Understand and Control Your Asthma 9780773564831

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Understand and Control Your Asthma

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Understand and Control Your

ASTHMA Helene Boutin and Louis-Philippe Boulet With the collaboration of Denis Berube, Johanne Cote, Michel Laviolette, and Pierre Leblanc

The Canadian Thoracic Society (Medical Section of the Lung Association), after review by its Asthma Committee, considers this material to be of value in the care of patients with asthma.

McGill-Queen's University Press Montreal & Kingston • London • Buffalo

WARNING: As asthma treatment is progressing very rapidly and should be individualized, we suggest that interested readers check that they have the most recent version of this book and strongly recommend that they consult their physicians before applying the measures suggested here. The opinions expressed in this manual are solely those of the authors. The authors, the editorial committee, and the administration of Laval Hospital decline all responsibility for any damage suffered by persons who use it without consulting a physician.

McGill-Queen's University Press 1995 ISBN 0-7735-1210-1 (cloth) ISBN 0-7735-1263-2 (paper) Legal deposit first quarter 1995 Bibliotheque nationale du Quebec Printed in Canada on acid-free paper Publication of this book has been supported by the Canada Council through its block grant program.

Canadian Cataloguing in Publication Data Boutin, Helene, 1954Understand and control your asthma Translation of: Comprendre et maitriser 1'asthme. ISBN 0-7735-1210-1 (bound) ISBN 0-7735-1263-2 (pbk.) 1. Asthma. 2. Asthma-Treatment. 3. Antiasthmatic agents. I. Boulet, Louis-Philippe, 1954-. II. Title. RC591.B68131994 616.2'38 C94-900520-7

This book is an updated English version of Comprendre et maitriser 1'asthme, Les Presses de 1'Universite Laval, 1993. Editing: Avivah Wargon Graphics: Norman Dupuis Illustrations: Dominique Simard Photographs: Robert Bellemare Design: Karin Oest

Contents Preface v\\ Acknowledgments ix 1 Introduction 3 2 The Respiratory System and Asthma s THE RESPIRATORY SYSTEM 5 WHAT IS ASTHMA?

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SYMPTOMS AND PHYSICAL SIGNS 8 DIAGNOSIS 9 RECORDING YOUR SYMPTOMS 10 WHAT WILL HAPPEN TO ME IF I HAVE ASTHMA?

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REVIEW: THE RESPIRATORY SYSTEM AND ASTHMA

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3 The Triggering Factors 1? ENVIRONMENTAL FACTORS PERSONAL FACTORS

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REVIEW: THE TRIGGERING FACTORS

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4 Medication 31 U S I N G M E D I C A T I O N 31 PRINCIPLES FOR USE 31 MAIN TYPES OF MEDICATION

USING INHALERS

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BRONCHODILATORS

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INHALED BRONCHODILATORS 41 BRONCHODILATORS IN TABLET FORM 45

B R O N C H I A L ANTI-INFLAMMATORY DR U G S 48 STEROIDS (CORTICOSTEROIDS, CORTISONE DERIVATIVES) NON-STEROIDAL BRONCHIAL ANTI-INFLAMMATORY DRUGS (CHROMONE DERIVATIVES)

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OTHER

D R U G S 54

ANTIBIOTICS 54 ANTIHISTAMINES 55 ZADITEN® 55

C O N T R O L L I N G Y O U R ASTHMA ss LEVELS OF ASTHMA TREATMENT 55 CRITERIA FOR SATISFACTORY ASTHMA CONTROL 56 WHEN SHOULD THE TREATMENT BE CHANGED? 57 ACTION PLAN 58 REVIEW: MEDICATION AND MANAGING ASTHMA 61

5 A Healthy Lifestyle and Asthma 63 DIET 63 FLUIDS 64 SLEEP 66 CAN I STILL EXERCISE? 66 RELAXATION 67 REVIEW: A HEALTHY LIFESTYLE AND ASTHMA 72

Appendices 73 APPENDIX 1 - MYTHS AND CONTROVERSIES

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APPENDIX 2 - EMPHYSEMA AND CHRONIC BRONCHITIS

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APPENDIX 3 - ASPIRIN INTOLERANCE 79 APPENDIX4-ASTHMAAND DIABETES 81 APPENDIX5-ASTHMAAND SURGERY 82 APPENDIX 6 - ASTHMA DURING PREGNANCY AND BREAST-FEEDING APPENDIX7-OCCUPATIONALASTHMA 86 APPENDIX 8 - ALLERGIC RHINITIS AND CONJUCTIVITIS 87 APPENDIX9-TRAVELLING 91 APPENDIX 10-ALTERNATIVEMEDICINE 92 APPENDIX 11 - RESOURCES

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APPENDIX 12 - ANSWERS TO REVIEW QUESTIONS DIARY FORMS 99

Glossary 103 Suggested Reading 109

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Preface This manual was written in response to requests from patients attending the Asthma and Allergy Clinic at Laval Hospital. It is intended for people with asthma, people living or working with asthma sufferers, and others who are interested in knowing more about this condition. The approach proposed is based on the principles described in recent reports of national and international consensus symposia on the management of asthma, and on the findings of recent studies. Although this book was written in Canada and some aspects of treatment or available medication may differ from one country to another, the information provided will be useful in other countries as well. Specific information on medications used in the United States and Great Britain has been included.

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Acknowledgments We wish to thank Mrs Helene Armstrong for her help with the translation of this book. We would also like to thank Mr Francois Gignac, psychologist, and (at Laval Hospital) Ms Marie Guimond, dietician, Ms Ann Lalumiere, pharmacist, and Mr Mario Grandmond, head of the Audiovisual Department, for their invaluable advice. As well, we thank Ms Avivah Wargon, the editor of the English edition, and all those people near and far who contributed to this book. We are indebted to Drs James G. Martin, Frederick E. Hargreave, and Jerry Dolovich, and also to the members of the Asthma Committee of the Canadian Thoracic Society (Medical Section of the Lung Association). We would like to express our sincere gratitude for their most relevant and useful comments. We also thank the Asthma Committee for its endorsement of this book. Finally, we wish to thank Astra Pharma, Inc. for their contribution to this book in providing an educational grant

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Understand and Control Your Asthma

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C H A P T E R

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Introduction Asthma is a common illness that can affect people of all ages. It is also a variable and unpredictable disease that should not be underestimated. If inadequately treated, asthma undermines the sufferer's quality of life. Thanks to medical research, knowledge of asthma has greatly improved in recent years. Unfortunately, no cure has yet been found. However, in most people asthma symptoms can be controlled. If you have asthma, you can play an important role in the treatment of your disease; by becoming more involved, you can help improve your quality of life and your pulmonary function. The purpose of this manual is to increase your independence with respect to your asthma. By following the steps suggested here, you can • improve your knowledge of asthma; • learn how to improve the quality of your environment and adopt a healthy lifestyle; • contribute actively to your own treatment through a better understanding of asthma and by knowing what to discuss with your doctor; • become aware of the resources available; • test your knowledge and analyse your attitudes toward asthma by completing the review questionnaires at the end of most chapters. Since this is a general manual with practical goals, it cannot answer all questions. You should discuss with your doctor any questions that may arise from reading this book.

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C H A P T E R

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The Respiratory System and Asthnu THE RESPIRATORY SYSTEM To understand asthma, we must first understand the different parts of the respiratory system (its anatomy) and how it works (its physiology). Air enters through the nose and mouth, and descends into the throat until it reaches the larynx, where the vocal cords are located. The air then enters the trachea, which is located below the larynx. Figure 1 THE RESPIRATORY SYSTEM

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The lungs are like an inverted tree with the trachea as its trunk. The trachea is about 2.5 cm (just under 1 inch) in diameter in adults. It is divided into two primary bronchi, one on the right and one on the left. The lungs are covered by a membrane called the pleura, and housed in the ribcage, which is made up of ribs, muscles, and ligaments. The lungs are separated from the abdomen by a powerful muscle called the diaphragm. Each time we breathe in the diaphragm contracts, allowing air to enter the lungs. When we breathe out, the diaphragm relaxes, allowing the air to leave the lungs. Each primary bronchus is divided about twenty-five times into smaller bronchi called bronchioles (the tree branches). The bronchioles are connected to small air sacs called alveoli (the leaves). The alveoli are surrounded by very small blood vessels. The lungs supply the oxygen (02) that is necessary for the body's survival. Inhaled oxygen moves from the alveoli to the blood vessels and is transported by the blood to the cells in our bodies. Carbon dioxide (CCh), a waste product constantly being generated by our bodies, is exhaled through the lungs. Carbon dioxide passes from the blood vessels into the alveoli and is then exhaled. Figure 2 GAS EXCHANGE

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WHAT IS ASTHMA? Asthma is characterized by overly reactive bronchi (increased "twitchiness"). This increased responsiveness, doctors and researchers believe, is due to underlying bronchial inflammation. The walls of the bronchi contain muscles, and the interiors are lined with a membrane (mucous membrane) that secretes mucus, or phlegm. In people with asthma, the bronchi decrease in size when they come in contact with certain triggering factors. The bronchi in young children, which are smaller, are more easily obstructed. During an asthma attack, the following changes take place in the bronchi and bronchioles: 1. the muscles encircling the bronchi contract, their interior diameter (lumen) narrows and air cannot reach the lungs as easily (in medical terms, this phenomenon is called bronchospasm); 2. the membrane lining the inside of the bronchi becomes inflamed and swollen, making it even more difficult for air to pass through (this is inflammation); 3. excess secretions can lead to the formation of mucus plugs, which reduce the air passages even more. Figure 3 ILLUSTRATION OF A NORMAL BRONCHUS AND AN INFLAMED BRONCHUS NORMAL BRONCHUS

INFLAMED BRONCHUS

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If inflammation persists, the bronchi become even more hyperreactive or "twitchy," and the tendency to constrict increases further, for example, on contact with respiratory irritants. The more inflamed the mucous membrane becomes, the more the bronchi shrink in internal diameter, as illustrated in figure 3. A mild asthma attack can improve either on its own or under the effect of a drug that dilates the bronchi. If asthma symptoms persist or recur frequently, inflammation becomes more severe and should be treated. SYMPTOMS AND PHYSICAL SIGNS Difficult breathing (dyspnea) which produces shortness of breath, with or without tightness in the chest (a feeling of pressure on the chest), is caused by the narrowing of the bronchi and bronchioles. In young children who are unable to express what they feel, parents may sometimes notice fast breathing and "retractions" (the chest being sucked in as the child inhales). Whistling sounds, or wheezing, may occur because of the decreased size of the bronchi. Coughing can be severe. In some asthmatic patients, it is the main and sometimes the only symptom. Typically, the coughing occurs mostly at night or early in the morning. Finally, asthma is often accompanied by bronchial secretions (coughing up mucus or phlegm). Asthmatic patients do not all experience symptoms in the same way or to the same degree. If asthma is well managed, symptoms can be minimized or eliminated. In severe asthma or when asthma is inadequately treated, symptoms can be continuous.

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DIAGNOSIS The main methods used to diagnose asthma are • interviews (questions asked by doctors); • physical examinations (pulmonary auscultation, or listening to the sounds in the lungs with a stethoscope); • the measurement of peak expiratory flow using a peak flow meter (the peak expiratory flow is the maximum speed at which you can expel air from your lungs); • a forced expiratory manoeuvre (with a spirometer), which measures the amount of air that you can exhale from your lungs in a certain time, such as one second. In asthma patients, the physical examination frequently shows nothing abnormal, so it is necessary to perform pulmonary function tests to determine whether the bronchi are obstructed or hyperreactive (overly stimulated by certain things). For children under three, there is no simple method, besides physical examination, of assassing the degree of bronchial obstruction. After three, a test called forced oscillation, which requires only minimal cooperation from the child, and other methods available in specialized hospitals can be used to assess Figure 4 FORCED EXPIRATORY MANOEUVRE (SPIROMETRY)

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obstruction of the airways. Peak flow measurement or spirometric tests can generally be done once children reach the age of five or six. Sometimes your doctor may order the following tests: • allergy skin tests, which do not diagnose asthma but may indicate allergies by detecting antibodies against allergens such as pollens, mould spores, animals, dust, and certain insects (see "Environmental Factors" in the next chapter); • chest x-rays, in order to detect other pulmonary (lung) diseases; • bronchial provocation tests (in which you inhale histamine or methacholine), which measure the degree of sensitivity (or responsiveness) of the bronchi. These tests are used to determine the severity of asthma or to confirm suspected cases of asthma, for example in a patient with a persistent cough or unexplained shortness of breath; • blood tests, especially in allergic asthma, which measure the levels of certain inflammatory cells or antibodies in the blood; • specific bronchial provocation tests (in which you are exposed to the substance suspected of causing or aggravating your asthma). These are specialized tests, used mostly for investigating occupational asthma.

Figure 5

ALLERGY SKIN TESTS

RECORDING YOUR SYMPTOMS If you have asthma, we recommend completing the diary forms at the end of this manual over a period of a few weeks to become familiar with your symptoms and understand your asthma better. After collecting the information, you can discuss it with your doctor. These diary forms will help your doctor determine the best treatment and suggest a plan of action in case your asthma worsens. If you measure your peak expiratory flow rate (see the next section), your doctor can also

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include information on what measurements suggest whether your asthma is under control or not. Measuring your peak expiratory flow rate (PEFR) If you need to take one or more asthma drugs every day, you could consider purchasing a peak flow meter. While the idea of prescribing peak flow meters for everyone with asthma is still debated, it is usually agreed that these devices can help many people to better control their asthma. A peak flow meter is a small portable device that makes it possible to measure the opening or closure of the bronchi. It provides objective measurement of the degree of obstruction of the bronchi, based on the maximum speed (in litres of air/minute or second) at which air is being expelled from the lungs. By using a peak flow meter, you can • determine the best peak expiratory flow rate (PEFR), reflecting lung function, that you can achieve; • obtain an objective measurement that indicates if your asthma is under control, especially if your symptoms are difficult to detect; • check that your treatment is adequate; • recognize that you must change your medication or need to consult your doctor immediately when your peak expiratory flow rate drops below the level set by the doctor (see the action plan on page 62); • identify the factors that trigger your asthma • at home, at work, on vacation, or seasonally (e.g., pollen); • in the case of exposure to certain allergens (cat, dog, dust, etc.); • in the case of exposure to certain respiratory irritants (strong odours, cigarette smoke, etc.). Children of five or six can learn to use a peak flow meter with a little help.

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How to use a peak flow meter 1. Check that the gauge is at zero. Hold the meter horizontally with one hand. Take a deep breath in (to fill your lungs completely). 2. Seal your lips around the mouthpiece and breathe out as quickly as possible for one or two seconds. 3. Read the level reached on the gauge, and then reset the gauge at zero. Repeat these steps twice more and record the best of the three readings. Figure 6 HOW TO USE A PEAK FLOW METER

NB: Be careful not to interfere with the movement of the

gauge when holding the peak flow meter. You can measure your peak expiratory flow every morning and evening, or more often if symptoms become uncomfortable or occur during the night.

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• Write the date and time when you take measurements on a diary card or booklet. It is better to take measurements at the same time each day (for example, on getting up and going to bed). • If you need to use an inhaled bronchodilator, measure your PEFR before using the inhaler, and again 10 minutes afterwards. Most asthmatics do not need to measure their PEFR every day if their asthma is stable. However, these measurements can be very useful • if your asthma symptoms reappear or worsen (e.g., following a cold); • after any medication change; • the week before a visit to the doctor; • while travelling, if your asthma worsens; • if you find it hard to tell whether you have reduced lung function. Diary forms On a daily basis, record the following: • • • •

peak expiratory flow rate (PEFR); daytime or night-time asthma symptoms; factors that presumably trigger your asthma; daily medication. These daily records will help determine

• if your asthma is stable or unstable; • your response to the medication; • the factors triggering your asthma. Even if you do not have a peak flow meter, fill in the information on the other aspects of your asthma on the diary form. The following is a sample of a completed diary form.

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Figure? EXAMPLE OF A COMPLETED DIARY FORM N.B. Indicate the best of 3 consecutive readings: 2 times a day -t- if you experience bothersome respiratory symptoms + if you are awakened during the night with asthma.

