Health

Diseases affecting the lungs—such as asthma, emphysema, bronchitis, and chronic obstructive pulmonary disease (COPD)—share many of the same medicines. These medicines are often delivered through a metered-dose inhaler (MDI).

Key points

Using an MDI:

• Delivers most of a measured dose of medicine directly to your lungs.
• Can help keep your symptoms under control and may help prevent long-term damage to your lungs.
• May prevent or decrease side effects of the medicine.
• May let you use less medicine than is found in a pill but get the same effect.
• May result in the medicine working faster than a pill form.

People who have asthma or other lung diseases that make it hard to breathe may use an inhaler to get the medicine they need into their lungs. Inhaled medicine works faster than the same medicine in a pill. An inhaler also lets you take less medicine than you would if you took it as a pill.

You may have used a metered-dose inhaler in the past. But a dry powder inhaler is different. These instructions are for using a dry powder inhaler. If you need information on using a metered-dose inhaler, see:

Using a metered-dose inhaler.

Key points

• A dry powder inhaler lets you breathe medicine into your lungs quickly.
• A dry powder inhaler is breath-activated. This means that when you breathe in through the inhaler, the inhaler releases the medicine into your lungs.
• Dry powder inhalers come in different shapes and sizes. Some come with the medicine already loaded inside the inhaler. With other inhalers, you have to put in the medicine right before you use it. Your doctor or pharmacist will tell you how to load the medicine into your inhaler.

As someone with asthma, you know how important it is to monitor your condition. You need to know how well your lungs are "working"—is their ability to move air in and out staying the same, or is it getting better or worse?

When you monitor your asthma, you can control it. When you control your asthma, you also control your life—you do what you want to do, and your asthma does not limit you.

Measuring your peak expiratory flow is an important part of monitoring your asthma.

Asthma is a long-lasting (chronic) disease of the respiratory system. It causes inflammation in tubes that carry air to the lungs (bronchial tubes). The inflammation makes your bronchial tubes likely to overreact to certain triggers. An overreaction can lead to decreased lung function, sudden difficulty breathing, and other symptoms of an asthma attack.

If you avoid triggers, you can:

• Prevent some asthma attacks.
• Reduce the frequency and severity of some attacks.

You may not be able to avoid or even want to avoid all your asthma triggers. However, you can identify many things that trigger your symptoms by:

• Monitoring your lung function (peak expiratory flow). Your lungs will not work as well when you are around a trigger.
• Being tested for allergies. If you have allergies, the substances to which you are allergic can trigger symptoms.

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, which are outlined in the asthma action plan. The goals are to:

• Control asthma over the long term. The asthma action plan 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. The asthma action plan tells you what to do when you have an asthma attack. It helps you identify triggers that can cause your attacks. You use quick-relief medicine, such as albuterol, during an attack.

If you need to use the quick-relief 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 action plan.

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.

Key points

The medicines used for asthma are often delivered through a metered-dose inhaler (MDI). Using an MDI with a mask spacer:

• Helps a young child get an accurate dose of medicine.
• Delivers most of a measured dose of medicine directly to your child's lungs.
• Can help keep your child's asthma symptoms under control and allow your child to live an active life.
• May prevent or reduce side effects of the medicine.
• May let your child use less medicine than is found in a pill but get the same effect.
• May result in the medicine working faster than a pill form.

You can prevent some asthma attacks by helping your child avoid 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. Try not to expose your child to tobacco smoke.
• Things your child is allergic to, such as pet dander, dust mites, cockroaches, or pollen. Taking certain types of allergy medicines may help your child.
• Exercise. Ask your doctor about using an inhaler before exercise if this is a trigger for your child’s asthma.
• Other things like dry, cold air; an infection; or some medicines, such as aspirin. Try not to have your child exercise outside when it is cold and dry. Talk to your doctor about vaccines to prevent some infections. And ask about what medicines your child should avoid.

It can be scary when your child has an asthma attack. You may feel helpless, but having an asthma action plan will help you know what to do during an attack. An asthma attack may be severe enough to need urgent medical care, but in most cases you can take care of symptoms at home if you have a good asthma action plan.

