Educational Information for New & Existing Patients

Spacers

While Metered Dose Inhalers (MDIs) provide the quickest way for medicines to enter your lungs, often the timing and amount of coordination necessary to use them can result in the user not taking them as efficiently as possible. That's where spacers (often called holding chambers) come in. Spacers discharge your medication into a chamber where it is held for a few seconds before and while you inhale. A spacer should be used with all inhaled corticosteroids

How to Use Your Spacer
There are several types of spacers. Your KCAA doctor will recommend which, if any, is best for you.
Inspirease: the Inspirease spacer has a reservoir bag that folds that up like an accordion when you inhale
Aerochamber/EasiVent/Optichamber/Vortex: these have a whistle that lets you know if you are inhaling too quickly.
Aerochamber with mask: if you are using an Aerochamber with mask, be sure that your mask has a proper fit.

Things to Remember
DO NOT PUT YOUR INHALER IN WATER. Recent studies have shown no correlation between how the inhaler floats and how much medicine remains in the inhaler. Some inhalers may malfunction after being submerged.
To keep track of how often to change your inhaler, see the inhalant canister calendar or counter.
Be sure to keep your spacer clean. Cleaning instructions are given in package inserts for each device.
Inhale your medicine within three to four seconds of spraying it into the chamber for the best effect.
 

Quiz Questions

Q - Why are most asthma medications inhaled?
A - Because the medication goes directly where it is most needed; the lungs.

Q - Athmatics who cannot tolerate short acting beta2-agonists can find relief by using what other medication?
A - An anticholinergic

Q - People who are allergic to peanuts or soy products should use which form of administration?
A - A nebulizer, as the nebulized form does not contain the soya lecithin and is safe.

Q - KCAA physicians refer to asthma medications as CPR. What does that stand for?
A - Control. Prevention. Rescue.

Q - Which type of asthma medications contain anti-inflammatories?
A - Control medications

Q - Prevention medicines are sometimes used along with Control medicines to control which kinds of reactions?
A - Twichiness and sensitivity of the airways.

Q - What type of medications give quick relief from symtoms such as coughing, wheezing, shortness of breath, and/or chest tightness?
A - Rescue medications

Q - Which are the most powerful and effective anit-inflammatory medicines for the treatment of asthma?
A - Corticosteroids.

Q - Do corticosteroids cause bronchodilitation (airway opening)?
A - No.

Or
 

Q - Should corticosteroids be used as an emergency "rescue" medicine?
A - No, because they do not open up the airways.

Q - What are the three ways to take corticosteroids?
A - Inhaled. Short-burst oral. Long-term oral.

Q - When should Long-term Oral corticosteroids be taken?
A - They should be taken in the morning to match the peak of corticosteroids produced within our own bodies.

Q - Should you try to get the most you can out of your inhalant canister?
A - No. You should take the medicine according and discard the canister according to the prescription calendar, otherwise the remaining puffs may not contain sufficient medication.

Q - What are Leukotriene Modifiers?
A - Leukotriene Modifiers are medications that prevent airway constriction, excess mucus production, and inflammation and swelling in the lungs.

Q - How should Short-acting beta2-agonists be used?
A - They should be used intermittently as a rescue medication only, not on a regular basis to control asthma.

Preparing Your Child with Asthma and Allergies for School

Asthma and Allergy Foundation of America

You can almost smell them from here: newly sharpened pencils, chalk dust, and new clothes. It's back to school time across the land - an exciting time of transition, change and growth! For the 5 million kids and teens that have asthma or allergies, time at school also can present a unique set of challenges. To help you better prepare for the school year ahead, here is some of the latest medical data about asthma and allergies as it relates to kids and school.

Quality of sleep impacts school performance

Studies show that kids and teens, whose nighttime sleep is disrupted by asthma symptoms, generally miss more school days and have greater difficulty with schoolwork during the day than their friends without asthma. Missed sleep due to nighttime asthma can cause children to have poor recall memory, lack of concentration and mood disorders.

Regular nighttime asthma flare-ups may be a sign that asthma is not under control and a different treatment approach may be needed. One cause for an increase in asthma symptoms during the night may be common household asthma. Triggers, such as dust mites and pet dander, are much more prevalent at home.

If you or your child gets up regularly during the night to handle problems with asthma, talk with your health care provider about medications that work overnight to reduce asthma symptoms. Also be sure to double-check the bedroom for possible allergy triggers. More sleep and prolonged deep sleep significantly improves student's memory capabilities.