NOTE: You will find blank forms at the end of this book to enter your results.

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WHAT WILL HAPPEN TO ME IF I HAVE ASTHMA? The development of asthma is different and unpredictable from one individual to another. In some, asthma is stable. In others, it disappears completely, only to reappear several years later. Sometimes, asthma is severe and difficult to control only for a certain period of time. Certain types of asthma caused by exposure to dust or chemicals in the workplace can disappear once the person is no longer exposed to the substance in question. Remember that in almost all cases it is possible to control asthma symptoms with proper treatment and to lead a normal life.

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Review

THE RESPIRATORY SYSTEM AND ASTHMA* Identify the parts of the respiratory system that match the following statements by referring to Figure 1: 1. I am the principal respiratory muscle that allows air to enter the lungs. 2. This is where oxygen and carbon dioxide are exchanged. 3. We are the part of the respiratory system that becomes inflamed in asthma. 4. By contracting, we reduce the diameter of your bronchi. 5. What are the changes that can be observed in the bronchi when an asthmatic experiences troublesome asthma symptoms? a) destruction of alveoli c) irreversible obstruction e) secretions

b) bronchospasm d) bronchial inflammation f) loss of elasticity

6. What asthma symptoms do you experience? a) shortness of breath c) wheezing e) other

b) tightness in the chest d) coughing

7. I am a portable device that allows you to measure the degree of opening or closure of your airways. 8. When is it particularly useful to measure your peak expiratory flow rate (PEFR)? a) If asthma symptoms reappear or worsen, for example following a cold b) after a change in medication c) if you find it hard to recognize bronchoconstriction d) if asthma is stable for many weeks NOTE 'Answers to these questions are found on page 95.

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9. Treatment will allow most asthmatics to lead a normal life. True D False D

C H A P T E R

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The Triggering Factors There are two types of factors that can trigger an asthma attack: environmental factors (extrinsic) and personal factors (intrinsic). Your lungs are in permanent contact with the surrounding air and the dust and particles it contains. In asthma, the bronchi often react to these substances in an exaggerated manner. Therefore the quality of the air you inhale, both inside and outside buildings, can affect the severity of the disease. The quality of your environment is essential. Try to minimize or, ideally, eliminate exposure to substances that can trigger your asthma attacks. You must tell your doctor and your pharmacist that you have asthma before taking any new medication. Certain drugs, such as aspirin, beta-blockers (for heart conditions), and nonsteroidal anti-inflammatories (for arthritis) can trigger an asthma attack in some asthmatics. Certain food additives can, if you are sensitive to them, also cause an asthma attack, particularly • metabisulfite, a preservative that may be present in wine, beer, some fruit juices, salads in restaurant salad bars, some dried or fresh fruits, some processed foods, dried fish, seafood, and other food products. You can check lists of ingredients on food packages and labels (though traces of sulfites may not be shown), or ask the waiter in a restaurant You can also ask your family doctor or allergist for a list of foods that contain sulfites. • monosodium glutamate, which is often used as a flavour enhancer in Chinese food. REMEMBER:

If you have asthma, avoid exposure to non-specific irritants such as dust, strong odours, and fumes. If you have allergies as well, avoid contact with allergens to which you are sensitive (animals, pollens, etc.).

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Finally, some substances present in the work environment can cause asthma. Among the many substances known to cause occupational asthma are flour, seafood, paint hardeners (isocyanates), and red cedar dust Once occupational asthma has been confirmed, you must avoid any contact with the substance responsible to prevent your asthma from becoming worse. (See appendix 7, "Occupational Asthma.") ENVIRONMENTAL FACTORS Allergens Not all asthmatics have allergies. The later asthma begins in life, the less likely it is that it has been caused by allergies. According to the research, in about 70% of children and young adults and 40% of people over thirty asthma is related to allergies. In children, it is often only at school age (after the age of five) that allergies become an important element in the development of their disease. What are allergies? Allergies are an abnormal reaction by the body to substances (allergens) to which a person has become vulnerable, or sensitized. The allergic person produces antibodies against these substances. When the antibodies come into contact with the allergen, certain body cells release chemical substances called mediators, such as histamine and leukotrienes. Mediators can cause • edema (swelling) of the mucous membrane of the nose with runny nose and sneezing (allergic rhinitis); • eye irritation with itchiness and watery eyes (allergic conjunctivitis) (these two groups of symptoms are often called rhinoconjunctivitis, or simply hay fever); • inflammation (redness and swelling) of the bronchi with bronchospasmfa//^^ asthma). Allergy sufferers may develop one of more of these symptoms. 18

The most common allergens are • tree, grass, and ragweed pollens; • animal hair, dander (skin particles), and secretions; • dust and dust mites (microscopic insects commonly found in house dust); • indoor and outdoor mould spores. Food allergies can cause asthma in some individuals, particularly in very young children. An asthma attack usually occurs shortly after contact with the allergen. If the relation between asthma and food is not obvious, there is probably no significant food allergy. You should discuss the possibility of food allergies with your doctor. The food allergies that most frequently cause asthmatic reactions in older children and adults are peanuts and seafood. Reactions to these foods can take the form of severe, lifethreatening attacks that may include flushing, hives, swelling of the lips, tongue, and throat, coughing and wheezing, stomach upset, and collapse. In babies and toddlers, the foods most likely to cause reactions are milk and eggs. General precautions

If you have both asthma and allergies, you should avoid any contact with the allergens to which you are sensitized as much as possible. Exposure to allergens to which you are sensitized will make your asthma worse (probably by increasing the underlying inflammation of the airways) and more difficult to control. If you can't avoid occasional contact with an allergen, you can reduce your asthmatic reaction by taking a medication such as cromoglycate (Intal®) or nedocromil (Tilade®) (see pages 52-3) immediately before the contact and every 3 to 4 hours during the time you are exposed to the substance (you should keep your exposure as short as possible). If you have food allergies, you must avoid the offending food completely. Antihistamines may be useful for treating these reactions, but some people who are very allergic must also keep an adrenalin (epinephrine) syringe with them (for 19

example, Ana-Kit® or EpiPen®) at all times. If a severe reaction occurs, take the medication prescribed by your doctor immediately and go to a hospital emergency department without delay. Call an ambulance if necessary. CAN I KEEP MY PET AT HOME?

If you are allergic to an animal, you should minimize exposure to it - and particularly not have one at home, whatever the breed or the amount of time you spend with it. If you have asthma and decide to keep an animal that you are allergic to, there is a high risk of your asthma becoming progressively worse. Even if contact with the animal doesn't seem to cause asthma symptoms, prolonged contact will be harmful, because it will increase the inflammation of your airways. If allergy tests confirm that you are sensitive to your pet, you should take no chances - find it another home. Not letting your pet into the bedroom - or keeping it in the basement - won't solve the problem. Allergenic particles from animals spread everywhere, throughout the house or apartment; you can't avoid inhaling them. Drugs such as cromoglycate (Intal®) or nedocromil (Tilade®) can provide some protection against exposure to allergens. However, this protection is often partial, so there may still be some damage to your airways - particularly if exposure is prolonged. Unfortunately, there is no acceptable compromise.

Pollen In Canada, the northern United States, and many northern European countries, there are high levels of pollen in the air in April and May (trees), in June and July (grasses), and in August and September (ragweed). Here is some advice that you might find useful: • Preventive drugs such as cromoglycate (Intal®), nedocromil (Tilade®), or inhaled steroids (see pages 48-9 and 52-3) reduce the effect of pollen on asthma symptoms. For hay fever, see the section on treating rhinoconjunctivitis in appendix 8. Changes in asthma medication will be necessary if your asthma becomes unstable.

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• Since pollen concentration is higher around noon and on sunny days, avoid exposing yourself needlessly: for example, by walking through fields or through freshly cut grass. • Keep your bedroom window closed during the day. An air conditioner may help, but it must be able to recycle the air, rather than drawing in outside air. You should close the outside air intake and clean the air conditioner regularly. Dust House dust is a mixture of dust mites, potentially allergic substances from animals (cats, dogs, etc.), and many other particles. It may act as an irritant or allergen because of its contents. The following general recommendations may be of benefit to anyone with asthma, although they are useful mainly if you are allergic to dust mites. Your bedroom in particular must be dust-free, because it tends to be the room where you spend the most time. • Keep the closets clean and closet doors shut. • Avoid heavy window drapes and horizontal blinds. Easy-to-wash curtains or roller-blinds are preferable. • Remove carpets. If this is not practical, they should be cleaned regularly and vacuumed frequently. Easy-to-wash rugs are preferable. • Keep furniture free from knick-knacks and cloth coverings. Avoid wall decorations and upholstered furniture, which catch dust. Keep bookcases to a minimum, and dust them weekly. • Avoid wool blankets, heavy or down duvets, and feather pillows. Washable, hypoallergenic synthetic pillows made of Dacron® and other polyesters are preferable. • Keep stuffed animals or dolls to a minimum, and wash them every time the bed linens are washed. • Use a damp cloth to dust. During major house cleaning, it helps to wear a mask. • If you have central air conditioning, clean the filter screens regularly. Keep the furnace room clean.

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Dust mites Dust mites (acarids) feed mainly on dead skin cells and grow in hot humid environments. They are found in dust generally, but particularly in mattresses and pillows. Even when dead, they can cause allergic reactions. If you have asthma and are allergic to dust mites, you must avoid them as much as possible. • Use vinyl covers on mattresses and pillows. Quilted cotton/polyester mattress covers (which are necessary to avoid sticking to vinyl-covered mattresses) are also a breeding ground for dust mites. You can control this by washing the mattress cover every one to two weeks, and then putting it in a dryer on a hot cycle for 45 minutes. If you do not want to put vinyl covers on pillows, consider giving them the same treatment. • Wash your bed linens in hot water at least twice a month. • Air your mattress outside for 15 minutes in cold weather (below 10°C or SOT) every two to three months, or expose it directly to the sun in warm weather. This will help kill dust mites, although it will not remove their particles. • Keep the humidity level in your bedroom at or below 40% (you can measure the humidity level in your house with a small device called a hygrometer; most are inexpensive). Too much humidity encourages dust mites and moulds. There are chemical products - acaricides - that kill dust mites; however, their use is still controversial. Mould Outdoor moulds are a greater trigger for most allergic patients than indoor ones. When they are at their peak in outdoor air, usually in late summer or early autumn, using an air conditioner with the outside air intake closed may be helpful. An air conditioner also dehumidifies your home, which helps to reduce indoor mould growth. Indoor moulds are found everywhere, but especially in well-insulated houses where air does not circulate enough;

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damp rooms such as basements, bathrooms (shower curtains, bathtub rim, window frames, and shower stalls), laundry rooms, and kitchens (refrigerator, sink, garbage can); and on house plants. • Keep the rooms mentioned above clean. Avoid living or sleeping in a basement. • Keep the house well ventilated (for example, use ventilators or exhaust fans in the roof and bathroom, and in the stove hood). Keep humidity in the house at or below 40%. • Keep plants out of the bedroom, and limit the number of plants in the rest of the house. • If possible, avoid using humidifiers. If this is not possible, portable humidifiers are preferable because they are easier to maintain (see the next section). Humidifiers If you have to use a humidifier, it is important to maintain it carefully to keep mould from forming and being vaporized. The risk of contamination seems to be lower with hot-water vaporizers. We recommend that the water be changed regularly, and the water reservoir washed with soapy water and, ideally, disinfected every week or according to the manufacturer's advice. We suggest the following steps for disinfecting a humidifier, depending on whether it is a conventional or an ultrasonic model. If you use a portable conventional humidifier, 1. Wash the humidifier carefully, refill it with water, and add one tablespoon of chlorine bleach. 2. Run the humidifier for about five minutes in a wellventilated room, with a towel covering the vent. 3. Rinse the humidifier, add clean water and repeat step 2, for two minutes. 4. Empty the humidifier, dry it, and refill it with water before using it again.

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If you use an ultrasonic humidifier, 1. Wash the humidifier carefully, then disinfect the base and the reservoir with a solution of one tablespoon of chlorine bleach to one litre of water, and rinse it. 2. Ultrasonic humidifiers should not leave white dust on furniture. The dust is a by-product of the breakdown of the minerals in the water and could irritate your bronchi if you have asthma. To prevent this, change the demineralizing filter regularly. 3. To remove calcium deposits, soak the metal base (where the water is turned into steam) for 30 to 60 minutes in a solution recommended by the manufacturer, or in vinegar. You can reuse the solution next time. Non-allergic Factors Asthmatics can feel uncomfortable after inhaling irritant substances; their bronchi react differently according to the severity of the asthma and the intensity of the exposure. The most frequently harmful substances include those in the following two groups: 1. Strong odours coming from household and industrial products, such as perfumes, aerosols, and solvents. • Avoid inhaling the fumes of these products. • Use these products only in well-ventilated areas. • If possible, avoid using aerosol products. They spray particles that are very fine and easily inhaled, and can further irritate the bronchi.

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2. Air pollutants, including exhaust fumes, cigarette smoke, various industrial products, and ground-level ozone (a gas derived from oxygen). • Do not smoke and insist, as much as possible, that no one else smokes in your presence. • Avoid underground parking garages. • Avoid heating with wood; it may be harmful because of the dust and smoke caused by burning wood. • If you use forced-air heating, have the air ducts cleaned regularly. Keep the furnace filters clean. Block off air vents in your bedroom or cover them with cheesecloth. • The usefulness of an air purifier is debatable. It has been suggested that high-performance types like the HEPA (high efficiency particulate air filter) may be helpful. Generally, the more expensive the device, the more effective it is. However, filters have to be kept clean, and some air purifiers emit ozone, which is a respiratory irritant. • Be careful to maintain any device you use (humidifier, dehumidifier, air conditioner, air purifier, or electronic filter) according to the manufacturer's instructions or the recommendations above.

CIGARETTES AND ASTHMA

Tobacco smoke is a mixture of gas and particles containing hundreds of chemical products, some of which are toxic or can induce cancer. Tobacco smoke is particularly harmful to asthmatics. It can increase airway inflammation and reduce the effects of anti-asthma drugs, thereby prolonging or worsening asthma. Smokers are also at higher risk of developing other diseases such as chronic bronchitis, emphysema, and cardiac problems. Smoking is harmful not only to those who smoke but also to everyone else: indirect or "second-hand" smoke contains even more concentrated pollutants and toxic substances. It is very important for you not to be exposed to smoke, and to ask others to respect your right to a smoke-free environment. Children who grow up in the homes of smokers are more likely to develop allergies and asthma. They have more frequent respiratory infections and their asthma is more difficult to control.

