Practice Exercises

Asthma is a dynamic condition, as you probably know if you have lived with it for many years. Although it is important to have an overall asthma management program that keeps your asthma well controlled, it is also helpful to prepare yourself for various scenarios that may call for different strategies. This section presents some common scenarios so that you can practice how you would respond in advance.

Scenario 1: The head cold

Tissue box

Imagine that your asthma has been generally well controlled. Your controller medicine is a steroid inhaler (two puffs twice daily). Most days you do not need your quick-relief bronchodilator (albuterol inhaler) at all. Other days you use it perhaps once or at most twice in a day, although you always carry it with you.

Last week you and other members of your family had a head cold. You had a low-grade fever for two days, with sore throat and nasal congestion. Earlier this week your cold seemed to improve, but you started coughing a lot. Last night you were awakened repeatedly with coughing and slept much of the night propped up on pillows. You used the albuterol inhaler twice overnight with some relief.

Today you are still coughing and raising clear phlegm that resembles egg white. In addition, you find yourself short of breath after even light exertion, such as walking 50 feet. You use your albuterol inhaler again, but it doesn’t seem to help for more than about five minutes. Your check your breathing capacity with your peak flow meter. You are dismayed to find that your peak flow is only 180 L/min, less than half of your usual 400 L/min.

What could you do next? (See “Management options.”)

Management options

The first point is to recognize that this episode is more than just a bad cold. It is a severe asthma attack. It is not normal for a routine chest infection to cause shortness of breath when you walk only a short distance. In this example a head and chest cold has triggered a flare-up of the underlying asthma. The low peak flow value, less than half of the usual best value, confirms that this is a severe attack.

If you have a nebulizer at home, this would be a good time to use it to deliver a quick-relief bronchodilator (such as albuterol) by continuous mist. If you don’t have a nebulizer, use your quick-relief bronchodilator inhaler with a spacer (to maximize delivery of the medication to the airways) and take four puffs at one-minute intervals. If you don’t have a spacer with you, use the inhaler as carefully as you can without one. You can continue to take your quick-relief bronchodilator (by nebulizer or by inhaler) every 20 minutes for an hour or two if needed.

It would be a mistake to rely solely on your bronchodilator medicine for treatment of a severe asthma attack. If you continue to have intense asthma symptoms after using your bronchodilator two to three times, you can be certain that a major part of the problem is swelling of the bronchial tubes and accumulation of mucus in the tubes. The air passageways are severely inflamed, and no amount of bronchodilator alone will treat this part of the problem. To treat swelling and inflammation of the bronchial tubes, turn to steroids.

When you are having a severe attack like this one, it is generally necessary to take steroid tablets. Prednisone and methylprednisolone are the steroids typically prescribed. Call your doctor (or a physician covering for him or her) immediately to discuss your condition and get a prescription for oral steroid tablets. It is particularly helpful if you can tell your physician what your peak flow value is. This information will help him or her to gauge how bad this attack is and how best to respond to it.

If you have had a severe attack of asthma in the past, your doctor may already have prescribed steroid tablets to keep at home. If so, take the dosage prescribed (usually 30–60 mg). Then notify your doctor that you are having an asthma attack and that you have begun taking the steroid tablets.

Steroid tablets usually take six or more hours to take effect. You can continue to use your bronchodilator (for example, albuterol inhaler) as often as every hour while waiting for the steroids to start working. You should rest and relax as much as possible while waiting for the medication to take effect. As long as your breathing (and peak flow) are steady or improving during this time, you will be fine.

On the other hand, if your breathing is getting worse despite frequent use of your bronchodilator, seek emergency help. Quickly get to a nearby urgent care center or emergency room. A severe asthma attack can be dangerous, especially if you are getting worse in spite of initial self-help measures. In particular, the following types of symptoms are signs that it is time for you or a family member to call 911 for an emergency rescue team:

• You are unable to speak more than a word or two because of shortness of breath.

• You pass out or nearly pass out.

• Your lips and skin have a bluish discoloration due to lack of oxygen.

• Your peak flow is less than 100 L/min.

Scenario 2: The neighbors’ cat

Cat

Imagine that you have multiple allergic sensitivities that worsen your asthma, including an allergy to cats. Nonetheless, you have been feeling well this fall, using your inhaled steroid medication every day (two inhalations twice daily). You are active and enjoy working out at the gym. You routinely use your bronchodilator inhaler before exercising but otherwise rarely seem to need it. Sometimes you wonder whether you still have asthma at all.

Then you are invited to your neighbors’ home for dinner. Your neighbors took in a stray cat last month, but because of your allergies, they promise to keep the cat outside or in the basement during your visit.

The evening seems to be going fine, until you sit on a certain sofa. Soon thereafter you begin to sneeze and develop watery, itchy eyes. You feel a tightening in your chest and itching below your chin. You use your bronchodilator inhaler once, but get only minor relief. You start coughing and raise some clear mucus. Your neighbor offers you some water.

What do you do next? (See “Management options.”)

Management options

Step one is pretty clear: Leave the neighbors’ house. It is likely that you are allergic to something in their house, probably cat dander on the sofa and elsewhere. The best first step in treating an asthma attack is, if at all possible, to end exposure to your asthma trigger.

In this circumstance, it is safe to use your bronchodilator inhaler more often than the usual limit of four or five times per day. If necessary, you can take it every 20–30 minutes for an hour or two, or less than that if you start to feel more comfortable.