Couch potatoes and web heads run a greater risk of developing asthma

Are the kids in your house spending a lot of time in front of the computer and television? If so, they may be increasing their chances of getting asthma, according to new medical studies. Over the last 30 years, physical activity among children has decreased dramatically. Back then, kids often played outside for several hours each day plus rode a bike or walked to school.

These days many children spend much more time on indoor entertainment activities and they tend to travel everywhere by car. The result? Kids of all ages today weigh more than their counterparts in the past, even though they are eating less. Recent research shows that obesity is associated with having asthma. (Obese people are at least 20 percent heavier than recommended for their height, age and sex.) Overweight kids may be two to three times more likely to develop asthma than their friends of normal weight.

Scientists speculate that an inactive lifestyle, increased exposure to indoor allergens from being indoors most of the time and increased body weight, which puts additional pressure on the chest, may be contributing factors to the increasing incidence of asthma.

Teenagers don't stick to their asthma treatment plans

A recent study conducted by the American Lung Association shows that teens with asthma often take less than half of their prescribed medications or don't take them at all. In another European-based study, researchers found that 40 percent of children with asthma don't use their controller medications regularly. When young people with asthma fail to use their medications properly, they often perform below par in school and miss out on sports and social activities.

Parents Helping Kids Manage Asthma

Asthma is a difficult disease to manage. Not only do people with asthma often have to make alterations to their lifestyles to avoid certain asthma triggers, they also have to learn how to juggle and use many medications.

For children this can be a challenge, especially if they don't receive their family's full support. A recent survey in five European countries of more than 600 families who have children with asthma, showed that many of these parents needed to be more involved in their child's asthma care. Results show that many parents still need to brush up on their asthma management knowledge such as:

• Learning how to properly administer their child's medications.
• Stressing to children that they need to take their medications exactly as prescribed.
• Making sure their child has medications on trips away from home.
• Understanding how to prevent an asthma attack.

To learn more about all of these issues, check out the asthma education resources provided through http://www.aafa.org.

Schools nurses and clinics can handle most asthma episodes. If asthma symptoms flare up while kids are at school, early intervention by school-based health care workers can often get students back to class-instead of sending them to the emergency room.

A 1998 review of student charts in two high schools found that 95 percent of students who visited the health center for asthma complaints went back to class the same day-and nearly 30 percent of those students needed a nebulizer treatment. Educated clinic personnel can check pre-and post-treatment peak flows, provide necessary medication and assess what care is needed.

Tips for Children at School with Asthma

Find out if your child's school allows them to keep inhaled medications in their possession. AAFA supports a written medication policy that allows safe, reliable, and prompt access to medications in the least restrictive way during all school-related activities and self-managed administration of medication (including consideration of allowing students to carry and self-administer medications) consistent with the needs of the individual child and the safety of others.

If your child has exercise induced asthma, make sure that coaches and gym teachers are familiar with your child's condition and doctor's recommendations regarding pre-treatment and acute or emergency asthma treatment. Include phone numbers to call with questions or in case of an emergency. Talk to your child about knowing his or her own limits. Children need to know that it is important to respond to their asthma symptoms immediately and not ignore an asthma attack. Information and communication are the most important tools in effective management of allergic disorders.

Tips for Children at School with Allergies

Before school starts, tour the school to identify potential asthma/allergy triggers in the classrooms. Ask staff about school policies regarding foods brought into the classroom and animals in the school.

Sometimes children are not able to express in words that their allergies are acting up. Monitor bouts of irritability, temper tantrums, or decreased ability to concentrate in school-symptoms of allergic irritability syndrome are often caused by nose, ear and sinus congestion in allergic children.

Inform staff of the child's allergies. If symptoms flare up at school, it may be the result of exposure to environmental allergens such as animal dander brought in on the clothing of pet-owning classmates or mold growth in the school building. Try to understand when and where symptoms worsen and work with the school to implement control measures.

Food allergic children who have been prescribed epinephrine should provide the school with an identification sheet with the child's name, photo, and specific allergy for distribution to appropriate personnel. Staff should be taught how to administer an epinephrine shot in the event of an emergency. Parents of food allergic children should work with the school to establish a no food-trading policy.

Are you using your Student Action Plan?

This one-page form, given to the patient during their appointment, provides space to describe your child's asthma triggers, medications and emergency directions for school personnel or day care workers. Single copies are available free from www.aafa.org.

Copyright 2000 - http://www.aafa.org

Start With a Plan and Stick to It!

Your Asthma Action Plan is your guide to keeping your asthma under control. As with any plan, it's important that you stick to it, even when you're feeling fine. That's because your peak flow measurements will let you forecast your asthma symptoms so you can anticipate potential problems, whether you have symptoms or not.

