eMedicine Specialties > Allergy and Immunology > Asthma

Allergic and Environmental Asthma: Follow-up

Author: William F Kelly III, MD, Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Staff Physician, Division of Pulmonary/Critical Care Medicine, Department of Medicine, Walter Reed Army Medical Center
Coauthor(s): John J Oppenheimer, MD, Clinical Associate Professor, University of Medicine and Dentistry of New Jersey; Director Clinical Research, Pulmonary and Allergy Associates, PA; Gregory J Argyros Col, MD, Chief, Graduate Medical and Dental Education, J7/Joint Task Force, National Capital Region Medical; Professor of Medicine, Uniformed Services University of the Health Sciences
Contributor Information and Disclosures

Updated: Jun 17, 2009

Follow-up

Further Inpatient Care

  • Consider admission to a hospital if the patient develops refractory symptoms with a marked decrease in spirometry or borderline oxygenation. Intravenous or oral corticosteroids (3- to 10-d course) may be required.
    • A reduced forced expiratory volume in 1 second (FEV1) or peak expiratory flow rate (PEFR) to less than 50% of the patient’s personal best, normocapnia or hypercapnia, severe symptoms, or mental status changes warrants admission to an ICU. Severe exacerbations require standard care that includes supplemental oxygen (goal PaO2 >60 mm Hg, arterial oxygen saturation >90%), systemic intravenous/oral corticosteroids (doubling the dose of inhaled corticosteroids is not effective17,18 ), nebulized medications including albuterol, nebulized anticholinergics, intravenous fluids, and even noninvasive or invasive ventilatory support if needed. Magnesium sulfate, Heliox (helium-oxygen gas mixture), or both can be used, but this treatment has not been systematically shown to be helpful. Antibiotics offer no added benefit during an asthma exacerbation but are often given if pneumonia is suspected.
    • If the patient responds to therapy, examination findings are normal 1 hour after the last medication dose, and the FEV1 or PEFR is >70% of patient’s personal best, consider discharging the patient home on therapy to include oral steroids and scheduling a follow-up visit within 1 week.

Further Outpatient Care

  • Medical office visits should occur every 6-12 months (every 1-6 mo if severe) and should include the following assessments:
    • Reassess severity, compliance, and response to therapy. Consider giving patients a written questionnaire such as the Asthma Control Test (ACT), Asthma Control Questionnaire (ACQ), or Asthma Therapy Assessment Questionnaire (ATAQ).
      • The American Lung Association has endorsed the ACT, a 5-question self-assessment tool for patients. The ACT asks about symptoms experienced during the previous 4 weeks. Scores ≤19 (out of a possible 25) suggest inadequate asthma control worthy of discussion with a clinician.
      • Other scorecards include the ACQ31 and the ATAQ.32
    • Objectively measure pulmonary function; initially check office spirometry, follow up with objective measures of lung function at each visit. If spirometry is not available, PEFR can be used.33
    • Reinforce inhaler technique and asthma management plan.
    • Ensure compliance with environmental avoidance techniques, and consider additional efforts (add one at a time).
    • Consider arranging a home visit to screen for environmental exposures and assess compliance with avoidance measures. According to a randomized controlled evaluation of community health worker intervention with African American children hospitalized for asthma, the presence of an asthma coach can reduce hospitalization.34
    • Consider modifying (stepping up or stepping down) doses of maintenance medications, if appropriate.

Prognosis

  • Signs that may indicate a poor prognosis (ie, risk factors for death) are as follows:
    • Severe exacerbations - Intubation, ICU stay, 2 or more hospitalizations per year, 3 or more urgent clinic or emergency department (ED) visits per year
    • More than 2 short-acting beta-2 agonist metered-dose inhalers (MDIs) per month
    • Glucocorticoid dependence
    • Poor patient perception of airflow obstruction
    • Significant medical comorbidities
    • Psychiatric disease
    • Illicit drug use
    • Sensitivity to Alternaria species (an outdoor mold)

