Adult Asthma
Young adult asthma shares many features with childhood asthma. In fact, many adults who develop asthma in their twenties and thirties often have a history of childhood asthma or were undiagnosed asthmatics who were labeled as “bronchial” children.
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- Asthma that begins after age forty is often quite different. Women outnumber men, and inheritance is less of a factor. Asthma triggers are harder to pinpoint, and asthma is usually the intrinsic or nonallergic type.
- Adult-onset asthma may be more severe and difficult to control than childhood asthma, and the outlook is less predictable. Adults with asthma are more likely to have aspirin allergy, sulfite reactions, chronic sinus problems, and nasal polyps
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Senior Citizens And Asthma
There are relatively few studies regarding asthma in the elderly, even though asthma is a relatively common problem in general population surveys. Asthma in the elderly may be increasing. A recent survey in England and Wales reported a doubling of asthma cases in people over the age of fifty-five.
- While nearly one-third of all asthma cases begin in childhood and the early teens, 10 percent of newly diagnosed asthma patients start to cough and wheeze after age sixty-five. Studies in elderly residential centers have found that a significant percentage of residents have unrecognized and untreated asthma.
- The reason for this underdiagnosis of asthma in the elderly may be that they are relatively inactive senior citizens in whom asthma is associated with chronic cough and the production of mucus rather than acute and sudden episodes of wheezing.
- Such patients are often labeled as having chronic bronchitis or emphysema, yet when breathing tests are performed on these patients, they are often found to have typical asthma that responds well to conventional asthma therapy.
Dr. Benjamin Burrows and his group at the University of Arizona College of Medicine have been particularly impressed by the number of elderly subjects, especially women, followed in their pulmonary clinic for what appears to be persistent asthma. They have followed a group of asthmatics over age sixty-five over a long term.
- Many of their elderly asthmatics had severe diseases with marked abnormalities in their pulmonary function tests. Almost 50 percent of the forty-six patients studied reported age of onset of asthma before age forty. This study shows that asthma in the elderly is not a rare disease and may be associated with severe symptoms.
- One encouraging part of Burrows’s study was that even though complete remission did not occur in most subjects with severe disease, asthma in the elderly was not a rapidly progressive form of asthma.
- Senior citizen asthma may range in severity from mild to severe. Asthma triggers are difficult to pinpoint, as they are more likely related to air pollutants and respiratory tract infections than allergies. Asthma symptoms in the elderly may consist of only chest tightness, shortness of breath, or coughing.
Such chest tightness and shortness of breath are often wrongly attributed to cardiovascular problems. Sleep disturbances associated with night-time or nocturnal asthma may be confused with urinary tract problems.
- Asthma treatment in the elderly can be difficult for a variety of reasons. Drug interactions with conventional asthma medications are common. Glaucoma or high blood pressure medications, such as beta-blockers, may increase asthma symptoms.
- The elderly patient is easily confused with multiple drug therapy, which leads to noncompliance or dosing errors. Elderly patients may require much lower doses of asthma medications, and the possibility of inadvertent drug overdoses is quite real.
- An average dose for a young or middle-aged adult may be a toxic dose for an elderly patient. People with arthritis or coordination problems may have a great deal of difficulty using pocket inhalers. Fortunately, this obstacle has been largely overcome by the development of inhaler aids or spacers.
The ideal treatment plan for the elderly patient should mirror any other treatment plan for asthma in that it should be individualized. Most elderly patients with moderate to severe asthma will benefit from an anti-inflammatory drug, and usually, cortisone inhalers work better than cromolyn sodium for this age group.
- Beta agonist drugs can be added when needed. A long-acting, low-dose theophylline preparation is often an ideal drug to add to anti-inflammatory management for patients in this age group. Asthma relapses can be controlled by short-term courses of oral prednisone.
- However, one must be careful with the long-term use of alternate-day prednisone, as the elderly are more prone to osteoporosis, ulcers, diabetes, and high blood pressure.
- Monitoring peak flow rates is very useful in the elderly, as the peak flow rate is easier to perform than a spirometry test and less likely to cause fatigue, which frequently leads to unreliable pulmonary function test results in the doctor’s office or clinic.
Asthma episodes triggered by respiratory infections should be promptly treated with antibiotics when clinically indicated. One should look for underlying signs of sinusitis. Many elderly asthmatics may also have intestinal problems, such as hiatus hernia or gastroesophageal reflux.
- Controlling indigestion and dyspepsia symptoms with antacids or anti-reflux medicines may minimize asthma symptoms. It is important to provide the senior citizen with simple, clear, written instructions, as complex multidrug programs can be quite confusing when one’s memory is not what it used to be.
- Senior citizens who live alone should be periodically visited by relatives or visiting nurses to ensure that they are following directions and taking the correct doses of asthma medications. It may be helpful to put each day’s supply of medicine in an old-fashioned pillbox.
Pregnancy And Asthma
Asthma may be the most common and potentially serious medical problem that can occur during pregnancy. There is little or no evidence that asthma in pregnancy causes spontaneous abortion or congenital malformations.