Discover your personal best peak flow reading and use this number as a benchmark. Take a peak flow reading and record your score. If you need help getting organized, MyAsthma Tracker, can help you keep a daily diary of your peak flow and symptoms.

YOU'RE IN A ZONE

Green Zone (80-100% of personal best peak flow)
The Green Zone means:
 

• you are experiencing no symptoms
• you are able to exercise
• you sleep well
• normal activity has no effect on your asthma
• your asthma is stable and under control
• you use your rescue inhaler or nebulizer less than twice a week

 

A few words of caution about being in the Green Zone: Just because you are in the Green Zone does not mean that you should reduce your medication or be less vigilant about following your Asthma Action Plan. Your plan helps you stay in the Green Zone and deviating from the plan without consulting your doctor may be risky. Stay the course and stick to the plan.
If you are in the Green Zone, congratulations - keep up the good work!

Yellow Zone (60-80% of personal best peak flow)
In the yellow zone, you:
 

• may experience few, if any, symptoms when you are resting
• may experience symptoms when you exert yourself
• cough at night
• may feel tired and have less energy than normal
• use your rescue inhaler or nebulizer several times a week

 

If your peak flow is in the Yellow Zone, you may be slipping downhill but don't know it yet. The Yellow Zone could last a few hours or several days. If you can't seem to get out of the yellow zone after several days, call your KCAA doctor so you can work together to get back into the Green Zone. Your medication dosage is different if your peak flow is in the Yellow Zone so be sure to follow your treatment plan carefully.

Red Zone (less than 60% of personal best peak flow)
If you are in the Red Zone, you could be headed for trouble. You may experience increasing symptoms of coughing, wheezing, chest tightness, and shortness of breath. Continue your control and prevention medications and follow the rescue instructions of your treatment plan. Check your peak flow reading before you take your medications and 20 minutes after taking them. If you are unable to move out of the Red Zone, or fall back into the Red Zone within four hours, call your doctor immediately.
 

Asthma - Drug Therapy

Depending on the severity of your asthma, your KCAA doctor will choose certain kinds of medicines for you.
Medication: CPR for asthma patients; Control, Prevention and Rescue

Control Medications
Control medications are meant to do just that, control your asthma. Control medicines are anti-inflammatories that decrease or prevent the inflammation or redness and swelling in your airways. They are first line treatment for long-term control of persistent (mild persistent, moderate persistent, or severe persistent) levels of asthma. These medications are usually taken daily. Your doctor will work with you to establish frequency and dosage.

Prevention Medications
Prevention medications help prevent asthma symptoms from occurring. Unlike control medications, they do not decrease inflammation but may be used in conjunction with anti-inflammatories to better control sensitivity or twitchiness in the airways.

Rescue Medications
Rescue medications give quick relief from asthma symptoms like coughing, wheezing, shortness of breath, and/or chest tightness. Generally, rescue medications begin to provide relief within five minutes of administration and their effects usually last for about four to six hours. Rescue medications are often used preventatively before exercise to keep from having problems. If you are using rescue medications more than twice weekly for symptoms, more than twice monthly for nighttime symptoms, or more than two canisters per year, your asthma is not well controlled and you should discuss this with your doctor.

Anticholinergics
Anticholinergics provide some bronchodilator (airway opening) effects in certain individuals. Although not generally the first choice of rescue medicines for acute symptoms, some asthmatics cannot tolerate short acting beta2-agonists and thus an anticholinergic is prescribed. An anticholinergic works by dilating the larger airways and is also useful in people who have Chronic Obstructive Pulmonary Disease (COPD) with or without an asthmatic component. Anticholinergics provide fairly fast relief of asthma symptoms, generally within one to two hours. They are sometimes used in conjunction with the shorter acting beta adrenergics like albuterol.

Side Effects
Possible side effects of anticholinergics are dry mouth, coughing, and an unpleasant taste, but using a spacer/holding chamber and rinsing and gargling with water or mouthwash can help prevent this. This class of medication is contraindicated in patients with glaucoma. Rare side effects include dermatitis, swelling of the face, lips, or eyelids, skin rash and hives.

Anticholinergics Brands
Ipratropium Bromide (Atrovent®) is available in inhaler and nebulizer forms. Combivent is an inhaler form containing both Ipratropium and Albuterol. Spiriva is a long-acting dry powder inhaler.

Control Medications
Control medications keep your asthma symptoms in check by decreasing the inflammation and swelling in your airways. They are often called anti-inflammatory medications. Read more about control medications such as corticosteroids and non-steroidal anti-inflammatories.

