Guide to Asthma

Practice Session #2 ("The Neighbor's Cat"):

Imagine that as part of your asthma you have multiple allergic sensitivities, including to cats. Nonetheless, you have been feeling well this fall, using your inhaled steroid medication every day two inhalations twice daily (except when you fall asleep without remembering your evening dose!). You are active and enjoy working out at the gym. You routinely use your bronchodilator inhaler before exercising but otherwise rarely seem to need it. Sometimes you wonder whether you still have asthma at all.

Today you are invited to your neighbor's home for dinner. They took in a stray cat last month, but because of your allergies, they promise to keep the cat outside or in the basement during your visit.

The evening seemed to be going fine, until you sat on a certain sofa. Soon thereafter you began to sneeze and to develop watery, itchy eyes. You feel a tightening in your chest and itching below your chin. You use your bronchodilator inhaler once, but get only minor relief. You start to have coughing and raise some clear mucus. Your neighbor offers you some water.

What would you do now?


Step one is pretty clear: leave the neighbor's house. It is likely that you are allergic to something in their house, probably cat dander on the sofa and elsewhere throughout the house. The best first step in treating an asthma attack, if possible, is to remove yourself from exposure to your asthma "trigger."

In this circumstance, it is safe to use your bronchodilator inhaler more often than the usual limit of 4-5 times per day. If necessary, you can take it every 20-30 minutes for 1-2 hours or until you feel more comfortable.

If available, use your peak flow meter to check your peak flow. It will help you to judge how severe this asthma attack is. You may be able to estimate its severity by how you feel, especially by how breathless you are as you walk around. However, sometimes you can be fooled. The greatest concern is that you might underestimate just how sick you really are. Many people tend to minimize their symptoms; we don't want to admit that something might be seriously wrong.

If you check your peak flow and find it to be more than half of your normal best value, you can be reassured that this is a mild-to-moderate attack. If your peak flow is less than half of your normal best value, you are having a severe attack, in which case you will need more intensive treatment and greater caution.

Practice Session #2 ("The Neighbor's Cat") (continued):

When you arrive back home, you find that you can walk up to your second-story apartment without much shortness of breath. You continue to experience some coughing and wheezing. You use your quick-relief bronchodilator again, and soon thereafter you check your peak flow. It is 400 liters per minute, whereas normally your peak flow is quite steady at 500 liters per minute.

What would you do at this point?


A good strategy for treating a mild-to-moderate asthma attack is to double your dose of inhaled steroids. In this example, you would begin taking four puffs twice daily (or two puffs four times a day) of the steroid inhaler. The results are usually not as rapid and dramatic as with steroids in tablet form (e.g., prednisone or Medrol®), but side effects are far fewer.

It is likely that by removing yourself from the cat dander and by increasing your dose of inhaled steroids, you will bring your asthma back under control over the next 12-24 hours. During this time, keep close watch on your asthma symptoms and, if possible, your peak flow values to make sure that you are improving. If you are not getting better, you should contact your medical provider. If you are improving, continue the extra puffs of the inhaled steroid for 3-4 extra days, and if then all better, you can resume your usual dose.

This practice example illustrates an effective strategy for using your inhaled steroids: increase the dose when your asthma is poorly controlled, decrease the dose to the lowest dose sufficient to control symptoms and prevent attacks when your asthma is well controlled. Choosing the appropriate doses should be done with your doctor.