Patient Education

  • Patient compliance rates for medications can be as low as 50%. Compliance with environmental measures, including mattress covers for dust mites, may be even worse. Health care professionals are also at fault, with only 63% of internists and only 81% of asthma specialists prescribing inhaled glucocorticoids according to recommended guidelines. In one study, more than 40% of patients did not feel that their asthma was well-controlled. Education reduces ED visits, but objective evidence for other outcome measures is limited. Adequate education programs for parents and/or patients include the following:
    • Asthma disease description
    • Identification and control of environmental triggers
    • Proper medication use: Take off the cap and shake the inhaler (not needed for dry-powder inhaler [DPI]). Breathe out deeply and hold the inhaler with lips pursed around the orifice or as far as 2 inches from the face or use a spacer. Depress the inhaler concurrent with slow inspiration. Hold breath for 10 seconds. Repeat until the desired dose is achieved (wait 1 min for short-acting beta-agonists).
    • Upper airway allergic symptoms: These can be an early warning system for allergic asthma.
    • Written self-management plan according to PEFR, exposure, and symptoms: For example, a drop below 80% is considered the yellow zone, and additional intervention is needed; a drop below 50% is considered the red zone (severe exacerbation), and the patient should seek medical assistance. While PEFR information has not been consistently shown to be of value over symptoms monitoring alone, the conservative approach would be to include this objective monitoring.
    • Parents with a history of allergies: These parents should be advised that some evidence suggests that environmental control measures may potentially prevent sensitization in their children. Simple but unproven measures include removing bedroom carpet, avoiding passive smoke exposure, venting gas appliances, increasing fish and vegetable intake, and breastfeeding.
  • Additional resources for health care professionals are available on the Internet and include the following:
  • For additional patient education resources, visit eMedicine's Asthma Center. Also, see eMedicine's patient education articles Asthma, Asthma FAQs, Occupational Asthma, and Understanding Asthma Medications.
  • For asthma resources from Medscape and eMedicine, visit Asthma News and Articles, Asthma Clinical Reference, and Asthma CME.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize conditions in the differential diagnosis (eg, foreign body aspiration in a child)
  • Failure to provide sufficient treatment for pregnant women
  • Prescribing long-term inhaled beta-agonists without also prescribing inhaled corticosteroids.
    • The safety of long-acting beta-agonists has been questioned because of the SMART trial of approximately 25,000 patients, in which the respiratory- and asthma-related deaths were increased in the group that received salmeterol compared to placebo.15 (This signal was only statistically significant in African Americans.)
    • Most experts continue to recommend the addition of long-acting beta-agonists when disease is not adequately controlled by low- or medium-dose inhaled corticosteroids but stress that long-acting beta-agonists should not be used without inhaled corticosteroids.
    • Patients should be counseled regarding these findings when medications that contain a long-acting beta-agonist are to be prescribed. This discussion should be documented.35
  • Failure to provide short-term rescue agents (eg, inhaled beta-2 agonists) and long-term maintenance medications
  • Failure to refer patients whose conditions are refractory to treatment to specialists and subjecting them to inappropriate long-term treatment (eg, long-term prednisone when the patient actually has vocal cord dysfunction [VCD])

Special Concerns

  • Patients dependent on oral glucocorticoids: These individuals should be referred to a specialist. The goal is the lowest possible oral glucocorticoid dose for the shortest possible duration. Patients must be screened and then referred or treated for complications such as cataracts (optometry/ophthalmology screening annually) and osteoporosis (bone densitometry, supplemental calcium, and vitamin D at a minimum, if not contraindicated). Excluding problems that can mimic asthma, such as VCD in "refractory" glucocorticoid-dependent cases, is important. A truncated inspiratory flow-volume loop on pulmonary function tests suggests possible VCD with corroboratory adduction of the vocal cords during inspiration.
  • Patients on long-acting beta-agonists: The safety of long-acting beta-agonists has been questioned because of the SMART trial of approximately 25,000 patients, in which the respiratory- and asthma-related deaths were increased in the group that received salmeterol compared to placebo (this signal was only statistically significant in African Americans).15 Most experts continue to recommend addition of long-acting beta-agonists when disease is not adequately controlled by low- or moderate-dose inhaled corticosteroids but stress that long-acting beta-agonists should not be used without inhaled corticosteroids. Patients should also be counseled about these findings whenever an inhaler containing these medications is prescribed.35
  • Infants and children younger than 4 years: Pulmonary function testing is difficult to perform because cooperation can be limited and reference ranges are not standardized. Fewer medications have been studied and approved for patients in this age group.
  • Elderly patients: These patients frequently have other medical diseases that can mimic asthma and are more likely to experience adverse effects from asthma medications.
  • Pregnant patients: Asthma affects up to 8% of pregnant women, and these patients should be treated similarly and possibly even more aggressively than other patients, given the detrimental effects of hypoxia on maternal and fetal outcomes. Generally during pregnancy, airway hyperreactivity (AHR) is stable to improved 69% of the time and worse 31% of the time. The following are specific interventions:
    • Theophylline may be associated with drug toxicity in the newborn because of poor clearance.
    • Beclomethasone is an older and therefore better-studied inhaled steroid for use during pregnancy. However, budesonide is the only inhaled corticosteroid with an FDA pregnancy rating of B. Thus, budesonide should be the drug of choice for pregnant women with asthma.
    • Systemic glucocorticoids may increase the risk of preeclampsia and decreased birth weight but should be used if asthma exacerbation is severe because untreated asthma bears its own risks on the pregnancy.
    • Long-acting beta-agonists are category C.
    • Leukotriene pathway medications generally should not be used because of a lack of safety information, though montelukast is a category B drug.
    • Immunotherapy should not be started nor dosage escalated during pregnancy, given the rare but significant risk of anaphylaxis. If already begun, immunotherapy may be maintained without further dose escalation.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of author Rohit K Katial, MD, to the development of the previous edition of this article.



