For PatientsEverything starts with the patients. It is why we exist. We understand that you or a loved one is struggling with the complexities that accompany asthma and it is our goal to make sure that you have access to all of the resources you need in order to ease the burdens you face.
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UC San Diego Health is a signature partner in this effort and provides all of the infrastructure for seeing and treating patients on a daily basis. In their commitment to putting patients first, they have earned a Gold Seal from The Joint Commission, as well as an "A" rating from the Leapfrog Group. To learn more about UC San Diego Health click HERE.
Within the UC San Diego School of Medicine, the Division of Pulmonary, Critical Care & Sleep Medicine is responsible for seeing and treating all of the asthma patients that walk through the doors. The division is staffed with leaders in the field of asthma whom directly contribute to the work we are doing here through the clinic as well as the lab.
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Additional Resources
There is a wealth of information on the internet about asthma and it can certainly be overwhelming at times. Our Leadership Council has made a conscious effort to collect and acknowledge useful and reputable sources of information that you can find by clicking HERE or reading some of the articles below.
Treating Severe Asthma
Once patients are diagnosed with severe asthma, they’re typically already taking a whole collection of medications, but their asthma is still not well controlled. The next step might be adding a biologic agent, which lowers levels of an antibody that creates inflammation. We might also try adding newer therapies that block proteins in the blood and tissues called cytokines. One type of cytokine, called IL-5, helps eosinophils survive and develop; eosinophils contribute to inflammation that makes asthma worse. New IL-5 inhibitors lower the number of eosinophils in the blood, decreasing inflammation and alleviating asthma symptoms. Not everyone’s severe asthma is related to eosinophils, but if you do have eosinophilic asthma, these new medications can greatly benefit you.
If you look at old papers about asthma from 100 years ago, you’ll find we actually knew a lot about the condition back then. The century-old descriptions of lung specimens from people with asthma are similar to how we’d describe asthma today; they detail airways that are tightened and inflamed, with lots of abnormal cells in the area. Now, however, we know more about why the inflammation happens and what causes these symptoms. We’ve also learned that different people have different kinds of asthma; some patients might have allergic asthma, triggered primarily by allergens in the environment, some may have exercise-induced asthma that appears with activity, and some may have what’s called eosinophilic asthma, in which tiny white blood cells called eosinophils contribute to inflammation.
Personally, I lead a basic science lab that looks at the biology of eosinophils; we’re trying to find out why eosinophils do what they do and what the nature of eosinophilic inflammation is. Research from my lab and from many others has helped us learn that higher numbers of eosinophils drive inflammation and worsen asthma symptoms. Today, new medications called IL-5 inhibitors work to lower the numbers of eosinophils in the bloodstream and tissues, reducing the number of severe asthma flares patients experience. New biologic agents are also a result of years of research—given by injection or infusion, biologic medications work at the root to block inflammation from occurring, easing asthma symptoms in the process. These new medications have been instrumental in helping patients with severe asthma stay in control, and I anticipate many more treatment options coming down the pipeline in the future. Asthma treatments continue to get more sophisticated and targeted, so patients should remain hopeful that they’ll find something that works for them.
It’s important to note that asthma symptoms are often triggered by specific allergens and other environmental conditions, and every asthma patient responds differently to different triggers. The most common triggers include dust mites, animal dander, cockroaches, pollen, mold, and hot or cold weather. The number one way to live a healthy lifestyle with asthma is to identify which triggers affect you and avoid them as much as possible. Some people have exercise-induced asthma, in which asthma symptoms flare during or after exercise. If exercise makes your symptoms worse, ask your pulmonologist about using your rescue inhaler before beginning activity. It’s crucial that people with severe asthma stay active and prevent their bodies from becoming deconditioned. It can be a tricky balance, but patients should do their best to not let their asthma prevent them from maintaining a healthy level of activity.
If you look at old papers about asthma from 100 years ago, you’ll find we actually knew a lot about the condition back then. The century-old descriptions of lung specimens from people with asthma are similar to how we’d describe asthma today; they detail airways that are tightened and inflamed, with lots of abnormal cells in the area. Now, however, we know more about why the inflammation happens and what causes these symptoms. We’ve also learned that different people have different kinds of asthma; some patients might have allergic asthma, triggered primarily by allergens in the environment, some may have exercise-induced asthma that appears with activity, and some may have what’s called eosinophilic asthma, in which tiny white blood cells called eosinophils contribute to inflammation.
