Asthma in Teens and Adults

	Overview
	Health Tools
	FAQs
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When to Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Living With Asthma
	Medications
	Other Treatment
	Other Places To Get Help
	Related Information
	References
	Credits

Is this topic for you?

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

What is asthma?

Asthma causes swelling and inflammation in the airways that lead to your lungs. When asthma flares up, the airways tighten and become narrower. This keeps the air from passing through easily and makes it hard for you to breathe. These flare-ups are also called asthma attacks or exacerbations.

Asthma affects people in different ways. Some people only have asthma attacks during allergy season, or when they breathe in cold air, or when they exercise. Others have many bad attacks that send them to the doctor often.

Even if you have few asthma attacks, you still need to treat your asthma. The swelling and inflammation in your airways can lead to permanent changes in your airways and harm your lungs.

Many people with asthma live active, full lives. Even though asthma is a lifelong disease, treatment can control it and keep you healthy.

What causes asthma?

Experts do not know exactly what causes asthma. But there are some things we do know:

• Asthma runs in families.
• Asthma is much more common in people with allergies, though not everyone with allergies gets asthma. And not everyone with asthma has allergies.
• Pollution may cause asthma or make it worse.

What are the symptoms?

Symptoms of asthma can be mild or severe. You may have mild attacks now and then, or you may have severe symptoms every day, or you may have something in between. How often you have symptoms can also change. When you have asthma, you may:

• Wheeze, making a loud or soft whistling noise that occurs when you breathe in and out.
• Cough a lot.
• Feel tightness in your chest.
• Feel short of breath.
• Have trouble sleeping because of coughing or having a hard time breathing.
• Quickly get tired during exercise.

Your symptoms may be worse at night.

Severe asthma attacks can be life-threatening and need emergency treatment.

How is asthma diagnosed?

Along with doing a physical exam and asking about your health, your doctor may order lung function tests. These tests include:

• Spirometry. Doctors use this test to diagnose and keep track of asthma. It measures how quickly you can move air in and out of your lungs and how much air you move.
• Peak expiratory flow (PEF). This shows how fast you can breathe out when you try your hardest.
• An exercise or inhalation challenge. This test measures how quickly you can breathe after exercise or after taking a medicine.
• A chest X-ray, to see if another disease is causing your symptoms.
• Allergy tests, if your doctor thinks your symptoms may be caused by allergies.

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

How is it treated?

There are two parts to treating asthma. The goals are to:

• Control asthma over the long term. To do this, use a daily asthma treatment plan. This is a written plan that tells you which medicine to take. It also helps you track your symptoms and know how well the treatment is working. Many people take controller medicine—usually an inhaled corticosteroid—every day. Taking controller medicine every day helps to reduce the swelling of the airways and prevent attacks. Your doctor will show you how to use your inhaler correctly. This is very important so you get the right amount of medicine to help you breathe better.
• Treat asthma attacks when they occur. Use an asthma action plan, which tells you what to do when you have an asthma attack. It helps you identify triggers that can cause your attacks. You use rescue medicine, such as albuterol, during an attack.

If you need to use the rescue inhaler more often than usual, talk to your doctor. This is a sign that your asthma is not controlled and can cause problems.

Asthma attacks can be life-threatening, but you may be able to prevent them if you follow a plan. Your doctor can teach you the skills you need to use your asthma treatment and action plans.

How can you prevent asthma attacks?

You can prevent some asthma attacks by avoiding those things that cause them. These are called triggers. A trigger can be:

• Irritants in the air, such as cigarette smoke or other air pollution. Don't smoke, and try to avoid being around others when they smoke.
• Things you are allergic to, such as pet dander, dust mites, cockroaches, or pollen. When you can, avoid those things you are allergic to. It may also help to take certain kinds of allergy medicine.
• Exercise. Ask your doctor about using an inhaler before you exercise if this is a trigger for you.
• Other things like dry, cold air; an infection; or some medicines, such as aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs). Try not to exercise outside when it is cold and dry. Talk to your doctor about vaccines to prevent some infections, and ask about what medicines you should avoid.

Sometimes you don't know what triggers an asthma attack. This is why it is important to have an asthma action plan that tells you what to do during an attack.

