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Archive-name: medicine/asthma/general-info Posting-Frequency: monthly Last-modified: 13 Dec 1994 Version: 3.2 alt.support.asthma FAQ: Asthma -- General Information ====================================================== Introduction: ------------ Welcome to alt.support.asthma! This newsgroup provides a forum for the discussion of asthma, its symptoms, causes, and forms of treatment. Please note that postings to alt.support.asthma are intended to be for discussion purposes only and are in no way to be construed as medical advice. Asthma is a serious medical condition requiring direct supervision by a physician. Please be aware that the information in this FAQ is intended for educational purposes only and should not be used as a substitute for consulting with a doctor. Many of the contributors are not health care professionals; this FAQ is a collection of personal experiences, suggestions, and practical information. Please remember when reading this that every asthmatic responds differently; what is true for some asthmatics may or may not be true for you. Although every effort is made to keep this information accurate, this FAQ should not be used as an authoritative reference. Comments, additions, and corrections are requested; if you do not wish your name to be included in the contributors list, please state that explicitly when contributing. I will accept additions upon my own judgement -- I'll warn you right now that I'm a confirmed skeptic and am not a great believer in alternative medicine. All unattributed portions are my own contributions. For more information about asthma medications, there is also an Asthma Medications FAQ that is posted as a companion to this one. * = not added yet + = added since last version & = updated/corrected since last version ====================================================================== Table of Contents: ----------------- General Information: 1.0 What is asthma? 1.0.1 What is emphysema? * 1.0.2 What is COPD? 1.0.3 What is status asthmaticus? 1.0.4 What is anaphylactic shock? 1.1 How is asthma normally treated? 1.1.1 How is an acute asthma attack treated? * 1.1.2 What is a peak flow meter? * 1.1.3 What is a spirometer? * 1.2 How is asthma diagnosed? * 1.3 What are the common triggers of asthma? 1.4 What are some of the most common misconceptions about asthma? Medications: 2.0 What are the major classes of asthma medications? 2.1 What are the names of the various asthma medications? 2.1.1 Are salbutamol and albuterol the same drug? 2.1.2 Are some asthma drugs banned in athletic competitions? 2.2 What kinds of inhalers are there? 2.2.1 Which kind of inhaler should I use? 2.2.2 What is a spacer? 2.2.3 What is "thrush mouth" and how can I avoid it? 2.2.4 Is Fisons still making the Intal Spinhaler? 2.2.5 What's the difference between Spinhalers and Rotahalers? 2.2.6 Should I use an inhaler or take pills? * 2.2.7 How can I tell when my MDI is empty? 2.3 What kinds of tablets are there? 2.3.1 Why do I need a blood test when taking theophylline? 2.3.2 Why are combination pills not commonly prescribed? 2.4 What is a nebulizer? 2.5 What medications should I avoid if I have asthma? Allergen Avoidance/Environmental Control: 3.0 What does HEPA stand for? + 3.1 What are some cheap ways to reduce my exposure to dust? Miscellaneous: 4.0 What resources are there for asthmatics? ====================================================================== 1.0 What is asthma? -------------------- Asthma is defined as *reversible* obstruction (blockage) of the airways inside the lungs. The 'reversible' part is important; if the condition is NOT reversible, either with medication or spontaneously, then the diagnosis is not that of asthma, but of some other condition, usually chronic obstructive pulmonary disease. Quickly reviewing the structure of the lung: air reaches the lung by passing through the windpipe (trachea), which divides into two large tubes (bronchi), one for each lung. Each bronchi further divides into many little tubes (bronchioles), which eventually lead to tiny air sacs (alveoli), in which oxygen from the air is transferred to the bloodstream, and carbon dioxide from the bloodstream is transferred to the air. Asthma involves only the airways (bronchi and bronchioles), and not the air sacs. Although everyone's airways have the potential for constricting in response to allergens or irritants, the asthmatic patient's airways are oversensitive, or hyperreactive. In response to stimuli, the airways may become obstructed by one of the following: - constriction of the muscles surrounding the airway; - inflammation and swelling of the airway; or - increased mucus production which clogs the airway. Contributed in part by: Ruth Ginzberg rginzberg@eagle.wesleyan.edu 1.0.1 What is emphysema? ------------------------- Emphysema is the disease in which the air sacs themselves, rather than the airways, are either damaged or destroyed. This is an irreversible condition, leading to poor exchange of oxygen and carbon dioxide between the air in the lungs and the bloodstream. 1.0.2 What is COPD? ----------------------------- - to be added in a future version 1.0.3 What is status asthmaticus? ---------------------------------- Status asthmaticus is defined as a severe asthma attack that fails to respond to routine treatment, such as inhaled bronchodilators, injected epinephrine (adrenalin), or intravenous theophylline. 1.0.4 What is anaphylactic shock? ---------------------------------- Anaphylactic shock is defined as a severe and potentially life-threatening allergic reaction throughout the entire body. It occurs when an allergen, instead of provoking a localized reaction, enters the bloodstream and circulates through the entire body, causing a systemic reaction. (There may also be an intrinsic trigger, as some cases of exercise-induced anaphylaxis have been reported.) The symptoms of anaphylactic shock begin with a rapid heartrate, flushing, swelling of the throat, nausea, coughing, and chest tightness. Severe wheezing, cramping, and a rapid drop in blood pressure follow, which may lead to cardiac arrest. The treatment for anaphylaxis is intravenous epinephrine (adrenalin). 