Breathing Better: Action Plans Keep Asthma In Check
During the mid-1980s, Sandra Fusco-Walker's life was filled with
sleepless nights, ruined vacations, emergency room visits, and
her children's frequent school absences. Two of her three children--all
under age 6 at the time--had asthma.
"I was always worried about when the next bad thing would happen,"
says the Kinnelon, N.J., resident. "But that was before we had
The "plan" was an asthma action plan that guided her on how to
track her children's symptoms, monitor their breathing, and give
them medication. "A plan tells you what to do and when," she says.
"Without it, asthma is out of control, and that's when the disease
wreaks havoc on your life."
Asthma causes the airways to be inflamed or swollen, and the
surrounding muscles are tight. When people with asthma react to
various triggers, such as dust, pollen or smoke, their airways
become narrow, which causes labored breathing, wheezing, chest
tightness, or coughing. About 15 million people in the United
States have asthma and almost 5 million are children, according
to the National Heart, Lung, and Blood Institute (NHLBI). Every
year, asthma causes roughly 2 million emergency room visits, up
to 500,000 hospitalizations, and 4,500 deaths.
Fusco-Walker says she learned to control asthma after she followed
her doctor's advice and called a nonprofit organization called
Allergy & Asthma Network Mothers of Asthmatics (AANMA). The woman
who answered the phone was Nancy Sander, who founded the organization
in 1985 after facing challenges in dealing with her own daughter's
asthma. Fusco-Walker says, "Nancy assured me that I wasn't going
With support and advice from AANMA, Fusco-Walker learned to look
for patterns in her children's illness. For example, her kids
got sick every time they visited her mother, and her mother smoked.
Her oldest daughter had an asthma attack when she visited their
horse barn. Fusco-Walker also learned to spot early warning signs
of trouble. "I noticed that one of my daughters rubbed her nose
when breathing became difficult," she says. "If I saw her rubbing
her nose, I knew to get the peak flow meter." A peak flow meter
is a small tool that measures how fast air moves out of the airways.
Fusco-Walker attributes the success of her asthma action plan
to the regular use of a peak flow meter.
By the time Fusco-Walker's youngest child was diagnosed with
asthma at age 5, her family had a much better understanding of
the disease. Shannon, who is now 16, Jared, 19, and Morgan, 21,
grew up learning how to use their asthma medicine. "They know
when to use their inhalers, they know when they need refills,
and they know when they need to take medication before doing an
activity," she says. They also grew up participating in just about
any activity they wanted to, including football, swimming, soccer,
Experts say most people with asthma can live a normal, active
life. What it takes is avoiding the triggers that make your asthma
worse, keeping track of your symptoms, and sticking to an effective
treatment regimen. Many people with asthma need short-term medicine
for when they experience symptoms, and also long-term daily medicine
that reduces inflammation in the airways and helps prevent asthma
"I'll hear people say they skipped their medication because they
haven't been coughing that much," says Richard L. Wasserman, M.D.,
Ph.D., clinical associate professor of pediatrics at the University
of Texas Southwestern Medical School. "But I tell them they probably
wouldn't have coughed at all if they kept to the regimen." He
says it's important to understand that asthma is a chronic inflammatory
lung disease. "Like high blood pressure, asthma is there all the
time even when there are no symptoms."
The first step in controlling asthma is an accurate diagnosis.
Fusco-Walker says doctors diagnosed her kids with all kinds of
illnesses before she knew the problem was asthma. According to
Kathleen Sheerin, M.D., an asthma specialist with the Atlanta
Allergy and Asthma Clinic, this is a common problem, and both
consumers and doctors play a role. "Some people are scared of
the word 'asthma' because they only think of an emergency room
scene on TV," she says. "I tell them there are a whole range of
asthma symptoms, and the disease doesn't have to be scary if it's
Sheerin says, "Doctors may call asthma other things like wheezy
bronchitis or reactive airway disease." Asthma symptoms vary by
individual, and the disease can look like other lung diseases.
Also, asthma symptoms usually surface before age 6, but it can
be difficult to establish a firm diagnosis in young children.
"Babies up to age 2 or 3 may wheeze only when they get a cold,
and we call them 'transient wheezers,'" Sheerin says. "For other
kids, the wheezing continues as they grow." These children, often
considered "persistent wheezers," have chronic asthma. (Also
see "What Causes Asthma?")
