How do you know if you

Treatment Guide Severe Asthma Are you in control? How do you know if you ha v e s e v e r e a s th m a ? Up to 15 percent of patients with asthma ha...
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Treatment Guide

Severe Asthma Are you in control?

How do you know if you ha v e s e v e r e a s th m a ? Up to 15 percent of patients with asthma have what is considered “severe asthma.” Unlike patients with “regular” asthma, those with severe asthma continue to have severe and frequent symptoms, despite aggressive treatment. They also are more at risk for a fatal attack. It is not yet entirely understood why patients with severe asthma do not respond to treatments that work for the other 85 to 90 percent of asthma sufferers, but research suggests that severe asthma may be a different form of the disease. The differences, which researchers at Cleveland Clinic and elsewhere continue to study, may be related to whether 1) lung inflammation in these people are different, 2) airway inflammation is less likely to respond to our current medications, 3) structural and anatomic differences in how air is trapped in the lungs, and/or 4) long-term effects of ongoing asthma activity. How often you have symptoms and how frequently you need to use your asthma rescue medication is used to determine if you have

Cleveland Clinic’s Respiratory Institute has a long history of excellence and innovation, and is ranked the #3 pulmonology program in the nation by U.S.News & World Report. Cleveland Clinic also is consistently ranked among America’s Top 4 hospitals. Using this guide Please use this guide as a resource as you learn about severe asthma, diagnosis and treatment options. As a patient, you have the right to ask questions and to seek a second option.

what is defined as severe persistent asthma. The type of asthma you have is classified in the following categories:


Mild Persistent

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Moderate Persistent

Severe Persistent


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Did you know? Similar to other major U.S. cities, Cleveland has an asthma and air pollution problem: • While up to 8 percent of children nationally suffer from asthma, a study by the Greater Cleveland Asthma Coalition found up to 26

What triggers asthma? The airways in a person with asthma are very sensitive and react to a variety of external factors, or “triggers.” These triggers cause the airways to tighten and become inflamed and blocked with mucus, resulting in difficulty breathing. An acute asthma attack can begin immediately after exposure to a trigger or several hours or days later. There are many kinds of triggers, and responses to them vary from person to person. A trigger may be harmless to some who have asthma but contribute to an inflammatory response in others, and an individual’s reaction to any trigger may vary from one exposure to the next. Some people are affected by numerous triggers; others may not be able to identify any. Recognizing and avoiding triggers, when possible, is an important way to control asthma.

percent of children on Cleveland’s

Common asthma triggers include:

east side (grades 2-5) have been

• Infections: colds, viruses, sinus infections, the flu

diagnosed with asthma.

• Outdoor allergens: pollens (trees, grasses, ragweed and weeds), mold spores

• In some Cleveland schools, 35 percent of students have asthma. • A survey found 20 percent of

• Indoor allergens: molds, animal dander, dust mites, cockroaches • Exercise • Cigarette smoke (active smoking, secondhand and thirdhand smoke)

adults asthma sufferers in Greater

• Wood smoke

Cleveland missed work because

• Strong odors from perfumes, cleaning agents, etc.

of asthma in the last year. It also found 31 percent of those surveyed are awakened at least once a week by sleeping problems. • In a 2011 Asthma and Allergy Foundation of America report of “the most challenging places to live with asthma,” Cleveland was ranked No. 17 among the 100 largest metropolitan areas. Reasons for these are likely multiple, including problems with access to proper asthma care, underuse of controller medication for asthma, and miscommunication between healthcare providers and patients.

• Air pollution • Weather: cold air or changes in temperature and humidity • Strong emotions such as anxiety, or episodes of crying, yelling, or laughing hard • Certain medications • Food allergies or sensitivities (such as to sulfites) To control symptoms, it’s important to first note what factors may have caused them and then avoid those triggers. (Exception: The only trigger you do not want to avoid is exercise. If your asthma is well-controlled, your goal should be to participate in any activity you want to do.)