1.1 How is asthma normally treated? ------------------------------------ Treatment of asthma attempts to alleviate both the constriction and inflammation of the airways. Drugs used for relieving the constriction are called bronchodilators, because they dilate (open up) the constricted bronchi. Drugs aimed at reducing inflammation of the airways are called anti-inflammatories, and come in both steroidal and nonsteroidal forms. If the asthma is triggered by allergies, then reducing the patient's exposure to the allergens or taking shots for desensitization are other alternatives. There are two main classes of bronchodilators, beta-agonists which are usually taken in an inhaled form, and xanthines, which are chemically related to caffeine. The major xanthine, theophylline, is present in coffee and tea, and is taken orally. Beta-agonists are chemically related to adrenalin. The inflammation component is treated primarily with steroids, which are a type of hormone. The steroids used in the treatment of asthma are corticosteroids, which are not the same as the anabolic steroids that have become notorious for their abuse by muscle builders and athletes. Up until fairly recently, doctors did not usually prescribe corticosteroids for asthma except as a final resort, when all else was not working to achieve the desired result. Now that has completely reversed. Steroid inhalers are now among the first line of drugs that a doctor will try in asthma management after an acute attack has resolved. They work by reducing inflammation of the bronchi, and making future acute attacks less likely. There are also two nonsteroidal anti-inflammatories available, cromolyn sodium and nedocromil, which are a popular alternative to inhaled corticosteroids. *IT IS IMPORTANT TO NOTE THAT OBTAINING RELIEF FROM AN ACUTE EPISODE OF ASTHMA (an asthma "attack") IS NOT THE SAME THING AS TREATING THE ASTHMA.* Years ago it was thought that "asthma" consisted only of the acute "attacks" which were suffered intermittently; when you weren't wheezing, you didn't have asthma any more. This is no longer thought to be the case. New asthma research emphasizes the role of the inflammation component of asthma, pointing out that bronchodilation alone does not reverse or treat the inflammation, although it does offer dramatic relief from an acute "attack". New thinking on the subject is that if the underlying inflammation is successfully treated, then the person with asthma will be much less susceptible to the airway constriction, wheezing, and increased mucus secretion which accompany an acute "attack". People with asthma have been found often to have ongoing inflammation which does not subside between acute "attacks", even when they are not wheezing. However, treatment of the inflammation cannot be done on an emergency basis. Treatment of the inflammation component is done after control is regained from an acute episode. Without treating the underlying inflammation, the asthma itself is not being addressed and the acute attacks will continue to recur. For this reason, it is particularly important for parents of asthmatic children NOT to use the emergency room as the *only* place or occasion for treating their children's asthma (during acute attacks). That is not actually treating the asthma; it is just alleviating the most acute symptoms. The child needs to be seen when it is NOT an emergency, for evaluation of the asthma and development of a treatment plan. Contributed in part by: Ruth Ginzberg rginzberg@eagle.wesleyan.edu 1.1.1 How is an acute asthma attack treated? --------------------------------------------- Treatment of acute asthma (an asthma "attack") usually is directed mainly toward alleviating the constriction of the airway. Drugs used for this effect are called bronchodilators, because they dilate (open up) the constricted bronchi. Adrenalin is often used in emergency rooms for this purpose, for an acute asthma "attack" that is seriously out of control. Theophylline also relaxes the muscles surrounding the airways, and may be given intravenously in the emergency room. Contributed in part by: Ruth Ginzberg rginzberg@eagle.wesleyan.edu 1.1.2 What is a peak flow meter? --------------------------------- - to be added in a future version 1.2 How is asthma diagnosed? ----------------------------- - to be added in a future version 1.3 What are the common triggers of asthma? -------------------------------------------- - to be added in a future version 1.4 What are some of the most common misconceptions about asthma? ------------------------------------------------------------------ People with asthma must not exercise because exercise might make them ill. They must live sedentary lives. (FALSE) Asthma is primarily a psychogenic illness caused by repressed emotions. (FALSE) All children outgrow their asthma eventually. (FALSE, but many do.) Childhood asthma turns into adult emphysema. (FALSE) All asthma is caused by allergies. (FALSE) Moving to another state or region will cure asthma. (FALSE) Food allergies are a frequent cause of children's asthma. (FALSE, though rarely they are) Asthma in children is made worse by paying attention to it, because it is just a way of trying to get attention in the first place. (FALSE) Asthma in children is caused by so-called "smother-mothers". (FALSE) Asthma is a drag, but it's not fatal. (FALSE. Especially among African-American children and young adults it is a growing cause of death for reasons not fully understood.) Smoking marijuana improves asthma. (FALSE) Asthma inhalers are addictive. (FALSE) Contributed by: Ruth Ginzberg rginzberg@eagle.wesleyan.edu ====================================================================== 2.0 What are the major classes of asthma medications? ------------------------------------------------------ There are five major classes of asthma medications: - steroidal anti-inflammatories, - non-steroidal anti-inflammatories, - anti-cholinergics, - beta-agonists, and - xanthines. The first two categories of drug treat the underlying inflammation of the lung, while the latter two categories are bronchodilators. Once I understand what anti-cholinergics do, I'll be sure to include a description for them, also. 2.1 What are the names of the various asthma medications? ---------------------------------------------------------- For a complete listing of asthma medications, please see the alt.support.asthma FAQ: Asthma Medications. It is posted monthly as the companion to this general information FAQ. 2.1.1 Are salbutamol and albuterol the same drug? -------------------------------------------------- Ventolin is the brand name of salbutamol, which is the WHO (World Health Organization) recommended name for the medication. Unfortunately, in the US this same drug is called albuterol, leading to endless confusion. In fact, it's one of the few drugs in which the brand name stays the same from country to country, while the chemical name changes! Ventolin is made in the U.S. by Allen & Hanburys, and Proventil is the same drug manufactured by Schering. You can also get this drug in a sustained-action tablet, called either Repetabs (by Schering, again) or Volmax (Muro). 