"What we do is look for factors that make it more likely that
a child's asthma will persist," Sheerin says. These factors include
having a family history of asthma. Asthma is also more likely
to persist if symptoms aren't only associated with a cold, but
if there are also symptoms associated with other triggers such
as smoke. People with asthma that persists also tend to experience
wheezing that occurs at night, with exercise, or with seasonal
changes. They also may have other allergic symptoms, such as allergic
rhinitis or eczema, an itchy skin condition.
Sheerin participates in a state education program called Breathe
Georgia, which uses the slogan "Call it what it is" to encourage
doctors to accurately diagnose asthma. "You have to know that
you have it in order to understand it and manage it," she says.
"And an earlier diagnosis usually means better health outcomes."
The older someone is, the easier asthma is to diagnose. Doctors
rely on a combination of a medical history, response to medications,
and lung function tests. Such tests are generally hard to use
in children under 6. One common lung function test, spirometry,
involves inhaling and exhaling through a tube for several seconds.
In some cases, allergy tests are performed to help determine asthma
Doctors determine whether asthma is intermittent (occurring from
time to time), or persistent, defined as having symptoms at least
twice a week during the day or twice a month during the night.
Asthma that is considered persistent is further categorized as
mild, moderate or severe. Fusco-Walker, who was diagnosed with
mild asthma in her thirties, says these categories help doctors
determine an appropriate treatment plan. "But remember that regardless
of the type, you still have asthma and it is still a life-threatening
illness," she says. "Some people hear the word 'mild' and think
they don't have to worry about it. But they do."
Though asthma can't be cured, it typically can be treated, and
scientists are currently studying whether untreated asthma causes
a permanent change in the airways. As a natural part of aging,
we begin losing lung function in our twenties. Untreated asthma
might further accelerate that loss.
Brian Thomas, 41, a book distributor in New York City, has childhood
memories of vaporizers by the side of his bed. "I remember wheezing
the night away, often with my mother sitting with me," he says.
He noticed some relief from asthma symptoms when he went off to
college in Syracuse, N.Y. But the symptoms returned whenever he
came home to his childhood bedroom. The culprits were dust mites,
tiny bugs that are too small to see. They live on mattresses,
bed linens, carpet, and stuffed animals. When Thomas' parents
removed the carpet from his room, his asthma symptoms improved
In people with asthma,
inflamed airways react to triggers such as smoke, dust,
or pollen. The airways become narrow, making it difficult
(Infographic: FDA/Renée Gordon)
He went about 10 years without problems, but after a bad cold
in 1989, he began wheezing and using an inhaler as needed. In
1990, Thomas had the worst asthma attack of his life when his
roommates began building an addition to their New York apartment.
"They were doing a lot of woodwork, and I noticed some wheezing,"
Thomas says. "I thought I had it under control with my inhaler."
Then his roommates painted, and that's when things got much worse.
"My chest felt tight and burned, and I just couldn't catch my
breath," he says. Luckily, his landlord got a cab to take him
to the emergency room at Beth Israel Hospital, and doctors were
able to quickly get Thomas' asthma under control. But it was the
longest cab ride of his life. "I thought I would die right there
on the bridge" that connects the Williamsburg section of Brooklyn
to the Lower East Side of Manhattan.
Common asthma triggers include dust, pollen, cockroaches, cold
air, smoke, and other strong odors, such as paint, cleaning fluids,
perfume, hair spray, and powder. For some people, the problem
is animal dander, flakes of skin and dried saliva from furry or
feathered animals. For others, asthma can be triggered by medication,
such as aspirin, or sulfites, preservatives used in food.
Stress is thought to be a trigger of asthma. Stress can create
strong physiologic reactions that lead to airway constriction.
Stress can also alter the immune system, which can, in turn, increase
the likelihood of an asthma attack in people with asthma. According
to the Centers for Disease Control and Prevention (CDC), after
the Sept. 11, 2001, attacks on the World Trade Center, some adults
in Manhattan reported an increase in their asthma symptoms due
to stress, as well as from smoke and debris.
It's not always possible to avoid triggers, but experts suggest
that you can track what causes problems and limit exposure as
much as possible. Also, talk with your doctor about preventive
steps you can take. When Thomas cleans up, for example, he wears
a dust mask, available at many hardware stores. To get rid of
dust mites, you can encase pillows and mattresses in dust-proof
covers and wash bed linens and stuffed animals in hot water each
The NHLBI recommends keeping furry and feathered pets out of
the home, or at least out of bedrooms, if pets are known to trigger
asthma symptoms. Recent research, however, suggests that children
with high exposure to cat allergens early in life develop an immune
response to cats, reducing the risk for asthma. In the study,
published in the March 10, 2001, issue of The Lancet, Thomas Platts-Mills
and colleagues at the University of Virginia found that exposure
to cats may be protective for some kids but a risk factor for
others. The research suggests you might not have to get rid of
your cat when the baby comes, but if you or your child experience
asthma symptoms because of the cat, the cat should go.