25

Physical activity Exercise can trigger bronchospasm in most asthmatics. Certain physical activities, such as winter sports and running, usually cause more symptoms than others, such as swimming. However, if you have asthma, it is essential to do some form of physical activity to keep in shape. You simply need to take precautions. See the recommendations in chapter 5, "A Healthy lifestyle and Asthma." Although exercise may trigger asthma symptoms, it does not make your asthma worse. It may indicate how well controlled your asthma is - if your tolerance for physical effort goes down, your asthma control may have dropped. Cold air and weather changes • Avoid sudden changes in temperature. • Breathe through your nose. Cover your nose with a scarf in cold weather. • If necessary, use your inhaled bronchodilator before going outside. Medications such as cromoglycate (Intal®) or nedocromil (Tilade®) can also be used (see pages 52-3). Respiratory infections Asthma frequently becomes worse during a respiratory infection. In children, infections are often the most frequent trigger of asthma. Since most of these infections are caused by a virus, antibiotics are of doubtful value. We get these infections through contact with an infected person. The more people we meet, the greater the risk that some of them may be infected and may spread their infection. To prevent infections, • Avoid contact with anyone who has a respiratory infection. • If you have children in daycare, try to choose a daycare centre with a limited number of children (if possible, fewer than six children). 26

• Avoid crowds during outbreaks of flu or colds. • If your asthma is severe or you are over 60, we recommend a flu shot each fall. However, you should not get a flu shot if you are allergic to eggs. • Ask your doctor how you should adapt your asthma medication (action plan) if you get a cold or flu. If you get a respiratory infection, • Rest. • Drink plenty of fluids to help flush out bronchial secretions (mucus or phlegm). • Take your asthma medication according to your doctor's instructions. • If you develop signs of bacterial infection (greenish secretions with or without a fever), consult your doctor, whether or not your asthma is becoming worse. PERSONAL FACTORS Hormonal changes in women For some unknown reason, the bronchi may be more sensitive to respiratory irritants before menstrual periods, and asthma can worsen. The effects of pregnancy on asthma are unpredictable and differ from one person to the next and from one pregnancy to another. During pregnancy, asthma can improve, worsen, or remain stable (see appendix 6 for more information). Medication for asthma should be modified by the doctor according to the needs of each individual. Gastroesophageal reflux Gastroesophageal reflux is the regurgitation of acid coming from the stomach. The sign that this is occurring is an acid taste in the mouth while leaning forward or on lying down. In some asthmatics, it can provoke asthma symptoms. 27

Regurgitation can be normal: for example, infants have it while burping. However, if asthma is not well managed, it can increase the tendency to regurgitate. Sometimes it is difficult to identify which came first: whether the reflux caused the asthma, or the asthma increased the reflux. If you have symptoms of gastroesophageal reflux, tell your doctor. He or she may suggest • placing 10-15 cm (4-6 in.) blocks under the head of the bed; • avoiding eating, or drinking carbonated beverages, before going to bed; • avoiding beverages containing caffeine, such as coffee or tea; • taking certain medication; • in the case of an infant, not moving the baby much for one hour after meals. Emotions Although asthma is not caused by psychological factors, emotions and tensions can provoke bronchospasm if you already have asthma. To learn about dealing with stress, read chapter 5, "A Healthy Lifestyle and Asthma." Laughing and crying may trigger asthma symptoms in anyone with asthma, but particularly in babies and toddlers. This is because breathing speeds up (as with exercise), and may cause bronchoconstriction.

28

Review

THE TRIGGERING"FACTORS* 1. Allergens a) Is there one or more of the following animals at home? Cat D Dog U Other animals

Bird D

Mouse, hamster, etc. D

b) Do you come into contact with one or more of the above animals in relatives' or friends' homes? Yes G No D If you answered "yes" to the last question, how often? Rarely G Occasionally Q Often G c) Which allergens are you allergic to? Cat G Dog D Bird Gl Mouse, hamster, etc. Q Pollen D Dust D Mould G None of these D 2. Check off the items that you have in your bedroom now. Feather pillows G None of these D

Plants Q

Carpet G

Down duvet G

3. Which of the following appliances do you use? Air purifier Q Dehumidifier D Humidifier G Air conditioner G None of these D 4. What type or types of heating do you have at home? Electric d

Hot water G

Forced air G

Wood Q

5. Smoking a) Do you smoke? Yes G

No G

b) Are you exposed regularly to cigarette smoke in your home? Q at work? Q

NOTE 'Answers to these questions are found on pages 96-7.

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C H A P T E R

4

Medication USING MEDICATION PRINCIPLES FOR USE Once asthma has been diagnosed, the goal of treatment is to minimize or eliminate respiratory symptoms and restore normal lung function by • identifying the triggering factors and effectively correcting the environment, as explained in the previous chapter (using avoidance strategies); • using the minimum of drugs appropriate to the severity of the asthma; • preventing and treating flare-ups early and effectively (using a written action plan). Medication varies according to the severity of asthma in each person. If you have asthma, you must know and understand • • • •

how to use asthma drugs and what effects they have; what drugs you must take; how to change medication if asthma symptoms worsen; when to consult a doctor.

Today, people take asthma medication mainly by inhalation. An inhaled drug can be taken at a lower dose and thus causes fewer side-effects than if it was taken in the form of pills or syrup. MAIN TYPES OF MEDICATION Two main types of medication are used: • Bronchodilators provide fast but temporary relief from asthma. They should be used when asthma symptoms occur (coughing, wheezing, shortness of breath, and

31

tightness in the chest). Those people for whom exercise and cold air or certain irritants cause asthma can use bronchodilators fifteen minutes before an activity or before contact with irritants (for example, smoke or cold air) in order to prevent an asthmatic reaction. Bronchial anti-inflammatory drugs such as inhaled steroids treat the problem at the source, that is, the inflammation. However, they do not act quickly. Anti-inflammatory drugs help to prevent symptoms from occurring and they should therefore be taken regularly at a dose that controls the biological phenomena that cause asthma. USING INHALERS It is essential to understand how to use inhalers correctly, since most asthma drugs are prescribed this way. The main types of inhaler and suggestions on how to use them are discussed below. If you are unable to use your inhaler as recommended, you should speak to your doctor. You should check the use of all your inhalers regularly with your doctor or another health professional. CAUTION:

1. Do not swallow capsules intended for use with inhalers: they are not effective when taken this way. 2. When taking inhaled medications, avoid getting the medication in your eyes.

Metered-dose inhaler (MDI)

Metered-dose inhalers can be used with a "closed-mouth" or an "open-mouth" technique. We prefer the "open-mouth" method, because some studies have shown that the distribution of the drug in the lungs is better with this method and that less Figure 8 HOW TO USE A METERED-DOSE INHALER

32

medication is deposited in the throat. However, the choice of the open- rather than closed-mouth technique is still being debated. You must use your MDI properly to get good results. Check your technique regularly with your doctor or other health professional. How to use a metered-dose inhaler: 1. Remove the cap from the metered-dose inhaler. 2. Shake well. 3. Hold the inhaler 2 to 5 cm (1 or 2 inches) from your mouth. Keep your mouth wide open. Tilt your head backwards slightly. 4. Breathe normally and slowly through your mouth. 5. Begin to inhale and push down once on the cartridge. Continue to inhale slowly and deeply through your mouth until you have finished taking that breath in. 6. Hold your breath for five seconds or more if you can. 7. Exhale slowly. 8. If a second inhalation is prescribed, wait one minute before taking it. Maintenance Clean the mouthpiece about once a week. Remove the cartridge from the mouthpiece and rinse the mouthpiece with hot water. Drain and dry the mouthpiece using a clean towel. The metered-dose inhaler cartridge is empty when it floats in a container of cold water. However, this method can let water into the aerosol container via the valve. It is preferable to check if there is some medication left by shaking the cartridge close to your ear (you should be able to hear the liquid) or by keeping track of the number of doses on a sheet of paper. Breath-actuated inhaler The breath-actuated inhaler (Autohaler®) is a new type of pressurized, multi-dose inhaler that delivers 400 doses of a drug called pirbuterol (Maxair®), not yet available in Canada. 33

Used with the closed-mouth technique, it is automatically activated when you breathe in. It thus avoids any problems with coordination and automatically delivers the correct dose. Spacers Spacers (also called spacing devices or inhalation chambers) are add-ons that attach to the mouthpieces of metered-dose inhalers (MDIS). They act as holding chambers for the aerosol medication, making it easier to take and reducing the amount that gets deposited in the throat. Spacers are prescribed for people who are unable to use an MDI properly, need high doses of inhaled steroids, or have frequent yeast infections in the mouth and throat. They are also prescribed for children under seven, who are often unable to use an MDI effectively. Different models of spacer, of different shapes and sizes, are available for different groups of patients. The most frequently used are the following: • the 145-ml Aerochamber® with its one-way valve; • the large-volume (about 750-ml) spacers, either rigid (VentAHaler®), or collapsible (InhalAid®), with a valved mouthpiece; • the 700-ml collapsible bag with a reed that vibrates if the user is breathing in too quickly (InspirEase®). The large-volume spacers are cheaper and have sturdier valves than the smaller ones, though they are also more cumbersome. There are also other small models that consist of an MDI combined with its own spacer.

34

Figure 9

Figure 10

VENTAHALER® SPACER

INSPIREASE® COLLAPSIBLE RESERVOIR SPACER

The methods for using the different spacers are similar. To illustrate these, the Aerochamber® with mouthpiece and Aerochamber® with mask are shown here. The Aerochamber® comes in an orange-coloured model for infants and children under eighteen months, a yellow one for children between one and five, and a blue one for adults. The blue one can also be used for children over three, just like other spacers such as the VentAHaler®, Nebuhaler®, etc. (These colours may change in the future; check that you have the appropriate model for your needs.) Using an Aerochamber® with mouthpiece 1. Shake the metered-dose inhaler and remove the cap. 2. Remove the cap on the Aerochamber® and insert the mouthpiece of the metered-dose inhaler into the opening at the end of the Aerochamber®. 3. Put the Aerochamber® mouthpiece in your mouth, making sure there are no air leaks. Check that you haven't covered the small holes on each side of the mouthpiece with your lips. Breathe normally into the spacer. 4. Push down on the canister of the metered-dose inhaler to allow the medication to enter the Aerochamber®, then inhale slowly and deeply for about three to five seconds. At the end of this inhalation, hold your breath for as long as you can. If you have trouble breathing deeply and holding your breath, inhale and exhale normally into the Aerochamber® three or four times. 5. Repeat steps 1-4 for as many times as prescribed. Wait one minute between each inhalation. NB: While you are inhaling the medication, you should see the valve open through the transparent chamber. Figure 11 HOW TO USE AN AEROCHAMBER® WITH MOUTHPIECE

35

Using an Aerochamber® with mask The instructions for using an Aerochamber® for infants or young children are slightly different. Instead of having a mouthpiece which is held in the mouth, the spacer is equipped with a mask that is placed against the child's face. Steps 1 and 2 are the same as for the Aerochamber® with mouthpiece. 3. Apply the mask to the child's face so that there are no leaks between the child's face and the mask. The valve should open with the child's breathing. 4. Push down on the canister of the metered-dose inhaler to allow the medication to enter the Aerochamber® and let the child breathe normally into the device five or six times (if the child is over eighteen months), or eight to ten times (if the child is under eighteen months), so that the medication can be absorbed. The child may complain and not cooperate during the first few attempts. However, even if the child is crying, the medication will be absorbed very well provided that you apply the Aerochamber® firmly. Your attitude is very important when you administer medication to a child using a spacer. You should be firm but gentle, so that the child will understand that this is not a punishment but a treatment that cannot be refused. Most importantly, try to distract the child with a story, a TV program, games, riddles, etc. If you do so, the child will quickly come to enjoy the treatment and will cooperate more often. NB: You should check that the valve has opened - if not, the child is not receiving any medication. On the old model of Aerochamber® you cannot see the valve, but you will see the mask membrane move. Figure 12 HOW TO USE AN AEROCHAMBER® WITH MASK

36

Maintenance Clean the mouthpiece or mask and the spacer about once a week by running warm water over it. You should also clean it if you see deposits within the chamber. The average life span of an Aerochamber® is one year, or as long as the valve remains flexible and closed. Dry-powder inhalers Another way of taking medication is to use a dry-powder inhaler. These contain medication in powder form, which you inhale with inspiration (breathing in). They are particularly useful for people who find it difficult to use MDIS, but they may be recommended to others as well, depending on your doctor's preference. Some dry-powder inhalers are single-dose devices, while others are multi-dose (i.e., do not have to be reloaded each time you take the drug). The Spinhaler® (not described) is a single-dose powder inhaler used to take Intal®.

Rotahaler® The Rotahaler® is a single-dose powder inhaler. Medication administered using a Rotahaler® is not propelled by an outside force: it enters the lungs when you inhale. Insert a capsule containing the medication into the Rotahaler®. Split open the capsule by turning the cylindrical cartridge, then inhale the medication, keeping your lips tightly closed around the mouthpiece, and hold your breath as for the metered-dose inhaler. This device is not recommended for children under twelve years of age. Figure 13 HOW TO USE A ROTAHALER®

37

Diskhaler® The Diskhaler® is a multidose powder inhaler (eight doses). As with the Rotahaler®, medication taken using a Diskhaler® is not propelled by an outside force: it enters the lungs on inhalation. It can be used by patients as young as five, as long as they are not having an acute attack. There are two dosages of Ventodisk® (200 and 400 |xg per shell), and two of Beclodisk®, with a third expected soon (100, 200, and soon 400 fjig per shell), corresponding to one and two, and one, two, and four inhalations of Ventolin® and Beclovent®, respectively. (The Diskhaler® is not available in the United States.) Figure 14 HOW TO USE A DISKHALER®

1. Remove the cover. 2. Remove the Diskhaler® cartridge by pressing the sides inward.

38

3. Place the treatment disk on the white rotating disk. 4. Slide the cartridge into the Diskhaler® case. 5. Turn the disk until you can see the figure 8 through the window. 6. Holding the Diskhaler® completely flat, lift the cover panel of the case to pierce the two sides of the shell. Once the shell has been pierced, close the cover. 7. Exhale and bring the Diskhaler® to your mouth, making sure that your mouth is not covering the air hole in the mouthpiece. 8. Inhale through your mouth as quickly and as deeply as possible. 9. Hold your breath for as long as possible. If any powder is left in the shell, take another breath. 10. Before the next inhalation, pull the cartridge in and out again. Repeat steps 6 through 9. Maintenance Clean powder deposits from all the parts of the Diskhaler® with the brush provided in the case each time you change the disk, or wash them off with hot water. The Diskhaler® should be dry before next use. Turbuhaler®

As with the other dry-powder inhalers, the medication taken using the Turbuhaler® enters your lungs when you inhale. The Turbuhaler®, like an MDI, will work effectively at a lower rate of inhalation than the Rotahaler® and Diskhaler®, which is an advantage for users who are weak or for other reasons unable to inhale at a high speed. The powder in a Turbuhaler® is so fine that you may not even taste or feel anything while inhaling it. The Turbuhaler® can be used by children as young as three, as long as they are not having an acute attack. The two drugs that can be taken using the Turbuhaler do not contain any additives, unlike other powder medications.

39

Figure 15

HOW TO USE A TURBUHALER®

1. Unscrew and remove the cap. 2. Hold the Turbuhaler® in an upright position and turn the base to the right, then back to the left until you hear it click. 3. Put the mouthpiece between your lips and inhale deeply through your mouth. Remove the Turbuhaler® from your mouth and hold your breath for 10 seconds. 4. Repeat the operation for the prescribed number of inhalations. 5. Replace the cap.

Maintenance The mouthpiece must be cleaned two or three times a week. Remove it by lifting it with your thumb. Clean the inside of the mouthpiece with a dry cloth. As you use up the medication, a red mark appears in a small window below the mouthpiece. The Turbuhaler® is empty when the red mark reaches the bottom edge of the window. Nebulizers Nebulizers are machines that vaporize (nebulize) drugs, using either compressed air or ultrasound. The resulting vapour, a fine mist, is inhaled from a mask that fits over the nose and mouth (Fig. 16), though it can also be inhaled through a mouthpiece. Nebulizers are used for asthma patients, mainly very young children, who are not able to take an inhaled drug by any of the other means available. They are also used to treat severe asthma attacks in the emergency room or elsewhere in hospital.

40

It is important to read the instructions that accompany each device and to use it according to your doctor's instructions. Abuse of bronchodilators is dangerous: if your asthma or your child's can no longer be controlled, you should consult your doctor immediately and not rely only on nebulizer treatments.