2.1.2 Are some asthma drugs banned in athletic competitions? ------------------------------------------------------------- Many asthma drugs are BANNED and may result in disqualification of an athlete from international and Olympic competition or other qualifying events, for a 2 year period for the first offense if urine drug analysis tests are positive. The USOC follows protocol in the US for the International Olympic Committee, so the banned substances are banned in both US and international competition. Banned substances unfortunately are not defined by whether they are medically necessary but by whether they enhance performance (and thus give an unfair advantage). A partial list of such substances includes: ephedrine, bitolterol, metaproterenol, orciprenaline, rimiterol, and pirbuterol. Albuterol, terbutaline, beclomethasone, dexamethasone, and triamcinolone, previously banned, are now allowed for use in Olympic competition in inhaler/or nasal form only with written notification from the physician in question on file with the United States Olympic Committee prior to competition. Oral use of certain beta-2 agonists is banned. Cromolyn sodium is allowed. ** However, athletes should be aware that recommendations regarding the use of asthma medications (i.e. allowed vs. banned) in athletic competition may be revised. Ultimately, it is the athlete's responsibility to check with the USOC Drug Hotline, (800) 233-0393, and the athlete's coaches and/or National Sport Governing Body to get the most current recommendations. Asthma medications do not cause false positives on drug tests, at least for substances tested for in drug control with sports testing. Most importantly, any athlete who is competing at the level where drug testing is being performed can check with the United States Olympic Committee Drug Hotline, (800) 233-0393, 24 hours, to confirm whether a particular drug is allowed or banned. Such an athlete should also discuss with both their coach and physician whether the drug is allowed or banned, and if banned, when should the drug be stopped prior to competition to get the medical benefits but avoid testing positive and suspension from competition. The USOC Drug Control Program also has a wide range of literature for athletes on what asthma medications are banned, allowed, and allowed with prior notification. Contributed by: Lyn Frumkin, M.D., Ph.D. lrfrum@u.washington.edu 2.2 What kinds of inhalers are there? -------------------------------------- aerosol inhalers: ---------------- MDI - metered-dose inhaler, consisting of an aerosol unit and plastic mouthpiece autohaler - MDI made by 3M which is activated by one's breath, and doesn't need the breath-hand coordination that a regular MDI does respihaler - aerosol inhaler for Decadron. I have no idea how this differs from the usual MDI dry powder inhalers: ------------------- rotahaler - dry powder inhaler used with Ventolin Rotacaps (see table above), i.e. albuterol sulfate in capsules. Each capsule contains one dose; the inhaler opens the capsule such that the powder may be inhaled through the mouthpiece. Available in the U.S., Canada, and UK. spinhaler - dry powder inhaler used with Intal capsules for spinhaler. Each capsule contains one dose; the inhaler opens the capsule such that the powder may be inhaled through the mouthpiece. Available in Canada, UK, and the U.S. diskhaler - dry powder inhaler. The drug is kept in a series of little pouches on a disk; the diskhaler punctures the pouch and drug is inhaled through the mouthpiece. Currently available in Canada and UK, not in U.S. turbohaler - dry powder inhaler. The drug is in form of a pellet; when body of inhaler is rotated, prescribed amount of drug is ground off this pellet. The powder is then inhaled through a fluted aperture on top. Available in Australia. 2.2.1 Which kind of inhaler should I use? ------------------------------------------ Some asthmatics find the dry powder inhalers more effective than their MDI (aerosol) counterparts. It is suspected that the aerosol or propellent in the MDI may act as an irritant to some asthmatics, as in the following article: J.R.W. Wilkinson et al., Paradoxical bronchoconstriction in asthmatic patients after salmeterol by metered dose inhaler, British Medical Journal 305 (1992) 931. The first sentence in the conclusion is: "Bronchoconstriction after both salmeterol and placebo by metered dose inhaler but not after salmeterol by diskhaler suggests that the irritant is not the salmeterol itself." . . . "The similarity in characteristics of bronchoconstriction after beclomethasone by metered dose inhalers implicates one or both chlorofluorocarbons . . . as the irritant. That salbutamol caused no bronchoconstriction was attributed to its faster onset of action opposing any bronchoconstrictor effects of the propellants." ** However, according to the 1994 Physicians' Desk Reference, Intal Spinhaler capsules are "contraindicated in those patients who have shown hypersensitivity to . . . lactose." So asthmatics who are lactose-intolerant may not have this form of cromolyn sodium as an option. 2.2.2 What is a spacer? ------------------------ A spacer is a device that simplifies the inhalation of aerosol metered-dose-inhalers (MDIs). Most people find it difficult (at least initially) to time the spraying of an MDI and the inhalation of the medicine, and, thus, most of the medicine is deposited in their mouths or the backs of their throats instead of their lungs. Besides being less effective, this can lead to other side effects (e.g., for inhaled steroids, an increased potential for thrush, an oral fungal infection). The spacer is basically a temporary holding chamber for the medication. You spray the medicine into the chamber where it temporarily remains suspended, and then you inhale deeply and SLOWLY. The column of medication rapidly passes through the mouth and goes into the lungs. There are a few different types of spacers. The one I'm most familiar with is the Aerochamber. It's a plastic tube with a mouthpiece on one end and a place to insert the MDI on the other. The mouthpiece has a delicate one-way valve built in so that you can exhale without displacing the medication in the chamber and then inhale. Some spacers are clear, some have a little whistle built in that tells you if you're inhaling too fast. I've read (and believe) that the medication is more efficiently delivered using a