Health tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I take allergy shots (immunotherapy) for allergic rhinitis and allergic asthma?
	Actionsets are designed to help people take an active role in managing a health condition.
	How to measure peak expiratory flow
	Identifying asthma triggers
	Taking charge of asthma
	Using a dry powder inhaler
	Using a metered-dose inhaler (MDI)
	Using an asthma action plan

The cause of asthma is not known. Health experts believe that inherited, environmental, and immune system factors combine to cause inflammation of the bronchial tubes, which carry air to the lungs. This can lead to asthma and asthma attacks.

• Asthma may run in families (be inherited). If this is the case in your family, you may be more likely than other people to develop long-lasting (chronic) inflammation in the bronchial tubes.
• In some people, immune system cells release chemicals that cause inflammation in response to certain substances (allergens) that cause allergic reactions. Studies show that exposure to allergens such as dust mites, cockroaches, and animal dander may influence asthma’s development.¹ Asthma is much more common in people with allergies, although not all those with allergies develop asthma. And not all people with asthma have allergies.
• Environmental factors and today's germ-conscious lifestyle may play a role in the development of asthma. Some experts believe that there are more cases of asthma because of pollution and less exposure to certain types of bacteria or infections.² As a result, children's immune systems may develop in a way that makes it more likely they will also develop allergies and asthma.

Asthma in adults also can be related to work (occupational asthma). Being around animals, plastic resin, wood dust, grain dust, insecticides, and metals can cause asthma, usually because your immune system reacts to the material. Some people continue to have asthma symptoms even after they are no longer exposed to what caused the symptoms. But for many people, symptoms will get better or go away when they are away from the asthma trigger.

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

• Wheezing, which is a whistling noise of varying loudness that occurs when the airways of the lungs (bronchial tubes) narrow.
• Coughing, which is the only symptom for some people.
• Chest tightness.
• Shortness of breath, which is rapid, shallow breathing or difficulty breathing.
• Sleep disturbance because of coughing or having a hard time breathing.
• Tiring quickly during exercise.

An asthma attack occurs when your symptoms suddenly increase. Factors that can lead to an asthma attack or make it worse include:

• Having a cold or another type of respiratory illness, especially one caused by a virus, such as influenza.
• Exercising (exercise-induced asthma), especially if the air is cold and dry.
• Exposure to triggers, such as cigarette smoke, air pollution, dust mites, or animal dander.
• Being around chemicals or other substances at work (occupational asthma).
• Changes in hormones, such as during the start of a woman's menstrual blood flow or pregnancy.
• Taking medicines, such as aspirin (aspirin-induced asthma) or nonsteroidal anti-inflammatory drugs.

Many people have symptoms that become worse at night (nocturnal asthma). In all people, lung function changes throughout the day and night. In people with asthma, this often is very noticeable, especially at night, and nighttime cough and shortness of breath frequently occur. In general, waking at night because of shortness of breath or cough indicates poorly controlled asthma.

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

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

Asthma often begins during infancy or childhood but may start at any age and last throughout your life. It can increase your risk for complications from lung and airway infections, such as acute bronchitis and pneumonia.

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

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

• Substances you are allergic to (allergens, such as dust mites or animal dander). Allergens cause long-term (chronic) inflammation and may cause asthma symptoms.
• Environmental factors, such as smoke or cold air. Environmental factors may lead to a tightening of the muscles that line the bronchial tubes (bronchospasm), which can trigger asthma symptoms.

What triggers asthma symptoms varies from person to person. When asthma is triggered by an allergen, it is called allergic asthma.

When asthma symptoms suddenly occur, it is called an asthma attack (also called a flare-up or exacerbation). Asthma attacks can occur rarely or frequently and may be mild to severe. Although some asthma attacks occur very suddenly, many become worse gradually over a period of several days. Generally, you can take care of symptoms at home with an asthma action plan, although a severe attack may require emergency treatment and on rare occasions can be fatal.

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

• People with mild intermittent asthma often have symptoms only after being around a trigger.
• People with mild intermittent asthma usually need medications only during an asthma attack.
• People with mild persistent or moderate persistent asthma may not always have noticeable symptoms, but they need to take medications daily to control the long-term inflammation in their airways.
• People with severe persistent asthma have symptoms almost all of the time. Their symptoms need to be treated daily. These people are at increased risk for severe, life-threatening asthma attacks known as status asthmaticus.

