospital admissions, unscheduled visits to their health professional, and lost time from work. 16 This questionnaire can help you determine what you already know about asthma and what you may need to discuss with your health professional.
Understand your barriers and solutions. What may prevent you from following your plan? These may be physical barriers, such as living far from your health professional or pharmacy, or emotional barriers, such as having undiscussed fears about the condition or unrealistic expectations. Discuss your barriers with your health professional, and work to find solutions.
Develop goals that relate to your quality of life. Being able to measure your success gives you greater motivation to follow asthma plans consistently. Decide what you want to be able to do. Have symptom-free nights? Be able to exercise on a regular basis? Feel secure in knowing you can deal with an acute asthma episode? Work with your health professional to see if your goals are realistic and how to meet them.
Your asthma plans generally consist of the following:

Seeing your health professional regularly to monitor your asthma. The frequency of checkups depends on how your asthma is classified. Checkups are recommended about every 6 to 12 months for mild intermittent or mild persistent asthma that has been under control for at least 3 months; every 3 to 4 months for moderate persistent asthma; and every 1 to 2 months for uncontrolled or severe persistent asthma. Bring your asthma plans to appointments.
Following your daily asthma treatment plan. The plan helps you prevent or slow development of the long-term effects of asthma and describes which medications to take every day. A daily treatment plan also may include an asthma diary where you record your peak expiratory flow, symptoms, triggers, and use of quick-relief medication for acute asthma episodes. This valuable tool helps you and your health professional manage your asthma. A daily asthma treatment plan is often combined with an asthma action plan.
Following your asthma action plan. This contains directions for the management of acute asthma episodes at home. It helps you better control asthma episodes by being aware of symptoms and knowing how to make quick decisions about medication and treatment. See an example of an asthma action plan (What is a PDF document?). For more information on these tools, see:
Using daily asthma treatment and action plans.
To effectively manage your asthma and use your daily asthma treatment and action plans, you will have to know how to monitor your peak airflow, identify asthma triggers, and take your asthma medication correctly.

Monitoring peak expiratory flow
People often underestimate the severity of their symptoms. They may not notice symptoms until their lungs are functioning at 50% of their personal best measurement. Measuring peak expiratory flow (PEF) is a way to keep track of asthma symptoms at home; it can help you know when your lung function is becoming worse before it drops to a dangerously low level. You can do this with a peak flow meter. For more information, see:

Monitoring peak flow.
Identifying asthma triggers
A trigger is anything that can lead to an acute asthma episode. A trigger can be:

Irritants in the air, such as tobacco smoke or air pollution.
Substances to which you are allergic (allergens), such as pollen or animal dander.
Other factors, such as a viral infection, exercise, stress, or dry, cold air.
Avoiding triggers will help decrease the chance of having an acute asthma episode and, in the case of allergens, will help control inflammation in the bronchial tubes, which carry air to the lungs. For more information, see:

Identifying asthma triggers.
If you have asthma triggered by an allergen, taking antihistamine medication may help you manage the allergy and thus limit its effect on your asthma.

Taking your asthma medication
Taking medications is an important part of asthma treatment. But because you often take many different medications, it can be difficult to remember to take them. To help yourself remember, understand the reasons people don't take their asthma medications, and then find ways to overcome those obstacles, such as taping notes to the refrigerator.

Most medications for asthma are inhaled. Inhaled medications give a specific dose of the medication directly to the bronchial tubes, avoiding or decreasing the effects of the medication on the rest of the body. Delivery systems for inhaled medications include metered-dose and dry powder inhalers and nebulizers. A metered-dose inhaler is used most often.

Most health professionals recommend that everyone who uses a metered-dose inhaler (MDI) also use a spacer, which is attached to the MDI. A spacer may deliver the medication to your lungs better than an inhaler alone, and for many people is easier to use than an MDI alone. Using a spacer with inhaled corticosteroids can help reduce their side effects and result in less use of oral corticosteroids.

It is important to keep track of the inhaler doses and discard the inhaler when you have used the number of doses indicated on the package labeling. This not only prevents you from having an empty inhaler when you need medication, but it also prevents you from inhaling only propellant after the medication has run out. For more information, see:

Using a metered-dose inhaler.
Travel
Most people with asthma can travel freely. However, if you travel to remote areas and participate in intensive physical activity, such as long hikes, you may be at increased risk for an acute asthma episode in an area where emergency help may be difficult to find. One study has identified risk factors for acute episodes while traveling. These include using inhaled beta2-agonists 3 or more times a week in the year before you travel and performing intensive physical activity during travel. 18

When traveling, always bring your medication with you, carry the prescription for it, and use it as prescribed.