There are two parts to treating asthma, and they are outlined in the asthma action plan. The goals are to:

• Control asthma over the long term. The asthma action plan tells you which medicine your child needs to take. It also helps you track your child’s symptoms and know how well the treatment is working. Many children take controller medicine—usually an inhaled corticosteroid—every day. Taking controller medicine every day helps reduce the swelling of the airways and helps prevent attacks.
• Treat asthma attacks when they occur. The asthma action plan tells you what to do when your child has an asthma attack. It helps you identify triggers that can cause your child’s attacks. Your child will use quick-relief medicine, such as albuterol, during an attack.

Using an inhaler with a spacer is the best way to get the most medicine to your child’s lungs. But your child has to use the inhaler correctly for it to work well. If you are not sure how to use the inhaler the right way, ask your doctor to show you how.

If your child needs to use the quick-relief inhaler more often than usual, talk to your doctor. This is a sign that your child’s 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 child’s asthma action plan.

Along with doing a physical exam and asking about your child’s symptoms, your doctor may order tests such as:

• Spirometry. Doctors use this test to diagnose and keep track of asthma in children age 5 and older. It measures how quickly your child can move air in and out of the lungs and how much air is moved. Spirometry is not used with babies and small children. In those cases, the doctor usually will listen for wheezing and will ask how often the child wheezes or coughs.
• Peak expiratory flow (PEF). This shows how fast your child can breathe out when trying his or her hardest.
• A chest X-ray to see if another disease is causing your child’s symptoms.
• Allergy tests, if your doctor thinks your child’s symptoms may be caused by allergies.

Your child needs routine checkups so your doctor can keep track of the asthma and decide on treatment.

Symptoms of asthma can be mild or severe. When your child has asthma, he or she may:

• Wheeze, making a loud or soft whistling noise that occurs when the airways narrow.
• Cough a lot.
• Feel tightness in the chest.
• Feel short of breath.
• Have trouble sleeping because of coughing and wheezing.
• Quickly get tired during exercise.

Many children with asthma have symptoms that are worse at night.

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 is asthma?

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

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

Even if your child has few asthma attacks, you still need to treat the asthma. If the swelling and irritation in your child’s airways isn't controlled, asthma could lower your child's quality of life, prevent your child from exercising, and increase your child's risk of going to the hospital.

Even though asthma is a lifelong disease, treatment can control it and keep your child healthy. Many children with asthma play sports and live healthy, active lives.

Pregnant women

manage asthma the same way nonpregnant women do. Like all people with asthma, pregnant women should have an asthma action plan to help them control inflammation and prevent and control asthma attacks. Part of a pregnant woman's action plan should also include recording fetal movements. You can do this by noting whether fetal kicks decrease over time. If you notice less fetal activity during an asthma attack, contact your doctor or emergency help immediately to receive instructions.

Considerations for treatment of asthma in pregnant women include the following:

• If more than one health professional is involved in the pregnancy and asthma care, they must communicate with each other about treatment. The obstetrician must be involved with asthma care.²
• Monitor lung function carefully throughout your pregnancy to ensure that your growing fetus gets enough oxygen. Because asthma severity changes for about two-thirds of women during pregnancy, you should have monthly checkups with your doctor to monitor your symptoms and lung function.² Your doctor will use either spirometry or a peak flow meter to measure your lung function.
• Monitor fetal movements daily after 28 weeks.
• Consider ultrasounds after 32 weeks to monitor fetal growth if your asthma is not well controlled or if you have moderate or severe asthma.² Ultrasound exams can also help your doctor check on the fetus after an asthma attack.
• Try to do more to avoid and control asthma triggers (such as tobacco smoke or dust mites), so that you can take less medicine if possible. Many women have nasal symptoms, and there may be a link between increased nasal symptoms and asthma attacks. Gastroesophageal reflux disease (GERD), which is common in pregnancy, may also cause symptoms.
• It is important that you have extra protection against influenza. Be sure to get the influenza vaccine before the flu season starts—sometime from October to mid-November—whether you are in your first, second, or third trimester at the time.³ The flu vaccine is effective for one season. The flu vaccine is safe in pregnancy and is recommended for all pregnant women.

If you have not previously had asthma, you may not think that shortness of breath or wheezing during your pregnancy is asthma. If you know you have asthma, you may not consider it a concern if you only have mild symptoms. But asthma can affect you and your fetus, and you should act accordingly.