Personally, I lead a basic science lab that looks at the biology of eosinophils; we’re trying to find out why eosinophils do what they do and what the nature of eosinophilic inflammation is. Research from my lab and from many others has helped us learn that higher numbers of eosinophils drive inflammation and worsen asthma symptoms. Today, new medications called IL-5 inhibitors work to lower the numbers of eosinophils in the bloodstream and tissues, reducing the number of severe asthma flares patients experience. New biologic agents are also a result of years of research—given by injection or infusion, biologic medications work at the root to block inflammation from occurring, easing asthma symptoms in the process. These new medications have been instrumental in helping patients with severe asthma stay in control, and I anticipate many more treatment options coming down the pipeline in the future. Asthma treatments continue to get more sophisticated and targeted, so patients should remain hopeful that they’ll find something that works for them.
It’s important to note that asthma symptoms are often triggered by specific allergens and other environmental conditions, and every asthma patient responds differently to different triggers. The most common triggers include dust mites, animal dander, cockroaches, pollen, mold, and hot or cold weather. The number one way to live a healthy lifestyle with asthma is to identify which triggers affect you and avoid them as much as possible. Some people have exercise-induced asthma, in which asthma symptoms flare during or after exercise. If exercise makes your symptoms worse, ask your pulmonologist about using your rescue inhaler before beginning activity. It’s crucial that people with severe asthma stay active and prevent their bodies from becoming deconditioned. It can be a tricky balance, but patients should do their best to not let their asthma prevent them from maintaining a healthy level of activity.
4 Signs Your Asthma Is Severe
Is your asthma severe?
If you have asthma, the airways bringing air in and out of your lungs become tight, restricting the flow of air. This translates into symptoms like shortness of breath and wheezing. Most people with asthma can control it successfully with medications and lifestyle changes. But some people have severe asthma, in which they experience symptoms frequently despite taking their medication as prescribed. As a pulmonologist, I look for certain signs that my patients’ asthma is severe. If you’re experiencing any of the following, reach out to your pulmonologist to take next steps.
1. You end up in the hospital after asthma flares.
Before they find the right treatment, people with severe asthma tend to have frequent flares, and often may end up needing to see their doctor or go to the hospital as a result. If a patient tells me they’ve been to the emergency room or were admitted to the hospital for an asthma flare, that’s indicative of severe asthma. And if they’ve been admitted to the intensive care unit of the hospital and needed a breathing machine to help them breathe, that’s a clear sign to me that their asthma is severe.
2. You often have asthma symptoms at night.
Having asthma symptoms at night is one of the barometers we as pulmonologists use to determine how well your asthma is managed. Experiencing shortness of breath and wheezing at night is fairly typical of asthma that’s not well controlled. If you frequently wake up in the middle of the night to use your inhaler, that could mean you have severe asthma.
3. You’re using your rescue inhaler too often.
The first step after someone is diagnosed with asthma is to put them on what’s called a rescue inhaler. Many patients will only need to use their rescue inhaler every once in a while to effectively control symptoms. But if you’re using your rescue inhaler at least once every week, we’ll need to step up your treatments, as your asthma might be more severe.
4. Stepping up treatments isn’t working.
If more therapy is needed beyond your rescue inhaler, I’ll prescribe a steroid inhaler that reduces inflammation in your airways. Many of my patients with milder asthma get their asthma under control within a few weeks of starting the inhaled steroid. But a smaller percentage of people can really struggle to figure out the right combination of therapies. For these patients, I’ll prescribe long-acting inhalers that open the airways, allergy medication, steroid pills, biologics, and other options. But if your asthma is severe, symptoms may persist despite all these treatments. Fortunately, new medications are available that address inflammation caused by white blood cells called eosinophils, and many of my patients with severe asthma finally get their symptoms under control using these therapies.
If you have asthma, the airways bringing air in and out of your lungs become tight, restricting the flow of air. This translates into symptoms like shortness of breath and wheezing. Most people with asthma can control it successfully with medications and lifestyle changes. But some people have severe asthma, in which they experience symptoms frequently despite taking their medication as prescribed. As a pulmonologist, I look for certain signs that my patients’ asthma is severe. If you’re experiencing any of the following, reach out to your pulmonologist to take next steps.
1. You end up in the hospital after asthma flares.
Before they find the right treatment, people with severe asthma tend to have frequent flares, and often may end up needing to see their doctor or go to the hospital as a result. If a patient tells me they’ve been to the emergency room or were admitted to the hospital for an asthma flare, that’s indicative of severe asthma. And if they’ve been admitted to the intensive care unit of the hospital and needed a breathing machine to help them breathe, that’s a clear sign to me that their asthma is severe.