spacer than if it were merely inhaled directly from the MDI. Some packages (AeroBID, I believe, and others) come with a spacer built into its MDI housing. There are special spacers for younger children. There's an Aerochamber that has a mask built in; the child breathes normally for a few seconds with the mask held over his/her mouth and nose. This is typically used when a nebulizer is not available or not required, and for medications that cannot be nebulized, such as Beclovent or Vanceril. There is also a device for children called InspirEase, which is kind of like a plastic bellows or balloon with a plastic mouthpiece. The child inflates it, the medicine is sprayed into it, and the child inhales, holds his/her breath for the count of 5 (or whatever the doctor recommends), exhales into the device, and then repeats. It's really helpful for younger children who don't really know about breathing in and breathing out or how to hold their breath or breathe evenly and slowly. It gives them immediate physical feedback, and also has a whistle built in to tell them when they're breathing too fast (although they seem to like making it whistle, so it's positive reinforcement for something that they shouldn't be doing). As the child grows, the Inspirease becomes less effective, since it has a limited capacity. Although spacers are sometimes provided by some HMOs and covered by some insurers, I don't believe that a prescription is required. Contributed by: Mark Feblowitz mfeblowitz@GTE.com 2.2.3 What is "thrush mouth" and how can I avoid it? ----------------------------------------------------- Thrush mouth is the popular term for a yeast infection (candida albicans) in the back of throat. The major symptom of thrush is a white film located at the back of the throat and tonsil area. It is usually cured by the use of an antifungal mouthwash. Thrush is a very common side effect of taking inhaled corticosteroids. The way to avoid this complication is to ensure that the back of the throat doesn't remain coated with corticosteroid after use of the inhaler, either by using a spacer or by rinsing the mouth very thoroughly afterwards. Unfortunately, some people still get it even when they are very thorough about rinsing. 2.2.4 Is Fisons still making the Intal Spinhaler? -------------------------------------------------- Yes, Fisons is still manufacturing both the Intal Spinhaler (a dry powder inhaler for cromolyn sodium) and the capsules for it. Many pharmacists in the U.S. are under the impression that it is unobtainable, probably due to the fact that the Spinhaler was unavailable for a short time in the U.S. some while back due to a change in formulation. During this time, some wholesalers stopped buying the inhaler, and didn't restock it once the Spinhaler was back in production. So your pharmacist's regular wholesaler still may not be carrying this product. For further information, Fisons Corporation's number for Rx Customer Service is (800) 334-6433. Contributed in part by: Paula Ford pxf3@psuvm.psu.edu 2.2.5 What's the difference between Spinhalers and Rotahalers? --------------------------------------------------------------- [Maintainer's note: the Rotahaler is a dry powder inhaler for Ventolin (albuterol), manufactured by Allen & Hanburys, while the Spinhaler is a dry powder inhaler for Intal (cromolyn sodium), manufactured by Fisons Corporation. Both inhalers are available in the U.S.] The Rotahaler and the Spinhaler are very different animals. The Rotahaler is a pussycat, the Spinhaler a ferocious lion. The Rotahaler is a two-part mouthpiece that you snap apart, put a capsule in, twist, and inhale. When you twist the device, the capsule breaks open. When you inhale, the medicine lands in your lungs. The Spinhaler is a three-piece device: a mouthpiece, a tiny fan, and a cap to cover the fan. You open it, put the capsule in a space on the fan, close it, push down then up on the cap (this breaks the capsule) and then tilt your head back, put the mouthpiece in your mouth, and inhale. The fan throws the medicine into the back of your throat. Then you gag. I don't like the propellants in MDIs, so I was highly motivated to get a Spinhaler. It took me a month to get my drugstore to find it, and now I must admit I'm disappointed. I tried using a capsule in the Rotahaler, since that device works so well, but the medicine seems to be of the wrong consistency, and the capsule is too small for the space it should go into. Another difference: The Spinhaler comes in a little container like a medicine bottle, but the lid doesn't stay on very well in a purse. The Rotahaler comes in a little plastic case sort of like a compact and stays shut (i.e. clean) in a purse, backpack, or jeans pocket. Contributed by: Paula Ford pxf3@psuvm.psu.edu 2.2.6 Should I use an inhaler or take pills? What's the difference? --------------------------------------------------------------------- Medications taken orally almost always have a much higher systemic concentration (concentration in your entire body) than inhaled medications. So if the side effects are due to systemic concentrations, then an inhaled drug is less likely to have these side effects, or may have them much less severely. The idea behind an inhaler is that the full dose is delivered to the lungs, where it is immediately absorbed by the lung tissue, and starts to take effect locally. Excess drug may be absorbed by the bloodstream and delivered to the rest of your body, but this amount tends to be minimal. So your lungs receive an immediate, high concentration of the drug, and the rest of your body receives very little. If you take the drug orally in tablet or capsule form, then you need a much higher dose. The reason is that for the same amount of drug to reach the lungs through the bloodstream, you need the same concentration of drug in the rest of your body. For example, most people take one or two puffs of albuterol (Ventolin or Proventil) every four to six hours, and each puff is 90 micrograms of albuterol. The usual dosage of Ventolin in tablets is 2-4 milligrams three or four times a day, which is something like 200 times the amount inhaled. However, one advantage that tablets have is that the medication may be available in a time-release format. So for a short-acting medication like albuterol, the inhaled version might need to be taken every four to six hours, while a extended-release tablet such as Volmax would need to be taken only every twelve hours. 