How is severe asthma diagnosed? Your physician will take a medical history, review your outside records and order any further testing that may be needed. Testing may include a pulmonary function test and measuring markers of airway inflammation (exhaled nitric oxide). Some of the most common pulmonary function tests: Spirometry – This is a simple breathing test that measures how much and how fast you can blow air out of your lungs. It is often used to determine the


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As an academic medical center, we offer novel agents and access to clinical trials not widely available. We are currently researching: • Factors that cause severe asthma, as part of the Severe Asthma Research Program, a National Institutes of Health-sponsored study • Inflammation in the airways of asthma sufferers, what factors make this inflammation worse and how asthma differs in patents to determine who will benefit from various treatments • How new blood vessel formation is involved in asthma development • Whether air pollution partially explains when Northeast Ohio patients go to the hospital for an asthma attack • If mepolizumab, a type of antibody, may improve exacerbations in patients with severe eosinophilic asthma, an adult-onset asthma which represents less than 5 percent of all asthma • A study to determine predictors of asthma improvement with bronchial thermoplasty, a nondrug supplement for asthma treatment • A study evaluating diet and asthma

amount of airway obstruction you have. Spirometry can be done before and after you inhale a short-acting medication called a bronchodilator, such as albuterol. The bronchodilator causes your airways to expand, allowing for air to pass through more easily. This test might also be done at future doctor visits to monitor your progress and help your doctor determine if and how to adjust your treatment plan. Airway challenge testing – • Methacholine challenge test – Methacholine is an agent that, when inhaled, causes the airways to spasm and narrow if asthma is present. During this test, you inhale increasing amounts of methacholine aerosol mist before and after spirometry. The methacholine test is considered positive, meaning asthma is present, if the lung function drops by at least 20 percent. A bronchodilator is always administered at the end of the test to reverse the effects of the methacholine. • Mannitol challenge test – This test is good for diagnosing asthma and requires inhalation of a sugar substance that tests airway sensitivity. • Cold air challenge test – A test using cold air that may help with diagnosis of exercise-induced asthma. • Exercise challenge test – An airway test done to measure lung function using a treadmill or other stationary workout equipment. Sometimes done jointly with a cold air challenge test. Biomarker testing – This testing is used to detect biomarkers of airway inflammation, such as exhaled nitric oxide (NO). Other possible tests include measuring breathing tests after cold air inhalation and/or exercise challenge. Bloodwork, X-rays as well as a CT scans may be obtained to evaluate your symptoms. Your doctor also may test you for medical conditions that might make severe asthma harder to treat and control. Two of these conditions are sinusitis and gastroesophageal reflux disease, commonly called GERD. A commonly unrecognized condition is called vocal cord dysfunction (VCD) when vocal cords are abnormally coming together (instead of staying apart) when breathing in.

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If you are diagnosed with asthma or severe asthma, your doctor also might test you for these conditions so that they can be treated.

How is severe asthma treated? Asthma is not the same for everyone, so care has to be personalized. But, asthma medications are the foundation of good asthma control.

of note

4 components of asthma treatment: • Monitor daily symptoms • Avoid and control triggers • Proper use of medications • Education allowing partnership of care between patient and caregiver

There are two main kinds of asthma medications. All but the people with the mildest cases of asthma will need both: 1) Symptom relief medications – Also known as bronchodilator medications, these medicine are used to treat the symptoms of shortness of breath, wheezing and coughing. However, they do not improve the underlying airway inflammation in asthma without the addition of controller medications. 2) Controller medications – Since asthma is an inflammatory condition of the airways, the cornerstone of treatment is anti-inflammatory therapy. These types of medications control asthma and are necessary for long-term management of all but the mildest forms of asthma. Here is a more indepth look at both of these types of asthma medications:

Symptom relief mediations (bronchodilators) These medications relax the muscle bands that tighten around the airways. This action rapidly opens the airways, letting more air in and out of the lungs and improving breathing. Bronchodilators also help clear mucus from the lungs. As the airways open, the mucus moves more freely and can be coughed out more easily. In short-acting forms, bronchodilators relieve or stop asthma symptoms and are very helpful during an asthma episode. In long-acting forms, bronchodilators provide control of asthma symptoms and prevent asthma episodes. Most of the medications are delivered by metered dose inhaler (MDI). Some are available by aerosol treatment and a few are available in oral form. In general, they are used to relieve or stop asthma symptoms and are very helpful during an asthma episode. Bronchodilators used for treatment of asthma symptoms include: •A  lbuterol (Proventil HFA®, Ventolin HFA®, ProAir®), levalbuterol (Xoponex HFA®) and pirbuterol (Maxair®) – These medications work quickly and last for a short time (four to six hours). They have several possible side effects, including a rapid heart rate, nervousness and shaking. Most of the time, these side effects do not occur and if they do are short lived. These medications are available as an inhaler and/or an aerosol. • Ipratopium (Atrovent®) – This medication is available as an inhaler or as an aerosol. •A  lbuterol and ipatropium (Combivent®) – This medication comes as an inhaler or an aerosol (Duo-Neb®). Bronchodilators used to prevent symptoms of asthma include: • Salmeterol (Serevent®) and formoterol (Foradil®) – These are long-acting bronchodilators. They are not to be used as a rescue inhaler and must always be used with an inhaled corticosteroid in the treatment of asthma.