Corticosteroids - The Big Guns
Corticosteroids are the most powerful and effective anti-inflammatory medications for the treatment of asthma. Because of the importance of controlling airway inflammation and hyper-responsiveness, corticosteroids are considered the first line treatment for asthma and are a key component in the management of mild, moderate and severe asthma.

When used regularly, corticosteroids help:
 

• decrease airway inflammation
• decrease mucus production
• decrease the allergic process
• improve peak flows and lung function tests
• decrease airway hyper-responsiveness or twitchiness
• prevent acute episodes of asthma
• increase the effectiveness of other asthma drugs

 

Though they may be the most important medication in your treatment plan arsenal, the effects of the corticosteroids are not immediate. Corticosteroids do not cause bronchodilitation (airway opening). In other words, this medication will not immediately open the airways. For that reason, corticosteroids should be taken on a regular basis for preventative purposes rather than in an emergency or for rescue.

Using Corticosteroids
There are three ways to take corticosteroids:
 

• Inhaled Corticosteroids - This is safe and effective treatment for persistent asthma. The inhaled corticosteroid can be used for short- or long-term treatment without the adverse side effects of oral corticosteroids.
• Short Burst of Oral Corticosteroids - Oral corticosteroids are used to treat a moderate to severe exacerbation or flare of asthma that is not coming under adequate control with other asthma medications. The short burst of oral corticosteroids begins to work within three hours, but may take up to 12 hours before any significant difference occurs. Frequent "bursting" is a good indication that the treatment plan may need to be reevaluated. Regular asthma medications should be continued as prescribed in the treatment plan.
• Long-term Oral Corticosteroids - Long-term oral corticosteroids are used only for the severe asthmatic who has not been well controlled with a combination of other asthma medications. When these are necessary, alternate day usage reduces the potential for systemic side effects.

Side Effects of Corticosteroids
Short Burst of Oral Corticosteroids side effects may include an increased appetite, a sense of well being, fluid retention, a slight weight gain, and/or acne. The patient may also feel mild body aches which usually can be controlled by taking acetaminophen. If stomach upset occurs, the corticosteroid should be taken with food. Moodiness may be experienced both during therapy and for a brief period after therapy is stopped.

Long-term Oral Corticosteroids may suppress your body's adrenal function that helps you respond to severe physical stress, such as major injury or surgery. The safest way of taking long-term oral corticosteroids is on an alternate, every-other-day basis. They should be taken in the morning to match the peak of corticosteroids produced within our own bodies. If corticosteroids are necessary, your doctor will prescribe the least amount possible and in the safest way.

Goals of Therapy
The main goal of your asthma therapy is to keep your asthma symptoms under control. By "under control" we mean:
 

• You don't have chronic or annoying symptoms like coughing or breathlessness in the night, the early morning or after exercise.
• You have normal lung function.
• You do not have acute attacks that send you to the Emergency Room or hospital.
• You have normal activity and are able to exercise.
• You have the right medication plan with minimal or no side effects.
• Your goals, and those of your family, should be met and you are satisfied with your care.

Asthma is a chronic condition with acute episodes, so therapy includes prevention of symptoms and early intervention. Your KCAA doctor will periodically assess your treatment plan to make sure it's meeting your current needs. We will be working closely with you to set and achieve your asthma therapy goals.

Steps to Take
Here are four steps to keep your asthma under control:  

1. Measures of Assessment and Monitoring - You will be diagnosing your asthma and judging the severity of it on a day-to-day basis with peak flow and symptom identification. You'll learn how your asthma is classified and how you can monitor your symptoms.

2.  Drug Therapy - You will be using the right medicine for treatment at the right time and you'll learn about different medications for different types of asthma severity.

3. Control of Asthma Triggers - You will learn what your asthma triggers are and how to control or avoid them.

4. Patient Education - You and your KCAA doctor will be partners in controlling your asthma. And, you'll discover how asthma education can help you live with your asthma "under control."

 Inhalant Canister Calendar

It is important that you take your medication as prescribed and discard your inhalant canister as indicated on this chart. Otherwise, the remaining puffs you take may not contain sufficient medication.

If the Medication is taken as prescribed, the canister should be discarded as indicated above. Otherwise, the remaining puffs may not contain sufficient medication.