Consult with a doctor about when or how much to increase medications
as a preventive measure, such as before allergy season starts
or if you're traveling to a place where it may be impossible to
know what you will encounter in the way of pollution or environmental
Types of Medication
There are two main categories of asthma drugs: short-term, quick-relief
medications that relieve asthma symptoms, and long-term controller
medications that are used every day by people with persistent
asthma, even when they feel fine.
Wasserman, who works with The Dallas Asthma Consortium, says
the organization advises consumers with "The Rules of Two": If
you take your quick-relief inhaler more than two times a week,
if you wake up with asthma more than two times a month, or if
you refill your quick-relief inhaler more than two times a year,
the group recommends that two medicines for asthma are needed
and that you should talk with your doctor about a long-term controller.
Short-term reliever medication refers to short-acting inhaled
beta-2 agonists such as albuterol and pirbuterol. Beta-2 agonists,
also known as bronchodilators, relax the muscles surrounding the
airways. In addition, systemic corticosteroids, such as prednisone
and prednisolone, are drugs that help relieve the inflammation
or swelling in the airway. Taken in tablet or syrup form, they
are often used to treat severe asthma attacks.
As for long-term controller medication, inhaled corticosteroids
are the most consistently effective. Other long-term controller
medications include long-acting beta-agonists, which are used
in addition to inhaled steroids. Examples of long-acting beta-agonists
are salmeterol and formoterol. (For recent news about salmeterol,
see "Safety Study on Serevent.")
Cromolyn sodium, nedocromil, and methylxanthines are also in the
controller anti-inflammatory category. Another class of long-term
controller drugs is called anti-leukotriene medication, and examples
include Singulair (montelukast) and Accolate (zafirlukast). These
drugs block the action of chemicals called leukotrienes, which
are involved in the development of asthma.
In June 2003, the FDA approved Xolair (omalizumab), the first
biotechnology product to treat people 12 years and older who have
moderate-to-severe allergy-related asthma. The product, which
is given as an injection under the skin, is a second-line treatment,
recommended only after first-line treatments have failed.
National guidelines on managing asthma now recommend that inhaled
corticosteroids are the preferred first-line treatment for people
of all ages with persistent asthma. (See
"NIH Updates Asthma Guidelines.") Developed by an expert panel
of the National Asthma Education and Prevention Program (NAEPP),
the guidelines also recommend that if inhaled corticosteroids
are not achieving optimal control, dual-control therapy should
be used. "We're advising doctors that if inhaled corticosteroids
are not proving effective, before increasing the dose, add a long-acting
beta-2 agonist," says James Kiley, Ph.D., director of the Division
of Lung Diseases at the NHLBI.
Badrul Chowdhury, M.D., Ph.D., acting director of the FDA's Division
of Pulmonary and Allergy Drug Products, says significant advances
in asthma drugs include the approval of Advair (fluticasone and
salmeterol) in 2000. "This drug might improve adherence because
you don't have to go between two drugs," Chowdhury says. It's
the first drug approved by the FDA that combines an inhaled corticosteroid
and a long-acting bronchodilator in one device, which has a built-in
counter that tracks the number of doses. Chowdhury says also significant
is the recent FDA approval of the inhaled corticosteroid Pulmicort
(budesonide) for children as young as 1 and the approval of Xolair
(omalizmab) in 2003.
Monitoring Symptoms, Using Medicine
Thomas says he felt lucky to survive his bad asthma attack in
New York, but the experience was so traumatic that he took a month
off work and went back home to his parents' house to recover.
"I had panic attacks and a lot of anxiety about having another
attack," he says. His anxiety level eased as he got a better handle
on monitoring and preventing symptoms and using medicine.
Thomas has gone for 10 years without a major asthma attack, and
he attributes that to several factors. He uses a daily long-term
inhaled corticosteroid called Azmacort (triamcinolone acetonide)
to relieve the inflammation that can cause an asthma attack, and
he uses a Ventolin (albuterol) inhaler as needed for short-term
quick relief of acute symptoms. He says that in the weeks before
his bad asthma attack, he was using a quick-relief inhaler several
times a day, even sometimes several times in the same hour. He
now recognizes such use as a sign of trouble.