Figure 16 NEBULIZER

BRONCHODILATORS Bronchodilators open the bronchi by relaxing the muscles that surround them. They do not affect asthmatic inflammation of the bronchi. Bronchodilators only relieve asthma symptoms or delay the effects of respiratory irritants or exercise on the bronchi for a few hours. INHALED BRONCHODILATORS "Short-acting" adrenergic agents (sympato-mimetics) or beta-2 agonists United States

Great Britain

Generic name

Canada

Salbutamol, albuterol (us)

Ventodisk®P200or400jjLg

Ventolin® Rotacaps

Ventodisk®

VentoIin®MDi100n,g

Ventolin®

Ventolin®

Proventil®

Cobutolin® Aerolin® Asmavent® Ventide® Salbulin®

Terbutaline

Bricanyl® P 500 (jig

Fenoterol

Berotec®MDi 100

Procaterol

Pro-Air® MDI 10jjLg

Brethaire®

Bricanyl® Berotec®

Bitolterol

Tornalate®

Pirbuterol

Maxair®

Note: Dosages and types of inhalers may differ from one country to another. MDI = metered-dose inhaler P = powder device

41

Inhaled "short-acting" adrenergic bronchodilators are the drugs of choice for treatment of asthma symptoms. They provide fast relief in less than 10 minutes and their effect lasts from four to six hours. Side-effects The main side-effects are tremors (shakiness) and palpitations (rapid or irregular heartbeats), in proportion to the dose taken. How do I take them? Inhaled short-acting adrenergic bronchodilators are usually taken "on demand." The aim is to use your inhaled bronchodilator as little as possible: if you need to use it regularly, particularly more than two to three times per day, it usually means that your asthma is inadequately controlled (though severe asthma may require these doses). What precautions should I take? If side-effects occur, you should decrease or space out the dose and advise your doctor. If you regularly need to use these drugs more than two or three times a day, you should consult your doctor. Figure 17 ADRENERGIC BRONCHODILATORS

42

Older products like Alupent®, Metaprel®, Aleudrin®, Isuprel®, Norisodrine®, and Brontisol® have been replaced by the ones named above. These newer drugs cause far fewer side-effects, and their effects last longer. Long-acting inhaled bronchodilators A new category of long-acting inhaled adrenergic agents has been developed recently, including formoterol and salmeterol. Salmeterol is now on the market in Great Britain and the United States, and both drugs should soon be available in Canada. They have a prolonged bronchodilator effect (more than 12 hours). The role and appropriate use of these new medications are still being determined, but doctors presently consider them to be most useful to patients who are suffering from bothersome asthma symptoms, particularly at night, even with what should be sufficient anti-inflammatory treatment. They are not for "quick relief" of acute asthma and are recommended for use together with an anti-inflammatory asthma medication. GENERIC NAME

CANADA

UNITED STATES

GREAT BRITAIN

Salmeterol®

Serevent® MDI 25 IJLQ P 50 ^g*

Serevent®

Serevent®

Formoterol®

Foradil®MDi12jjig*

Foradil®*

*Should be marketed soon. MDI = metered-dose inhaler

REMEMBER:

Take one inhaled bronchodilator such as Ventolin® or Ventodisk®, Berotec®, Brethaide®, Bricanyl®, Pro-Air®, Proventil®, or Tornalate® as needed to relieve coughing, wheezing, chest tightness, and shortness of breath, but at the lowest frequency possible. (See also "Criteria for satisfactory asthma control" on pages 56-7.) You can also use these drugs to prevent asthma attacks (15 minutes before exercising or exposure to cold air or respiratory irritants).

43

A controversy surrounding adrenergic agents Recent studies have suggested that taking short-acting adrenergic drugs (also called beta-2-agonists) either regularly (at high doses) or too frequently may be linked to an increased risk of severe asthma. While these observations have yet to be confirmed, it is preferable to use these drugs only when you need them and to consult a doctor or follow the adjustments indicated in the action plan if your need for a bronchodilator increases. The situation for the new long-acting bronchodilators (salmeterol and formoterol) is different, as they are usually prescribed for regular twice-daily use in conjunction with a bronchial anti-inflammatory drug. You should discuss the use of these drugs with your doctor. Anticholinergic drugs Ipratropium and oxitropium (Atrovent® and Oxitropium) are bronchodilators that act through a different mechanism than adrenergic agents. They have been reported to be especially useful for elderly patients whose asthma is accompanied by chronic bronchitis or for people who do not tolerate other bronchodilators well. They can also be added to other medication in certain cases of severe asthma. They do not act as vigourously or as quickly as inhaled adrenergic agents. Side-effects

Side-effects are rare. Dryness of the mouth is the most common; other possible side-effects include blurred vision if the aerosol comes in contact with the eyes, tremors or palpitations, and urinary retention in elderly men. GENERIC NAME

CANADA

UNITED STATES

GREAT BRITAIN

Ipratropium

Atrovent^Moi 20 |xg

Atrovent®

Atrovent®

Atrovent® 250 p-g/ml for nebulization Oxitropium MDI = metered-dose inhaler

44

Atrovent6 forte

Oxitropium

NB: If you suffer from glaucoma or increased pressure in the anterior chamber of the eye, you must avoid any contact of these drugs with the eyes, because this could increase your intraocular pressure. If you have this problem and take Atrovent® with a metered-dose inhaler, put the mouthpiece into your mouth and close your lips around it while inhaling. If you take the drug by nebulization, make sure the mask fits snugly on your face.

Figure 18

ANTICHOLINERGIC BRONCHODILATOR

How do I take them? On a regular basis, as prescribed. Normally, if both Atrovent® and an adrenergic bronchodilator are prescribed, Atrovent® is used a few minutes after the other bronchodilator. What precautions should I take?

In case of side-effects, reduce the dose and call your doctor. BRONCHODILATORS IN TABLET FORM Theophylline

There are more than 100 drugs that include theophylline; a few of the most frequently used ones follow. GENERIC NAME

CANADA

UNITED STATES

GREAT BRITAIN

Theophylline

Theodur®

Theodur®

Theodur®

Aminophylline

Theolair®

Theolair®

Oxtriphylline

Phyllocontin®

Phyllocontin®

Phyllocontin®

Quibron-T/SR®

Quibron T/SR®

Biophylline®

Somophylline® 12

Somophyllin-CRT®

Prevent®

Tedral SA®

Choledyl-SA®

Lasma®

Choledyl SA®

Slo-Bid

Nuelin®

Theobid®

Slophylline®, etc.

Note: Drugs in the table above do not necessarily correspond to those of other contries appearing on the same horizontal line, or to the generic name on the same line. Dosages of the same drug may also differ from one country to another.

45

The bronchodilating effect of these drugs is proportionate to their concentration in the blood: to be effective, they must be taken regularly. The two most-used types are those with effects that last for 12 or 24 hours. In Canada, only one 24-hour theophylline (Uniphyl®) is available; in the United States, there are two (Uniphyl® and Theo-24®).

Side-effects Side-effects are caused by either too high a concentration of the drug in the blood or the patient's inability to tolerate it. The most frequent side-effects are nausea, vomiting, headaches, diarrhea, irritability, and insomnia. It has been reported that these drugs cause learning disorders in children and depression in adults, although this has been controversial. Heart problems and convulsions can occur in some cases of overdose. Therefore, choosing an appropriate dose and frequent monitoring of blood theophylline levels are very important. How do I take them? You should take 24-hour-acting theophylline drugs around 6 P.M. Take 12-hour forms at breakfast and at dinner, particularly if they cause digestive problems, or as close as possible to 12 hours apart.

What precautions should I take? Some drugs can increase blood theophylline levels and cause side-effects. If you need to take stomach medication such as cimetidine, or antibiotics such as erythromycin or ciprofloxacin, you should inform your doctor. REMEMBER:

The different forms of theophylline must be taken regularly to be effective. Their concentration in the blood must be monitored at regular intervals. Theophylline sometimes causes side-effects (gastro-intestinal problems, headache, nervousness, etc.). These side-effects must not be ignored; if you experience them, consult your doctor so that your treatment can be adjusted.

46

If you experience side-effects from theophylline, do not ignore them: consult your doctor promptly. Adrenergic agents (sympathomimetics): syrups or tablets Product names Ventolin®, Volmax®, Alupent®, Brethine®, Bricanyl®, Metaprel®, or Proventil®. Adrenergic drugs are less effective in syrup or tablet form than in inhaled form and their side-effects (agitation, palpitations, etc.) are more severe. These drugs are therefore rarely prescribed now except for young children with very mild asthma.

B R O N C H I A L ANTIINFLAMMATORY DRUGS STEROIDS (CORTICOSTEROIDS, CORTISONE DERIVATIVES) Inhaled steroids reduce bronchial inflammation and the production of mucus. They bring asthma back under control, while inhaled bronchodilators only provide relief of acute symptoms. Inhaled steroids gradually decrease symptoms and the need Figure 19

LOW-CONCENTRATION INHALED STEROIDS

47

for bronchodilators, which indicates that the bronchi are less likely to close up. The effects are not immediate, and the drugs act gradually. Normally their effects appear 24 to 48 hours after the first use and peak two weeks later, although a continuing improvement may be observed over many months. Low-concentration inhaled steroids GENERIC NAME

CANADA

UNITED STATES

GREAT BRITAIN

Bedomethasone

Beclovent® MDI 50ng

Bedovenf

Becotide®

Vanceril® MDI 50 jig

Vanceril®

Becotide Rotacaps®

Bedodisk«P100or200(ig

Bedodisk®

Budesonide

Pulmicort®P100jji,g

Pulmicort®

Triamcinolone

Azmacort® MDI 200 (i,g

Azmacort®

Flunisolide

Bronalide® MDI 250 (j,g

AeroBid*

Fluticasone

Fluxotide® Decadran respihaler*

Dexamethasone MDI = metered-dose inhaler

P = powder device

High-concentration inhaled steroids GENERIC NAME

CANADA

Bedomethasone

Becloforte® MDI 250 |j,g

UNITED STATES

GREAT BRITAIN Bedoforte® Becotide Rotacaps®

Budesonide MDI = metered-dose inhaler

Pulmicort®P200or400(j,g

Pulmicort®

P = powder device

Side-effects

At the usual doses, inhaled steroids cause few side-effects, even when they are taken over a prolonged period of time. It is important to know that at regular doses they do not produce the same side-effects as steroid tablets. The principal side-effects are voice changes (reversible) and mild fungal infections of the mouth and throat (known as thrush or candidiasis). If these infections occur, you can treat them effectively by gargling with an antifungal agent However, they are less likely to appear if you rinse your mouth with water after taking the medication, or take it before a meal. In the case of young children who cannot rinse their mouths adequately, having them drink 48

something after taking the medication will have the same effect. At doses of 1,000 fig/day or above (or more than 400 jjug/day for children), absorption by the body can be significant, although usually with minimal side-effects. If side-effects do occur, they are clearly less than those produced by steroid tablets. Your doctor will prescribe this level of dosage if low doses are not sufficient to control your asthma, or for a short period if your asthma becomes worse. Fear of potential side-effects should not prevent or discourage you from treating your asthma adequately. Unstable asthma is much more dangerous.

Figure 20 HIGH-CONCENTRATION INHALED STEROIDS

Note: Pulmicort® is now available in a nebulizing solution (see the description of a nebulizer on p. 00), at 250 and 500 mg/ml.

How do I take them? Inhaled steroids are given at a dosage appropriate to the symptoms and must be taken regularly to be effective. They are usually used twice daily, although some people require them four times daily. It has been suggested recently that once a day (in the late afternoon or evening) may be sufficient for some patients whose asthma is stable, particularly if they are taking a low dose. Inhaled steroids can be used on their own. However, you can use an inhaled bronchodilator 5 to 10 minutes before inhaling steroids if inhaling them induces a cough or shortness of breath (though this rarely occurs). REMEMBER:

Inhaled steroids are currently among the drugs that best stabilize asthma. They act locally on the airways and absorption by the body is low. At low doses they are safe, and even at high doses their side-effects are minimal compared to steroid tablets. However, it is important that you rinse your mouth with water (and spit the water out) after inhaling steroids to avoid thrush (a relatively harmless fungal infection, which should, however, be treated properly), and to reduce absorption of the drug. For inhaled steroids to be effective, you must take them on a regular basis. Changes in steroid dose are required if asthma worsens or improves, and you should discuss this with a physician. 49

Steroid tablets GENERIC NAME

CANADA

UNITED STATES

GREAT BRITAIN

Prednisone

Deltasone® 5 and 50 mg

Deltasone®

Decortisyl®

Meticorten®

Econosone®

Medrol®

Medrone®

Methylprednisolone Prednisolone

Medral® 4 mg

19

Delta-cortef

Deltacortril® Deltastab® Precortisyl® Prednesol®

Oral steroids are the most powerful anti-asthma drugs, but because of their side-effects after prolonged use, doctors reserve them for patients whose asthma symptoms cannot be treated with other drugs. If you must take oral steroids for long periods of time, the doctor will determine the minimum dose required, and may prescribe it to be taken every second day (you take it one day, but not the next) to reduce side-effects. Steroid tablets are also often prescribed for short periods of time when asthma worsens severely. Side-effects If you take this medication for only a few days, it will usually cause few problems. When the drug is taken only for a short time, the main possible side-effects are an increase in appetite, mood swings, and digestive disorders. It may also cause an increase in blood sugar in diabetics, or high blood pressure in hypertensive patients. Long-term side-effects depend on the dose used, how often it is taken (every day or every second day), and for how long. These side-effects also vary from one person to another. Oral steroids can produce weight gain (with salt and water retention), stomach upsets, ulcers, acne, and slow growth in children. They can also promote infections, diabetes or hypertension, osteoporosis (bone demineralization), cataracts, and psychological changes, and cause skin to bruise easily.

50

Even if the side-effects of steroid tablets are more numerous and more serious than those of other asthma drugs, it is important to remember that the goal of asthma treatment is to eliminate or reduce symptoms as much as possible and to ensure a good quality of life. For some people with asthma, it is impossible to avoid using this type of medication. What precautions should I take? If you need to take steroid tablets over several weeks or months, your doctor will review your needs regularly to determine the minimum dose required to control asthma. He or she will also suggest the regular use of a high dose of inhaled steroids, four times a day, to try to reduce the dose of steroid tablets. Oral steroids should never be stopped rapidly after long-term me, because this creates a risk of withdrawal symptoms, such as fatigue, weakness, nausea, fever, joint pain, a drop in blood pressure, or even, in serious cases, shock (cardiovascular collapse). Cardiovascular collapse can be fatal if not treated immediately.

REMEMBER:

Steroid tablets are presently the strongest and most effective asthma drug. However, you must take them only as prescribed, because of the many side-effects that they can cause when taken for prolonged periods. If your asthma gets seriously worse, your doctor will generally prescribe them for a few days or weeks. They will usually cause few or no side-effects. If you have severe asthma, steroid tablets may be prescribed for longer periods. In such cases, you should ideally wear identification (such as a Medic-Alert bracelet) and let doctors and dentists know that you use steroids on a regular basis. Whether the treatment is short- or long-term, you should take tablets strictly according to the prescription, with breakfast. Never stop these drugs or reduce the dose except according to your doctor's instructions.

51

If you use steroids or have taken them in recent months, you should inform any doctor or dentist, especially in case of surgery, serious physical injury, an accident, etc. (If you are taking steroids, your body produces less natural cortisone and won't produce enough to deal with severe physical stress - so you will require a higher dose of steroids to deal with these situations.) If you use oral steroids regularly, it is safer to wear a Medic-Alert-type bracelet carrying that information. Your diet should be low in salt and fat, but rich in calcium unless there are contraindications to it Steroid tablets are usually taken at breakfast, to facilitate their absorption and to imitate the normal rhythm of the body's own secretion of cortisone. NON STEROIDAL BRONCHIAL ANTI-INFLAMMATORY DRUGS (CHROMONE DERIVATIVES) GENERIC NAME

Cromoglycate

Nedocromil

CANADA

UNITED STATES

GREAT BRITAIN

Intal MDI 1 mg

Intal®

Intal®

Intal Spincaps® P 20 mg/capsule for inhalation

Intal Spincaps® for inhalation

Intal Spincaps®

Intal® 10 mg/ml for nebulization

Intal® for nebulization

Tilade® MDI 2 mg

Tilade8

8

Tilade®

Note: Doses refer to the content of one inhalation of the medication. MDI = metered-dose inhaler P = powder device

These drugs come in metered-dose inhalers, but Intal® is also available as a dry powder (Intal Spincaps®, for use with either the Intal Spinhaler® or Halermatic® single-dose dry powder inhalers) or a solution for nebulization. In young children, Intal® can be administered using a nebulizer. These drugs are especially useful in preventing exercise-induced asthma or for reducing the effects of allergen exposure on airways. Some asthma patients might also benefit from taking this type of drug regularly to improve their asthma control. The effect of this medication on asthma varies and cannot be predicted from one person to the next. Consequently, doctors

52

should prescribe it initially on a trial basis for at least four to six weeks. If it is used in an attempt to reduce oral steroid dosage, a three-month trial may be required.