Asthma—even mild asthma—may result in changes to the airway system (airway remodeling) and may speed up and make worse the natural decrease in lung function that occurs as we age.³ Asthma may raise your risk for developing chronic obstructive pulmonary disease (COPD).⁴

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

Asthma during pregnancy

Asthma can affect your pregnancy. It may occur for the first time during pregnancy, or it may change during pregnancy.

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

Many factors may increase your risk of developing asthma. Some of these are not within your control; others you can control. The major risk factors for developing asthma as an adult are ongoing (chronic) wheezing when you were a child and cigarette smoking.⁵

Asthma risk factors that you cannot control

The following risk factors are not within your control:

• Gender and age. Women and men seem to have the same risk of developing asthma until they reach their 40s. After 40, women have a higher risk for asthma.
• A family history of allergies and asthma. People who have an allergy and asthma usually have a family history of allergies or asthma.
• Inherited tendency (genetic predisposition) to overreaction of the bronchial tubes. People who inherit a tendency of the bronchial tubes (which carry air to the lungs) to overreact often develop asthma.
• A history of allergy. If you have an allergy, you are more likely than others to develop asthma. Most children and many adults with asthma have atopic dermatitis, allergic rhinitis, or both. Studies indicate that 40% to 50% of children with atopic dermatitis develop asthma. Having atopic dermatitis as a child may also increase your risk of having more severe and persistent asthma as an adult than someone who did not have atopic dermatitis.⁶
• Rhinitis. Adults who have inflamed nasal passages (rhinitis) have a higher-than-average risk of developing asthma.

Asthma risk factors that you can control

You may be able to change some factors to reduce your or your teen's risk of developing asthma. These include:

• Cigarette smoking. People who smoke are more likely to get asthma. If you already have asthma and you smoke, it may make your symptoms such as wheezing worse.
• Cigarette smoking during pregnancy. Women who smoke during pregnancy increase the risk of wheezing in their babies. Babies whose mothers smoked during pregnancy also have worse lung function than those whose mothers did not smoke.
• Workplace exposure to irritants.Occupational asthma may develop after exposure to a specific inhaled irritant or allergen in the workplace. Such substances also can make symptoms worse in people with existing asthma.
• Dust mites. Exposure to dust mites is a risk factor in the development of asthma.⁷
• Cockroaches. In one study, children who had high levels of cockroach droppings in their homes were 4 times more likely to have a new diagnosis of asthma than children whose homes had low levels.⁷
• Obesity. Studies have found that obese children may be more likely to have asthma. But the reason for this is unclear. Experts don't know whether one condition contributes to the other or whether some unknown mechanism contributes to both.⁸ Some people who are obese and who lose weight may have fewer asthma symptoms. And sometimes symptoms caused by obesity are thought to be asthma symptoms.

No one is sure if breast-feeding affects a child's risk of getting asthma. Some studies show that breast-feeding protects a child from getting asthma.^{9, 10} Other studies show that breast-feeding, especially when mothers with asthma breast-feed, may actually raise a child's risk of getting asthma.¹¹ A large study following children until 14 years of age found that breast-feeding had no effect on the development of asthma.¹² Mothers are encouraged to breast-feed their children for all the other proven health benefits that come from breast-feeding.

Experts are also not sure about the effect that pets in the home have on getting asthma. Some research shows that having cats or dogs in the home raises an adult's risk of getting asthma.¹³ But other research has seemed to show that being around pets early in life might actually protect a child against getting asthma.¹⁴ If your child already has asthma and allergies to pets, having a pet in the home will make his or her asthma worse.

Risk factors that may make asthma worse (triggers)

Triggers that may make asthma worse and may lead to asthma attacks include:

• Infections, such as severe upper respiratory infections (URIs), sinusitis, and influenza (flu). URIs cause more than half of the asthma attacks in adults.^{15, 16}
• Allergens, such as dust mites, mold, or pet dander.⁷

If you have been diagnosed with asthma and have an asthma action plan, do the following:

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

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

Call your health professional immediately if you:

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

Call your health professional if you:

• Have asthma symptoms, you do not have an asthma action plan, and your symptoms are mild (chest tightness, cough, and slight shortness of breath or tiring easily during exercise).
• Are having symptoms in the yellow zone almost every day, and you need to use your inhaler medication to control your symptoms.
• Have asthma and your PEF has been getting worse for 2 to 3 days.