Use your peak flow meter to check your breathing capacity and help you judge how severe this asthma attack is. You may be able to estimate an attack’s severity by how you feel, especially by how breathless you are as you walk around. However, you can be fooled. The greatest concern is that you might underestimate just how sick you really are. Many people tend to minimize their symptoms; it’s human nature to not want to admit that something might be seriously wrong.

If your peak flow is more than half of your normal best value, you can be reassured that you are experiencing a mild-to-moderate attack. If your peak flow is less than half of your normal best value, you are having a severe attack, which will require more intensive treatment and greater caution.

Assume that when you arrive back home, you find that you can walk up to your second-story apartment without much shortness of breath. You continue to experience some coughing and wheezing. You use your quick-relief bronchodilator again, and soon thereafter check your peak flow. It is 400 L/min. Normally your peak flow is quite steady at 500 L/min. All indications are that this is a mild-to-moderate asthma attack.

A good strategy for treating a mild-to-moderate asthma attack is to double your dose of inhaled steroids. In this example, you would begin taking four puffs twice daily (or two puffs four times a day) of the steroid inhaler. The results are usually not as rapid and dramatic as with steroids in tablet form (such as prednisone or methylprednisolone), but side effects are far fewer.

It is likely that this two-part strategy — ending your exposure to cat dander in the neighbors’ house and increasing your dose of inhaled steroids — will bring your asthma back under control over the next 12–24 hours. During this time, keep close watch on your asthma symptoms and continue to monitor your peak flow values to make sure that you are improving. If you are not getting better, contact your doctor for advice. If you are improving, continue the extra puffs of the inhaled steroid for three or four more days. At that point, if you are back to normal, you can resume your usual dose, which is typically the lowest dose sufficient to control symptoms and prevent further attacks when your asthma is under control. Choosing the appropriate doses should be done with your doctor.

Scenario 3: A run in the park

Couple running

Just yesterday you had commented to a friend how well your asthma seemed to be doing lately. You were taking your controller medication in the form of a tablet every day and rarely needed to use your quick-relief bronchodilator. People at work no longer recognized you by your ever-present cough. Even your sleeping had become more restful, no longer interrupted by coughing and a sense of chest tightness.

Today, at the insistence of family and friends, you agree to participate in a local July 4 walk/run family race. It is a hot and muggy summer day, and your breathing does not feel its best even when you are sitting quietly. When your turn comes, you go at it hard for 15 minutes, until your legs feel like rubber. Your breathing becomes labored and you start to cough repetitively. You find the nearest bench and plop onto it, feeling like a wet dishrag.

You search deep in all your pockets for your quick-relief bronchodilator. When your asthma was under poor control, you could not have imagined going anywhere without it. You always carried one with you and kept one in your car, one at your office, and one by the bedside table at night. Now, to your dismay, you find that you have forgotten to bring it with you. Fortunately, you feel your strength coming back to your arms and legs and your breathing has begun to slow.

What would you do next? (See “Management options.”)

Management options

Exercise has the potential to trigger symptoms in virtually everyone with asthma. Physical activity causes you to breathe heavily, which means that you bring extra amounts of air down into your lungs and into your bronchial tubes. If the air inhaled during exercise is cold and dry, or filled with air pollutants, fumes, or other irritating substances, the muscles surrounding the bronchial tubes may contract and the airways narrow.

The good news, however, is that an attack of asthma brought on by exercise is generally short-lived. The bronchial muscles usually begin to relax over a period of minutes and your breathing tends to return to normal in about 30–60 minutes. Exercise also causes much less inflammation and swelling of the bronchial tubes than allergic triggers, such as cat dander or dust mites. Unless you are allergic to pollen and ran your race on a day with a high pollen count, there is a good chance that your breathing will continue to improve as you sit quietly and relax.

Staying calm is a good strategy for any asthma attack. Breathe slowly and deeply, and with each breath give adequate time for breathing out. Try counting three beats out for every one beat spent breathing in.

If your breathing remains difficult despite resting, another option is to borrow a quick-relief bronchodilator inhaler from a friend or family member. Asthma is common and there is a good chance that you will find someone nearby willing to help. At the same time, it is a good rule never to use an unfamiliar medication. If you have any doubt that the offered medication is appropriate and safe for you, it is best to decline its use. If you find yourself gradually getting better, you would do best to wait until you return home and retrieve your own medicine.

Once the attack is over, you make a mental list of the things that you could have done differently that might have prevented this attack. Most important, you vow always to bring a quick-relief bronchodilator inhaler with you, even when your asthma is under good control. You also remember that using the quick-relief bronchodilator about 5–10 minutes before exercising is an effective strategy for preventing the bronchial muscle contraction brought on by exercise.

Other strategies do not require any medication. Abstinence is one option: You could have declined to participate in a race on a day when your breathing did not feel fully comfortable. Another option is to make time for a brief warm-up period before exercising (for example, light walking or jogging in place) and a brief cool-down period afterwards. This can help to minimize the effect of exercise on breathing.

If you exercise during the winter, it is helpful to avoid breathing cold air while you exercise. You may decide to exercise indoors, or you can try wearing a thick scarf over your nose and mouth. With the scarf, you can trap some of the warm, moist air that you exhale and lessen your intake of cold, dry air. A cold-weather face mask is sold for the same purpose.