Figure 21 TILADE® AND INTAL®

Side-effects These drugs cause few side-effects. They can cause coughing on inhalation. Some people don't like the taste of Tilade®. How do I take them ? If you are taking one of these drugs because of allergic exposure or exercise-induced asthma, take the medication 10 to 20 minutes before undertaking physical activity or coming into contact with an allergen. You can use the medication every three to four hours if exposure to the allergen continues. (However, you should avoid continued exposure as much as possible.) If you are taking the drug to stabilize asthma, you should take two inhalations of it four times a day. If you are taking the drug by nebulization, take one ampoule (2 ml) three to four times a day (check this with your doctor). What precautions should I take? If taking these drugs produces a cough or shortness of breath, you can use an inhaled bronchodilator 5 to 10 minutes beforehand (as for inhaled steroids). REMEMBER:

Cromoglycate and nedocromil are bronchial anti-inflammatory agents that are used especially to prevent asthma caused by allergies or exertion. When these drugs are used regularly, they can also help to control asthma symptoms, and sometimes make it possible to reduce the dose of inhaled or oral steroids or replace low doses of inhaled steroids. However, their effectiveness varies from one person to the next. These drugs have very few sideeffects.

53

OTHER DRUGS The following drugs are sometimes used to treat asthma and associated problems. ANTIBIOTICS Product names These products have different names (penicillin, Amoxil®, Bactrim®, DoxyCaps®, Septra®, Septrin®, Biaxin®, Vibramycin®, etc.), according to the antibiotic they contain. Antibiotics do not treat asthma itself, but can be useful in treating a bacterial infection of the respiratory airways (sinusitis, bronchitis, pneumonia, etc.). They are ineffective against viral infections. Side-effects The most frequent side-effects are allergies (mainly causing skin rashes), upset stomach, nausea, diarrhea, and vaginitis. Some antibiotics (ciprofloxacin and erythromycin) can increase the level of theophylline in the blood (see page 46). If you take a theophylline, inform any doctor who prescribes antibiotics for you. How do I take them? You should take antibiotics regularly for the time period specified by your doctor. If you experience side-effects, consult a doctor immediately. REMEMBER:

Antibiotics do not act on asthma. However, they fight bacterial infections like sinusitis, bronchitis, and pneumonia, which could make your asthma worse. Antibiotics must be taken for the whole period indicated unless side-effects (allergies, diarrhea, etc.) appear. If you experience side-effects, you should consult your doctor immediately.

54

ANTIHISTAMINES Antihistamines such as Claritin®, Hismanal®, Reactine®, and Seldane® do not act on asthma but are used to relieve allergy symptoms of the eyes and nose. They can be a useful source of relief for allergy symptoms, but you should be aware of the contraindications and possible side-effects. See appendix 8, "Allergic Rhinititis and Conjunctivitis," for a full account of these drugs. ZADITEN® The role of Zaditen® in asthma treatment has yet to be determined. This drug, which acts like an antihistamine, is taken orally in the form of tablets or syrup, on a regular basis. (It is not available in the United States.) Some doctors feel that it may have an effect on bronchial inflammation. In Canada, it is only authorized for use in children. Its side-effects include sleepiness and an increase in appetite. It can be used by children with mild asthma who cannot use an inhaled drug.

C O N T R O L L I N G YOUR ASTHMA LEVELS OF ASTHMA TREATMENT The following stages provide an overview of the different levels of treatment corresponding to the severity of asthma. They are only general guidelines: treatment should be adjusted for each individual by the physician. They are based on the recommendations of an "International Consensus Report on the Diagnosis and Meanagement of Asthma" (see page 110). Level 1: mild asthma Your doctor will prescribe an inhaled bronchodilator (see pages 41-3), to be taken as needed. Note: There is an increasing tendency to use bronchial antiinflammatory drugs earlier in asthma treatment. Antiinflammatory agents are now considered as first-line drugs for the control of asthma, while inhaled bronchodilators are 55

only used as "rescue medication" if troublesome symptoms develop, and then at the lowest possible dose. Level 2: moderate asthma If symptoms occur regularly and if you need to use an inhaled bronchodilator daily, your doctor may add a low-dose inhaled steroid (cortisone derivative) (see pages 48-9), or cromoglycate (Intal®) or nedocromil (Tilade®) (see pages 52-3). Level 3: moderately severe asthma If the above treatment is inadequate to control asthma, you will need to use a higher dose of inhaled steroids, with or without additional drugs such as one of the theophyllines, ipratropium (Atrovent®), cromoglycate (Intal®), nedocromil (Tilade®) (see pages 45-7, 44-5, and 52-3), or a long-acting adrenergic bronchodilator (see page 43). Level 4: severe asthma If the above treatment is inadequate, your doctor will add a steroid (cortisone derivative) in pill form at a minimum dose (see pages 50-2). Note: 1. Asthma, even the most severe, can be treated effectively and should not prevent an active lifestyle 2. Treatment of asthma should be individualized and the treatment plan must be determined by your doctor. CRITERIA FOR SATISFACTORY ASTHMA CONTROL Controlling your asthma means • leading a normal life and being able to exercise; • having minimal or no troublesome symptoms and needing to use an inhaled bronchodilator only occasionally - not more than twice a day (or even, ideally at least for a mild asthmatic, not more than three times a week); • not being woken up by asthma symptoms; • achieving a good peak expiratory flow rate, as established by your doctor. 56

If you measure your peak expiratory flow rate, your readings should • match or be close to the best results you have obtained; • not vary by more than 20% over the day (the ideal daily variation is less than 10%). The above criteria for controlled asthma are achievable for most people with asthma. If this is not possible for you, you may need a stronger treatment. If, despite changing the treatment, it is still not possible, you and your doctor will determine the best result you can expect to achieve and will try to maintain that state using appropriate treatment. This means that a person who has more severe asthma should • have a minimum of symptoms; • need to use his or her inhaled bronchodilator no more than four times a day with a minimum of side-effects; • obtain good peak expiratory flows. WHEN SHOULD THE TREATMENT BE CHANGED? Signs of asthma worsening It is essential that you recognize the signs and symptoms that indicate that your medication must be modified according to an established action plan or after consulting your doctor. The symptoms that indicate that asthma is no longer under control are • coughing, wheezing, shortness of breath and more frequent tightness in the chest, especially at night or on waking in the morning; • thoracic depression during inspiration (breathing in) and rapid breathing in young children • a greater need to use an inhaled bronchodilator; • the onset of a cough that produces mucus; • greater difficulty in exercising or carrying out daily activities; • a drop in peak expiratory flow measurements. If any of these signs appear, you must adapt your treatment immediately according to the prescribed action plan. If you do not know what to do, consult your doctor, who will modify your treatment. 57

Degrees of asthma worsening Slight worsening Exercise or respiratory irritants trigger symptoms more easily, and lead to the more frequent use of an inhaled bronchodilator. Peak expiratory flow measurements drop below 85% of the best results obtained, for a period of more than 24 hours. Moderate aggravation Symptoms occur on slight exertion, an inhaled bronchodilator is needed more than four times a day, and sleep is disturbed by asthma during the night or early in the morning. Peak expiratory flow measurements drop to close to 60% of the best results obtained, for a period of more than 24 hours. Severe aggravation Symptoms occur at rest or on slight exertion. Relief obtained by using an inhaled bronchodilator lasts less than four hours. Peak expiratory flow measurements drop to 50% or less of best results. ACTION PLAN

You should discuss an action plan with your doctor in case your asthma worsens or becomes severe. Generally, the plan will involve increasing your medication in one or two steps, depending on the current level of your asthma and the degree of worsening. Your doctor should determine the action plan and you should understand exactly how to use it.

ACTION PLAN If your asthma does get worse, it is important • to change the medication quickly according to your doctor's instructions; 58

• to measure your peak expiratory flow regularly (if you normally check your PEFR) • to improve your environment • to consult a doctor immediately if your asthma continues to worsen. It is particularly important to consult a doctor immediately when • • • • • •

changes in medication do not appear to be effective; you have a fever; mucus becomes thick or discoloured; the medication causes side-effects; peak expiratory flow rates do not improve; or you do not know what to do. If your asthma becomes severe, see a doctor immediately. Your action plan must include

• your current medication; • criteria, based on symptoms or peak expiratory flow measurements, that indicate that you should change your medication or consult a doctor; • instructions on how to modify your medication (type of drug and how often to take it) if your asthma worsens. If your doctor prescribes steroid tablets to take if your asthma becomes much worse, he or she will indicate • when you must begin that treatment and at what level of symptoms or peak expiratory flow; • how many tablets you must take each day and how many days you must take them for; • how to taper the dose. Different types of action plans have been developed by national Lung Associations or Thoracic Societies. Your doctor can suggest one of those plans, or one developed locally. The following is an example of an action plan.

59

Figure 22 EXAMPLE OF AN ACTION PLAN IF YOU USE A PEAK FLOW METER, FOLLOW THESE INSTRUCTIONS

Expected flow (PEFR): ^25 over litres/minute If your peak expiratory flow drops repeatedly (during 24 hours) below ^ 25 adjust your medication as described in step 1 below.

GENERAL RECOMMENDATIONS

Always keep a completed form of this guide with you. Do not forget to take your medications regularly as prescribed. If you develop undesirable sideeffects, call your doctor.

PATIENT'S RECORDS

Name:. File no.: Physician* Physician's telephone: Physician on duty:

NOTES: (allergies, etc) Asthma clinic:

If there is no improvement or if your peak expiratory flow drops below -3OQ act quickly as described in step 2.

Resource-person:

If there is rapid deterioration and/or your peak expiratory flow drops below 2.SO call for help immediately (doctor, Emergency).

*May be your respirologist, internist, allergist, or family doctor.

CURRENT TREATMENT

Medication

Dose (number of puffs or tablets)

Number of times/day

ADJUSTING YOUR MEDICATION IF YOUR ASTHMA WORSENS

If, during a 24-hour period, •you need to use your bronchodilator inhaler more than TU'L£ per day; •you wake up during the night or early in the morning because of respiratory symptoms (coughing, wheezing, shortness of breath, etc.); •you find it difficult to carry out your daily activities because of your asthma; •your medication appears to be less effective: 1. Adjust your treatment as follows: for 7* days or until your asthma is under control, then gradually reduce your medication to your usual dose. 2. If you experience no improvement or if your condition deteriorates, 3. If you experience a severe and/or rapid deterioration, call for help as quickly as possible (your doctor, Emergency). NB: If you notice greenish mucus with or without fever related to your deteriorating condition, consult a doctor immediately.

60

Review

MEDICATION* 1. Which inhaled bronchodilator do you use? a) Does it cause side-effects? Yes D

No D

2. Do you use your inhaler as illustrated on pages 32 to 40?

Yes LJ No D 3. Do you take a bronchodilator in tablet form? Yes LJ No D If you answered yes, answer the following questions: a) What is it called? b) Does it cause side-effects, and if so which ones? digestive disorders D nausea D insomnia LJ agitation D palpitations D headaches D none LJ 4. Do you use an inhaled steroid? Yes D

No D

If yes, answer the following questions: a) Do you use a low-dose inhaled steroid? D

high-dose? D

b) What is it called? c) Do you rinse your mouth after using it? Yes D If yes, why?

No LJ Yes

No

To prevent throat irritation. To prevent candidiasis (thrush) in the throat. d) What does this drug do? It provides relief from asthma attacks. It stabilizes asthma. It prevents asthma attacks. 5. Have you ever taken or are you taking steroid tablets? Yes D

No D

If yes, answer the following questions: a) Are you afraid of these products? Yes D

No LJ

b) If yes, why?

61

6. Have you been able to identify all your asthma drugs? Yes D

No D

If no, write out the names of those drugs.

MANAGING ASTHMA 7. Is your asthma well controlled? Yes U

No D

To verify that your asthma is adequately treated, answer the following questions: a) Does your asthma wake you up at night? Often Lj

Rarely L

Never U

Only during a cold or flu LJ

b) Does your asthma wake you up early in the morning? Often U

Rarely U

Never D

Only during a cold or flu [II

c) Do you need to take an inhaled bronchodilator? Rarely D Less than twice a day L More than four times a day D

More than twice a day U

d) Do you have bronchial secretions (mucus or phlegm)? Often n

Rarely LJ

Never D

8. Do you have an action plan?

Only during a cold or flu U Yes D

No U

If yes, answer the following questions: If your asthma worsens, what is the first step? a) Which medication should you increase or introduce? b)To what dose should you increase it? c) How many times per day should you take it?

NOTE "Answers to these questions are found on pages 97-8

62

d) How long should you keep up this increase in medication? If no, read the description of an action plan on pages 58-9.

C H A P T E R

5

A Healthy Lifestyle and Asthma Up to now we have discussed what asthma is, and how to assess its severity. We talked about measuring peak expiratory flow, about the importance of your environment, about asthma drugs and how to use them. You must also be aware of how your lifestyle affects your asthma, and, consequently, how it affects your quality of life. It is important that your lifestyle be healthy, which means, physically, that you keep in shape by following the suggestions in this chapter, and, psychologically, that you accept your asthma and gain the support of those close to you. A healthy lifestyle reduces the need for medication and may reduce the number of restrictions. DIET You can achieve a healthy diet by following a few basic principles. First, eat three meals a day that include foods from the four food groups in Canada's Food Guide to Healthy Eating (see figure 23). Second, maintain a healthy weight. Your body mass index (BMI) gives you a good idea of how much you should weigh to be healthy. However, the BMI is not accurate when applied to anyone under the age of 20, to adults over 65, to pregnant or nursing women, or to very muscular people, such as athletes. See figure 24 for how to calculate your BMI. Third, restrict your intake of the following: • fat; • salted foods and salt (basically, you should settle for the seasoning added in cooking and not add more salt at the table); • concentrated sugar (sugar and candy) and foods high in sugar; give preference to complex carbohydrates (cereals, rice, pasta) and high-fibre foods (fruit, vegetables, whole grains).

63

Figure 23 THE RECOMMENDATIONS OF CANADA'S FOOD GUIDE

5-12* servings per day

Children (age eleven or younger): 2-3 servings per day

2-3 servings per day

5.10 servings per day

Adolescents and pregnant or breast-feeding women: 3-4 servings per day Adults: 2 servings per day * The amount of food you need each day depends on your age, size, and activity level, and on whether you are male or female (and, if you are female, on whether you are pregnant or breast-feeding). For example, an active male teenager might choose the highest number of servings from each food group, while a child might need the lowest number. Most other people would fall somewhere in between.

FLUIDS Since our bodies are made up mostly of water, it is important to drink plenty of fluids. An adequate intake of fluids is one litre (one quart, or four good-sized glasses) or more per day, depending on weather conditions and amount of exercise. During a cold or flu, it is important to drink more water this replaces the water you lose through bodily functions like sweating and eliminating wastes (which increases when you are ill), prevents dehydration, and helps secretions to liquefy. If you do drink alcohol, do it in moderation.

64

Figure 24 HOW TO CALCULATE YOUR BMI

HOW TO FIND YOUR BMI 1. Mark an X at your height on Scale A. 2. Mark an X at your current weight on Scale B. 3. Draw a line to join the two Xs. 4. Extend this line to Scale C. Your BMI is where the line meets Scale C.

:

FOR EXAMPLE:

• If Jim is 180 cm (5'11") tall and weighs 85 kg (187 Ibs), his BMI is about 26. • If Louise is 160 cm (5'3") tall and weighs 60 kg (132 Ibs), her BMI is about 23. Less than 20: A BMI of less than 20 may contribute to health problems in some people. You should probably consult a dietician or your doctor. From 20 to 25: This BMI range represents the lowest risk of disease for most people. If you fall within this range, stay there! From 25 to 27: A BMI in this range is sometimes linked to health problems in some people. You should be more careful about your daily eating and exercise habits. Over 27: A BMI over 27 is linked to a higher risk of health problems such as heart disease, high blood pressure, and diabetes. You should probably consult a dietician or your doctor.

IF YOUR BMI IS UNDER 20 OR OVER 27... It is time to reduce your risk of developing health problems. Most importantly, you should understand why you are not in your healthy weight range. Consult a dietician or your doctor.