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•T  heophylline (Theo-dur®, Uniphyl®, Slo-bid®, Aminophylline®) – This medication is taken either orally (by mouth) or through a vein (intravenous, or IV). The patient must be monitored while taking this medication, which can have side effects – including nausea, vomiting, headache, irregular heartbeat and shaking – and can interact with some other medications. This medication is not commonly used in the initial treatment of asthma, but reserved for more difficult-to-control asthma, if deemed necessary.

Controller medications (anti-inflammatories) These are the most important medicines for most people with asthma. Anti-inflammatory medications reduce swelling and mucus production in the airways. As a result, airways are less sensitive and less likely to react to triggers. These medications need to be taken daily and may need to be taken for several weeks before they will begin to control asthma. Anti-inflammatories lead to fewer asthma symptoms, better airflow, less-sensitive airways, less airway damage and fewer asthma episodes. If taken every day, they control or prevent asthma symptoms. These medications are available as MDIs, DPI (dry powder inhalers) or in oral form. These medications include: • I nhaled corticosteroids (Alvesco HFA®, Advair HFA® and Advair DPI® (combination of fluticasone and salmeterol), Asmanex DPI® (mometasone), Azmacort® (triamcinolone), Flovent HFA® (fluticasone) and Flovent DPI®, Pulmicort® DPI (budesonide), Qvar®, Symbicort® (combination of budesonide and formoterol) • Oral or IV corticosteroids (Prednisone®, Medrol®), mast cell stabilizers (cromolyn – soon only in nebulizer form) • Leukotriene inhibitors (Singulair®, Accolate®, Zyflo®) In patients who have allergic asthma that is moderate to severe in nature, the medication Xolair® (omalizumab) may be used. Xolair® prevents allergens from attaching to a natural substance in the body called IgE. This prevents the allergic reaction (which causes inflammation) and can prevent asthma attacks in some patients. This medication is administered in an asthma specialist’s office and is in injection form.

Novel Agents and Approaches For patients with poorly controlled or severe asthma, select centers including our Asthma Center offer innovative services that are at the forefront of asthma care. These include:

Our Services Cleveland Clinic's Asthma Center offers a full range of services for both newly diagnosed asthma patients as well as those with poorly controlled or severe asthma. You can benefit from: • Treatment for asthma, and any coexisting conditions that complicate asthma control • Comprehensive consultative services and ongoing care for difficult-to-control asthma • Testing for suspected sensitivities to foods, food additives, aspirin and allergens • Specialized testing to determine how well your asthma is under control • Comprehensive patient education • Occupational and environmental asthma evaluation • Access to clinical trials for patients who qualify

• Anti-IgE therapy •M  easurement of inflammatory biomarkers in exhaled breath for patients not responding to therapies, and requiring high doses of corticosteroids • Bronchial thermoplasty, a new non-drug technique designed to reduce the contractility of airway smooth muscle by applying radiofrequency energy to airway walls • Aspirin desensitization to induce and maintain a state of tolerance to aspirin and aspirin-like drugs for patients with aspirin-exacerbated respiratory disease

Cleveland Clinic Asthma Center


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Bronchial Thermoplasty Bronchial thermoplasty (BT) is a major advance in the treatment of patients who suffer from severe or persistent asthma. Recently approved by the U.S. Food

of note


and Drug Administration, BT is the first procedure that reduces the primary source of bronchial spasm – the smooth muscle that lines the airway. BT is a way of safely thinning it.