More on Allergic and Environmental Asthma

Overview: Allergic and Environmental Asthma
Differential Diagnoses & Workup: Allergic and Environmental Asthma
Treatment & Medication: Allergic and Environmental Asthma
Follow-up: Allergic and Environmental Asthma
References
[ CLOSE WINDOW ]

References

  1. Braman SS. The global burden of asthma. Chest. Jul 2006;130(1 Suppl):4S-12S. [Medline].

  2. Expert panel-3. NHLBI NIH; AUG 2007. 440. [Full Text].

  3. Eder W, Ege MJ, von Mutius E. The asthma epidemic. N Engl J Med. Nov 23 2006;355(21):2226-35. [Medline].

  4. Marcus P. Incorporating anti-IgE (omalizumab) therapy into pulmonary medicine practice: practice management implications. Chest. Feb 2006;129(2):466-74. [Medline].

  5. Scirica CV, Celedon JC. Genetics of asthma: potential implications for reducing asthma disparities. Chest. Nov 2007;132(5 Suppl):770S-781S. [Medline].

  6. Bleecker ER, Postma DS, Lawrance RM, Meyers DA, Ambrose HJ, Goldman M. Effect of ADRB2 polymorphisms on response to longacting beta2-agonist therapy: a pharmacogenetic analysis of two randomised studies. Lancet. Dec 22 2007;370(9605):2118-25. [Medline].

  7. Woessner KM, Simon RA, Stevenson DD. Monosodium glutamate sensitivity in asthma. J Allergy Clin Immunol. Aug 1999;104(2 Pt 1):305-10. [Medline].

  8. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. Nov 2005;26(5):948-68. [Medline].

  9. Bernstein IL, Li JT, Bernstein DI, et al. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol. Mar 2008;100(3 Suppl 3):S1-148. [Medline].

  10. Irwin RS. Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines. Chest. Jan 2006;129(1 Suppl):80S-94S. [Medline].

  11. Juniper EF, Kline PA, Vanzieleghem MA, et al. Effect of long-term treatment with an inhaled corticosteroid (budesonide) on airway hyperresponsiveness and clinical asthma in nonsteroid-dependent asthmatics. Am Rev Respir Dis. Oct 1990;142(4):832-6. [Medline].

  12. The Childhood Asthma Management Program Research Group. Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med. Oct 12 2000;343(15):1054-63. [Medline].

  13. Pauwels RA, Lofdahl CG, Postma DS, et al. Effect of inhaled formoterol and budesonide on exacerbations of asthma. Formoterol and Corticosteroids Establishing Therapy (FACET) International Study Group. N Engl J Med. Nov 13 1997;337(20):1405-11. [Medline].

  14. Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. Aug 3 2000;343(5):332-6. [Medline].

  15. [Best Evidence] Nelson HS, Weiss ST, Bleecker ER, Yancey SW, Dorinsky PM,. The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest. Jan 2006;129(1):15-26. [Medline].

  16. Rabe KF, Pizzichini E, Stallberg B, Romero S, Balanzat AM, Atienza T. Budesonide/formoterol in a single inhaler for maintenance and relief in mild-to-moderate asthma: a randomized, double-blind trial. Chest. Feb 2006;129(2):246-56. [Medline].

  17. Woolcock A, Lundback B, Ringdal N, Jacques LA. Comparison of addition of salmeterol to inhaled steroids with doubling of the dose of inhaled steroids. Am J Respir Crit Care Med. May 1996;153(5):1481-8. [Medline].

  18. Currie GP, Lee DK, Srivastava P. Long-acting bronchodilator or leukotriene modifier as add-on therapy to inhaled corticosteroids in persistent asthma?. Chest. Oct 2005;128(4):2954-62. [Medline].

  19. [Best Evidence] Sheikh A, Hurwitz B, Shehata Y. House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database Syst Rev. Jan 24 2007;CD001563. [Medline].