Source: Expert Group on Weight Standards, Health and Welfare Canada

65

SLEEP Try to get enough sleep. The number of hours required varies from person to person. Sleep helps the healing process, so it is especially important if you have been ill or under stress. If you suffer from insomnia, the relaxation methods on pages 67-8 might help you. CAN I STILL EXERCISE?

Asthma sufferers often avoid exercise to prevent triggering bronchospasm. (It is recognized that about 75% of asthma patients experience respiratory symptoms on exertion.) However, if you have asthma, you should practice some form of physical activity on a regular basis in order to • • • •

increase your tolerance for exertion; improve your heart and lung function; maintain a healthy weight; help you handle everyday stress.

You should choose activities that are suited to your abilities. The more severe your asthma, the more likely it is that exercise will cause symptoms. Consequently, you must take precautions. Most asthma sufferers can exercise without difficulty by using their inhaled bronchodilator (e.g., Berotec®, Pro-Air®, Bricanyl®, or Ventolin®) 15 minutes before exertion. If this is not enough to allow you to exercise without troublesome symptoms, you should speak to your doctor, who might determine that • your asthma is not being adequately treated, especially if the same level of exercise did not cause symptoms previously; • your physical fitness is low due to lack of exercise; • you need to use Intal® or Tilade® before exercising, in addition to your inhaled bronchodilator. Obey the following general rules: • Discuss exercise with your doctor. • Choose a suitable activity. 66

• • • •

Exercise regularly. Go at your own pace and follow a progressive program. Avoid exercising in poor conditions (very cold or polluted air). Plan a warm-up period before exercising and a cool-down period afterwards. WHICH SPORTS ARE BEST FOR ME?

The sports most often recommended to asthmatics are swimming and activities that require a gradual effort or are played indoors (as long as the room is clean and dust-free). Bicycle riding and skiing (particularly cross-country skiing) are excellent in good weather. However, it is always best to go with another person. You should avoid sports that are violent or dangerous, sports that require intensive or fast effort, sports practised far from medical services, and those that can expose you to allergens to which you are sensitized. No one with asthma should scuba dive: it can cause serious respiratory complications. It is better to speak to your doctor before starting a new sport.

RELAXATION Daily stress is a triggering factor for asthma in many patients. It is not known how this happens, but each person reacts differently to emotional tension. Under stress, some people suffer from migraines, insomnia, or panic, while people who are susceptible to stomach problems develop stomach ulcers. Some asthma sufferers experience more symptoms when they are under stress. There are many physical and psychological techniques for overcoming stress. Physical Techniques There are many different relaxation techniques. One of the simplest is listening to your favourite music and imagining yourself in a pleasant setting. It's up to you to choose the activity best suited to you and to practise it regularly. Several weeks may pass before you notice the benefits of a chosen relaxation technique. The better you learn it, the sooner you will feel its good effects. Joining a relaxation group is a good way to start on a relaxation program. 67

Check your local recreation centre or the health and community service centre in your area for sessions on relaxation techniques. While joining a group is probably the most effective way to get started, there are also many good tapes available - some leading you through particular techniques, some providing music or sounds from nature that help you to relax. Muscle relaxation Muscle relaxation is a good way to combat stress and to give yourself high-quality periods of rest. It involves relaxing groups of muscles while breathing deeply and regularly. Conscious breathing Conscious breathing, or pursed-mouth breathing, is a method of regulating your breathing (slowing down and deep-breathing in a controlled manner). It may help when you feel tense or out of breath after physical exertion, or at the onset of an attack while you are preparing your inhaler, although its benefits are still unproven. Conscious breathing means breathing in slowly through your nose and then breathing out while keeping your lips pursed (as if you were whistling or blowing out a candle) for twice as long as you breathed in. You must repeat the exercise several times. Physical exercise Besides keeping you in shape, physical exercise relieves stress and helps you relax. See the preceding section on exercise for some practical suggestions. Psychological Aspects* NOTE * This section, adapted with permission from the Asthma Education Handbook, by Gillian Browne © Department of Health Promotion and Education, Royal North Shore Hospital, Sydney, Australia, 1990, is also addressed to members of the immediate family (parents or spouse) of anyone with asthma.

68

Accepting your disease Like any other chronic disease, asthma can change your perception of yourself. Some people with asthma experience a loss of self-esteem. This can lead them to deny their illness and to refuse treatment. By denying that you have asthma and not managing it adequately, you risk a deterioration in your health and possibly a decrease in your quality of life.

People with asthma generally do not have any trouble accepting their disease when treatment is keeping it under control. It is during asthma attacks or when their condition worsens that some experience denial, fear, anger, or depression. These feelings are normal and can arise in any person faced with a difficult life situation. It is not easy to adapt to a chronic disease, but understanding it and forcing yourself to accept it are essential first steps to being able to control it. The same holds true for parents and siblings of children with asthma. Your ability to communicate (asserting yourself) We communicate with others every day, and the way we do so affects our life and theirs. To understand how you communicate, answer the following questions: Yes No

1. When cigarette smoke bothers you, do you tell the smokers around you? 2. When you don't want visitors to smoke in your home, do you ask them not to? 3. When you don't understand your doctor's instructions, do you ask him or her to explain them again? 4. If you had to go to Emergency because you were having an asthma attack and they asked you to wait, would you insist on being examined immediately? 5. If your asthma becomes worse and that worries you, do you tell the people close to you? If you answered "Yes" to these questions, you have the ability to express your needs freely. It is important to be able to communicate your feelings and thoughts in order to care for yourself and prevent your asthma from worsening.

69

Your ability to solve problems What should you do in the following situations? Think about the possible options. Do you have enough information to make a decision? If you find some of the questions difficult to answer, or you have other questions, you should discuss them with your doctor. Yes

No

1. Do you know what to do if your asthma gets worse and you are unable to contact your doctor? 2. Do you take your inhaler with you when you go out? 3. Do you use your inhaler before exercising because exercising triggers your asthma? 4. Do you avoid visiting relatives who have a pet that you are allergic to? 5. When you feel the first signs of a cold or flu, do you quickly increase your medication if necessary? 6. Do you consult your doctor or your action plan rapidly when your asthma becomes unstable? 7. When your asthma is stable, do you discuss what to do with your doctor, rather than quickly reducing your asthma medication? 8. If you have side-effects from a drug you take, do you consult your doctor promptly? 9. If your drug dose is increased following a deterioration of your asthma and you see no improvement, do you contact your doctor immediately? 10. Do you use your inhaler in front of other people when you need to? If you did not answer "Yes" to all of these questions, you should discuss the "Nos" with your doctor. Don't forget that by taking precautions, you can control your asthma better. If you have any doubts, consult a health professional. 70

Family support Asthma can sometimes cause anxiety for people with asthma and their families and friends. This may be caused by prejudices surrounding the disease. During an attack, family members may feel helpless or confused about what treatment is needed. It helps if your family and friends become better informed about asthma and its treatment. You can ask them to • encourage you and provide support; • not smoke or expose you to other respiratory irritants or substances to which you are allergic; • remain calm and help you during an attack; • know where your medication and action plan are kept; • recognize the signs that your asthma is deteriorating and know what to do if that happens; • know your doctor's telephone number and encourage you to call the doctor early if your asthma deteriorates rapidly or if it does not respond to treatment.

71

Review

A HEALTHY LIFESTYLE AND ASTHMA* Yes

1. Is your body mass index (BMI) between 20 and 25? 2. How many glasses of fluids do you drink each day? 3. Do you exercise regularly? If yes, answer the following questions: a) Do you have difficulty exercising because of your asthma? b) Do you use your inhaled bronchodilator before exercising? 4. Do you have trouble managing your breathing and your anxiety during an asthma attack? 5. Have you spoken to your spouse or your family and friends about your treatment and your action plan? 6. Have you answered the questions on problem solving?

NOTE "Answers to these questions are found on page 98.

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No

Appendices

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APPENDIX 1 MYTHS AND CONTROVERSIES

Answer the questions below and check your answers on the next page. True False 1. Asthma is a common disease. 2. Asthma mostly affects young people. 3. Asthma drugs are habit-forming. 4. Asthma is hereditary. 5. Asthma can rarely be cured. 6. Asthma can be fatal. 7. Asthma is caused by emotions. 8. Asthma and asthma drugs cause heart problems. 9. Asthma makes you prone to chronic bronchitis and emphysema.

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1. Asthma is a common disease. True Asthma is the main chronic disease in children and one of the commonest in adults. It is estimated that at least 5 to 10% of people will show signs of asthma during their lifetime. 2. Asthma mostly affects young people. False About half of asthma patients first experience asthma as adults; there is no age limit for this disease. 3. Asthma drugs are habit-forming.

False

The drugs used to treat asthma are not habit-forming. They also continue to be effective even after you have used them for a long time. If they appear to be becoming less effective, it is generally because the level of asthma treatment is no longer adequate. 4. Asthma is hereditary. True and false People are not born with asthma, but they can inherit a certain tendency to develop the disease. A hereditary tendency to develop asthma seems to be linked to a tendency to have allergies. 5. Asthma can rarely be cured. True We do not know the cause of asthma yet. It is a chronic disease whose symptoms can be controlled. Once asthma has been stabilized through treatment, it can sometimes disappear, at least for a while, although in most people medication will still be required to keep asthma symptoms under control. 6. Asthma can be fatal. True This is a rare occurrence, but over the last twenty years there has been an increase (although a slight one) in the number of deaths attributable to asthma everywhere in the world. About 2 out of every 100,000 people die of asthma each year, although the rate varies from country to country. Most of the people who die underestimated their disease and were either not treating it properly or not treating it at all.

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7. Asthma is caused by emotions.

False

Emotions do not cause asthma but they can trigger asthma symptoms, just like certain other factors such as cold air, exertion, dust, etc. Asthma sufferers tend to react to stress with a bronchospasm, in the same way that people who are ulcer-prone react to stress by developing ulcers in the lining of their stomach or small intestine. 8. Asthma and asthma drugs cause heart problems. False People with asthma do not usually run any risk of heart disease because of their asthma or the drugs they take. Heart disease can occur in people with severe asthma that is not being properly treated, or if asthma drugs are taken at overly high doses, particularly over a long period of time, and especially by a person who has an underlying heart condition. 9. An asthma sufferer is prone to chronic bronchitis and emphysema. False It is important to distinguish asthma from emphysema and chronic bronchitis. Unlike asthma, these two diseases are almost always caused by smoking, and are usually irreversible.

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AP P E N D I X 2

EMPHYSEMA AND CHRONIC BRONCHITIS Emphysema

In certain people, the toxic products in tobacco smoke can progressively destroy the small air sacs (alveoli). The lungs then lose their elasticity and the bronchi collapse easily. Breathing becomes increasingly more difficult over the years; shortness of breath is the main symptom of the disease. Bronchodilators are less effective in emphysema than in asthma. Chronic bronchitis

Chronic bronchitis is almost always caused by smoking and can be aggravated by respiratory infections and air pollution. People who suffer from it have chronic inflammation of the bronchi and increased production of bronchial secretions. The bronchial glands secrete an abnormal quantity of mucus, which accumulates in the bronchi and promotes infection. People with chronic bronchitis have a characteristic daily cough with greyish sputum. Over time, their bronchi become irreversibly obstructed and they become chronically short of breath, though this may improve with treatment and giving up smoking. People can have chronic bronchitis and emphysema at the same time. They can sometimes have asthma as well as one or both of these diseases; however, asthma does not cause chronic bronchitis or emphysema.

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APPENDIX 3 ASPIRIN INTOLERANCE

Some people with asthma are "aspirin intolerant" Taking aspirin or its derivatives can cause severe symptoms in these asthma patients, symptoms which can even develop into a major asthma attack. If your doctor has diagnosed aspirin intolerance, you should take the following precautions. 1. Avoid all drugs containing aspirin (acetylsalicylic acid or ASA), such as Aspirin®, Alka Seltzer®, Anacin®, Bufferin®, Coricidin®, Dristan®, Entrophen®, Fiorinal®, Instantine®, Novahistex®, Percodan®, 222®, etc., as well as certain nonsteroidal anti-inflammatory drugs used to treat arthritis or other muscular or joint problems such as Feldene®, Indocid®, Motrin® (ibuprofen), Nalfon®, Naprosyn®, Orudis®, Toradol®, Voltaren®, etc. (You can consult your pharmacist or doctor for a more complete list of these compounds.) Note that many types of drugs contain aspirin: these include drugs for pain, flu, and arthritis. 2. If you need drugs for pain or fever, you can use an analgesic (pain reliever) that contains acetaminophen (Tylenol®, Tempra®, Atasol®, Exdol®, or Robigesic®). Acetaminophen should not produce reactions like those caused by aspirin. However, the first time you use these drugs, you should take half a tablet to check your tolerance. 3. If you take an aspirin accidentally and have difficulty breathing, tightness in the chest, nasal congestion, or redness of the skin, call a doctor immediately or go to Emergency right away. 4. As a precaution, do not use any over-the-counter (nonprescription) drug unless your doctor has told you that you can take it. You should inform any doctors, surgeons, pharmacists, and dentists you deal with that you are aspirin intolerant. You should also wear a warning bracelet (MedicAlert type) that says "Intolerant (or allergic) to aspirin."

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Nasal polyps

We do not know why, but there is an "aspirin triad," an association between nasal polyps, aspirin intolerance, and asthma. If you have both asthma and nasal polyps, you must be considered potentially intolerant to aspirin and may have severe asthmatic reactions to this drug and its derivatives. Nasal polyps are accumulations of inflammatory tissue that obstruct the nasal passages. It is not known why certain people are prone to polyps, but they are probably not caused by allergies. Polyps can be treated with inhaled cortisone or, if they become a serious obstruction, with oral cortisone or surgery, but they tend to recur even after treatment.

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AP P E N DI X 4

ASTHMA AND DIABETES

If you suffer from both asthma and diabetes, and need to use oral steroids (steroid tablets) or steroid injections, your blood sugar level may rise and your dose of insulin or oral hypoglycemic drug may need to be adjusted temporarily. Inhaled steroids do not have any significant effect on blood sugar levels. However, while you are taking steroid tablets or injectable steroids, it is important to measure sugar levels in your urine and blood regularly.

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APPENDIX 5 ASTHMA AND SURGERY

You will need to take certain precautions if you have asthma and must have surgery. You should tell the doctor or surgeon about each of the following: • that you take steroid tablets to control your asthma. This is very important, because you will need increased doses of steroids before and during the operation. • what drugs you take, how stable your asthma has been in the last few weeks, and any allergies you have; • any side-effects caused by your current medication; • any difficulties you have had during past operations; • if your sputum has been coloured in the last few days; • whether you measure your peak expiratory flow rate. If so, show tracings and results from the last few days or weeks to the doctor, especially if there has been a recent drop. Before your operation, the anaesthetist will visit you and will ask a number of questions. Ideally, a pulmonary function test before surgery will determine the degree of your bronchial obstruction and the stability of your asthma. When patients with asthma have satisfactory respiratory function and the necessary preparations are made, they generally do not experience any more complications from the anaesthetic than other people undergoing surgery. Local anaesthetics generally do not affect breathing unless they cause an allergic reaction. Whether the anaesthetic you are given is local or general will depend on the kind of operation and the severity of your asthma. Medication after surgery

Aspirin and other anti-inflammatories should be avoided, because these drugs can sometimes cause asthma attacks. However, your doctor will determine which drug to treat pain is best for you. You can take your inhalation drugs as usual before and after surgery. 82

AP P E N DI X 6

ASTHMA DURING PREGNANCY AND BREAST-FEEDING

The goals of asthma treatment during pregnancy do not differ from those of regular treatment. To reduce the frequency of side-effects in both the mother and the fetus, the mother's asthma must be treated with a minimum of drugs. However, her symptoms must be well controlled to avoid the development of severe asthma attacks, which could reduce the amount of oxygen supplied to the fetus. How does asthma affect pregnancy?

Generally, asthma has no significant harmful effect on pregnancy unless it is severe or uncontrolled. However, women with asthma must be monitored more closely by their doctors during pregnancy. If you are pregnant, you must tell your doctor you have asthma and which drugs you use. How can a pregnancy affect asthma?