- What happens to women with asthma when they become pregnant? The answer is: one-third get worse, one-third are unchanged, and one-third get better. It is rare or unheard of for labor and delivery to be complicated by acute asthma.
- Most women revert to their prepregnancy asthma status within three months after their delivery. Some studies suggest that asthma occurs in 1 percent of all pregnancies and that asthmatics have a somewhat greater risk of delivering a premature or low- birth-weight infant.
- Two large studies in the 1970s of 380 asthmatic pregnant women looked at the potential adverse effects of asthma and pregnancy on the infant. There was a statistically significant increase in premature and low-birth-weight infants as well as increased bleeding during pregnancy.
- There was no increase in congenital malformations. Uncontrolled asthma causes a decrease in oxygen content in the mother’s blood and the fetus, leading to impaired fetal growth. Another study of 277 women yielded similar findings. Most studies show no adverse effects of medicine on the fetus.
- The most common asthma trigger during pregnancy is a simple cold or upper respiratory infection. Asthma relapses are more likely to occur between the twenty-fourth and thirty-sixth weeks of pregnancy, with fewer asthma symptoms during late pregnancy-thirty-seven to forty weeks.
- Adverse effects on asthma and pregnancy are due to poor asthma control, possible side effects of medications, increased prevalence of cigarette smoking, and increased severity of severe asthma in blacks. Noncompliance may be associated with poor asthma control, particularly in adolescents.
- Adequate control of asthma during pregnancy increases the favorable outcome of pregnancy. Important factors to consider during pregnancy include maintaining environmental controls, avoiding allergens such as dust mites and animal dander, and minimizing contact with people with respiratory infections.
- Maternal smoking and exposure to passive cigarette smoke are also risks that should be eliminated.
Drug Therapy In Pregnancy
The use of drugs considered to be generally safe should not be held back during pregnancy due to the hazard of uncontrolled asthma and acute respiratory failure, which are likely to endanger the lives of both the fetus and the mother.
- Asthma is not a significant risk factor for pregnancy when asthma is well managed with appropriate medications. What are the best asthma medicines for the pregnant woman? The Food and Drug Administration has labeled drugs into categories A, B, and C as to their level of safety during pregnancy.
- No asthma medication licensed by the FDA since 1980 falls into category A. However, several drugs are listed in categories B and C. Most beta-agonist drugs are considered safe in pregnancy.
- A collaborative perinatal project showed a significant increase in fetal malformation in mothers who received epinephrine during pregnancy, and it is thus recommended that safer beta-agonist drugs such as terbutaline (Brethine) be used.
Terbutaline is commonly used to control premature labor, and the doses used for premature labor have not increased the incidence of congenital malformations. Inhaled forms of beta-agonists are preferable because of their lower absorption and immediate onset of action. The beta-agonists are very effective in mild episodic asthma.
- Patients with moderate or severe asthma should be given an anti-inflammatory drug such as cromolyn or a cortisone aerosol. The manufacturers of cromolyn sodium (Intal) do not recommend the use of cromolyn in pregnancy.
- However, there are a few problems reported with the use of cromolyn in pregnancy. In a 1982 study, 296 women who used Cromolyn during pregnancy delivered normal babies.
- When selecting a cortisone aerosol, it is probably best to use the below-methasone drugs (Vanceril/Beclovent), as most studies of pregnant asthmatics have looked at this preparation and found it to be relatively safe.
One cortisone aerosol that should be avoided is Azmacort, as its base drug, triamcinolone, has been shown to cause fetal malformations. While theophylline has generally been considered to be safe in pregnancy, a recent report on three asthmatic women who took theophylline throughout pregnancy raises some concerns.
- These pregnant women, who used theophylline as well as beta-agonist drugs, delivered children with severe congenital heart defects. Studies in chick embryos have shown that high doses of theophylline can cause congenital cardiac defects.
- These findings. suggest that theophylline should be withheld during the early phases of pregnancy (the first three months) unless the potential benefit to the mother outweighs the risk to the developing fetus.
- The ideal drug therapy during pregnancy is no therapy, especially during the first three months of pregnancy, when the likelihood of fetal malformation is at its highest. However, no matter what is done, 3 to 8 percent of all pregnant.
Women will deliver an infant with a birth defect, and two-thirds of the time the cause of the birth defect is unknown. Some important drugs to avoid during pregnancy include iodide-containing expectorants, sedatives, and tranquilizers.
- Allergy tests should be postponed until after pregnancy, as there is a small risk that testing could trigger an allergic reaction that in turn might provoke premature labor.
- There is no risk in continuing allergy shots during pregnancy, but it is wise to reduce the strength of the injections to reduce the chances of developing a reaction to the injections. No competent allergist or asthma specialist would ever recommend starting allergy injections during pregnancy.
Breastfeeding And Asthma
The concerns of the asthmatic mother do not end with her delivery if she decides to breastfeed her baby. Mothers with allergic asthma should be encouraged to breastfeed, as breastfed infants are less likely to develop eczema or asthma at an early age.
- Even though 10 percent of any drug a breastfeeding woman takes ends up in her breast milk and is ingested in her baby, there is usually little or no risk to the infant.