Every day in America,

The technique works like this: A flexible tube is inserted into the patient’s

40,000 people miss

airway, and a catheter is threaded through the tube to deliver tiny blasts of

school or work due to asthma, 30,000 people have an asthma attack, 5,000 people have an asthma-related emergency room visit, and 1,000 people are admitted to the hospitaldue to the disease. Also, 11 people die from asthma every day.

radio energy, applying heat to the smooth muscle that lines the airway. This thins smooth muscle, causing only minimal, transient injury to the tissue. In clinical trials, the method has reduced this muscle layer by 50 percent. Once airway muscle is thinned, it isn’t as sensitive and is less likely to spasm. The procedure is quick – it takes less than 30 minutes – and can be done on an outpatient basis with only a light anesthesia. A full course of bronchial thermoplasty treatment includes three separate bronchoscopic procedures: one for the each lower lobe of the lung and another for both upper lobes. Each outpatient procedure is performed approximately at least three weeks apart. The most frequent side effects from bronchial thermoplasty include coughing, wheezing and shortness of breath. To be considered for bronchial thermoplasty treatment, you should:

• Be an adult between 18-65 years old

• Be a non-smoker for at least the past year

• Have severe or persistent asthma not well controlled by inhaled corticosteroids or long-acting bronchodilator medications


Cleveland Clinic Asthma Center

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Asthma Action Plan Based on your history and asthma severity, you and your doctor will develop a care plan called an asthma action plan. The asthma action plan describes when and how to use your medicines, actions to take when asthma worsens, and when to seek emergency care. Make sure you understand this plan; if not, ask your asthma care provider any questions you may have. Your asthma action plan is one of the keys to controlling asthma. Keep it readily available to remind you of what you need to do every day to control asthma and what you need to do when symptoms occur.

Did you know? •L  ow income and minority children bear the heaviest burden of asthma, including death. The cost of childhood asthma exceeds $8 billion in direct treatment costs and $10 billion in indirect costs (such as missed work, school days). •M  ore than 20 million children and adults live with asthma all over the U.S., making it one of the most common and costly diseases.

Goals of asthma therapy These are the goals of asthma treatment: 1) Live an active, normal life 2) Perform daily activities without difficulty

of note

3) Attend work or school every day


4) Prevent chronic and troublesome symptoms

Cleveland Clinic’s

5) Use and adjust medications to control asthma


with few or no side effects

Institute treats

6) Stop urgent visits to the doctor, emergency room or hospital

more than 90,000

If you are unable to reach all of these goals, your asthma is not under

patients annually.

control. You should contact your asthma care provider for advice.

Work closely with your asthma care team to learn all you can about your asthma, how to avoid triggers, what your medications do, and how to take them correctly. With proper care, you can live free of asthma symptoms and maintain a normal, healthy lifestyle.

Cleveland Clinic Asthma Center


About the Respiratory Institute At the Respiratory Institute, one of 26 institutes at Cleveland Clinic, experts in Pulmonary, Allergy and Critical Care Medicine; Thoracic and Cardiovascular Surgery; Thoracic Imaging; and Pulmonary Pathology diagnose and manage the full spectrum of respiratory and allergic disorders, serving nearly 90,000 patients annually. Cleveland Clinic is a nonprofit, multispecialty academic medical center consistently ranked among the top hospitals in America by U.S.News & World Report. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,300 staffed beds, an education institute and a research institute.

Why the Asthma Center? At Cleveland Clinic Asthma Center, we offer patients the most advanced treatments for asthma. Our center uses a multidisciplinary team approach, bringing all of the experts that you need together under one roof, including allergists/immunologists and pulmonary/critical care specialists, including sports medicine experts for the care of elite and professional athletes. Together, our team works with you to develop an individualized plan to best meet your needs. Being part of Cleveland Clinic also means you have easy access to any of our other specialists to manage any related conditions – including sinusitis, gastroesophageal reflux, vocal cord dysfunction, cataracts, glaucoma and osteoporosis. Our pulmonary program is ranked No. 3 in the United States by U.S.News & World Report and Cleveland Clinic is consistently ranked as one of the top hospitals in the nation.

Need a second opinion but cannot travel to Cleveland? Our MyConsult service offers secure online second opinions for patients who cannot travel to Cleveland. Through this service, patients enter detailed health information and mail pertinent test results to us. Then, Cleveland Clinic experts render an opinion that includes treatment options or alternative recommendations regarding future therapeutic considerations. To learn more about MyConsult, please visit

Making an Appointment Call 866.CCF.LUNG to schedule an appointment with an asthma expert today. Same-day appointments are available.



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