If your asthma is not controlled, risks to your health include:¹

• High blood pressure during the pregnancy.
• Preeclampsia, a condition that causes high blood pressure and can affect the placenta, kidneys, liver, and brain.
• More than normal vomiting early in pregnancy (hyperemesis gravidarum).
• Labor that does not occur naturally (your doctor starts it) and may be complicated.

Risks to the fetus include:¹

• Death immediately before or after birth (perinatal mortality).
• Abnormally slow growth of the fetus (intrauterine growth retardation). When born, the baby appears small.
• Birth before the 37th week of pregnancy (preterm birth).
• Low birth weight.

The more control you have over your asthma, the less risk there is.

Asthma is a fairly common health problem for pregnant women, including some women who have never had it before. During pregnancy, asthma not only affects you, but it can also cut back on the oxygen your fetus gets from you. But this does not mean that having asthma will make your pregnancy more difficult or dangerous to you or your fetus. Pregnant women with asthma that is properly controlled generally have a normal pregnancy with little or no increased risk to themselves or their fetus.

Most asthma treatments are safe to use when you are pregnant. After years of research, experts now say that it is far safer to manage your asthma with medicine than it is to leave asthma untreated during pregnancy. Talk to your doctor about the safest treatment for you.

Months after a federal ban went into effect outlawing a propellant used in most rescue inhalers, some asthma sufferers insist the replacement inhalers don't work and might even be harmful.

Millions of asthma sufferers were forced to switch to a different quick-acting inhaler by Jan. 1, after an amendment to the Clean Air Act outlawed chlorofluorocarbons, or CFCs, an ozone-depleting chemical that delivered medication deep into the lungs. People with asthma and other breathing disorders now are prescribed more environmentally friendly hydrofluoroalkane-propelled inhalers.

The devices are just as effective as CFC inhalers, according to many medical experts, including a spokesman for the American College of Allergy, Asthma and Immunology. But differences in operation and sensation have led to confusion, experts said. The HFA inhalers deliver a softer mist, taste different and must be primed before use and cleaned more often.

The less forceful spray makes many users think the inhalers are not working, said Dr. Thomas Stern, a pulmonologist in Charlotte, N.C. He said it will take time for people to adjust their expectations, but most of his patients have made the transition.

"The medication is exactly the same, the effectiveness is the same," said Dr. Clifford Bassett, assistant clinical professor of medicine at Long Island College Hospital, State University of New York. "The only difference is that the propellant has some mild qualitative differences."

Some users, however, are adamant that the inhalers don't work. The National Campaign to Save CFC Asthma Inhalers has collected more than 4,500 signatures as part of its drive to bring the CFC inhalers back.

Arthur Abramson, an asthma patient in San Francisco who runs the group's website, SaveCFCinhalers.org, said patients are being forced to buy drugs that are less safe and less effective. He said he developed permanent tinnitus in his left ear after using an HFA inhaler.

"What they tell you is that everything is the same, just the propellant is different, and that is a lie," Abramson said. "The fact of the matter is, it is not the active ingredient albuterol that is causing the problems. It is the inactive ingredients, such as ethanol, and also the unique impurities."

The HFA propellant itself also appears to be causing problems for some people, he said.

Karen Riley, a spokeswoman for the Food and Drug Administration, said the agency has received more than 500 complaints about HFA inhalers, many of them about the ethanol. But she said one of the four FDA-approved HFA inhalers on the market, Ventolin, lacks the ingredient.

"There is an alternative available for patients who cannot tolerate or do not want ethanol in their albuterol inhaler," she said.

Three albuterol HFA inhalers are available in the United States: Ventolin, Proventil and ProAir. Another inhaler, Xopenex, contains a medicine similar to albuterol. Riley said each was approved based on research showing its safety and effectiveness. All of the active and inactive ingredients are considered safe in the amounts found in the approved inhalers, she said.

Sandra Fusco-Walker, director of patient advocacy at Allergy and Asthma Network Mothers of Asthmatics, based in Virginia, said many inhaler users have not been given instruction on how to properly use the devices. She worries about asthmatics having problems but not consulting their doctors.

"If you need albuterol more than two times a week or wake up during the night, you need other medications," she said. "That's considered asthma out of control."