  20. Abramson MJ, Puy RM, Weiner JM. Allergen immunotherapy for asthma. Cochrane Database Syst Rev. 2003;CD001186.

  21. Bruggenjurgen B, Reinhold T, Brehler R, et al. Cost-effectiveness of specific subcutaneous immunotherapy in patients with allergic rhinitis and allergic asthma. Ann Allergy Asthma Immunol. Sep 2008;101(3):316-24. [Medline].

  22. Cox G, Thomson NC, Rubin AS, et al. Asthma control during the year after bronchial thermoplasty. N Engl J Med. Mar 29 2007;356(13):1327-37. [Medline].

  23. Aaron SD, Fergusson D, Dent R, Chen Y, Vandemheen KL, Dales RE. Effect of weight reduction on respiratory function and airway reactivity in obese women. Chest. Jun 2004;125(6):2046-52. [Medline].

  24. Hallstrand TS, Bates PW, Schoene RB. Aerobic conditioning in mild asthma decreases the hyperpnea of exercise and improves exercise and ventilatory capacity. Chest. Nov 2000;118(5):1460-9. [Medline].

  25. Israel E, Chinchilli VM, Ford JG, et al. Use of regularly scheduled albuterol treatment in asthma: genotype-stratified, randomised, placebo-controlled cross-over trial. Lancet. Oct 23-29 2004;364(9444):1505-12. [Medline].

  26. Hendeles L, Colice GL, Meyer RJ. Withdrawal of albuterol inhalers containing chlorofluorocarbon propellants. N Engl J Med. Mar 29 2007;356(13):1344-51. [Medline].

  27. US Food and Drug Administration. National Transition from Chlorofluorocarbon (CFC) Propelled Albuterol Inhalers to Hydrofluroalkane (HFA) Propelled Albuterol Inhalers. FDA Public Health Advisory. FDA web site. August 28, 2008. Available at: http://www.fda.gov/cder/drug/advisory/albuterol_cfc.htm. Accessed January 13, 2009.

  28. Szefler SJ, Phillips BR, Martinez FD, et al. Characterization of within-subject responses to fluticasone and montelukast in childhood asthma. J Allergy Clin Immunol. Feb 2005;115(2):233-42. [Medline].

  29. Sander N, Fusco-Walkert SJ, Harder JM, Chipps BE. Dose counting and the use of pressurized metered-dose inhalers: running on empty. Ann Allergy Asthma Immunol. Jul 2006;97(1):34-8. [Medline].

  30. Levenson M. Long-acting beta-agonists and adverse asthma events meta-analysis. Statistical briefing package for Joint Meeting of the Pulmonary-Allergy Drugs Advisory Committee, Drug Safety and Risk Management Advisory Committee and Pediatric Advisory Committee. December 10-11, 2008. Available at: http://www.fda.gov/ohrms/dockets/ac/08/briefing/2008-4398b1-01-FDA.pdf. Accessed January 13, 2009.

  31. Juniper EF, O'Byrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J. Oct 1999;14(4):902-7. [Medline].

  32. Vollmer WM, Markson LE, O'Connor E, et al. Association of asthma control with health care utilization and quality of life. Am J Respir Crit Care Med. Nov 1999;160(5 Pt 1):1647-52. [Medline].

  33. Li J, Oppenheimer J, Bernstein IL, et al. Attaining asthma control. A practice parameter. J Allerg Clin Immunol. 2005;115:S3-11.

  34. [Best Evidence] Fisher EB, Strunk RC, Highstein GR, et al. A randomized controlled evaluation of the effect of community health workers on hospitalization for asthma: the asthma coach. Arch Pediatr Adolesc Med. Mar 2009;163(3):225-32. [Medline].

  35. Oppenheimer J, Aaronson D. Impact of recent black box warnings in the allergy world. Ann Allergy Asthma Immunol. Oct 2007;99(4):364-6. [Medline].

  36. Adkinson NF Jr, Eggleston PA, Eney D, et al. A controlled trial of immunotherapy for asthma in allergic children. N Engl J Med. Jan 30 1997;336(5):324-31. [Medline].

  37. Alberts WM, do Pico GA. Reactive airways dysfunction syndrome. Chest. Jun 1996;109(6):1618-26. [Medline].

  38. American Thoracic Society. Lung function testing: selection of reference values and interpretative strategies. American Thoracic Society. Am Rev Respir Dis. Nov 1991;144(5):1202-18. [Medline].

  39. Barnes PJ. Is immunotherapy for asthma worthwhile?. N Engl J Med. Feb 22 1996;334(8):531-2. [Medline].

  40. Barnes PJ. Is there a role for immunotherapy in the treatment of asthma? No. Am J Respir Crit Care Med. Nov 1996;154(5):1227-8. [Medline].