- One oral drug that causes more problems than others in breastfed infants is oral theophylline. Small amounts of theophylline in breast milk may cause the infant to become irritable or jittery.
- If so, the mother’s theophylline dose should be carefully adjusted by monitoring the mother’s theophylline blood level. If the infant’s irritability persists, the mother should stop her theophylline drug.
- The adrenaline-like and cortisone aerosols have been a boon to nursing mothers, as only trace amounts of these inhaled drugs end up in the mother’s breast milk. Nursing mothers who require high doses of oral cortisone to control severe asthma should not breastfeed.
Surgery And Asthma
Any patient with moderate or severe asthma who requires surgery should be closely observed before undergoing surgery that requires general anesthesia. Everyone who is involved with the operation should be aware of the nature and severity of the patient’s asthma.
- Some patients will need breathing tests and a brief checkup prior to surgery, while others may have to be admitted to the hospital a day or two in advance of the surgery for special breathing treatments.
- Any asthmatic who has used an oral cortisone drug or a cortisone inhaler on a regular basis during the past year should receive a booster dose of cortisone before or during surgery to guard against adrenal gland failure.
- Patients with complicated asthma who need elective surgery should arrange to be treated in hospitals where asthma specialists and respiratory care units are readily available. When all of the involved doctors are aware of the patient’s asthma, surgery and anesthesia can usually be carried out with no problems.
Sex And Asthma
There is very little scientific information concerning the effects of asthma on sex. As sexual activity may require the equivalent amount of exercise to that needed to walk three miles an hour or climb two flights of stairs, “sexercise-induced asthma” can be troublesome for some asthmatics.
It can usually be prevented by using a beta-agonist inhaler prior to sexual activity. Sometimes asthma drugs, especially cortisone drugs, cause impotency or a temporary decrease in sexual desires.
Beta-Blocking Drugs
Many medical conditions, including irregular heart rates, high blood pressure, migraine headaches, glaucoma, and anxiety states, respond well to drugs that block the beta receptor. These drugs are called beta blockers.
- The best known of the beta-blocking drugs is called propranolol (Inderal, Ciplar) As many (if not all) asthmatics already have an abnormal beta receptor, taking a beta-blocking drug may unmask latent or hidden asthma or worsen preexisting asthma.
- One potent beta blocker, called timolol (Glucomol) widely used to treat glaucoma, can cause very severe asthma, and a few patients have even died after placing only one or two drops of Timoptic into their eyes.
- The obvious message is that asthmatics should avoid beta blockers whenever possible. Beta-blockers also have the potential to block the effect of drugs (for example, adrenaline) that are used to treat very severe allergic reactions such as anaphylaxis.
- I have seen patients on beta blockers who have had life-threatening reactions to various allergens. They required aggressive and vigorous emergency room treatment to reverse what otherwise might have been an easily managed reaction.
- Our practice will not do complicated skin testing or initiate allergy injections in any patient who is taking a beta-blocker. In most instances, many other drugs can be used in place of beta blockers.
- For example, people with high blood pressure or irregular heart rates can be switched to a calcium-blocking drug (for example, Verapamil, Nifedipine, or, Depin, Calcigard) or an enzyme-inhibiting drug (for example, Vasotec, Lisinopril)
Skin Diving And Asthma
Can asthmatics safely skin dive? Most diving authorities advise against it. One New Zealand study found that asthma was a con- tributing factor in two of nine diving fatalities.
Dr. Sheldon Spector of the UCLA Medical Center investigated eighteen consecutive scuba-diving fatalities at the Los Angeles Coroner’s Office and found no evidence of asthma in these eighteen fatalities. Therefore, the ban on scuba diving is controversial, as it is based on very limited studies.
Traveling And Asthma
Asthmatics need not be wary of traveling. The following hints will make your trips and vacations more enjoyable if you are asthmatic.
- Bring along enough medicine for the entire trip. Drugs manufactured in foreign countries may be of inferior quality. Keep a duplicate set of medicines in your carry-on luggage.
- Avoid sitting in the smoking sections of trains or airplanes. Rent automobiles with air conditioning.
- When traveling to a foreign country, bring along a letter from your doctor that states you have asthma and lists your medications. This letter will serve a dual purpose. It will defuse suspicious customs officials and make it easier for doctors unfamiliar with your asthma to treat you should your asthma flare up unexpectedly in a remote area or foreign country.
- If you have a significant food or drug allergy, wear a Medic-Alert-type bracelet. Ask your doctor to prescribe a self-injectable form of adrenaline such as the Epi-Pen or Ana-Kit. I usually give my patients with significant asthma a supply of prednisone for acute asthma relapses, as the patient (or parent) may be the best “asthma doctor on the block” in many remote areas or foreign countries.
- Allergic asthmatics should avoid vacationing in those locales with high pollen counts. Become familiar with the dates of pollen release.
- When traveling by automobile, carry your own caller-genic pillow and avoid cheap hotels with dust- or mold-laden heating systems or air conditioners. Leave your pets at home!
- Lastly, when you must visit a friend or relative who has pets in the home that may trigger your asthma, start taking your usual asthma medicines a day or two in advance of your visit, and do not stop these medications until you return home.
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