If you have not been diagnosed with asthma but have mild asthma symptoms, call your health professional and make an appointment for an evaluation.

If your teenager has symptoms of asthma, it is important to see a health professional. A large portion of teens with frequent wheezing may have asthma but are not diagnosed with the disease. Teens who have asthma but are less likely to be diagnosed are most often:¹⁷

• Girls.
• Smokers, or teens who are exposed to household cigarette smoke.
• Those with low socioeconomic status.
• Those who have allergies.
• African Americans, Native Americans, or Mexican Americans.

Watchful Waiting

Watchful waiting is a period of time during which you and your health professional observe your symptoms or condition without using medical treatment. Self-treatment is not appropriate if you have asthma symptoms. See your health professional, even if you are taking nonprescription medications and they relieve your symptoms.

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

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

Who to See

Health professionals who can diagnose and treat asthma include:

• Pediatricians.
• Family medicine physicians.
• Nurse practitioners.
• Physician assistants.
• Internists.

You may need to see a specialist (allergist or pulmonologist) if you have:

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

Other reasons to see a specialist include:

• Having severe persistent asthma.
• Needing to take continuous oral corticosteroid medications or high-dose inhaled corticosteroids or having had more than two treatments with oral corticosteroids in 1 year.
• Having asthma because of your workplace (occupational asthma).
• Needing skin testing for allergy.
• Thinking about starting treatment with allergy shots (immunotherapy).

A diagnosis of asthma is based on your medical history, a physical exam, and lung function tests. If you developed asthma in adulthood, your health professional will ask about your job to determine whether you have occupational asthma.

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

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

Regular checkups

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

• About every 6 to 12 months for people with mild intermittent or mild persistent asthma that has been under control for at least 3 months.
• Every 3 to 6 months for those with moderate persistent asthma.
• Every 1 to 2 months for people with uncontrolled or severe persistent asthma.

During checkups, your health professional will ask whether your symptoms and peak expiratory flow have held steady, improved, or become worse and will ask about asthma attacks during exercise or at night. You track this information in an asthma diary. You may be asked to bring your peak expiratory flow meter to an appointment so your health professional can see how you use it. Based on the results, your asthma category may change, and your health professional may change the medications you use or how much medication you use.

Tests for other diseases

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

• Additional lung function tests may be needed if other lung diseases, such as chronic obstructive pulmonary disease (COPD), are suspected.
• An electrocardiogram (EKG, ECG) measures the electrical signals that control the rhythm of your heartbeat. This test might be done to rule out serious conditions with similar symptoms, such as chronic heart failure.
• A bronchoscopy involves using a flexible scope called a bronchoscope to examine the airways. Occasionally airway problems such as tumors or foreign bodies will create symptoms that mimic those of asthma. The test might be done if you have unequal wheezing in the lungs or a poor response to asthma therapy. Biopsies of the airways can be done to look for changes characteristic of asthma.
• A chest X-ray may be used to see whether other lung diseases, such as fibrous tissue caused by chronic inflammation (pulmonary fibrosis), are causing symptoms.
• A sweat test, which measures the amount of salt in sweat, may be used to see whether cystic fibrosis is the cause of your symptoms.

Tests to identify triggers

If you have persistent asthma and take medication every day, your health professional may ask about your exposure to substances (allergens) that cause an allergic reaction. For more information about the following tests, see the topic Allergic Rhinitis.

Allergy tests include:

• Skin tests. The skin on the back or arms is pricked with one or more small doses of allergens that might cause an allergy. The amount of swelling and redness at the sites of the skin pricks is measured to see which allergens cause a reaction. Skin tests are quick, simple, and relatively safe. Skin tests are necessary if you are interested in allergy shots (immunotherapy).
• Enzyme-linked immunosorbent assay (ELISA). A blood sample is taken from a vein and tested for immunoglobulin E (IgE) antibodies, which are produced in response to particular allergens.

Other tests may be done to see whether other conditions such as sinusitis, nasal polyps, or gastroesophageal reflux disease (GERD) are present.