Give teens extra attention
Teens who have asthma may view the disease as cutting into their independence and setting them apart from their peers. Parents and other adults should offer support and encouragement to help teens stick with a treatment program. It's important to:

Help your teen remember that asthma is only one part of life.
Allow your teen to meet with the health professional alone. This will encourage your teen to become involved in his or her care.
Work out a daily management plan that allows a teen to continue daily activities, especially sports; exercise is important for maintaining strong lungs and overall health.
Talk to your teen about the dangers of smoking and drug use.
Encourage your teen to meet others who have asthma so they can support each other.
Medications
Medication does not cure asthma. However, it is an important part of managing the condition. Medications for asthma treatment are used to:

Prevent and control the underlying airway inflammation, to minimize long-term lung damage.
Decrease the severity, frequency, and duration of acute asthma episodes.
Treat the episodes as they occur.
Asthma medications are divided into two groups: those for prevention and long-term control of inflammation and those that provide quick relief for acute asthma episodes. Most people with persistent asthma need to use long-term medications daily. Quick-relief medications are used as needed and provide rapid relief of symptoms during asthma episodes.

Because asthma develops from a complex interaction of genetics, environmental factors, and the reaction of the immune system, different people may use different medications and doses of medications. Special consideration may be necessary if you:

Are pregnant. If a woman had asthma before becoming pregnant, her symptoms may become better or worse during pregnancy. Pregnant women whose asthma is not well controlled may be at risk for a number of complications.
Are an older adult. Older adults tend to have worse asthma symptoms and a higher risk of death from asthma than younger people. They may also have one or more other health conditions or take other medications that can make asthma symptoms worse.
Have exercise-induced asthma. Exercise often causes an acute asthma episode. Steps you can take to reduce the risk of this include using medication immediately before exercising.
Need surgery. People with moderate to severe asthma are at higher risk than people who do not have asthma of developing problems during and after surgery.
Medication delivery
Most medications for asthma are inhaled. Inhaled medications are used because a specific dose of the medication can be given directly to the bronchial tubes. Different types of delivery systems may be used to do this, and one type may be more suitable for certain people or age groups than another. Delivery systems include metered-dose and dry powder inhalers and nebulizers. A metered-dose inhaler is used most often.

Most health professionals recommend that everyone who uses a metered-dose inhaler (MDI) also use a spacer, which is attached to the MDI. A spacer may deliver the medication to your lungs better than an inhaler alone, and for many people is easier to use than an MDI alone. Using a spacer with inhaled corticosteroids can help reduce their side effects and result in less use of oral corticosteroids.

It is important to keep track of the inhaler doses and discard the inhaler when you have used the number of doses indicated on the package labeling. This not only prevents you from having an empty inhaler when you need medication, but it also prevents you from inhaling only propellant after the medication has run out. For more information, see:

Using a metered-dose inhaler.
Medication Choices
The most important asthma medications are:

Inhaled corticosteroids. These are the preferred medications for long-term treatment of asthma. They reduce inflammation of your airways and are taken every day to keep asthma under control and to prevent sudden and severe symptoms (acute asthma episodes). Inhaled corticosteroids include beclomethasone dipropionate, triamcinolone acetonide, fluticasone propionate, budesonide, and flunisolide.
Oral or injected corticosteroids (systemic corticosteroids) to get your asthma under control before you start taking daily medication. You may also need these medications to treat acute asthma episodes. Oral corticosteroids are used much more than injected corticosteroids. Systemic corticosteroids include prednisone and dexamethasone.
Short-acting beta2-agonists for acute asthma episodes. They relax the airways, allowing you to breathe easier. These medications include albuterol and pirbuterol.
Long-term medications sometimes used alone or with other medications for daily treatment include:

Mast cell stabilizers (such as cromolyn sodium or nedocromil).
Theophylline, such as Theo-Dur, Slo-bid, Uniphyl, or Uni-Dur.
Leukotriene pathway modifiers (such as zafirlukast, zileuton, or montelukast).
Long-acting beta2-agonists (such as salmeterol and formoterol). They are sometimes combined as a single medication with inhaled corticosteroids.
Other medications may be given in some cases.

Anticholinergics (such as ipratropium) and magnesium sulfate sometimes are used in the emergency room during severe acute asthma episodes.
Other medications, such as cyclosporine A, omalizumab, methotrexate, and gold, may be used if asthma does not improve with treatment. An asthma specialist generally prescribes these medications.
See a chart of asthma medications for teens and adults.

What to Think About
Medications are usually added one at a time to keep the number of medications low. The dosage of each medication should correspond to the severity of your asthma. Generally, your health professional will start you at a higher dose within your asthma classification so that the inflammation is immediately controlled. After symptoms improve, the dose of the last medication added is reduced to the lowest possible dose for maintenance. This is known as step-down care. Step-down care is believed to be a better way to control inflammation in the bronchial tubes than starting at lower doses of medication and increasing the medication if the dose is not enough. 19

Because quick-relief medication quickly reduces symptoms, people sometimes overuse these medications instead of using the slower-acting long-term medications. However, overuse of quick-relief medications has harmful effects, such as decreasing the future effectiveness of these medications. Overuse of quick-relief medication is also an indication that asthma symptoms are not being controlled. You should talk with your health professional immediately.