Source: Expert Panel Report 2: Practical Guide for the Diagnosis and Management of Asthma. National Institutes of Health, National Heart, Lung, and Blood Institute. 1997

Breathe Deeply! - Inhalers

Most asthma medicines are inhaled so that the medicine goes directly where it is most needed - the lungs. Inhalants also decrease the medication dosage, have fewer side effects, and work faster than medications taken other ways, such as ingested. It is important that you use your inhaler correctly in order to get the best results.

Using Spacers
You should always use a spacer with your metered dose inhaler. Here's why:

Spacers help slow the initial rapid inhalation, reducing the irritant properties of the aerosol. This helps decrease the tendency to cough after you inhale your medication.

With a spacer, the delivery of medication to your lungs is improved and medication going into your mouth and throat is lessened. This decreases the possibility of oral candidiasis (thrush) sometimes associated with inhaled corticosteroids.

Spacers and holding chambers make your metered dose inhaler more efficient and easier to use.

Spacers are especially helpful for people who have highly irritable airways.

Anticholinergics Brands
Ipratropium Bromide (Atrovent®) is available in inhaler and nebulizer forms. Combivent is an inhaler form containing both Ipratropium and Albuterol.

Leukotriene Modifiers
Leukotrienes are chemicals in the body that cause airway constriction, excess mucus production, and inflammation and swelling in the lungs. Leukotriene modifiers prevent these things from happening. Most leukotriene modifiers are taken at least once a day, and depending on the type prescribed, may not have noticeable effects for one week to one month so it is important that you take the medication as prescribed by your KCAA physician.

Types of Leukotriene Modifiers
Montelukast (Singulair®) is the only once-a-day leukotriene modifier and is taken orally. Bronchodilator (airway opening) effects may begin within two hours, but the preventive anti-inflammatory effects will not begin for up to one week. Side effects may include headache, fatigue, fever, intestinal symptoms, laryngitis, and/or pharyngitis.

Zafirlukast (Accolate®) is taken orally, and generally is prescribed twice a day. Zafirlukast (Accolate®) should be taken on an empty stomach, one hour before or two hours after a meal. As with Montelukast (Singulair®), bronchodilator effects may begin within two hours, but preventive effects will not begin for up to one week. Side effects may include headache, dizziness, infection, nausea, vomiting or diarrhea.

Zileuton CR (Zyflo®) is taken orally, generally twice daily. Depending on your treatment plan, the dosage may be decreased by your doctor. Be sure you do not decrease dosage on your own without consulting your physician, even if you are feeling better. Side effects may include headache, nausea, abdominal pain, or indigestion. Some patients may develop abnormal liver functionality while on this medication. If you have a known liver problem, you should avoid using Zileuton (Zyflo®). Liver function will be monitored if this medication is prescribed.

Prevention Medications
Prevention medications are different than control medications in that they are not anti-inflammatory medicines; they do not work by decreasing inflammation in the airways. Leukotriene modifiers, one type of prevention medicine, prevent asthma attacks by blocking the effects of leukotriene mediators, a potent active substance created as the result of an allergic response. Leukotriene modifiers have both control and prevent aspects. Long-acting beta2-agonists (LABAs) work by relaxing the smooth muscles around the airways to prevent bronchospasm. LABAs should not be used as monotherapy, but are used in combination with inhaled corticosteroids. Advair and Symbicort are inhalers that combine a LABA with an inhaled steroid.

Short-Acting Beta2-Agonists
Short-acting beta2-agonists open the bronchial tubes by relaxing the smooth muscles surrounding the airways. They act fast to relieve shortness of breath, chest tightness, coughing, or wheezing and are generally used in case of an acute asthma attack to quickly relieve these symptoms.

Short-acting beta2-agonists should be used intermittently as a rescue medication only, not on a regular basis to control your asthma. If you find that you are using short-acting beta2-agonists regularly, you should check with your doctor, as anti-inflammatory medications may be needed for control measures.

Side Effects
Possible side effects of short-acting beta2-agonists are shakiness, headache, or rapid heartbeat. Overuse of short-acting beta2-agonists can lead to an irregular heartbeat, unresponsiveness to the inhaled medication, and a delay in seeking necessary treatment.

Short-Acting Beta2-Agonists Brands
There are several types of short-acting beta2-agonists that perform the same functions including:

• Albuterol Inhaler (ProAir HFA, Proventil HFA® or Ventolin HFA and generic nebulizer solution)
• Pirbuterol Inhaler (Maxair®, Maxair Autohaler®)
• Terbutaline Inhaler (Brethaire®)
• Levalbuterol HCl - Nebulizer Solution (Xopenex®) and Inhaler (Xopenex HFA)

 

Check with your KCAA doctor to see which type is right for you. See "How to Use Your Inhaler" for proper use.