  41. Beasley R, Burgess C, Crane J, Pearce N, Roche W. Pathology of asthma and its clinical implications. J Allergy Clin Immunol. Jul 1993;92(1 Pt 2):148-54. [Medline].

  42. Blackhall K, Appleton S, Cates CJ. Ionisers for chronic asthma. Cochrane Database Syst Rev. 2003;CD002986. [Medline].

  43. Boulet LP, Chapman KR, Cote J, et al. Inhibitory effects of an anti-IgE antibody E25 on allergen-induced early asthmatic response. Am J Respir Crit Care Med. Jun 1997;155(6):1835-40. [Medline].

  44. Bousquet J, Lockey R, Malling HJ. Allergen immunotherapy: therapeutic vaccines for allergic diseases. A WHO position paper. J Allergy Clin Immunol. Oct 1998;102(4 Pt 1):558-62. [Medline].

  45. Bousquet J, Lockey R, Malling HJ, et al. Allergen immunotherapy: therapeutic vaccines for allergic diseases. World Health Organization. American academy of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol. Nov 1998;81(5 Pt 1):401-5. [Medline].

  46. Britton J, Lewis S. Objective measures and the diagnosis of asthma. We need a simple diagnostic test-but don't yet have one. BMJ. Jul 25 1998;317(7153):227-8. [Medline].

  47. [Best Evidence] Buist AS, Vollmer WM, Wilson SR, Frazier EA, Hayward AD. A randomized clinical trial of peak flow versus symptom monitoring in older adults with asthma. Am J Respir Crit Care Med. Nov 15 2006;174(10):1077-87. [Medline].

  48. Burney P. The changing prevalence of asthma?. Thorax. Oct 2002;57 Suppl 2:II36-II39. [Medline].

  49. Busse WW. Mechanisms and advances in allergic diseases. J Allergy Clin Immunol. Jun 2000;105(6 Pt 2):S593-8. [Medline].

  50. Busse WW, Lemanske RF Jr. Asthma. N Engl J Med. Feb 1 2001;344(5):350-62. [Medline].

  51. Christopher KL, Wood RP 2nd, Eckert RC, Blager FB, Raney RA, Souhrada JF. Vocal-cord dysfunction presenting as asthma. N Engl J Med. Jun 30 1983;308(26):1566-70. [Medline].

  52. Corren J, Casale T, Deniz Y, Ashby M. Omalizumab, a recombinant humanized anti-IgE antibody, reduces asthma-related emergency room visits and hospitalizations in patients with allergic asthma. J Allergy Clin Immunol. Jan 2003;111(1):87-90. [Medline].

  53. Creticos PS, Reed CE, Norman PS, et al. Ragweed immunotherapy in adult asthma. N Engl J Med. Feb 22 1996;334(8):501-6. [Medline].

  54. Cross S, Buck S, Hubbard J. Allergy in general practice. BMJ. May 23 1998;316(7144):1584-7. [Medline].

  55. Demoly P, Bousquet J. Anti-IgE therapy for asthma. Am J Respir Crit Care Med. Jun 1997;155(6):1825-7. [Medline].

  56. Durham SR, Walker SM, Varga EM, et al. Long-term clinical efficacy of grass-pollen immunotherapy. N Engl J Med. Aug 12 1999;341(7):468-75. [Medline].

  57. Fahy JV, Fleming HE, Wong HH, et al. The effect of an anti-IgE monoclonal antibody on the early- and late-phase responses to allergen inhalation in asthmatic subjects. Am J Respir Crit Care Med. Jun 1997;155(6):1828-34. [Medline].

  58. Gaga M, Papageorgiou N, Zervas E, Gioulekas D, Konstantopoulos S. Control of asthma under specialist care: is it achieved?. Chest. Jul 2005;128(1):78-84. [Medline].

  59. Gardner MO, Doyle NM. Asthma in pregnancy. Obstet Gynecol Clin North Am. Jun 2004;31(2):385-413, vii. [Medline].

  60. Georgitis JW. Immunotherapy and Allergen Avoidance for Allergic Airways Disorders. Lesson 3, Vol 12. Northbrook, Ill: American College of Chest Physicians; 1997:[Full Text].

  61. Gergen PJ, Mortimer KM, Eggleston PA, et al. Results of the National Cooperative Inner-City Asthma Study (NCICAS) environmental intervention to reduce cockroach allergen exposure in inner-city homes. J Allergy Clin Immunol. Mar 1999;103(3 Pt 1):501-6. [Medline].