You may have to take many different medications daily to manage your asthma. It can be difficult to remember when to take your medication and which medication to take. To help yourself remember, understand the reasons people don't take their asthma medications, and then find ways to overcome those obstacles, such as taping notes to the refrigerator to remind yourself.

Using the fewest medications possible is important for older people because they may be taking medications for other conditions. Tell your health professional about all the medications you are taking, so he or she can select asthma medications that won't interfere with other medicines.

Some people only have symptoms during certain times of the year (seasonal asthma). If you know when you will most likely have symptoms, start using a medication to decrease inflammation before the symptoms start.

Other Treatment
Allergy shots (immunotherapy) are used for people who have asthma symptoms when they are around substances to which they are allergic (allergens). Allergy shots have been shown to reduce asthma symptoms and the need for medications in some people. 20 For more information, see:

Should I take allergy shots (immunotherapy) for allergic asthma?
Allergy shots are similar to vaccinations because they contain small doses of one or more substances to which you are allergic so that your body can become less responsive to them over time.

Complementary medicine
Alternative treatments such as homeopathy, acupuncture, and breathing exercises have been used to treat asthma. The research on these treatments is limited. A review of research shows: 21

No evidence to support using homeopathy, air ionizers, manual therapy, or acupuncture for asthma.
A possible but not clearly established role for using antioxidants.
That breathing exercises practiced in yoga may improve lung function.
Some people have used ephedra—a stimulant sold for weight loss and sports performance—to try to treat asthma symptoms. However, the U.S. Food and Drug Administration (FDA) has banned the sale of this dietary supplement because of concerns about safety. Ephedra, also called ma huang, has been linked to heart attacks, strokes, and some deaths.

For more information on alternative treatments, see the topic Complementary Medicine.

Other Places To Get Help
Organizations
American Academy of Allergy, Asthma, and Immunology
555 East Wells Street
Suite 1100
Milwaukee, WI 53202-3823
Phone: (414) 272-6071
1-800-822-2762
E-mail: info@aaaai.org (For general questions; the AAAAI cannot answer individual questions relating to the diagnosis or treatment of allergies.)
Web Address: http://www.aaaai.org

This organization publishes an excellent series of pamphlets on allergies, asthma, and related information. It also provides physician referrals.



Asthma and Allergy Foundation of America (AAFA)
1233 20th Street, N.W.
Suite 402
Washington, DC 20036
Phone: (202) 466-7643
1-800-7-ASTHMA (1-800-727-8462)
Fax: (202) 466-8940
E-mail: info@aafa.org
Web Address: http://www.aafa.org

The Asthma and Allergy Foundation of America (AAFA) provides educational materials to the public, the medical profession, and health workers. It maintains a library and speakers' bureau and publishes a monthly newsletter and educational pamphlets. It has 14 local chapters.


Related Information
Allergic Rhinitis
Asthma in Children
Atopic Dermatitis
Chronic Obstructive Pulmonary Disease (COPD)
References
Citations
Bush RK (2002). Environmental controls on the management of allergic asthma. Medical Clinics of North America, 86(3): 973–989.

McGeady SJ (2004). Immunocompetence and allergy. Pediatrics, 113(4): 1107–1113.

Jarjour NN, Kelly EAB (2002). Pathogenesis of asthma. Medical Clinics of North America, 86(3): 926–936.

Weiss ST (2002). Does asthma progress to chronic obstructive pulmonary disease? In SL Johnston, ST Holgate, eds., Asthma Critical Debates, pp. 99–115. London: Blackwell Science.

National Asthma Education Program (1993). Report of the Working Group on Asthma and Pregnancy: Management of Asthma During Pregnancy (NIH Publication No. 93-3279). Available online: http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg.txt.

Guilbert T, Krawiec M (2003). Natural history of asthma. In Pediatric Clinics of North America, 50(3): 524–538.

Eichenfield LF, et al. (2003). Atopic dermatitis and asthma: Parallels in the evolution of treatment. Pediatrics, 111(3): 608–616.

Staton GW Jr, Ingram RH Jr (2002). Asthma. In DC Dale, DD Federman, eds., Scientific American Medicine, section 14, chap. 2. New York: WebMD.

Etzel RA (2003). How environmental exposures influence the development and exacerbation of asthma. Pediatrics, 112(1): 233–239.

Goldbloom R (2001). More on breast-feeding and asthma—A population-based study. Pediatric Notes, 25(48): 192.

Sears MR, et al. (2002). Long-term relation between breast-feeding and development of atopy and asthma in children and young adults: A longitudinal study. Lancet, 360(9337): 901–907.

Bacharier LB, Strunk RC (2003). Pets and childhood asthma—How should the pediatrician respond to new information that pets may prevent asthma? Pediatrics, 112(4): 974–976.