Although asthma cannot be cured, you can manage the symptoms with medications, especially inhaled corticosteroids and beta2-agonists. You will probably work with your health professional to develop a management plan consisting of a daily treatment plan and an asthma action plan. These plans help you meet treatment goals and get your asthma under control. The goals of asthma treatment are to:¹⁸

• Prevent symptoms.
• Keep your peak flow and lung function as close to normal as possible.
• Be able to do your normal daily activities, including work, school, exercise, and recreation.
• Prevent asthma attacks.
• Have few or no side effects from medicine.

For more information, see:

Taking charge of asthma.

Emergency treatment

If you have a severe asthma attack (the red zone of your asthma action plan), use medication based on your action plan and talk with a health professional immediately about what to do next. This is especially important if your peak expiratory flow (PEF) does not return to the green zone or stays within the yellow zone after you take medication. You may have to go to the hospital or an emergency room for treatment. Be sure to tell the emergency staff if you are pregnant.

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

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

Medical checkups

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

• About every 6 to 12 months for people with mild intermittent or mild persistent asthma that has been under control for at least 3 months.
• Every 3 to 6 months for those with moderate persistent asthma.
• Every 1 to 2 months for people with uncontrolled or severe persistent asthma.
• Every month if you are pregnant.

During checkups, your health professional will ask whether your symptoms and peak expiratory flow have held steady, improved, or become worse and will ask about asthma attacks during exercise or at night. You track this information in an asthma diary. You may be asked to bring your peak expiratory flow meter to an appointment so your health professional can see how you use it.

Initial treatment

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

• Oral or injected corticosteroids (systemic corticosteroids). These medications may be used to get your asthma under control before you start taking daily medication. In the future, you also may take oral or injected corticosteroids to treat any sudden and severe symptoms (asthma attacks), such as shortness of breath. Oral corticosteroids are used more than injected corticosteroids. Oral corticosteroids include prednisone and dexamethasone.
• Inhaled corticosteroids. These are the preferred medications for long-term treatment of asthma. They reduce the inflammation of your airways, and you take them every day to keep asthma under control and to prevent asthma attacks. Inhaled corticosteroids include beclomethasone dipropionate, triamcinolone acetonide, fluticasone propionate, budesonide, and flunisolide.
• Short-acting beta2-agonists. These medications are used for asthma attacks. They relax the airways, allowing you to breathe easier. Short-acting beta2-agonists include albuterol and pirbuterol.
• A combination of an inhaled corticosteroid and long-acting beta2-agonist. This combination is often used to treat persistent asthma.
• Basic education about asthma. The more you know about asthma, the more likely it is you will control symptoms and reduce the risk of asthma attacks. Keep in mind that even severe asthma can be controlled, and cases where the condition cannot be controlled are unusual.
• Instruction on how to use a metered-dose inhaler (MDI) or dry powder inhaler (DPI). Inhalers deliver medicine directly to the lungs. If you use your inhaler correctly, you can control your symptoms and avoid asthma attacks that can send you to the emergency room. Most health professionals recommend using a spacer with an MDI. For more information, see:

  Using a metered-dose inhaler.

  Using a dry powder inhaler.

Your short-term goal is to control your current symptoms. Long-term, your goal is to prevent symptoms so that asthma does not impact your daily activities.

Special considerations in treating asthma include:

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

Ongoing treatment

After your initial treatment for asthma, it is important to learn more about the condition and develop an overall plan to manage the disease. You and your health professional will work together to do this. Because asthma develops from a complex interaction of genetics, environmental factors, and the reaction of the immune system, no one management plan is effective for everyone.

Asthma management consists of:

• A daily asthma treatment plan. A daily asthma treatment plan outlines in writing how to treat and control inflammation in your lungs. The plan helps you keep asthma under control and prevent asthma attacks. The plan also tells you which medications to take every day. A daily treatment plan may include an asthma diary where you record your peak expiratory flow (PEF), symptoms, triggers, and quick-relief medication used for asthma attacks. This valuable tool helps you and your health professional manage your asthma. A daily asthma treatment plan is often combined with an asthma action plan.
• An asthma action plan. An asthma action plan contains directions to treat asthma attacks at home. It helps you identify triggers that can be changed or avoided, be aware of your symptoms, and know how to make quick decisions about medication and treatment. See an example of an asthma action plan(What is a PDF document?). For more information, see:

  Using an asthma action plan.