During pregnancy, asthma improves in about one-third of women, remains unchanged in another third, and becomes more severe in the last third. The effects are unpredictable from one woman to the next and from one pregnancy to the next. Pregnancy and asthma medication

Inhaled adrenergic drugs (such as Ventolin®, Proventil®, Berotec®, Bricanyl®, Brethaide®, Pro-Air®) No cases of birth defects have been reported. If you need your inhaled bronchodilator more than two or three times per day, check your action plan or consult your doctor. Steroids Inhaled steroids (Azmacort®, AeroBid®, Beclovent®, Becloforte®, Pulmicort®, Vanceril®, etc.) No birth defects have been reported.

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Steroid tablets (prednisolone, prednisone, etc.) If you need them for severe asthma, you can take steroid tablets safely. You must take the lowest dose that will control your symptoms appropriately, as determined by your doctor. If your condition permits, your doctor may suggest taking one dose every two days to try to reduce side-effects. Women taking these drugs seem to have a slightly higher number of premature babies and newborns with low birth weight. Intal® (cromoglycate) No significant effects on the fetus have been described. Tilade® (nedocromil) Probably does not cause significant side-effects; however, as far as we know, no studies have been conducted to date. Theophylline No birth defects have been reported. However, theophylline, in its various forms, easily crosses the placenta into the baby's system. The fetus tolerates these drugs in the doses normally used to treat asthma, but can be affected by high doses. Therefore, it is important that your doctor monitor your blood levels and that both of you recognize the symptoms of excessive theophylline in the blood. Other drugs you should avoid during pregnancy (partial list only always check with your doctor or pharmacist)

Some antibiotics Tetracyclines cause delays in growth and discoloured teeth in children. (You should also avoid other antibiotics such as aminoglycosides, sulfamides, and quinolones.) Aspirin (acetysalicylic acid, ASA) Can cause bleeding in the mother and the fetus, can trigger asthma attacks in women who are aspirin-intolerant, and may increase the length of the pregnancy and labour.

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Certain antihistamines and decongestants Can cause birth defects (see appendix 8). Iodines (found in certain cough syrups) Can affect the thyroid gland in the fetus. Flu shots May cause fever or allergic reactions that can be harmful. Certain prostaglandins (sometimes used to induce labour) Can cause asthma attacks. Immunotherapy (allergy shots) Should not be started during pregnancy, but can generally be continued if your doctor feels that they are beneficial (see appendix 8).

Asthma and delivery

If you need an anaesthetic, a local one is preferable. If necessary in a long labour, steroids and theophylline can be given intravenously. Asthma and breast-feeding

Theophylline Gets into breast milk and can make the baby irritable. Inhaled bronchodilators and inhaled steroids Do not appear to cause side-effects. Steroid tablets Taken at high doses, can interfere with growth and the natural production of corticosteroids in children. Antihistamines Should be avoided, because they can cause sleeplessness and irritability in children. Moreover, they can reduce or prevent the production of breast milk.

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AP P E N DI X 7

OCCUPATIONAL ASTHMA

Occupational asthma is asthma induced by exposure to a "sensitizing" agent in the workplace. Such an agent may also increase the severity of pre-existing asthma (measured by airway responsiveness and medication needs). The sensitizing agent increases bronchial reactivity and the severity of the asthma. There are over 200 recognized substances that can cause occupational asthma. The most common, and some of the fields in which they are used, include isocyanates (the manufacture of paint hardeners, plastics, and foam insulation), red cedar dust (carpentry, door- and window-frame manufacturing), flour (baking), shellfish (the crab processing industry), and psyllium powder (nursing, where it is prepared as a laxative for patients). At the moment, it is difficult to predict which people are likely to develop occupational asthma. The diagnosis is confirmed by measuring peak expiratory flow and bronchial reactivity both in and outside the workplace, or by bronchial provocation tests in a specialized laboratory, where the effects of exposure to the substance that is suspected of affecting respiratory function will be measured for periods as long as 8 to 10 hours, and compared to the effects of "control" substances. As soon as the diagnosis is confirmed, exposure to the substance must stop or the asthma will continue to worsen.

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AP P E N DI X 8

ALLERGIC RHINITIS AND CONJUNCTIVITIS

Allergic rhinitis is an inflammation of the mucous membrane that lines the inside of the nose. This inflammation resembles that found in the bronchi of patients suffering from allergic asthma, and the two conditions often occur together. Rhinitis also often accompanies conjunctivitis, the inflammation of the conjunctiva, the membrane that covers the eyes and the inside of the eyelids; this is called rhinoconjunctivitis. It may result from hay fever, or from exposure to other irritants. Rhinoconjunctivitis involves edema (swelling) of the nasal mucous membrane and an increased production of nasal secretions. Symptoms include a runny nose, itchiness, sneezing, and eye irritation with red and watery eyes. Allergic rhinoconjunctivitis is a physical reaction of the body to contact with certain substances to which a person has become sensitized (against which that person has developed antibodies). When the substance to which a person is allergic comes into contact with the antibodies present in the nasal mucous membrane or the conjunctiva, the cells release chemicals, including histamine, that trigger the inflammatory reaction and cause the symptoms mentioned above. Allergens such as pollen are seasonal, but dust, moulds, animals, and certain insects can cause rhinitis throughout the year. People who tend to be allergic may react to any of the common allergens present in the air, and are usually allergic to several of these. There are also cases where rhinitis or conjunctivitis does not have an allergic cause. These are called vasomotor rhinitis or non-allergic rhinitis or conjunctivitis. Treatment 1. Control of the environment

Avoiding relevant allergens is the most important factor.

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2. Antihistamines GENERIC NAME

CANADA

UNITED STATES

GREAT BRITAIN

Loratadine

Claritin®

Claritin®

Claritin®

Astemizole

Hismanal®

Hismanal®

Hismanal®

Cetirizine

Reacting®

Reactine®

Zirtek®

Terfenadine

Seldane®

Seldane®

Triludan®

The more recent drugs, such as Claritin®, Hismanal®, Reactine®, Seldane®, etc., may act for up to 24 hours. An antihistamine called livostin® (generic name levocabastine) recently became available in Canada both as eye-drops and as a nasal inhaler. None of these drugs act on asthma itself, but they can all be useful to treat accompanying rhinoconjunctivitis. Side-effects

Recent forms of these drugs cause little or no drowsiness or mouth dryness compared to their predecessors. Arrhythmia (rapid and/or irregular heartbeat) has recently been reported in some people using Seldane® and Hismanal®. These problems seem rare and (with Seldane®) happened to patients who had liver function abnormalities, who overdosed, or who were also using Nizoral®, a drug used to treat some yeast infections, or erythromycin, an antibiotic. Different cardiac problems have also been described with Hismanal®, but at higher doses than those usually prescribed. You should not use Seldane® if you have a heart condition (unless specified by your doctor), hepatitis or liver damage (such as that from chronic alcoholism), or a metabolic disorder (electrolyte imbalance), or if you are taking Nizoral® (ketoconazole or drugs with related molecular structures), Diflucan® (fluconazole), Flagyl® (metronidazole), or erythromycin (or drugs with related molecular structures).

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You should not take Hismanal® if you have a metabolic disease (electrolyte problems) or take erythromycin or Nizoral (ketoconazole or drugs with related molecular structures). If you have a heart condition, you should check with your doctor before taking Hismanal®. We recommend that you consult a doctor before taking either of these two drugs. Never take more than the indicated dosage. How do I take them?

Regularly, when the symptoms of rhinoconjunctivitis (sneezing, runny nose, itchy and watery eyes, etc.) are uncomfortable. REMEMBER: Antihistamines do not act on asthma. They are used to relieve allergy symptoms of the eyes and nose. Antihistamines such as Claritin®, Hismanal®, Reactine®, Seldane®, etc., cause little or no drowsiness or dryness of the mouth. 3. Inhaled nasal steroids GENERIC NAME

CANADA

UNITED STATES

GREAT BRITAIN

Beclomethasone

Beconase® MDI or MAP

Beconase®

Beconase®

Vancenase® MDI

Vancenase®

Fluticasone

Flonase® MAP

Triamcinolone

Nasocort® MDI

Nasocort®

Flunisolide

Rhinalar® MAP

Nasalide®

Budesonide

Rhinocort® P

Syntaris® Rhinocort®

MDI = metered-dose inhaler MAP = metered atomizing pump P = powder device These drugs gradually reduce inflammation of the nasal mucous membrane.

These drugs gradually reduce inflammation of the nasal mucous membrane. Side-effects

These drugs are either not absorbed by the body, or absorbed only to a minor degree. However, they can cause nosebleeds.

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If this happens, you should stop taking the drug or reduce the dose, and consult your doctor. How do I take them ?

It is better to blow your nose before taking these steroids, because the presence of nasal secretions makes the drug less effective. You must take these steroids on a regular basis at first; then your doctor will reduce the dose gradually to the minimum necessary to eliminate symptoms. REMEMBER:

Inhaled nasal steroids do not have a direct effect on asthma. They are used for treating allergic or non-allergic rhinitis. However, effective treatment of rhinitis may help, along with the other treatments, to maintain asthma control. Nasal steroids must be taken regularly to be effective. If you get nosebleeds, stop taking the steroid or reduce the dose, and consult your doctor.

4. Cromoglycate

Rynacrom® (for the nose) and Opticrom® (for the eyes) are used mostly to prevent allergy symptoms. 5. Immunotherapy ("allergy shots")

Immunotherapy (desensitizing vaccines or allergy shots) is usually reserved for allergic rhinitis caused by pollen and for where it is most valuable, treating life-threatening allergies to insect venom. Given the new developments in this field, it may hold promise for the future treatment of asthma. However, at this point immunotherapy is considered by many to be of questionable benefit in asthma treatment.

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AP P E N DI X 9

TRAVELLING

1. Never leave for a trip while your asthma is unstable. 2. Ask your doctor to define an action plan in case your asthma flares up. In certain situations, you may want to carry a supply of prednisone, and perhaps of antibiotics. 3. While travelling abroad, never stop taking your regular medication, even if your asthma seems better. 4. Bring extra medication and a letter signed by your doctor explaining the need for those drugs. 5. If you use a peak flow meter, carry it to help assess your asthma control. 6. You should also carry an action plan written and signed by your doctor.

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A P P E N D I X 10 ALTERNATIVE MEDICINE

If you experiment with alternative forms of medicine (acupuncture, homeopathy, etc.), do not stop your current treatment; that could be dangerous. Some asthma patients who have interrupted their prescribed medication to try an alternative form of medicine without medical supervision have experienced severe asthma attacks. You can use alternative medicine in addition to regular medical treatment, but it is neither a solution nor a replacement. Very few serious studies exist on the effects of these treatments on asthma, and the results to date have not shown significant benefits. If you wish to experiment with alternative medicine, be objective and record your symptoms and peak expiratory flow rate regularly during the treatment.

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APPENDIX11

RESOURCES Hospitals

Keep a list of telephone numbers for your doctor, the Emergency department, and the clinic you usually attend. Asthma, Allergy and Lung Associations

Canada Allergy/Asthma Information Association 30 Eglinton Ave. West Suite 750 Mississauga, ON L5R3E7 Asthma Society of Canada P.O. Box 213, Station K Toronto, ON M4P2G1 Canadian Lung Association 1900 City Park Drive Suite 508 Blair Industrial Park Gloucester, ON K1J 1A3 Alberta Lung Association Box 4500 Edmonton, AB T6E6K2 Allergy and Asthma Association of Alberta 205 - 9th Avenue S.E. Suite 826 Calgary, AB T2GOR3 British Columbia Lung Association 2675 Oak Street Vancouver, BC V6H2K2

Manitoba Lung Association 629 McDermot Avenue Winnipeg, MB R3A1P6 New Brunswick Lung Association Victoria Health Centre 257-65 Brunswick Street Fredericton, NB E3B 1G5 Newfoundland Lung Association P.O. Box 5250 93 Water Street St. John's, NF A1C 5W1 Nova Scotia Lung Association 17 Alma Crescent Halifax, NS B3N 3E6 Ontario Lung Association 573 King Street East Suite 201 Toronto, ON M5A4L3 Prince Edward Island Lung Association 65 McGill Avenue Charlottetown, PE C1A2K1

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Quebec Lung Association 4837 Boyer Suite 100 Montreal, PQ H2J 3E6 or 1173CharestW. Suite 240 Quebec City, PQ GIN 2C9 Saskatchewan Lung Association 1231 8th Street East Saskatoon, SK S7H 085 United States American Academy of Allergy and Immunology 611 East Wells Street Milwaukee, WI53202 American Allergy Association P.O. Box 7273 Menlo Park, CA 94026 - 7273 American College of Allergy and Immunology 800 E. Northwest Highway Suite 1080 Palatine, IL 60067-6516 American College of Chest Physicians 3300 Dundee Road Northbrook, IL 60062 American Lung Association National Headquarters 1740 Broadway New York, NY 10019 Asthma and Allergy Foundation of America 1717 Massachusetts Avenue N.W. Suite 305 Washington, DC 20036

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Asthma Care Association of America P.O. Box 568 Spring Valley Road Ossining, NY 10362 Asthma Project National Heart, Lung and Blood Institute (NHLBI) National Institutes of Health Building 31, Room 4A21 9000 Rockville Pike Bethesda, MD 20205 Mothers of Asthmatics, Inc. The National Allergy and Asthma Network 10875 Main Street Suite 210 Fairfax, VA 22030 Greaf Britain Asthma Research Council 12 Pembridge Square London W24EH England British Thoracic Society 1 St. Andrews Place London NW1 4LB England Australia and New Zealand National Asthma Campaign 5th Floor, 615 St. Kilda Road Melbourne, Victoria 3004 Australia Thoracic Society of Australia and New Zealand 145 Macquarie Street Sydney, NSW 2000 Australia

A P P E N D I X 12 ANSWERS TO REVIEW QUESTIONS

The respiratory system and asthma

1. Diaphragm 2. Alveoli 3. Bronchi 4. Bronchial muscles For a better description of the parts of the lung, reread the section on the respiratory system (p. 5). 5. b) bronchospasm, d) bronchial inflammation, e) secretions. Reread "What is asthma?" (pp. 7-8). 6. Compare your symptoms with those described in the section on symptoms and physical signs (p. 8). Note that not all asthma sufferers experience the same symptoms or have them to the same degree. 7. Peak flow meter See the section on measuring your peak expiratory flow rate (p. 11). A peak flow meter is a device that allows you to measure the severity of your asthma objectively by indicating how open or closed your bronchi are, and consequently helps to determine your need for medication. 8. a), b), and c). You can measure your peak expiratory flow rate every day during a cold or flu, when drug doses are changed, the week before visiting your doctor, and if your asthma is difficult to control. We also recommend that you take a peak flow meter on trips, in case your asthma gets worse. Some asthma patients have difficulty recognizing that their airways are partially closed (bronchoconstricted). Measuring your PEFR may help you to assess your level of pulmonary function.