  62. Hamid Q, Tulic' MK, Liu MC, Moqbel R. Inflammatory cells in asthma: mechanisms and implications for therapy. J Allergy Clin Immunol. Jan 2003;111(1 Suppl):S5-S12; discussion S12-7. [Medline].

  63. Herxheimer H, Schaefer O. Letter: Asthma in Canadian Eskimos. N Engl J Med. Dec 26 1974;291(26):1419. [Medline].

  64. Holgate ST. Science, medicine, and the future. Allergic disorders. BMJ. Jan 22 2000;320(7229):231-4. [Medline].

  65. Hughes AT. Anti-IgE antibody may help treat some asthma patients. JAMA. Dec 13 2000;284(22):2859-60. [Medline].

  66. Humbert M, Beasley R, Ayres J, Slavin R, Hebert J, Bousquet J. Benefits of omalizumab as add-on therapy in patients with severe persistent asthma who are inadequately controlled despite best available therapy (GINA 2002 step 4 treatment): INNOVATE. Allergy. Mar 2005;60(3):309-16. [Medline].

  67. Juniper EF, O'Byrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J. Oct 1999;14(4):902-7. [Medline].

  68. Kay AB. Allergy and allergic diseases. First of two parts. N Engl J Med. Jan 4 2001;344(1):30-7. [Medline].

  69. Kharitonov SA, Barnes PJ. Exhaled biomarkers. Chest. Nov 2006;130(5):1541-6. [Medline].

  70. Kuipers H, Lambrecht BN. The interplay of dendritic cells, Th2 cells and regulatory T cells in asthma. Curr Opin Immunol. Dec 2004;16(6):702-8. [Medline].

  71. Kwon HL, Belanger K, Bracken MB. Effect of pregnancy and stage of pregnancy on asthma severity: a systematic review. Am J Obstet Gynecol. May 2004;190(5):1201-10. [Medline].

  72. Lang DM, Polansky M. Patterns of asthma mortality in Philadelphia from 1969 to 1991. N Engl J Med. Dec 8 1994;331(23):1542-6. [Medline].

  73. Larche M. Regulatory T cells in allergy and asthma. Chest. Sep 2007;132(3):1007-14. [Medline].

  74. Legorreta AP, Christian-Herman J, O'Connor RD, Hasan MM, Evans R, Leung KM. Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience. Arch Intern Med. Mar 9 1998;158(5):457-64. [Medline].

  75. Lewis SA, Britton JR. Measles infection, measles vaccination and the effect of birth order in the aetiology of hay fever. Clin Exp Allergy. Dec 1998;28(12):1493-500. [Medline].

  76. Leynaert B, Bousquet J, Neukirch C, Liard R, Neukirch F. Perennial rhinitis: An independent risk factor for asthma in nonatopic subjects: results from the European Community Respiratory Health Survey. J Allergy Clin Immunol. Aug 1999;104(2 Pt 1):301-4. [Medline].

  77. Li JT, Pearlman DS, Nicklas RA, et al. Algorithm for the diagnosis and management of asthma: a practice parameter update: Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol. Nov 1998;81(5 Pt 1):415-20. [Medline].

  78. Lipworth BJ. Systemic adverse effects of inhaled corticosteroid therapy: A systematic review and meta-analysis. Arch Intern Med. May 10 1999;159(9):941-55. [Medline].

  79. Littner MR, Leung FW, Ballard ED 2nd, Huang B, Samra NK,. Effects of 24 weeks of lansoprazole therapy on asthma symptoms, exacerbations, quality of life, and pulmonary function in adult asthmatic patients with acid reflux symptoms. Chest. Sep 2005;128(3):1128-35. [Medline].

  80. Livingston E, Thomson NC, Chalmers GW. Impact of smoking on asthma therapy: a critical review of clinical evidence. Drugs. 2005;65(11):1521-36. [Medline].

  81. Mannino DM, Homa DM, Pertowski CA, et al. Surveillance for asthma--United States, 1960-1995. MMWR CDC Surveill Summ. Apr 24 1998;47(1):1-27. [Medline].

  82. Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med. Jan 19 1995;332(3):133-8. [Medline].

  83. Matricardi PM, Rosmini F, Ferrigno L, et al. Cross sectional retrospective study of prevalence of atopy among Italian military students with antibodies against hepatitis A virus. BMJ. Apr 5 1997;314(7086):999-1003. [Medline].