2.2.7 How can I tell when my MDI is empty? ------------------------------------------- - to be added in a future version 2.3 What kinds of tablets are there? ------------------------------------- SA - sustained action. SA and CR (below) have been used interchangeably and almost mean the same thing, except SA refers to the pharmacologic action while CR refers to the drug release process. Any drug release which is controlled in a zero-order fashion (constant rate of release) is generally referred to as Sustained or Controlled Release. CR - controlled release. See SA. DR - delayed release. This generally refers to enteric- coated tablets which are designed to release the drug in the intestine where the pH is in the alkaline range. ER - extended release. Dosage forms which are designed to release the drug over an extended period of time, e.g. implants which release drug over a period of one or two months or years. TD - time delayed. This is slightly different from DR in that the drug release is designed to occur after a certain period of time, e.g. pellets coated to a certain thickness or multi-layered tablets or tablets within a capsule or double-compressed tablets. Contributed by: Susan Graham sgraham@hpb.hwc.ca 2.3.1 Why do I need a blood test when taking theophylline? ----------------------------------------------------------- Theophylline is a very effective drug but unfortunately its therapeutic level is quite close to its toxic level. This means that the dose that the patient needs to get the full benefit of the drug is not very much lower than the dose which causes side effects which range from unpleasant to dangerous. This would not be such a problem if there weren't such large variations in the rate at which people metabolize theophylline. Apparently, if a group of people are given the same dose of theophylline, the concentration of the drug in their bloodstreams may vary by up to a factor of seven. Therefore, the best way to monitor that the patient is receiving the optimal amount of theophylline is to take a blood level concentration. 2.3.2 Why are combination pills not commonly prescribed? --------------------------------------------------------- The combination drugs such as Tedral and Marax commonly contain theophylline, ephedrine, and some form of sedative such as phenobarbital. These combination pills are no longer commonly prescribed because the amount of theophylline in the pill cannot be varied with respect to the other drugs. Since there is great variation in the rate at which an individual metabolizes theophylline, it is now considered better to take theophylline separately, for better adjustment of theophylline levels. In fact, Tedral is no longer manufactured by Parke-Davis. Also, ephedrine is no longer considered the bronchodilator of choice. From Drs. Haas, _The Essential Asthma Book_, "ephedrine initiates the release of catecholamines -- including adrenaline -- that are already stored in the body. This is its biggest drawback. Its effects depend on the availability of catecholamine in the body at the time it is given, and these concentrations vary." Since much better bronchodilators are now available, ephedrine is no longer commonly prescribed. 2.4 What is a nebulizer? ------------------------- A nebulizer is a device that uses pressurized air to turn a liquid medication into a fine mist for inhalation. If you've ever received emergency treatment for asthma, they've probably used a nebulizer on you. The term nebulizer is often used to describe both the pump that pressurizes the air, and the part that holds and "nebulizes" the medication. There are hand-held nebulizer units and ones with masks that you strap onto your face. The pressurized air typically comes from a portable pump unit that internally consists of a motor-driven air pump that resembles the fancier types of aquarium pumps. It forces air through a plastic tube into the plastic nebulizer unit. Inside, the nebulizer unit acts much like a perfume atomizer, creating a fine mist that is directed either through a tube that you inhale through or a mask that directs the mist into your nose and mouth. Since the nebulizer takes a few minutes to deliver the medication, you inhale it over a longer period of time than if you were using an inhaler. This can really help, especially if your passages are not fully open and you're taking a bronchodilator. As you breathe the medication, your lungs can gradually accept more and more of the medication. In addition to the medication, many people find the accompanying mist (typically a sterile saline solution) to be soothing. For very young children, the nebulizer is the only practical means of administering inhaled medications. Older children and adults have the options of using inhalers and a variety of spacers to make the timing a bit easier. The doctor overseeing the treatment decides which is the most effective/appropriate delivery mechanism. At least in Massachusetts, the nebulizer pump unit, the hand-held nebulizers, the medications, and the sterile saline inhalation solution are all prescription items. Replacement parts for the pumps are not available to the general public (if there are sources, I'd like to hear about them). The portable nebulizer pump units cost little ($100-$300) relative to the cost of an emergency room visit, so some health plans / insurers provide them to patients for times when an asthma episode is "manageable but not dangerous." This seems to be a trend in the management of pediatric asthma. Our family has been able to successfully avoid a few trips to the ER, and have even been able to head off some more severe allergic asthma episodes with early intervention. After a few rather gruesome visits to the Mass. General Hospital's waiting room on a Saturday night, we welcome opportunity to treat our children at home, when it's safe. We tend to go in to the doctor or ER for the more severe episodes or those that don't respond well enough to early intervention. Contributed by: Mark Feblowitz mfeblowitz@GTE.com 2.5 What medications should I avoid if I have asthma? ----------------------------------------------------- Aspirin can trigger an asthma attack in approximately one in five asthmatics. This is especially common in those patients who also have nasal polyps. As acetominophen (Tylenol) doesn't have this effect, it may be used as an alternative for anyone who suspects that they might have aspirin sensitivity. ====================================================================== 3.0 What does HEPA stand for? ------------------------------ Maintainer's contribution: ------------------------- HEPA is an acronym that has been around for so long that people no longer remember what it stands for. I personally have