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

  Monitoring peak flow.

• A plan to deal with factors that can make asthma worse (triggers). Being around triggers increases symptoms. Try to avoid situations that expose you to irritants (such as smoke or air pollution) or to substances (such as animal dander) to which you may be allergic. If substances at work are causing your asthma or making it worse (occupational asthma), you may have to change jobs. See information on:

  Identifying asthma triggers.

• A plan to treat other health problems. If you also have other health problems, such as inflammation and infection of the sinuses (sinusitis) or gastroesophageal reflux disease (GERD), you will need treatment for those conditions.

• Using your prescribed medications correctly. Your health professional may adjust your medications depending on how well your asthma is controlled. Medications include:
  • Inhaled corticosteroids. These are the preferred medications for long-term treatment of asthma. Inhaled corticosteroids include beclomethasone dipropionate, triamcinolone acetonide, fluticasone propionate, budesonide, and flunisolide.
  • Long-acting beta2-agonists (such as salmeterol and formoterol), which are used along with inhaled corticosteroids.
  • Oral or injected corticosteroids (systemic corticosteroids) to treat any sudden and severe symptoms (asthma attacks), such as shortness of breath. Oral corticosteroids are used more than injected corticosteroids. Oral corticosteroids include prednisone and dexamethasone.
  • Quick-relief medication, such as short-acting beta2-agonists and anticholinergics (ipratropium) for asthma attacks. If you are using quick-relief medication more than 2 times a week (except for exercise) or more than 1 canister in 3 months, you probably need long-term treatment. Overuse of quick-relief medication can be harmful.
• Education. Continue to learn about asthma. This questionnaire can help you determine what you already know about asthma and what you may need to discuss with your health professional.

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

Should I take allergy shots (immunotherapy) for allergic rhinitis and allergic asthma?

You can expect to live a normal life if you control symptoms by following your daily treatment and action plans. Control of your asthma symptoms can help keep your lungs as healthy as possible.

Special considerations in treating asthma include:

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

Treatment if the condition gets worse

If your asthma is not improving, make an appointment with your doctor to:

• Review your asthma diary to see if you have a new or previously unidentified trigger, such as animal dander. Talk to your health professional about how best to avoid triggers.
• Review your medications, to be sure you are using the right ones and are using them correctly.
• Review your asthma plans, to be sure they are suitable for your condition.
• Determine whether you have a condition with symptoms similar to asthma, such as sinusitis.
• Make sure you are using your inhaler correctly.

If your medication is not working to control airway inflammation, your health professional will first check to see whether you are using the inhaler correctly. If you are using it correctly, your health professional may increase the dosage, switch to another medication, or add a medication to the existing treatment.

Your doctor may suggest other medications, such as leukotriene pathway modifiers (zafirlukast, zileuton, or montelukast). Less commonly, your doctor may recommend mast cell stabilizers (cromolyn sodium or nedocromil) or theophylline (Theo-Dur, Slo-bid, Uniphyl, or Uni-Dur).

If your asthma does not improve with treatment, you may require more intensive treatment, including larger doses of corticosteroids or other medication. An asthma specialist generally prescribes these medications.

If you have persistent asthma and react to allergens, you may need to have skin testing for allergies. Allergy shots (immunotherapy) may be helpful.

What to think about

If you have been diagnosed with asthma, it is important that you treat it. You may feel good most of the time—so much so that you find it hard to believe you have a long-lasting condition. But all asthma—even mild asthma—may result in changes to your airways that speed up and make worse the natural decrease in lung function that occurs as we age.³

Although there is no certain way to prevent asthma, you can take steps to reduce airway inflammation and the likelihood of asthma attacks.

Preventing asthma attacks

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

Identifying asthma triggers.

If you can predict or often have asthma attacks when you exercise, use your inhaler 10 minutes before you start the activity so you can avoid an attack.

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

Irritants in the air

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

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

• Pregnant women who smoke cigarettes during pregnancy increase the risk of wheezing in their newborn babies.
• Exposing young children to secondhand tobacco smoke increases the likelihood that they will develop asthma and increases the severity of symptoms if they already have the disease.

Consider staying inside when air pollution levels are high. Other irritants in the air (such as fumes from gas, oil, or kerosene or wood-burning stoves) can sometimes irritate the bronchial tubes, which carry air to the lungs. Avoiding these may decrease your asthma symptoms.