Maureen Damitz of the Respiratory Health Association said some patients are doubling up on medications when they don't have to.

Bassett, a spokesman for the American College of Allergy, Asthma and Immunology, said talking about inhaler concerns gives patients and doctors a chance to go over prevention strategies, asthma triggers and instruction on use of medications.

Many studies show inhalers are commonly misused, Bassett said.

"If the medication is not used correctly," he said, "you're going to have a problem."

Critics of the inhalers say it's not their technique that's the problem, it's the inhalers.

Like a number of other users, Jane Malloy, who lives in Streamwood, Ill., now gets inhalers from outside the United States through the Internet. She's not comfortable with the idea but doesn't want to use HFA inhalers after coughing up blood and feeling a strange itchy feeling in her lungs after using one.

However, now that an international treaty on chlorofluorocarbons has gone into effect, even overseas sources of the older inhalers are drying up. She is becoming worried as she watches her supply run out.

An asthma

action plan is a written plan that tells you how to treat your asthma on a daily basis. The plan also helps you deal with sudden increases in your or your child's asthma symptoms (asthma attacks). You need to treat the inflammation in your lungs to minimize the long-term effects of asthma. The plan tells you what medicine is needed every day, what steps to take for an asthma attack (based on its severity), and when you should call a doctor or seek emergency treatment.

You and your doctor make the asthma action plan. In general, the plan includes:

• Treatment goals, which include your personal goals about your asthma.
• When to take the medicines you need daily to control airway inflammation.
• How to measure your peak expiratory flow (PEF) with a peak flow meter.
• What medicine to take and what steps to follow to deal with an asthma attack.
• An asthma diary, where you can record your PEF values and the triggers that cause your symptoms.

Your action plan is based on zones of asthma severity defined by symptoms and your personal best peak expiratory flow (PEF), which is your highest peak flow recorded over a 2- to 3-week period when your asthma is under control. Personal best is never taken during an asthma attack. If you do not know your personal best, talk to your doctor.

• Green zone. Green means go. You are in the green zone of the asthma action plan if your peak expiratory flow is 80% to 100% of your personal best measurement. You want to be in the green zone every day. You should have no asthma symptoms when you are in the green zone. And you do not need quick-relief treatment. To figure 80% of your personal best peak flow, multiply your best flow by 0.80. For example, if your personal best flow is 400, multiplying by 0.80 gives you 320.
• Yellow zone. Yellow means caution. You are in the yellow zone of your asthma action plan if your peak expiratory flow is 50% to 79% of your personal best measurement. You may not have any symptoms, but your lung function is reduced. When you have symptoms, they may be mild to moderate, or they may keep you from your usual activities or disturb your sleep. Your action plan should state which quick-relief medicines you need to take, how much to take, and when to take them. To figure 50% of your personal best peak flow, multiply your best flow by 0.50. For example, if your personal best flow is 400, multiplying by 0.50 gives you 200.
• Red zone. Red means STOP. You are in the red zone of your asthma action plan if your peak expiratory flow is less than 50% of your personal best measurement. Your symptoms may be severe, and you may have extreme shortness of breath and coughing. If your symptoms and peak expiratory flow are in the red zone, seek medical help immediately. While you are seeking emergency help, follow your action plan and take your medicines as directed. You may need emergency treatment or admission to a hospital.

The best strategy for avoiding and treating asthma attacks is being able to recognize an attack and know what to do. Talk to your doctor about:

• Your triggers. Asthma triggers are substances that can cause an attack, such as pollen or cigarette smoke. Avoiding your triggers can help reduce your risk of an attack and reduce its severity.
• Your symptoms. In general these include a drop in your peak expiratory flow (PEF) and increased and more severe coughing, wheezing, shortness of breath, and tightness in your chest. The symptoms may vary from one person to another.
• Which quick-relief medicines you need to take and how to give them to yourself.
• How to evaluate whether your quick-relief medicines are working.
• When emergency care is necessary. If you have a large drop in PEF, or your quick-relief medicines are not working, or you are very short of breath, you may need emergency care. Your doctor will help you know about these signs.
• A possible pregnancy. If you are pregnant, you may have other options for asthma medicines. During an attack, your doctor may also ask that you monitor your fetus's activity by noting a change in fetal kicks.