2. You often have asthma symptoms at night.
Having asthma symptoms at night is one of the barometers we as pulmonologists use to determine how well your asthma is managed. Experiencing shortness of breath and wheezing at night is fairly typical of asthma that’s not well controlled. If you frequently wake up in the middle of the night to use your inhaler, that could mean you have severe asthma.
3. You’re using your rescue inhaler too often.
The first step after someone is diagnosed with asthma is to put them on what’s called a rescue inhaler. Many patients will only need to use their rescue inhaler every once in a while to effectively control symptoms. But if you’re using your rescue inhaler at least once every week, we’ll need to step up your treatments, as your asthma might be more severe.
4. Stepping up treatments isn’t working.
If more therapy is needed beyond your rescue inhaler, I’ll prescribe a steroid inhaler that reduces inflammation in your airways. Many of my patients with milder asthma get their asthma under control within a few weeks of starting the inhaled steroid. But a smaller percentage of people can really struggle to figure out the right combination of therapies. For these patients, I’ll prescribe long-acting inhalers that open the airways, allergy medication, steroid pills, biologics, and other options. But if your asthma is severe, symptoms may persist despite all these treatments. Fortunately, new medications are available that address inflammation caused by white blood cells called eosinophils, and many of my patients with severe asthma finally get their symptoms under control using these therapies.
Diagnosing Severe Asthma
If you have asthma, you’ll experience shortness of breath, wheezing, and chest tightness due to inflammation in your airways. Millions of Americans live with asthma and manage it well every day, but a small percentage of patients have severe asthma—asthma that’s not well controlled even though patients are taking their medications every day as prescribed. When you’re first diagnosed with asthma, your doctor will likely start you on a rescue inhaler, but if you’re using that at least once a week, you’ll need a longer-acting inhaler. If that doesn’t help, your doctor might try adding steroid pills, allergy pills, and other treatments. However, if, despite receiving what we call “maximal therapy,” your asthma symptoms are still uncontrolled, your doctor may suspect your asthma is severe and have you take a variety of tests to be sure.
Testing for Severe Asthma
When you were first diagnosed with asthma, your pulmonologist may have ordered pulmonary function tests, also known as lung function tests. These tests measure how well you breathe. In order to determine if you have severe asthma, we might go through these tests again. One type of pulmonary function test is called a bronchodilator challenge. It measures the amount of air you can forcefully blow out before and after using an inhaler, called a bronchodilator.
A test called the methacholine challenge can help doctors determine if asthma is present. During this test, we’ll have patients breathe in a tiny bit of an irritant, called methacholine—it’s a drug that can cause your airways to squeeze and narrow. After inhaling the drug, you’ll take a breathing test to measure how much your airways have constricted, and the results will tell us if you have asthma.
If your doctor thinks you have severe asthma, he or she may also do some tests to measure the number of eosinophils in your blood. Eosinophils are white blood cells that contribute to inflammation, and high numbers of eosinophils typically correlate with severe asthma symptoms. Fortunately, in recent years, we’ve seen new medications come out that specifically block eosinophils from causing inflammation. To test whether these medications will help your specific asthma, you’ll undergo a test to see if your asthma is related to eosinophils. In some specialized practices, pulmonologists will have patients undergo a sputum induction test, in which patients breathe in a mist of saline and then cough out phlegm. The doctor then examines the phlegm under a microscope to determine if there are high numbers of eosinophils. But in most cases, a blood test measuring eosinophils will suffice.
Everyday Signs of Severe Asthma
The hallmark of severe asthma is uncontrolled symptoms despite maximal treatment, which is why clinical history goes a long way towards diagnosing it. Pulmonary function tests and eosinophil counts can significantly help in making a diagnosis, but often, there are clear signs that a patient’s asthma is severe. If you’re taking all your medications as prescribed, and if you’re using all the available medication options, including a rescue inhaler, long-acting inhaler, inhaled steroids, steroid pills, allergy pills, and others, but your asthma still isn’t controlled, it’s likely you have severe asthma. Other signs of severe asthma include waking up at night with asthma symptoms, experiencing frequent flares, and being hospitalized for asthma symptoms.
However, it’s important to note that before diagnosing a patient with severe asthma, a pulmonologist needs to know the patient is taking his or her medications appropriately. If you’re having trouble adhering to your treatment plan, let your doctor know; we can figure out together how to help you take your medication as prescribed so your asthma symptoms are controlled. But if you’re taking all your medications and still have frequent asthma symptoms, that’s how we know your asthma is severe.
