Is Your Asthma Under Control: The Rules of Two

What Does Well Controlled Asthma Look Like?

Asthma is a long-term disease and although it cannot be cured, it can be controlled.  So what does well controlled asthma look like?
Some have suggested that it would include the following:

  1. Infrequent symptoms such as coughing and shortness of breath
  2. Minimal use of quick-relief medicines
  3. Normal lung function
  4. No night-time symptoms or symptoms associated with exercise.
  5. No severe asthma attacks that could result in a trip to the emergency room or being admitted to the hospital for treatment

The Two Faces of Asthma

Asthma has two parts: inflammation and bronchospasm.
Inflammation is present in the airways of asthmatics all the time, even when symptoms are quiet.  The inflamed airways are hypersensitive and easily irritated and will spasm with exposure to a variety of irritants such as cigarette smoke, cleaning fumes, air pollution, dust, exercises, and even cold viruses.  (In fact most asthma attacks are triggered by viral colds.)  We call the tightening and narrowing of the airways in asthma bronchospasm and it is the cause of most asthma symptoms including cough, chest tightness, and wheezing.

Asthma Inflammation

Although not all asthmatics are allergic, allergy is the primary cause of the inflammation found in children with asthma.  In Phoenix,  pollen and mold levels remain high much of the year. Other environmental factors such as the dry air and fine particulates (dust) and other elements of air pollution may contribute to airway inflammation.

So inflammation causes airway hypersensitivity which leads to bronchospasm which causes the symptoms of asthma.  In other words, if we are having a lot of asthma symptoms, that fact tells us that there is significant inflammation in the airways.

Two Types of Asthma Medications

Just like the two components of asthma, there are two broad categories of asthma medications:  anti-inflammatory medications and bronchodilators.   We call the anti-inflammatory medications “controllers” because they are used daily to keep inflammation under control which in turn will bring asthma symptoms under control.
Inhaled corticosteroids are the most effective anti-inflammatory medications. and are generally safe when taken as prescribed. They’re very different from the illegal anabolic steroids taken by some athletes. Inhaled corticosteroids aren’t habit-forming, even if you take them every day for many years.
Like many other medicines, inhaled corticosteroids can have side effects although most doctors agree that the benefits of taking inhaled corticosteroids and preventing asthma attacks far outweigh the risks of side effects.
Singulair (montelukast) is also used as a daily controller medication although it is not as effective as the inhaled corticosteroids.

Two Types of Bronchodilators

Short-Acting Bronchodilator (albuterol)

There are two types of bronchodilators: short acting and long-acting.  Both act to relax the muscles surrounding the airways.  The short acting bronchodilators are called “relievers” because they  are used as needed to relieve symptoms.   Long-acting bronchodilators (LABAS) are often used with inhaled steroids to reduce the dose of steroid needed to achieve control of symptoms.

One Size Does Not Fit All

Some patients with asthma have very mild and infrequent symptoms while others have continual symptoms or severe attacks requiring emergency treatment in a doctors office or hospital.    How do we know what medications are needed?
To answer this question, the NHLBI Expert Panel Report for the Diagnosis and Management of Asthma suggested dividing  asthma patients into four groups based on indicators of their asthma severity.  The categories ranged from mild to severe.   The first category, called mild persistent, included patients that had symptoms no more than than twice a week,  night-time symptoms no more than twice a month, and no more than one acute attack requiring oral steroids in a year.    For  this “mild intermittent’ group, use of an as needed rescue inhaler was needed.
For asthmatics with symptoms occurring more than twice a day, night-time symptoms occurring more than twice a month. and severe attack requiring emergency treatment or oral steroids more than twice a year, a daily controller medication is recommended, preferable an inhaled corticosteroid.
This  then is the  basis of the rules of two.

The Rules of Two:   If…..

  1. You have symptoms more than twice a day
  2. Night-time symptoms more than twice a month
  3. Severe asthma attacks requiring emergency treatment or oral steroids more than twice a year
  4. Uuse more than two canisters of a rescue medication in a year,

You should be taking two medications: a daily controller medication and an as-needed rescue medication