Thomas avoids known triggers and monitors his breathing with
a peak flow meter. "As a kid, I just dealt with the asthma attacks
as they happened," he says. "Now, I pay attention to what's going
on before it gets bad."
According to the NAEPP Expert Panel Report, peak flow meters
may be most helpful for people with moderate or severe asthma.
A meter reading will tell you your peak flow zones, which are
based on the colors of a traffic light. The green zone signals
that your asthma is in good control, the yellow zone signals caution
and is a sign to use quick-relief medicine to relieve symptoms,
and the red zone signals a medical alert that means you should
contact a doctor. Written plans can be useful for telling you
what kind of medicine to take and how much to take when you're
in each zone.
Inhaled asthma medications are delivered through many different
devices, including metered dose inhalers, dry powder inhalers,
and nebulizers. It's important to get instructions on how to use
each medicine you take, and to have your doctor or nurse check
your technique. To improve effective use of medication for kids
or adults, plastic devices called spacers are often used with
inhalers. Spacers create a space between the inhaler and the person's
mouth to help more medicine get into the lungs. A nebulizer, which
delivers medicine in a fine mist, also is useful for young children.
The issue of using asthma medications in school remains a challenging
area for children and parents. To date, 18 states have laws or
policies allowing children to carry inhalers in schools, according
to AANMA. Many schools require an inhaler to be kept in the nurse's
office because it's a drug. "But if a child is in gym class and
the nurse is three buildings away, that could be a problem," says
Sheerin, the asthma specialist in Atlanta. Experts say the two
best things we can do for children with asthma are to teach them
how to manage their asthma as they grow up, and to share a written
plan from your doctor with the school.
Fusco-Walker, who now works with AANMA as an educator, points
to the American Lung Association's asthma camp program as a good
support system for parents of children with asthma. "It's a great
place for children to learn how to manage their asthma, and parents
can enjoy peace of mind while their children experience summer
camp," she says. Kids participate in regular camp activities like
swimming and biking, and there are trained medical personnel who
teach the kids proper use of medication and other aspects of asthma
Sheerin says all kids should be able to sleep, play and learn.
"If parents are up at night, if kids can't play, or if they are
missing a lot of school because of asthma, then the asthma management
plan is not right."
NIH Updates Asthma Guidelines
When it comes to managing asthma, adherence has two parts. "The
first is that doctors use the guidelines on asthma management,
and the second is that people with asthma follow their plans,"
says William Busse, M.D., professor of medicine in allergy and
immunology at the University of Wisconsin Medical School. Busse
is also chairman of the National Asthma Education and Prevention
Program Expert Panel, which updated the Guidelines for the Diagnosis
and Management of Asthma in June 2002.
Targeted to doctors, these guidelines were first published in
1991 and then revised in 1997. An update in June 2002 reflects
scientific advances over the last five years. Here are highlights
from the most recent update:
Inhaled corticosteroids, which treat chronic inflammation of
the airways, are safe, effective, and preferred first-line therapy
for children and adults with persistent asthma.
Inhaled corticosteroids are safe at recommended dosages. There
has been concern about slowed growth in children due to use of
inhaled corticosteroids. Research shows that this potential risk
is temporary and possibly reversible. Nonetheless, doctors should
monitor children's growth while giving inhaled corticosteroids,
because slowing of growth is a good marker for side effects in
other organs in the body. The expert panel also found that other
concerns associated with use of corticosteroids, such as reduced
bone mineral density, suppressed adrenal function, and increased
risk of cataracts, are not considered significant risks for children.
The risk-benefit assessment favors the use of inhaled corticosteroids
for the treatment of persistent asthma.
When inhaled corticosteroids are not achieving optimal effectiveness,
doctors should add a long-acting beta-2 agonist. These types of
drugs, also known as bronchodilators, relax the muscles surrounding
Asthma Death Rates Higher for Minorities
Black Americans have only a slightly higher prevalence rate of
asthma than whites (8.5 percent versus 7.1 percent), but blacks
are three times more likely to die or be hospitalized because
of the disease. According to the Centers for Disease Control and
Prevention, while asthma mortality rates have gone down overall
since 1995, racial disparities remain.
Floyd Malveaux, M.D., dean of Howard University's College of
Medicine in Washington, D.C., says the reasons are complex. "We
know that this is one of many diseases in which minorities and
underserved populations are disproportionately affected," he says.
"A lot of the disparities are related to poverty."