Testing for Severe Asthma
When you were first diagnosed with asthma, your pulmonologist may have ordered pulmonary function tests, also known as lung function tests. These tests measure how well you breathe. In order to determine if you have severe asthma, we might go through these tests again. One type of pulmonary function test is called a bronchodilator challenge. It measures the amount of air you can forcefully blow out before and after using an inhaler, called a bronchodilator.
A test called the methacholine challenge can help doctors determine if asthma is present. During this test, we’ll have patients breathe in a tiny bit of an irritant, called methacholine—it’s a drug that can cause your airways to squeeze and narrow. After inhaling the drug, you’ll take a breathing test to measure how much your airways have constricted, and the results will tell us if you have asthma.
If your doctor thinks you have severe asthma, he or she may also do some tests to measure the number of eosinophils in your blood. Eosinophils are white blood cells that contribute to inflammation, and high numbers of eosinophils typically correlate with severe asthma symptoms. Fortunately, in recent years, we’ve seen new medications come out that specifically block eosinophils from causing inflammation. To test whether these medications will help your specific asthma, you’ll undergo a test to see if your asthma is related to eosinophils. In some specialized practices, pulmonologists will have patients undergo a sputum induction test, in which patients breathe in a mist of saline and then cough out phlegm. The doctor then examines the phlegm under a microscope to determine if there are high numbers of eosinophils. But in most cases, a blood test measuring eosinophils will suffice.
Everyday Signs of Severe Asthma
The hallmark of severe asthma is uncontrolled symptoms despite maximal treatment, which is why clinical history goes a long way towards diagnosing it. Pulmonary function tests and eosinophil counts can significantly help in making a diagnosis, but often, there are clear signs that a patient’s asthma is severe. If you’re taking all your medications as prescribed, and if you’re using all the available medication options, including a rescue inhaler, long-acting inhaler, inhaled steroids, steroid pills, allergy pills, and others, but your asthma still isn’t controlled, it’s likely you have severe asthma. Other signs of severe asthma include waking up at night with asthma symptoms, experiencing frequent flares, and being hospitalized for asthma symptoms.
However, it’s important to note that before diagnosing a patient with severe asthma, a pulmonologist needs to know the patient is taking his or her medications appropriately. If you’re having trouble adhering to your treatment plan, let your doctor know; we can figure out together how to help you take your medication as prescribed so your asthma symptoms are controlled. But if you’re taking all your medications and still have frequent asthma symptoms, that’s how we know your asthma is severe.
5 Pulmonologist Tips for People With Severe Asthma
You can get control of your severe asthma.
I’ve been a pulmonologist, or lung doctor, for 10 years now, and in that time, we’ve learned a lot. A decade ago, we had some decent options for treating asthma. But now, new medications are coming to the market all the time that more specifically treat the root of some types of severe asthma and help ease symptoms. My patients with severe asthma—asthma that’s uncontrolled despite trying many treatments—now have new therapy options that block inflammation at the root to ease symptoms. Because we understand severe asthma better, we can treat it better. Here are the things I want my patients to know about controlling severe asthma.
1. Find the right pulmonologist.
Finding a doctor you connect with can be a tough nut to crack. But partnering with your pulmonologist will help you better manage and understand your severe asthma, which is why it’s so important to find the right one. Patients should look for pulmonologists who listen to them, show empathy and interest in their lives, and take the time to treat them as an individual. Everyone’s severe asthma is different, so finding the right treatment can be a long process--find a pulmonologist you trust and that process will be a lot smoother.
2. Avoid triggers as much as possible.
Severe asthma symptoms often worsen when a patient is exposed to specific triggers. Everyone’s triggers are different, but the most common ones include dust mites, pollen, cockroaches, molds, animals dander, and even hot or cold weather. Work with your pulmonologist to narrow down your triggers, and once you do, try your best to stay away from them if possible.
3. Keep “stepping up” treatments until you find a combination that works.
One way to identify severe asthma is if a patient tries every available treatment but still can’t get control of asthma symptoms. Patients will usually try a rescue inhaler, then a steroid inhaler, a long-acting inhaler, and allergy medications. People will poor asthma control will often need courses of steroid pills. If a patient has used all these medications and still has poor asthma control, that’s when we try a new biologic agent, which is injected or given by infusion. We’ll also test patients with severe asthma to see how high their eosinophil count is—eosinophils are white blood cells that contribute to inflammation in some cases of severe asthma. If you have eosinophilic asthma, new treatments that block eosinophils will likely help you get control of your asthma. I tell my patients to stay hopeful; it might take a while, but eventually we can find the right treatment approach to help you manage your severe asthma.