  84. Milgrom H. Is there a role for treatment of asthma with omalizumab?. Arch Dis Child. Jan 2003;88(1):71-4. [Medline].

  85. Milgrom H, Fick RB Jr, Su JQ, et al. Treatment of allergic asthma with monoclonal anti-IgE antibody. rhuMAb-E25 Study Group. N Engl J Med. Dec 23 1999;341(26):1966-73. [Medline].

  86. Moller C, Dreborg S, Ferdousi HA, et al. Pollen immunotherapy reduces the development of asthma in children with seasonal rhinoconjunctivitis (the PAT-study). J Allergy Clin Immunol. Feb 2002;109(2):251-6. [Medline].

  87. National Asthma Education and Prevention Program. Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2. NIH Publication No. 97-4051. Bethesda, Md: 1997:[Full Text].

  88. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics--2002. J Allergy Clin Immunol. Nov 2002;110(5 Suppl):S141-219. [Medline].

  89. Nelson HS. Allergen immunotherapy: where is it now?. J Allergy Clin Immunol. Apr 2007;119(4):769-79. [Medline].

  90. Nelson HS. The Bela Schick lecture for 1985. The atopic diseases. Ann Allergy. Sep 1985;55(3):441-7. [Medline].

  91. Newman-Taylor A. Environmental determinants of asthma. Lancet. Feb 4 1995;345(8945):296-9. [Medline].

  92. Norman PS. Is there a role for immunotherapy in the treatment of asthma? Yes. Am J Respir Crit Care Med. Nov 1996;154(5):1225-6. [Medline].

  93. Oba Y, Salzman GA. Cost-effectiveness analysis of omalizumab in adults and adolescents with moderate-to-severe allergic asthma. J Allergy Clin Immunol. Aug 2004;114(2):265-9. [Medline].

  94. Osborne ML, Vollmer WM, Pedula KL, Wilkins J, Buist AS, O'Hollaren M. Lack of correlation of symptoms with specialist-assessed long-term asthma severity. Chest. Jan 1999;115(1):85-91. [Medline].

  95. Pearce N, Douwes J, Beasley R. Is allergen exposure the major primary cause of asthma?. Thorax. May 2000;55(5):424-31. [Medline].

  96. Peat JK, Li J. Reversing the trend: reducing the prevalence of asthma. J Allergy Clin Immunol. Jan 1999;103(1 Pt 1):1-10. [Medline].

  97. Pollart SM, Smith TF, Morris EC, Gelber LE, Platts-Mills TA, Chapman MD. Environmental exposure to cockroach allergens: analysis with monoclonal antibody-based enzyme immunoassays. J Allergy Clin Immunol. Feb 1991;87(2):505-10. [Medline].

  98. Rambasek TE, Lang DM, Kavuru MS. Omalizumab: where does it fit into current asthma management?. Cleve Clin J Med. Mar 2004;71(3):251-61. [Medline].

  99. Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute asthma patients. Cochrane Database Syst Rev. 2003;CD002884. [Medline].

  100. Rodrigo GJ, Rodrigo C. The role of anticholinergics in acute asthma treatment: an evidence-based evaluation. Chest. Jun 2002;121(6):1977-87. [Medline].

  101. Sears MR, Burrows B, Flannery EM, Herbison GP, Hewitt CJ, Holdaway MD. Relation between airway responsiveness and serum IgE in children with asthma and in apparently normal children. N Engl J Med. Oct 10 1991;325(15):1067-71. [Medline].

  102. Shaheen SO, Aaby P, Hall AJ, et al. Measles and atopy in Guinea-Bissau. Lancet. Jun 29 1996;347(9018):1792-6. [Medline].

  103. Sheikh A, Alves B, Dhami S. Pneumococcal vaccine for asthma. Cochrane Database Syst Rev. 2002;CD002165. [Medline].

  104. Shirakawa T, Enomoto T, Shimazu S, Hopkin JM. The inverse association between tuberculin responses and atopic disorder. Science. Jan 3 1997;275(5296):77-9. [Medline].

  105. Sin DD, Man J, Sharpe H, Gan WQ, Man SF. Pharmacological management to reduce exacerbations in adults with asthma: a systematic review and meta-analysis. JAMA. Jul 21 2004;292(3):367-76. [Medline].

  106. Smith DH, Malone DC, Lawson KA, Okamoto LJ, Battista C, Saunders WB. A national estimate of the economic costs of asthma. Am J Respir Crit Care Med. Sep 1997;156(3 Pt 1):787-93. [Medline].

  107. Sporik R, Holgate ST, Platts-Mills TA, Cogswell JJ. Exposure to house-dust mite allergen (Der p I) and the development of asthma in childhood. A prospective study. N Engl J Med. Aug 23 1990;323(8):502-7. [Medline].