seen: High Efficiency Particulate Arrestor, High Efficiency PArticle, High Efficiency Particle Air, High Efficiency Particulate Air, and High Efficiency Particulate Abatement. Either the first or last seem to me to be the most likely. (At least there is some consensus on what the `HE' stands for.) At any rate, it is a standard for the filtration of particles in air. From National Allergy Supply's product literature: "Filtering efficiency on a HEPA air cleaner, by law, has to be at least 99.97% on all particles down to 1/3 micron in size (a hair is about 60 microns, or 180 times larger than that!) The term "HEPA" may not be used by any manufacturer unless these two requirements are met. In addition, HEPA filters lose no efficiency and stay at 99.97% for years." Andrew M. Gough's contribution: ------------------------------ HEPA filters are basically folded (to increase surface area) high-density fiberglass sheets. HEPA filters for home use usually have a capture efficiency rating of 99.97% at 0.3 micron size. This means that 99.97% of particles of 0.3 micron diameter, or larger, are captured when passing through the filter. Below 0.3 micron, the capture efficiency will drop quickly. Other filter types (disposable foam/fiberglass, electronic, electrostatic) typically have high capture efficiencies for particles above 10 microns in diameter. They are absolutely useless for particles below 1 micron in diameter, where they have capture efficiencies of about 1%. Why is this important you ask? Many common allergens are below 10 microns in size, with many below 1 micron. A "micron" is a micrometer, or one millionth (10E-6) of a meter. For comparison, a strand of human hair is typically 75 to 100 microns in diameter. The sizes (diameter in microns) of allergens and other items of interest are: Pollens 8 - 80 Molds 4 - 12 Mold spores 5 - 15, with some down to 0.4* Dust mites 0.8 - 1 micron Dust mite feces 0.2 - 0.02 Animal dander 0.4 - 10 Tobacco smoke 0.02 - 1 Ragweed pollen 21 Red blood cell 8 Polio virus 0.025 Bacteria 0.2 - 40 Smallest visible 40 - 10 depending on individual & conditions * I recall reading once that the spore diameter for aspergillus is 0.4 micron. The 5-15 range comes off a chart I have, but I need to look out for further information, as I believe a lot of mold spores are below 1 micron. HEPA filters are the only type that are really effective in eliminating allergens from the air, especially if you are allergic to molds. I am aware of two choices for HEPA filters for the home market: freestanding and whole-house: Freestanding units are short circular tubes which suck in air from the sides and exhaust filter air at the base. An example is the Honeywell Enviracare. You put it in a closed room and run it all day, and at night if you can stand the noise (they can be quite noisy). Freestanding units will go for $250-$350 and are available in retail stores or mail order. I used one for my apartment, where I tried to cheat fate by trying to filter all the apartment air by placing it near the air return. It helped. HEPA filters need to be replaced every 2-3 years, depending on conditions, and will cost $70-$90. You need to change prefilters every 3 months, but they are cheap. I am aware of one company that makes a whole-house unit, Pure Air Systems, Inc. in Plainfield Indiana, phone (800) 869-8025. They make a system that attaches to the air return of a furnace in a bypass configuration. The unit has its own blower, as a normal furnace blower wouldn't be able to pull air through a HEPA filter (very dense, remember) and transport it through the house. The unit operates whenever the furnace/AC does, but of course you can leave your thermostat in the "fan on" position and run it as long as you want. This will run you $1000-1200 installed. From the personal experience with HEPA air, I recommend it. I used to work in a semiconductor fabrication clean room, of class 10, which means that there were only 10 particles per cubic foot that were 0.5 microns in diameter or larger. Whenever I would walk into the cleanroom, my nose would instantly clear up and I would feel much better. Contributed by: Andrew M. Gough andrew_m_gough@ccm.ch.intel.com 3.1 What are some cheap ways to reduce my exposure to dust? ------------------------------------------------------------ The approach that I've found to be most beneficial when trying to avoid allergens is to concentrate on the bedroom, since that's where I spend eight hours a night. I find that if my bedroom is reasonably allergen-free, then I can tolerated much higher levels of allergens elsewhere. Also, I then have a place to retreat to when I have a cold or are otherwise more prone to an allergic reaction. Being a student, I've tried to keep expenses down, so here are the steps I've taken in every place I've lived so far: - I keep the room as bare as possible. It can still be cheerful, with a brightly-coloured bedspread and posters, but I do my best to keep it uncluttered. - if possible, I sleep in an uncarpeted room, or one with a very short pile (hard to arrange when sleeping in student housing, I know) - I don't hang dust traps such as wall hangings on walls. I prefer posters, which are easy to wipe down. - if I must have small fiddley things such as ornaments or knickknacks around, I keep them behind glass - I turn off any forced air heating in the room, and just use extra blankets if necessary (yes, even in Edmonton). Another alternative would be to install a filter in the room outlet. - I buy one really good air filter (currently an Enviracaire EV-25) and leave it running 24 hours a day - I bought some allergy control covers for my pillows, since they're closest to my face when I sleep. If I had more money, I'd buy the mattress and comforter covers also. (For those interested, I bought the Perfect Allergy Control Membrane covers from Allergy Control Products, and I highly recommend them. They're both effective and very comfortable.) - I trade chores with my roommates so that someone else vacuums my room when I'm not there I'd recommend trying some of these low-expense, low-tech approaches to the bedroom before going all out and buying lots of expensive stuff. If these approaches don't work, then it's time to think about the more expensive options. ====================================================================== 4.0 What resources are there for asthmatics? --------------------------------------------- Please see the alt.support.asthma Reading/Resource List. It is maintained by Lynn Short <lfshort@europa.com>, and is posted monthly to alt.support.asthma, alt.med.allergy, sci.med, and