Asthma Medicines

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A challenge test may be used by the physician to demonstrate that a patient with a normal result on pulmonary function testing may indeed have asthma. This bronchial challenge or provocation testing would only be performed if the patient’s history and physical findings suggested that the patient is asthmatic but spirometry was normal. It is not a routine part of pulmonary function testing. The substances or agents commonly used for challenge testing include histamine, methacholine, and cold air.

Histamine is stored in allergy cells such as mast cells and is released during allergic or asthmatic attacks. It is thought to be one of the mediators of asthma. For this reason it is very suitable for provoking asthma in challenge testing. Methacholine is a chemical that stimulates one part of the nervous system called the parasympathetic nervous system to fire. If inhaled into the bronchial tubes in an asthmatic subject, methacholine will trigger impulses that produce airway constriction. Cold air irritates the bronchial tubes and may also be used for challenge testing. In an asthmatic subject with hyperreactive airways, inhaling cold air will produce significant tightening of the bronchial tubes.

In the patient thought to have occupational asthma the specific offending substance may be used to confirm the direct link between the substance and the patient’s asthmatic reaction. A similar challenge test has been used in patients to confirm allergy to sulfites and aspirin. With any challenge test there is a risk of a severe asthmatic reaction and for this reason these tests are reserved for difficult diagnostic situations and are only performed under careful observation and control.

Guidelines have been developed for performing and interpreting bronchial challenge testing. It is vital to standardize this type of testing to avoid “false positive” or “false negative” results. Generally, for a provocation test to be positive, there must be at least a 15 percent fall in airflow after inhaling the challenge material.

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In an acute attack the fastest means of getting this medication to the bronchial tubes is by inhalation. This can be achieved in minutes by inhaling medicated spray administered by a metered-dose inhaler or powder delivered by a simple handheld device. A medicated mist generated by a nebulizer can also be used for inhalation.

What Is an Asthma Aerosol?

An asthma aerosol is a mixture of a liquid medication suspended in a gas that can be inhaled. Aerosols differ in the size of the spray or mist particles that are inhaled. Particle size is important since large particles are not likely to reach the bronchial tubes and may land in the mouth or throat. Examples of asthma aerosols are sprays from metered-dose inhalers (MDIs) and nebulizers. The goal of aerosol therapy is inhalation of active medication with penetration into the bronchial tubes.

Metered-Dose Inhalers

Metered-dose inhalers contain medication in aerosol form. These devices were first introduced in 1956 and have become widely used for asthma and rhinitis. MDIs consist of a canister of medication and an actuator with a mouthpiece. The actuator is the outer shell in which the canister “sits.” In the canister, medication is suspended in a mixture of a liquid propellant gas and preservatives. The current propellant used in most MDIs is a mixture of freon gases called chlorofluorocarbons.

When the canister is pressed into the actuator, the mixture of medication and propellant passes through a valve. The release of the contents under pressure transforms the liquid mixture into a spray that can be inhaled.

The metered-dose inhaler is the most common means of administration of the B-adrenergic agonists. It is a compact and portable device which dispenses a certain amount of medication rapidly. Coordination between hand activation of the MDI and breathing must exist for the medication to be properly delivered. Metered-dose inhalers come in many shapes and sizes.

Although the metered-dose inhaler is in general a safe device, it should be noted that a small number of patients may have adverse reactions to the propellants. This reaction may produce a worsening of asthma symptoms instead of the expected improvement after use of the MDI. Patients must also be careful to keep the mouthpiece of the metered-dose inhaler closed when not in use and free of foreign objects. Many patients have inadvertently aspirated foreign objects such as coins which slipped into the open mouthpiece and were then inhaled. MDIs are frequently kept in a pocket or purse where such foreign objects are usually found, so it is best to carefully check the MDI before its use.

A thirty-two-year-old man under my care for bronchial asthma called me in distress one night stating that “something went wrong when I sprayed.” He had been in the habit of keeping his uncovered MDI in his pocket and while shopping had placed loose change in the same pocket.

After dinner he had used his MDI and felt “something go in.” An x-ray in the emergency room showed a dime lodged in his windpipe. A procedure called bronchoscopy was required to remove it. The patient was released the next day with an MDI that he had carefully capped.

Nebulizer

A nebulizer may also be used to rapidly deliver aerosol medication containing B-adrenergic agonists. This device, which is commonly used in an emergency room setting, is basically a simple system that allows rapidly flowing air or oxygen to be bubbled through a solution containing the drug. This system produces a vapor that the patient inhales. Nebulizers differ in terms of the size of mist particles they produce. Of note, the nebulizer does not require the coordination between hand and breathing necessary for MDI use.

Nebulizer delivery of a B-agonist is preferred in emergency settings due to the greater quantity of drug that can be delivered. This has been estimated to be approximately from four to ten times the amount of medication delivered by two puffs from a metered-dose inhaler. The greater quantity of drug delivered by the nebulizer method may also result in greater side effects (tremors, rapid heartbeat, muscle cramps, nervousness) than those noted after metered-dose inhalation. In an emergency setting the beneficial effect of opening the bronchial tubes usually out-weighs any adverse side effects.

Nebulizers may be obtained for the home but this should not be necessary for most asthma patients. In view of the adverse effects and increased dosage noted above, a home nebulizer should only be prescribed for the most severely afflicted patients with asthma that cannot be controlled with metered-dose sprays or powder. These devices are much more expensive and cumbersome than MDIs, although portable units are available.

One advantage of the nebulizer may be its ability to combine more than one drug in solution given as one treatment. It should be noted, however, that metered-dose inhalers with more than one medication are likely to be available soon.

Metered-Dose Inhaler versus Nebulizer Delivery

A number of studies have compared the effectiveness of a B-agonist delivered by a metered-dose inhaler with a spacer attachment and the same drug delivered by a nebulizer. These studies have shown little or no difference in effectiveness between the two delivery systems. One explanation is that with a metered-dose spray the patient takes a deep breath to deliver medication to the bronchial tubes, while with a nebulizer the patient breathes normally. The deep breath may actually be advantageous to the delivery of medication to smaller bronchial tubes. During a severe attack, however, it may be difficult for patients to actively inhale deeply enough. wnile routine use of a nebulizer for stable asthma should be discouraged, there remains a definite place for nebulizer delivery of medication in patients with severe disease and in an emergency.

Nebulizers also require more maintenance and cleaning than do MDIs. There is a greater risk of contamination with nebulizers and patients must follow a proper cleaning routine.

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