  108. Sullivan TJ, Selner JC, Patterson R, et al. Expert care and immunotherapy for asthma. A review of published studies with emphasis on patient outcome and cost. American College of Allergy, Asthma, and Immunotherapy Monograph. Nov 1996;1-25.

  109. Theodoropoulos DS, Lockey RF. Allergen immunotherapy: guidelines, update, and recommendations of the World Health Organization. Allergy Asthma Proc. May-Jun 2000;21(3):159-66. [Medline].

  110. Tilles SA. Differential diagnosis of adult asthma. Med Clin North Am. Jan 2006;90(1):61-76. [Medline].

  111. Turkeltaub PC. FDA Medical Bulletin. 1994;24:7.

  112. von Hertzen L, Haahtela T. Signs of reversing trends in prevalence of asthma. Allergy. 2005/03;60(3):283-92.

  113. Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. Oct 2007;120(4):855-64. [Medline].

  114. Weiss KB, Sullivan SD. The health economics of asthma and rhinitis. I. Assessing the economic impact. J Allergy Clin Immunol. Jan 2001;107(1):3-8. [Medline].

  115. Wilson DR, Torres LI, Durham SR. Sublingual immunotherapy for allergic rhinitis. Cochrane Database Syst Rev. 2003;CD002893. [Medline].

  116. [Best Evidence] Pavord ID, Jeffery PK, Qiu Y, Zhu J, Parker D, Carlsheimer A, et al. Airway inflammation in patients with asthma with high-fixed or low-fixed plus as-needed budesonide/formoterol. J Allergy Clin Immunol. May 2009;123(5):1083-9, 1089.e1-7. [Medline].

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Further Reading

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Keywords

reactive airways disease, RAD, occupational asthma, reversible airway obstruction, increased bronchial reactivity, airway inflammation, passive smoke inhalation, allergic disease, aeroallergen exposure, viral respiratory illness, allergen-specific immunoglobulin E, allergen-specific IgE, allergen immunotherapy, airway hyperreactivity, AHR, airway remodeling, status asthmaticus, atopy, asthma triggers, nonallergic rhinitis, early allergic response, EAR, late allergic response, LAR, mite antigens, cockroach antigens, occupation-induced airway disease, occupation-induced asthma, industry-induced airway disease, industry-induced asthma, industrial asthma, occupational asthma, seasonal pollen allergens, mold spore allergens, dust mite allergens, animal allergens, food allergens, breath-actuated inhaler, BDI, dry-powder inhaler, DPI, metered-dose inhaler, MDI, breath actuated inhaler, dry powder inhaler, metered dose inhaler

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Contributor Information and Disclosures

Author

William F Kelly III, MD, Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Staff Physician, Division of Pulmonary/Critical Care Medicine, Department of Medicine, Walter Reed Army Medical Center
William F Kelly III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, and American College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

John J Oppenheimer, MD, Clinical Associate Professor, University of Medicine and Dentistry of New Jersey; Director Clinical Research, Pulmonary and Allergy Associates, PA
John J Oppenheimer, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology and American College of Allergy, Asthma and Immunology
Disclosure: AZ, Glaxo, Schering, Sepracor, Novartis/Genetic, Apieron Grant/research funds Other; AZ, Glaxo, Schering, Sepracor, Novartis/Genetic Honoraria Speaking and teaching

Gregory J Argyros Col, MD, Chief, Graduate Medical and Dental Education, J7/Joint Task Force, National Capital Region Medical; Professor of Medicine, Uniformed Services University of the Health Sciences
Gregory J Argyros Col, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, and American Thoracic Society
Disclosure: Nothing to disclose.

Medical Editor

Stephen Rosenfeld, MD, Professor Emeritus, Department of Medicine, Allergy, Immunology and Rheumatology Unit, University of Rochester School of Medicine and Dentistry
Stephen Rosenfeld, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American Federation for Clinical Research, Clinical Immunology Society, and Medical Society of the State of New York
Disclosure: Elan Ownership interest None; Invitrogen Ownership interest None; Merck Ownership interest None; Pfizer Ownership interest None; Medco Health Ownership interest None; Millipore Ownership interest None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Stephen C Dreskin, MD, PhD, Director of Allergy, Asthma, and Immunology Practice, Professor of Medicine, Departments of Internal Medicine and Immunology, University of Colorado Health Sciences Center
Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American Association of Immunologists, American Association of Neuropathologists, American Association of Ophthalmic Pathologists, American Association of Oral and Maxillofacial Surgeons, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology
Disclosure: Genentech Consulting fee Consulting

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
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