Allergens

If you are allergic to certain substances (allergens), you may decrease your asthma symptoms by limiting exposure to these substances.

To help reduce your exposure to allergens:

• Control cockroaches, especially if you live in an inner-city area or the southern part of the United States.
• Control dust mites. House dust mites have been linked with the development of asthma in children.¹
• Control animal dander and pet allergens. If you know your pet is a trigger, you may need to think about giving it away. If that is too hard, taking steps such as keeping your pet out of your bedroom and dusting and vacuuming often may help your asthma.
• Control indoor mold, especially if you live in an area with high humidity.

It also may be necessary to avoid exposure to other types of triggers that cause asthma symptoms.

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

You can control the impact asthma has on your life by following your asthma plans consistently. A management plan can reduce inflammation to decrease the severity, frequency, and duration of asthma attacks. Following your plans may be difficult due to the many different factors involved.

To help yourself remain consistent in following your asthma plans:

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

Your asthma plans generally consist of the following:

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

For more information on how to monitor and treat asthma, see:

Taking charge of asthma.

Using an asthma action plan.

To effectively manage your asthma and use your daily asthma treatment and action plans, you will have to know how to monitor your peak airflow, identify asthma triggers, and take your asthma medication correctly.

Monitoring peak expiratory flow

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

Monitoring peak flow.

Identifying asthma triggers

A trigger is anything that can lead to an asthma attack. A trigger can be:

• Irritants in the air, such as tobacco smoke or air pollution.
• Substances to which you are allergic (allergens), such as pollen or animal dander.
• Other factors, such as a viral infection, exercise, stress, or dry, cold air.

Avoiding triggers will help decrease the chance of having an asthma attack and, in the case of allergens, will help control inflammation in the bronchial tubes, which carry air to the lungs. For more information, see:

Identifying asthma triggers.

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

Taking your asthma medication

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

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

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

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

Using a metered-dose inhaler.

Using a dry powder inhaler.

Travel

Most people with asthma can travel freely. But if you travel to remote areas and participate in intensive physical activity, such as long hikes, you may be at increased risk for an asthma attack in an area where emergency help may be difficult to find.

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

Give teens extra attention

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

• Help your teen remember that asthma is only one part of life.
• Allow your teen to meet with the health professional alone. This will encourage your teen to become involved in his or her care.
• Work out a daily management plan that allows a teen to continue daily activities, especially sports. Exercise is important for maintaining strong lungs and overall health.
• Talk to your teen about the dangers of smoking and drug use.
• Encourage your teen to meet others who have asthma so they can support each other.

Medication does not cure asthma. But it is an important part of managing the condition. Medications for asthma treatment are used to:

• Prevent and control the underlying airway inflammation, to minimize asthma symptoms.
• Decrease the severity, frequency, and duration of asthma attacks.
• Treat the attacks as they occur.

Asthma medications are divided into two groups: those for prevention and long-term control of inflammation and those that provide quick relief for asthma attacks. Most people with persistent asthma need to use long-term medications daily. Quick-relief medications are used as needed and provide rapid relief of symptoms during asthma attacks.

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

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

Medication delivery

Most medications for asthma are inhaled. Inhaled medications are used because a specific dose of the medication can be given directly to the bronchial tubes. Different types of delivery systems may be used to do this, and one type may be more suitable for certain people or age groups than another. Delivery systems include metered-dose and dry powder inhalers and nebulizers. A metered-dose inhaler is used most often.

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

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

Using a metered-dose inhaler.

Using a dry powder inhaler.

Medication Choices

The most important asthma medications are:

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

Other long-term medications for daily treatment include:

• Leukotriene pathway modifiers (such as zafirlukast, zileuton, or montelukast).
• Long-acting beta2-agonists (such as salmeterol and formoterol). These medicines are combined with inhaled corticosteroids as a single medication.
• Less commonly, your doctor may recommend mast cell stabilizers (such as cromolyn sodium or nedocromil) or theophylline (such as Theo-Dur, Slo-bid, Uniphyl, or Uni-Dur).

Other medications may be given in some cases.

• Anticholinergics (such as ipratropium) and magnesium sulfate are usually used for severe asthma attacks.
• Other medicine such as omalizumab may be used if asthma does not improve with treatment. An asthma specialist generally prescribes this medicine.