Malveaux says lack of access to care plays a large role. "It's
not just about having health insurance," he says, "but also about
whether there is access to transportation and knowing how to use
the health care system. There may be no access to asthma specialists,
perhaps because of limitations in managed care. So then what you
have is a reactive situation and a lot of emergency room visits
versus a proactive situation that focuses on prevention."
He also points out that when you're living in poverty you can't
control the environment like you may want to. "I think of an area
in Detroit where big diesel trucks come across from Canada," he
says. "You can see the line of trucks emitting diesel fuel in
a poor neighborhood, and the people who live there can't control
Other factors may be the challenge of paying for asthma medications
and exposure to smoking and cockroaches. Research supported by
the National Institute of Allergy and Infectious Diseases has
found that children in inner-city areas who were both allergic
to cockroaches and heavily exposed to them had higher rates of
hospitalization for asthma, missed school more often, and suffered
more sleep loss.
Hispanics also have higher death rates from asthma compared
with whites, with Puerto Ricans experiencing the highest burden.
What Causes Asthma?
Inflammation (swelling) of the airways is the underlying cause
of asthma, and there are two main reasons that people develop
the disease, says Fernando Martinez, M.D., director of the Arizona
Respiratory Center at the University of Arizona College of Medicine
in Tucson. "Some people develop asthma because they react to viral
infections like the common cold. Another group is genetically
predisposed to it, and for them, asthma is associated with the
way the lungs grow and the way the immune system develops." It
is in this second group that asthma tends to be persistent, and
there is often a family history of asthma and allergies. "Over
the next decade," Martinez says, "determining which genes are
involved will help scientists prevent and treat the disease."
William Busse, M.D., professor of medicine in allergy and immunology
at the University of Wisconsin Medical School, says the causes
of the increasing asthma rates are not fully understood. He says
that the prevalence of asthma is higher in developed countries,
such as the United States, Europe, and New Zealand, and is lower
in less developed areas, such as China and Africa. This suggests
a possible role of environmental or lifestyle factors that may
affect the type and magnitude of exposure to environmental allergens
and immune response to that exposure. Researchers are exploring
possible factors such as diet, frequent use of antibiotics, and
fewer and less severe infections in early life. Busse says studies
have shown that children who are enrolled in day care before 6
months of age have more frequent infections in early life, but
significantly less asthma after age 6.
Asthma also occurs more in urban environments than in farming
ones. The Hygiene Hypothesis, first proposed in 1989, remains
under debate and requires further study, according to Busse. This
hypothesis states that environments that are too clean may actually
make immune function more likely to develop allergic responses.
In a study published in the Sept. 19, 2002, issue of The New
England Journal of Medicine, researchers studied 812 children
ages 6 to 13 living in rural areas of Germany, Austria, and Switzerland,
and found that children in farming households experienced a decreased
risk of hay fever and asthma.
Safety Study on Serevent
In January 2003, the FDA announced that an interim analysis of
a large safety study of the asthma drug Serevent (salmeterol)
Inhalation Aerosol suggests that the drug may be associated with
an increased risk of life-threatening asthma episodes or asthma-related
deaths. Further analyses of the data suggest that the risk might
be greater in blacks. Also, people not taking inhaled corticosteroids
when they entered the study appeared to have greater risk for
serious outcomes than those who were taking inhaled corticosteroids.
Serevent Inhalation Aerosol belongs to the class of asthma medications
known as beta-2 receptor agonists, commonly called beta-agonists.
The FDA approved the drug in 1994 to treat asthma, and approval
was later extended for treatment of chronic obstructive pulmonary
The safety study began in 1996 after the FDA received reports
of several asthma deaths associated with the use of Serevent Inhalation
Aerosol, and after studies raised concern about the regular use
of short-acting and long-acting beta-agonists.
Because people with asthma can sometimes suffer sudden, serious
life-threatening episodes of bronchospasm, the deaths and serious
adverse events reported for Serevent could neither be attributed
to use of the product, nor could Serevent be excluded as a cause.
The drug's manufacturer, GlaxoSmithKline of Research Triangle
Park, N.C., stopped the study, mostly due to difficulties in enrollment
and the likelihood the study would not give a clear result.
The FDA is considering what steps are warranted to address this
important new risk information. The FDA has emphasized that, based
on available data, the benefits of Serevent for people with asthma
continue to outweigh the risks and that serious problems reported
in the trial were rare. The FDA has strongly advised that people
who take Serevent should not stop taking it, or any other asthma
drug, without first talking with their physicians.