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9. True. Even if it is difficult to predict how asthma will develop from one patient to another, studies tend to show that if asthma is properly treated, the chances are good that it will remain stable and improve over time. This is why we emphasize prevention through appropriate environment, correct drug dose, prompt adjustment of treatment if your condition changes, peak flow measurements, and good communication with your doctor. The triggering factors

1. If you are regularly exposed to one of these animals or allergens at home or while visiting friends, talk to your doctor about the possibility of having allergy tests. Exposure to one or more animals or allergenic substances can cause your asthma to worsen, even if you don't feel it. If you go to a place where there are animals to which you are allergic, you would benefit from taking a preventive drug like Intal® or Tilade® before the exposure. You should also minimize your exposure as much as possible. You can reread the section on allergens (pp. 18-19) for advice on what steps to take if you are allergic to one or more of these substances. 2. If you have any of these items in your bedroom, you can reread the section on dust (p. 21) for advice on what to do with them. 3. After answering this question, you can reread the discussions of mould (pp. 22-3), humidifiers (pp. 23-4), and air pollutants (pp. 24-5) in the section "Non-allergic factors." 4. After answering this question, you can reread the section on air pollutants (p. 25) in the section "Non-allergic factors," regarding different types of heating systems. 5. If you answered "Yes" to a, remember that cigarette smoke is a powerful respiratory irritant It is not easy to quit smoking, but there are many organizations that can help. You can get their names and addresses from the Lung Associations (see appendix 11). 96

If you answered 'Yes" to b, tell smokers about the problems you have because of cigarette smoke. You can reread "Cigarettes and asthma" in chapter 3 (p. 25) and "Psychological aspects" in chapter 5 (pp. 68-70) for suggestions on how to improve your communication skills. Medication

1. Reread the section on bronchodilators (pp. 41-5) to check if you have correctly identified your inhaled bronchodilator and any side-effects. Side-effects from inhaled bronchodilators are rare unless the bronchodilators are not used properly. They act rapidly and are mainly used as needed. 2. If you answered "No" to this question, you can reread the information on pages 32 to 40 and discuss your technique with your doctor. If it appears that you can't use an MDI properly, you should ask your doctor about using a different type of inhaler. 3. If you use a bronchodilator in tablet form and have sideeffects, consult your doctor. You can reread the information on pages 45-7. 4. Check your answers by rereading the sections on inhaled steroids (pp. 47-9). It is important to rinse your mouth or brush your teeth after using these steroids to avoid a sore throat and candidiasis (thrush). If you have problems with these side-effects or must take high doses, using a spacer can also help. Inhaled steroids have no immediate effect on asthma, but both prevent and stabilize it. These drugs play a fundamental role in action plans in cases where asthma worsens. 5. While oral steroids are known for their side-effects, remember that they are never prescribed casually. Steroids in tablet form are often prescribed to combat a severe deterioration in asthma or to allow patients suffering from severe asthma to lead lives which are as normal as possible. Consult the sections on steroid tablets (pp. 50-2) and action plan (pp. 58-60) for more information. 6. If you had difficulty identifying your asthma drugs, reread all the sections on drugs. 97

7. Reread "Criteria for satisfactory asthma control" (p. 56) and "Signs of asthma worsening" (p. 57). Asthma is a disease that changes; for example, it can become worse after a respiratory infection or exposure to an allergen. Ask your doctor what he or she considers adequate asthma management, and establish an action plan to use if your asthma deteriorates (see answer no. 8, below). 8. It is important to know how and when to change your treatment if your asthma worsens, and when to consult a doctor. You should establish an action plan with your doctor to ensure that you can control your symptoms by adjusting your medication rapidly if your asthma does become worse. A healthy lifestyle and asthma

1. Reread the section on diet (pp. 63-5) for instructions on how to calculate your healthy weight. If your body mass index (BMI) is above or below the ideal, you should follow the suggestions provided in order to achieve it. You should also discuss this with your doctor. 2. Remember to drink plenty of fluids. Under normal conditions, one litre of fluids (one quart, or four glasses per day) is recommended. If your asthma is not stable, it is important to drink more fluids so that you can eliminate secretions more easily. 3. Remember that exercise is recommended for asthma patients. Use a bronchodilator before exercising if exercise brings on asthma symptoms. 4. If you answered "Yes" to this question, you can reread the section on conscious breathing (p.68). 5. You should talk to your family about your respiratory condition and its treatment. The section on "Family support" (p. 71) lists topics to be discussed with family and friends. 6. You should think about the impact of your decisions on your asthma. Depending on whether they are appropriate or not, these decisions can help stabilize your asthma, or cause it to become worse. 98

Figure 7 EXAMPLE OF A DIARY FORM N.B. Indicate the best of 3 consecutive readings:

times a day + if you experience bothersome respiratory symptoms + if you are awakened during the

night with astjhma.

Please note any specific triggering factors or comments on the graph or on the back.

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Figure 7 EXAMPLE OF A DIARY FORM N.B. Indicate the best of 3 consecutive readings:

times a day + if you experience bothersome respiratory symptoms + if you are awakened during the

night with asthma.

Please note any specific triggering factors or comments on the graph or on the back.

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Glossary Accepting your disease

A state of mind in which you deal with your asthma by adopting behaviour that can result in better asthma control.

Short-acting adrenergic agents are usually used as required, while long-acting ones should be taken regularly at the dose prescribed. Airways

Action plan

A sheet of instructions reminding you of how to change asthma medication according to your level of symptoms (and/or peak expiratory flow rates) in order to maintain the best possible pulmonary function with the fewest possible symptoms. The instructions are individualized drawn up for you or your child by the doctor. You should discuss the plan with your doctor so that you understand exactly how to use it. Adrenalin

A hormone that is naturally produced by the body, particularly at times of stress. It is also taken by injection, from a syringe (Ana-Kit®) or a pen (EpiPen®), as a treatment for severe allergic reactions. Adrenergic agent

A type of bronchodilator (a drug that relaxes the bronchial muscles) that acts via the adrenergic (sympathetic) nervous system. Adrenergic agents act rapidly when inhaled. The effects may last 4-8 hours or be prolonged (more than 12 hours).

See bronchi. Allergen

A substance that may cause an allergic reaction (e.g., pollen, dust mites, animal dander). Alveoli

Small air bags near the outer surface of the lungs where oxygen and carbon dioxide are exchanged. Antibiotic

A drug that treats bacterial infection. Antibiotics have no effect on asthma itself. Anticholinergic agent

A type of bronchodilator that acts more slowly than adrenergic agents. An anticholinergic bronchodilator is sometimes used as an "add-on" medication with other asthma medication. Auscultation

Listening to the sounds produced in the lungs with a stethoscope.

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Beta-2-agonist

Candidiasis

A type of bronchodilator that acts via beta-type receptors of the adrenergic (sympathetic) nervous system (see adrenergic agent}.

Also called thrush. A benign fungus infection of the mouth and throat that sometimes results from inhaled steroid use.

Bronchi

Conjunctivitis

Also called airways. They are the tubes of the body that carry air into the lungs. In asthma, the bronchi are inflamed and narrow easily (a condition called bronchoconstriction) .

Inflammation of the eyes caused by either allergy or infection.

Bronchial provocation tests

Tests that measure the degree of responsiveness of the airways by determining how much of an inhaled bronchoconstrictor agent (e.g., histamine or methacholine) will induce a given reduction in pulmonary function (usually a 20% fall in forced expiratory volume in one second -FEVI).

Control of asthma

Asthma control is defined by certain criteria such as the absence of symptoms or minimal symptoms, no waking at night because of asthma, minimal use of bronchodilators for short-term relief ("rescue bronchodilators"), optimal pulmonary function tests, and the ability to carry out normal activities without significant or bothersome sideeffects from the asthma medication. With some preventive measures and adequate treatment, most people with asthma can achieve this.

Bronchodilator

A drug that causes the airways to widen by relaxing the muscles that surround them. Bronchodilators provide temporary relief from asthma symptoms. See also Beta-2-agonist, anticholinergic agent and theophylline. Bronchospasm

Narrowing of the airways because the muscles that surround them have contracted, or because of airway inflammation (swelling of the airway walls).

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Corticosteroids

Drugs that treat inflammation; they are sometimes called "cortisone." Corticosteroids are different from the "anabolic steroids" used by some athletes. They are usually taken in aerosol (inhaled) form, but in severe asthma they may be given as tablets or intravenously. They should be used regularly to be effective. Their effect usually takes a few days to appear (a few hours for the tablet or intravenous forms). They may lead to better control of asthma and reduce symptoms over time.

Cromoglycate

An anti-inflammatory agent taken as an aerosol, which is less powerful than corticosteroids. Its effects vary from one patient to another. It may reduce the asthmatic reaction to an allergen. Diaphragm

The main respiratory muscle, which contracts to allow air to enter the lungs. Eosinophils

A type of cell sometimes found in higher than normal levels in the blood of people with asthma and allergic diseases. When eosinophils are activated in the airways, they are thought to damage the bronchial mucosa and take part in the inflammatory reaction.

in the first second of a forced expiratory manoeuvre. Hay fever

See rhinoconjunctivitis. Histamine

This substance is normally produced by the body, particularly during an allergic reaction. Histamine seems to be mainly responsible for allergic symptoms of the eye and nose (rhinoconjunctivitis). It is also used in bronchial provocation tests to narrow (constrict) the airways slightly in order to determine their responsiveness. Hygrometer

A device used to measure the humidity of the air. Immunotherapy

Expectorations

Phlegm or mucus: any secretions of the bronchial tubes that are coughed up. Forced expiratory manoeuvre

Also called "allergy shots." Immunotherapy consists of repeated injections of small doses of an allergen to which the patient is sensitized, in an attempt to create a tolerance to this allergen.

A test to measure the functioning of the lungs and airways, also called Inflammation spirometry. A forced expiratory A response of the tissues to extermanoeuvre measures the volume of nal irritation or injury. In the airair that can be exhaled from the ways inflammation is characterized lungs in a certain time, such as one by swelling and redness of the airsecond. way mucosa and an increased production of secretions. Forced expiratory volume in one second (FEVI)

Leukotrienes

The maximum volume of air a person can breathe out from the lungs

Natural substances that are involved in inflammatory reactions

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in the body. They may cause constriction of the bronchi, swelling of the bronchial mucosa, and increased production of bronchial secretions. Mediators Natural substances (e.g., histamine, leukotrienes) that are released during inflammatory processes. They are responsible for many of the features of inflammation such as swelling of the mucosa, redness, and production of secretions. Metabisufite See sulfites. Methacholine A substance used in bronchial provocation tests to narrow the airways slightly, in order to determine their responsiveness. Metered-dose inhaler (MDI) A small device used for taking aerosol medication. Monosodium glutamate A food additive used to enhance flavour that can cause asthma or allergy-like reactions, such as the "Chinese restaurant syndrome." Mucus plug An accumulation of thickened bronchial secretions that may block a bronchus. In some people, it may occur when asthma is not under control.

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Peak expiratory flow The maximum speed at which someone can expel air from the lungs. Peak flow meter A device used to measure peak expiratory flow. People with asthma can easily learn to use one of the small, portable models at home. Prednisone A corticosteroid in tablet form, which can be prescribed for a short period of time to control asthma flare-ups, or for longer periods for people with the most severe form of asthma. Pulmonary function tests A series of tests used to evaluate the functioning of the lungs and airways. Rhinitis Inflammation of the nose caused by either allergy or infection. Rhinoconjunctivitis Inflammation of the eyes and nose (featuring itchy and watery eyes, runny nose, and sneezing), commonly called hay fever. Self-management of asthma Knowing enough about the disease and its treatment to control your asthma (or your child's) - see also control of asthma. Self-management includes effective use of medication, proper inhaler technique,

preferably objective measurement of airway obstruction (by using a peak flow meter), and active involvement in treatment, particularly by being able to intervene at an early stage during asthma flare-ups. Self-management is highly recommended as a goal for everyone with asthma, or for the parents of young

Theophylline A type of bronchodilator taken in tablet form: there are many different theophyllines. Some are effective for 12 hours or less, and others for about 24 hours. Thrush See candidiasis.

children with asthma. Spacers Tubes of different sizes that attach to metered-dose inhalers to make it

Triggers Factors that can provoke asthma symptoms.

easier to take aerosol medication properly. Sulfites A group of food additives (particularly metabisulfite). They can cause asthma or severe, occasionally lifethreatening, allergy-like reactions in some individuals. Spirometry The measurement of forced expiratory volume using a spirometer. Sputum Phlegm or mucus: any bronchial secretions that are coughed up. Steroid See corticosteroids. Sympathomimetic A substance that acts via the adrenergic (sympathetic) nervous system. See adrenergic agent.

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Suggested Reading BROWNE, G. Asthma Education Handbook: Learn to Manage Your Asthma. Sydney, Australia: Departments of Patient Education and Thoracic Medicine, the Royal North Shore Hospital of Sydney 1985. 48 pages.

CANADIAN LUNG ASSOCIATION. The Asthma Handbook, by P. Tames. Ottawa: Canadian Lung Association 1993. DOLOVICH, J. You Can Control Cough, Wheeze and Breathlessness. Lachine, Que.: Glaxo Canada 1989. 51 pages.

NATIONAL HEART, LUNG, AND BLOOD INSTITUTE. NATIONAL ASTHMA EDUCATION PROGRAM. Asthma: Reading and Resource List. Bethesda, Md.: National Institutes of Health. - Open Airways/Spiro Abierto: Asthma Self-Management Program. NIH Publication no. 84-2635. Bethesda, Md.: National Institutes of Health 1984. NEWHOUSE, M.T., AND P.J. BARNES. Conquering Asthma: Revised Reprint. Hamilton, Ont: Empowering Press 1994.124 pages.

PLAUT, T.F. Children with Asthma: A Manual for Parents. Amherst, Mass.: Pedipress 1988.291 pages. - One Minute Asthma: What Parents Need to Know. Amherst, Mass: Pedipress 1991. 32 pages. SANDER, N. A Parent's Guide to Asthma: How You Can Help Your Child Control Asthma at Home, School, and Play. New York, N.Y.: Doubleday 1989. SPECTOR, S. AND N. SANDER. Understanding Asthma: A Blueprint for Breathing. Palatine, III: American College of Allergy and Immunology 1990.248 pages.

TAMES, P., J.L. MALO, AND J.H. TOOGOOD. Every Breath You Take. Grosvenor House Press Inc. 1989. 158 pages. Distributed by Astra Pharma Inc. and the Canadian Lung Association. WEINSTEIN, A. Asthma: The Complete Guide to Self-Management of Asthma and Allergies for Patients and Their Families. New York, N.Y.: McGraw-Hill 1987. Useful educational material (books, hand-outs, etc.) can be obtained from Lung or Asthma and Allergy Associations (see their addresses in Appendix 11, "Resources").

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Specialized publications

BRITISH THORACIC SOCIETY. Research Unit of the Royal College of Physicians of London, King's Fund Centre, National Asthma Campaign. "Guidelines for Management of Asthma I-Chronic Persistent Asthma and II-Acute Severe Asthma." British Medical Journal 1990; 301:651-3. BUIST, A.S. "Asthma Mortality: What Have We Learned?" Journal of Allergy and Clinical Immunology 1989; 84:275-83. CROSS, D., AND H.S. NELSON. "The Role of Peak Flow Meters in the Diagnosis and Management of Asthma." Journal of Allergy and Clinical Immunology 1991; 87:120-8. GROSSMAN, J. "The Evolution of Inhaler Technology." Journal of Asthma 1994; 31:55-64. HARGREAVE, F.E., J. DOLOVICH, AND M.T. NEWHOUSE, EDS. "The Assessment and Treatment of Asthma: A Conference Report." Journal of Allergy and Clinical Immunology 1990; 85:1098-1111. "International Consensus Report on the Diagnosis and Management of Asthma." International Asthma Management Project. Clinical and Experimental Allergy 1992; 22 (Suppl. l):l-72.

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INTERNATIONAL PEDIATRIC CONSENSUS GROUP. "Asthma: A Follow-Up Statement from an International Consensus Group." Archives of Disease in Childhood 1992; 67:240-8. NATIONAL HEART, LUNG, AND BLOOD INSTITUTE. International Consensus Report on Diagnosis and Treatment of Asthma. NIH Publication no. 92-3091. Bethesda, Md.: National Institutes of Health 1992.

NATIONAL HEART, LUNG AND BLOOD INSTITUTE. NATIONAL ASTHMA EDUCATION PROGRAM. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 91-3042. Bethesda, Md.: National Institutes of Health 1991. THORACIC SOCIETY OF AUSTRALIA AND NEW ZEALAND. "The Pediatric Asthma Management Plan." 1st ed. Australia 1991. To be used in conjunction with "The Asthma Management Plan." 1st ed. 1990. (A.J. Woolcock, A.R. Rubinfeld, J.P. Scale et al. "Asthma Management Plan, 1989." Medical Journal of Australia 1989; 151:650-3). WARNER, J.O., M. GOTZ, L.I. LANDAU, H. LEVISON, A.O. MILNER, S. PETERSEN, AND SILVEHMAN: "Management of Asthma: A Consensus Statement." Archives of Disease in Childhood 1989; 64:1065-79.