misc.kids. I highly recommend it! ====================================================================== Contributors: ------------ Mark Delany markd@bushwire.apana.org.au Mark Feblowitz mfeblowitz@GTE.com Paula Ford pxf3@psuvm.psu.edu Lyn Frumkin, M.D., Ph.D. lrfrum@u.washington.edu Ruth Ginzberg rginzberg@eagle.wesleyan.edu Andrew M. Gough andrew_m_gough@ccm.ch.intel.com Susan Graham sgraham@hpb.hwc.ca ====================================================================== References: ---------- The Physicians' Desk Reference is published annually by: Medical Economics Data Production Company Montvale, NJ 07645-1742 ISBN 1-56363-061-3 It is a compendium of official, FDA-approved prescription drug labeling. The FDA is the U.S. Food and Drug Administration. Drs. Francois Haas and Sheila Sperber Haas, _The Essential Asthma Book_, (Ballentine Books, USA) 1987. ISBN 0-8041-0287-2 Dr. Francois Haas is the director of the Pulmonary Function Laboratory at the Medical Center of the New York University School of Medicine, and is on the faculty of the Dept. of Physiology there. Paul J. Hannaway, M.D. _The Asthma Self Help Book_, 2nd ed., (Prima Publishing, USA) 1992. ISBN 1-55958-166-2 1-55958-434-3 paperback The author is Assistant Clinical Professor of Tufts University School of Medicine. The first edition of this book won an American Medical Writers Association Award. Allan M. Weinstein, M.D., _Asthma - The Complete Guide to Self-Management of Asthma and Allergies for Patients and their Families_, (Fawcett Crest, NY, USA) 1987. ISBN 0-449-21562-8 The author is Assistant Clinical Professor of Medicine at Georgetown University, and is a board-certified allergist who practices in Washington, D.C. ====================================================================== Disclaimer: I am not a physician; I am only a reasonably well-informed asthmatic. This information is for educational purposes only, and should be used only as a supplement to, not a substitute for, professional medical advice. Copyright 1994 by Patricia Wrean. Permission is given to freely copy or distribute this FAQ provided that it is distributed in full without modification, and that such distribution is not intended for profit. -- Patricia Wrean wrean@caltech.edu Archive-name: medicine/asthma/medications Posting-Frequency: monthly Last-modified: 19 Feb 1995 Version: 3.5 alt.support.asthma FAQ: Asthma Medications =========================================== This FAQ attempts to list the most commonly prescribed medications for the prevention and treatment of asthma, both in the U.S. and overseas. It is maintained by Patricia Wrean <wrean@caltech.edu>. The following information came from two sources: most of the drugs available in the U.S. are listed in the 1994 Physician's Desk Reference (full citation at end of post); the remainder of the information, including those medications available overseas, came from the many helpful contributors listed at the end of the post. If you do not wish your name to be included in the contributors list, please state that explicitly when contributing. Also, if I have left anyone's name out, please let me know so that I may include it. ** Although the maintainer and contributors do their best to keep this FAQ updated, it is by no means an authoritative work. Asthma is a serious illness requiring supervision by a physician. Please do not attempt to change your medication regime without consulting your doctor. Corrections, additions, and comments are requested; please include the name of the country in which the medication is available, as it isn't always obvious from the user-id. If the drug is available as an inhaler, please specify it as a MDI or one of the other types mentioned in the glossary, or add a description of the inhaler if it is not present already. Abbreviations are explained in the glossary at the end of the table. If the medication is followed by a country name in brackets, then to the best of my knowledge it is only available in that country, and not in the U.S. If the drug is available in a nasal form for allergies, I've included it for completeness. I haven't covered oral steroids, only inhaled, or antihistamines at the present time. + = added since last version & = updated/corrected since last version ---------------------------------------------------------------------- Type of drug Chemical name Brand name Comments ---------------------- ---------- -------- Anti-inflammatory, non-steroidal cromolyn sodium Intal available as MDI, (called sodium capsules for Spinhaler, cromoglycate neb soln in UK) Nasalcrom nasal spray nedocromil Tilade MDI Tilade Mint MDI (UK) sodium cromoglycate -- see cromolyn sodium Anti-inflammatory, steroidal (inhaled) beclomethasone Beclovent MDI dipropionate Beclodisk diskhaler (Can) Becloforte MDI (Can, Sw), larger dose than Beclovent Becotide MDI (UK) Beconase nasal MDI Beconase AQ nasal spray Respocort MDI, autohaler (NZ) Vanceril MDI Vancenase Pockethaler (nasal MDI) Vancenase AQ nasal spray budesonide Pulmicort turbuhaler (Aus, Can) neb soln (UK) Rhinocort nasal inhaler (US), nasal turbuhaler (Can) Nebuamp neb soln (Can) dexamethasone Decadron Respihaler sodium phosphate Phosphate flunisolide Aerobid MDI Aerobid-M MDI, with menthol as flavouring agent Bronalide nasal turbuhaler (Can) Nasalide nasal spray Rhinalar nasal spray (Can) fluticasone Flixotide MDI (UK) proprionate diskhaler (UK) triamcinolone Azmacort MDI acetonide Nasacort nasal MDI Anticholinergics (bronchodilators) ipratropium Atrovent MDI, inh soln bromide Beta-agonists (bronchodilators) albuterol* Airet inh soln (salbutamol is Proventil MDI, inh soln, syrup, WHO recommended tablets, name generally Repetabs (SA tablets) in use outside Respolin MDI, autohaler (NZ) the U.S.) Ventolin MDI, inh soln, syrup, neb soln, tablets, Rotacaps for Rotahaler Ventodisk diskhaler (Can, UK) Volmax ER tablets * MDI uses albuterol, all other forms (tablets, etc.) use albuterol sulfate bitolterol mesylate Tornalate MDI ephedrine Ephedrine inh soln (Can) epinephrine Bronkaid Mist MDI, OTC - epinephrine in form of nitrate and hydrochloride Bronkaid Mist MDI, OTC - epinephrine Suspension in form of bitartrate Medihaler-Epi MDI, OTC - epinephrine in form of bitartrate Primatene Mist MDI, OTC Primatene Mist MDI, OTC - epinephrine Suspension in form of bitartrate Sus-Phrine injection fenoterol Berotec MDI, inh soln, tablets hydrobromide (Can, Aus, NZ) + isoetharine Bronkosol inh soln + hydrochloride Bronkometer MDI Isoetharine inh soln Arm-a-Med isoproterenol Medihaler-Iso MDI sulfate Isuprel MDI, neb soln (Can) -- as hydrochloride