See a chart of asthma medications for teens and adults.

What to Think About

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

Because quick-relief medication quickly reduces symptoms, people sometimes overuse these medications instead of using the slower-acting long-term medications. But overuse of quick-relief medications may have harmful effects, such as decreasing the future effectiveness of these medications.²⁰ Overuse of quick-relief medication is also an indication that asthma symptoms are not being controlled. Be sure to talk with your health professional immediately.

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

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

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

Allergy shots (immunotherapy) may be recommended for people who have asthma symptoms when they are around substances to which they are allergic (allergens). In some people, allergy shots have been shown to reduce asthma symptoms and the need for medications.²¹ But allergy shots are not equally effective for all allergens. Allergy shots should not be given when asthma is poorly controlled. For more information, see:

Should I take allergy shots (immunotherapy) for allergic rhinitis and allergic asthma?

Allergy shots are similar to vaccinations, because they contain small doses of one or more substances to which you are allergic so that your body can become less responsive to them over time.

Complementary medicine

Alternative treatments such as homeopathy, acupuncture, and breathing exercises have been used to treat asthma. The research on these treatments is limited. A review of research shows:²²

• No evidence to support using homeopathy, air ionizers, manual therapy, or acupuncture for asthma.
• A possible but not clearly established role for using antioxidants.
• Breathing exercises practiced in yoga may improve lung function.

Some people have used ephedra—a stimulant sold for weight loss and sports performance—to try to treat asthma symptoms. But the U.S. Food and Drug Administration (FDA) has banned the sale of this dietary supplement because of concerns about safety. Ephedra, also called ma huang, has been linked to heart attacks, strokes, and some deaths.

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

Organizations

• Allergic Rhinitis
• Asthma in Children
• Atopic Dermatitis
• Chronic Obstructive Pulmonary Disease (COPD)

Citations

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

4. Silva GE, et al. (2004). Asthma as a risk factor for COPD in a longitudinal study. Chest, 126(1): 59–65.

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

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

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

8. Rodriguez MA, et al. (2002). Identification of population subgroups of children and adolescents with high asthma prevalence: Findings from the third National Health and Nutrition Examination. Archives of Pediatrics and Adolescent Medicine, 156(3): 269–275.

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12. Burgess SW, et al. (2006). Breastfeeding does not increase the risk of asthma at 14 years. Pediatrics, 117(4): 787–792.

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14. Ownby DR, et al. (2002). Exposure to dogs and cats in the first year of life and risk of allergic sensitization at 6 to 7 years of age. JAMA, 288(8): 963–972.

15. Lemanske RF Jr (2003). Viruses and asthma: Inception, exacerbations, and possible prevention. Proceedings from the Consensus Conference on Treatment of Viral Respiratory Infection-Induced Asthma in Children. Journal of Pediatrics, 142(2, Suppl): S3–S7.

16. Sutherland ER, Martin RJ (2002). Is infection important in the pathogenesis and clinical expression of asthma? In SL Johnston, ST Holgate, eds., Asthma: Critical Debates, pp. 69–84. London: Blackwell Science.

17. Yeatts K, et al. (2003). Who gets diagnosed with asthma? Frequent wheeze among adolescents with and without a diagnosis of asthma. Pediatrics, 111(5): 1046–1054.

18. Joint Task Force on Practice Parameters (2005). Attaining optimal asthma control: A practice parameter. Journal of Allergy and Clinical Immunology, 116(5): S3–S11. Available online: http://www.jcaai.org/pp/Attaining_Optimal_Asthma_Control.pdf.

19. National Institutes of Health (1997). Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Clinical Practice Guidelines (NIH Publication No. 97-4051). Bethesda, MD: U.S. Department of Health and Human Services.

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21. Abramson MJ, et al. (2006). Allergen immunotherapy for asthma. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.

22. Györik SA, Brutsche MH (2004). Complementary and alternative medicine for bronchial asthma: Is there new evidence? Current Opinion in Pulmonary Medicine, 10(1): 37–43.

Other Works Consulted

• Grayson MH, Holtzman MJ (2005). Asthma. In DC Dale, DD Federman, eds., ACP Medicine, , section 14, chap. 2. New York: WebMD.