4. Make sure you’re using proper inhaler technique.
Typically, we find a treatment that works to control severe asthma. But sometimes, patients come to me with worsening asthma symptoms and we realize they’re just not using their inhalers the right way. When you use your inhaler improperly, less medicine gets to your lungs. If you’re having trouble with inhaler technique, don’t be afraid to ask your doctor for guidance. There are also helpful videos online that demonstrate how to use inhalers properly, and sometimes I go over those videos with patients in my clinic. Additionally, I might recommend my patients use a spacer device connected to the inhaler, because it can help them inhale the appropriate amount of medicine.
5. Monitor your symptoms and inhaler use.
My patients do best when they take some ownership over their care. Track how often you need to use your rescue inhaler and report that back to your physician. If your severe asthma symptoms worsen, record your symptoms in a diary so you and your physician can determine the best steps forward. Communicate with your pulmonologist as much as you need to, so you both know whether or not it’s time to step up treatment.
I’ve been a pulmonologist, or lung doctor, for 10 years now, and in that time, we’ve learned a lot. A decade ago, we had some decent options for treating asthma. But now, new medications are coming to the market all the time that more specifically treat the root of some types of severe asthma and help ease symptoms. My patients with severe asthma—asthma that’s uncontrolled despite trying many treatments—now have new therapy options that block inflammation at the root to ease symptoms. Because we understand severe asthma better, we can treat it better. Here are the things I want my patients to know about controlling severe asthma.
1. Find the right pulmonologist.
Finding a doctor you connect with can be a tough nut to crack. But partnering with your pulmonologist will help you better manage and understand your severe asthma, which is why it’s so important to find the right one. Patients should look for pulmonologists who listen to them, show empathy and interest in their lives, and take the time to treat them as an individual. Everyone’s severe asthma is different, so finding the right treatment can be a long process--find a pulmonologist you trust and that process will be a lot smoother.
2. Avoid triggers as much as possible.
Severe asthma symptoms often worsen when a patient is exposed to specific triggers. Everyone’s triggers are different, but the most common ones include dust mites, pollen, cockroaches, molds, animals dander, and even hot or cold weather. Work with your pulmonologist to narrow down your triggers, and once you do, try your best to stay away from them if possible.
3. Keep “stepping up” treatments until you find a combination that works.
One way to identify severe asthma is if a patient tries every available treatment but still can’t get control of asthma symptoms. Patients will usually try a rescue inhaler, then a steroid inhaler, a long-acting inhaler, and allergy medications. People will poor asthma control will often need courses of steroid pills. If a patient has used all these medications and still has poor asthma control, that’s when we try a new biologic agent, which is injected or given by infusion. We’ll also test patients with severe asthma to see how high their eosinophil count is—eosinophils are white blood cells that contribute to inflammation in some cases of severe asthma. If you have eosinophilic asthma, new treatments that block eosinophils will likely help you get control of your asthma. I tell my patients to stay hopeful; it might take a while, but eventually we can find the right treatment approach to help you manage your severe asthma.
4. Make sure you’re using proper inhaler technique.
Typically, we find a treatment that works to control severe asthma. But sometimes, patients come to me with worsening asthma symptoms and we realize they’re just not using their inhalers the right way. When you use your inhaler improperly, less medicine gets to your lungs. If you’re having trouble with inhaler technique, don’t be afraid to ask your doctor for guidance. There are also helpful videos online that demonstrate how to use inhalers properly, and sometimes I go over those videos with patients in my clinic. Additionally, I might recommend my patients use a spacer device connected to the inhaler, because it can help them inhale the appropriate amount of medicine.
5. Monitor your symptoms and inhaler use.
My patients do best when they take some ownership over their care. Track how often you need to use your rescue inhaler and report that back to your physician. If your severe asthma symptoms worsen, record your symptoms in a diary so you and your physician can determine the best steps forward. Communicate with your pulmonologist as much as you need to, so you both know whether or not it’s time to step up treatment.
THIS CONTENT DOES NOT PROVIDE MEDICAL ADVICE. This content is provided for informational purposes and reflects the opinions of the author. It is not a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of a qualified healthcare professional regarding your health. If you think you may have a medical emergency, contact your doctor immediately or call 911. This content was originally produced by Dr. Praveen Akuthota for heathgrades.com.