metaproterenol Alupent MDI, inh soln, tablets, sulfate neb soln, syrup Metaprel MDI, inh soln, syrup, tablets Metaproterenol inh soln Sulfate Arm-a-Med pirbuterol acetate Maxair MDI, autohaler procaterol HCl Pro-Air MDI (Can) salbutamol -- see albuterol salmeterol Serevent MDI xinafoate diskhaler (UK) terbutaline Brethaire MDI sulfate Brethine tablets, neb soln, injection Bricanyl tablets, injection turbuhaler (Aus) Xanthines (bronchodilators) theophylline Aerolate TD capsules, liquid Quibron-T tablets, SA tablets (see also combinations) Respbid SR tablets Slo-bid ER capsules Slo-phylline ER capsules T-Phyl CR tablets Theo-24 ER capsules Theo-Dur ER tablets Theo-Dur SA capsules Sprinkle Theo-X tablets Theolair tablets, SR tablets, liquid Uniphyl CR tablets dyphylline** Lufyllin tablets, injection, syrup ** similar to theophylline oxtriphylline*** Choledyl DR tablets, SA tablets *** oxtriphylline is the choline salt of theophylline, and 400 mg of it is equivalent to 254 mg of anhydrous theophylline ---------------------------------------------------------------------- Combination Medications: Brand name Chemical names of ingredients Comments ---------- ----------------------------- -------- Asbron G theophylline sodium glycinate, elixir, tablets guaifenesin (expectorant) Bronkaid Caplets ephedrine sulfate, guaifenesin tablets, OTC Congess guaifenesin, pseudoephedrine tablets Duo-Medihaler isoproterenol hydrochloride, MDI phenylephrine bitartrate Duovent fenoterol hydrobromide, MDI (UK) ipratropium bromide Marax ephedrine sulfate, tablets theophylline, Atarax (hydroxyzine HCl) Primatene Tablets theophylline, ephedrine HCl tablets, OTC Quadrinal theophylline calcium salicylate, tablets ephedrine HCl, phenobarbital, potassium iodide Rynatuss carbetapentane tannate, tablets, syrup chlorpheniramine tannate, ephedrine tannate, phenylephrine tannate Tedral theophylline, ephedrine HCl, tablets -- no longer phenobarbital manufactured Ventolin-Plus albuterol, beclomethasone MDI (Sw) dipropionate ---------------------------------------------------------------------- Glossary -------- aerosol inhalers: MDI - metered-dose inhaler, consisting of an aerosol unit and plastic mouthpiece autohaler - MDI made by 3M which is activated by one's breath, and doesn't need the breath-hand coordination that a regular MDI does respihaler - aerosol inhaler for Decadron (see table above). I have no idea how this differs from the usual MDI dry powder inhalers: rotahaler - dry powder inhaler used with Ventolin Rotacaps (see table above), i.e. albuterol sulfate in capsules. Each capsule contains one dose; the inhaler opens the capsule such that the powder may be inhaled through the mouthpiece. Available in the U.S., Canada, and UK. spinhaler - dry powder inhaler used with Intal capsules for spinhaler. Each capsule contains one dose; the inhaler opens the capsule such that the powder may be inhaled through the mouthpiece. Available in Canada, UK, and the U.S. diskhaler - dry powder inhaler. The drug is kept in a series of little pouches on a disk; the diskhaler punctures the pouch and drug is inhaled through the mouthpiece. Currently available in Canada and UK, not in U.S. turbuhaler - dry powder inhaler. The drug is in form of a pellet; when body of inhaler is rotated, prescribed amount of drug is ground off this pellet. The powder is then inhaled through a fluted aperture on top. Available in Australia and Canada. forms of tablets: SA - sustained action. SA and CR (below) have been used interchangeably and almost mean the same thing, except SA refers to the pharmacologic action while CR refers to the drug release process. Any drug release which is controlled in a zero-order fashion (constant rate of release) is generally referred to as Sustained or Controlled Release. CR - controlled release. See SA. DR - delayed release. This generally refers to enteric- coated tablets which are designed to release the drug in the intestine where the pH is in the alkaline range. ER - extended release. Dosage forms which are designed to release the drug over an extended period of time, e.g. implants which release drug over a period of one or two months or years. TD - time delayed. This is slightly different from DR in that the drug release is designed to occur after a certain period of time, e.g. pellets coated to a certain thickness or multi-layered tablets or tablets within a capsule or double-compressed tablets. forms of solutions: neb soln - nebulizer solution. Drug comes in nebules for use with nebulizer. inh soln - inhalation solution. Some manufacturers use this as a synonym for neb soln; others use it to mean that drug comes in bottle with dropper, distinct from neb soln. country abbreviations: Aus - Australia Can - Canada UK - United Kingdom Sw - Switzerland NZ - New Zealand misc: OTC - over-the-counter, all other medications are prescription- only in the U.S. ---------------------------------------------------------------------- The Physicians' Desk Reference is published annually by: Medical Economics Data Production Company Montvale, NJ 07645-1742 ISBN 1-56363-061-3 It is a compendium of official, FDA-approved prescription drug labeling. The FDA is the U.S. Food and Drug Administration. ---------------------------------------------------------------------- Contributors: ------------ Lawrence M. (Larry) Bezeau BEZEAU@UNB.CA Daniel Canonica d_canonica@trzcl1.mrgate.mailer.umc.alcatel.ch John Connett jrc@concurrent.co.uk Mark Delany markd@bushwire.apana.org.au Walter de Wit dewit@hamilton.niwa.cri.nz Steve Dyer dyer@spdcc.com Ian Ford ianford@dircon.co.uk Susan Graham sgraham@hpb.hwc.ca Rick Hughes richardh@Newbridge.COM Simon Kelley srk@sanger.ac.uk Rick Nopper nopperrw@esvax.dnet.dupont.com Kevin A. Nunan pp000165@interramp.com Janet Pierson JPierson@highlands.com Matt Ray M.J.Ray@bradford.ac.uk John Saunders John@gemini.demon.co.uk Stephan Seillier seillier@on.bell.ca + John R. Strohm strohm@mksol.dseg.ti.com John Underhay junderhay@upei.ca David Williams exudnw@exu.ericsson.se Travis Lee Winfrey travis.winfrey@fi.gs.com ---------------------------------------------------------------------- Disclaimer: I am not a physician; I am only a reasonably well-informed asthmatic. This information is for educational purposes only, and should be used only as a supplement to, not a substitute for, professional medical advice. Copyright 1995 by Patricia Wrean. Permission is given to freely copy or distribute this FAQ provided that it is distributed in full without modification, and that such distribution is not intended for profit. -- Patricia Wrean wrean@caltech.edu