Asthma Medication

  • Author: Michael J Morris, MD; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Apr 19, 2012
 

Medication Summary

Asthma medications are generally divided into 2 categories:

  • Quick relief (also called reliever medications)
  • Long-term control (also called controller medications)

Quick relief

Quick relief medications are used to relieve acute asthma exacerbations and to prevent exercise-induced asthma (EIA) or exercise-induced bronchospasm (EIB) symptoms. These medications include short-acting beta agonists (SABAs), anticholinergics (used only for severe exacerbations), and systemic corticosteroids, which speed recovery from acute exacerbations.

Long-term control

Long-term control medications include inhaled corticosteroids (ICSs),[84, 85] cromolyn sodium, nedocromil, long-acting beta agonists (LABAs), combination inhaled corticosteroids and long-acting beta agonists, methylxanthines, and leukotriene antagonists. Inhaled corticosteroids are considered the primary drug of choice for control of chronic asthma, but unfortunately the response to this treatment is characterized by wide variability among patients. A study by Tantisira et al showed the glucocorticoid-induced transcript 1 gene (GLCCI1) to be the cause of this decrease in response.[91]

In a study by Peters et al, the use of the anticholinergic agent tiotropium in 210 asthmatic patients resulted in a superior outcome compared with a doubling of the dose of an inhaled glucocorticoid, as assessed by measuring the morning peak expiratory flow and other secondary outcomes. The addition of tiotropium in this study was also shown to be noninferior to the addition of salmeterol.[92]

In a cross-sectional population-level comparison study of asthmatics from 1997-1998 and 2004-2005, researchers evaluated controller-to-total asthma medication ratio (greater than 0.5) with asthma exacerbation rates (dispensing of systemic corticosteroid or emergency department visit/hospitalization for asthma). They were able to demonstrate an increased use of asthma controllers based on a 16% increase in controller-to-total asthma medication ratio. However, there was no change in annual asthma exacerbation rates (0.27/year to 0.23/year) despite this improvement in controller use.[93]

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Beta2-adrenergic agonist agents

Class Summary

Beta2 agonists (albuterol sulfate [Proventil HFA, Ventolin HFA, ProAir HFA; pirbuterol acetate [Maxair Autohaler]; levalbuterol [Xopenex]) relieve reversible bronchospasm by relaxing the smooth muscles of the bronchi. These agents act as bronchodilators and are used to treat bronchospasm in acute asthmatic episodes and to prevent bronchospasm associated with exercise-induced asthma or nocturnal asthma.

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Albuterol sulfate (Proventil HFA, Ventolin HFA, ProAir HFA)

 

This beta2-agonist is the most commonly used bronchodilator that is available in multiple forms (eg, solution for nebulization, metered-dose inhaler, oral solution). This is most commonly used in rescue therapy for acute asthmatic symptoms and is used as needed. Prolonged use may be associated with tachyphylaxis due to beta2-receptor down-regulation and receptor hyposensitivity.

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Pirbuterol (Maxair Autohaler)

 

This agent is available as a breath-actuated or ordinary inhaler. The ease of administration with the breath-actuated device makes it an attractive choice in the treatment of acute symptoms in younger children, who otherwise may not be able to use a metered-dose inhaler. The Autohaler delivers 200 mcg per actuation.

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Levalbuterol (Xopenex)

 

A nonracemic form of albuterol, levalbuterol (R isomer), is effective in smaller doses and is reported to have fewer adverse effects (eg, tachycardia, hyperglycemia, hypokalemia). The dose may be doubled in acute severe episodes when even a slight increase in the bronchodilator response may make a big difference in the management strategy (eg, in avoiding patient ventilation).

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Anticholinergic Agent

Class Summary

Anticholinergic agents such as ipratropium may be added to beta2 -agonist therapy for acute exacerbations.

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Ipratropium (Atrovent)

 

Ipratropium is chemically related to atropine. It has antisecretory properties and, when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa.

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Anticholinergic agent combinations

Class Summary

Combination agents with ipratropium and albuterol. A test spray of 3 sprays is recommended before using this combination for the first time and when the aerosol has not be used for more than 24 hours. Ipratropium is chemically related to atropine. It has antisecretory properties and, when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa. Albuterol is beta-agonist for bronchospasm refractory to epinephrine. It relaxes bronchial smooth muscle by action on beta2-receptors, with little effect on cardiac muscle contractility.

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Ipratropium and albuterol (Combivent, DuoNeb)

 

Ipratropium is chemically related to atropine. It has antisecretory properties and, when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa. Albuterol is beta-agonist for bronchospasm refractory to epinephrine. It relaxes bronchial smooth muscle by action on beta2-receptors, with little effect on cardiac muscle contractility.

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Corticosteroid, oral

Class Summary

Oral steroids (prednisone [Deltasone, Orasone]; prednisolone [Pediapred, Prelone, Orapred]; methylprednisolone [Solu-Medrol]) are used for short courses (3-10 d) to gain prompt control of inadequately controlled acute asthmatic episodes. They are also used for long-term prevention of symptoms in severe persistent asthma as well as for suppression, control, and reversal of inflammation. Frequent and repetitive use of beta2 agonists has been associated with beta2 -receptor subsensitivity and down-regulation; these processes are reversed with corticosteroids.

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Prednisone (Deltasone, Orasone)

 

Prednisone is an immunosuppressant for the treatment of autoimmune disorders; it may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear leukocyte activity.

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Methylprednisolone (Solu-Medrol, Medrol)

 

Methylprednisolone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear leukocyte activity.

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Prednisolone (Pediapred, Prelone, Orapred)

 

This glucosteroid occurs naturally and synthetically. It is used for both acute and chronic asthma. It may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear leukocyte activity.

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Long-acting beta2 agonists

Class Summary

Long-acting bronchodilators are not used for the treatment of acute bronchospasm. They are used for the preventive treatment of nocturnal asthma or exercise-induced asthmatic symptoms, for example. Currently, 2 LABAs are available in the United States: salmeterol (Serevent) and formoterol (Foradil). Salmeterol and formoterol are available as combination products with inhaled corticosteroids in the United States.

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Formoterol (Foradil, Performist)

 

By relaxing the smooth muscles of bronchioles in conditions associated with bronchitis, emphysema, asthma, or bronchiectasis, formoterol can relieve bronchospasms. The effects may also facilitate expectoration. It has been shown to improve symptoms and morning peak flows. Adverse effects are more likely when formoterol is administered at high doses or more frequent doses than recommended.

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Salmeterol (Serevent)

 

Salmeterol can relieve bronchospasm by relaxing the smooth muscles of the bronchioles in conditions associated with bronchitis, emphysema, asthma, or bronchiectasis. The effect also may facilitate expectoration. Adverse effects are more likely when salmeterol is administered at high doses or more frequent doses than recommended.

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Arformoterol (Brovana)

 

Arformoterol is an (R, R)-enantiomer of formoterol, a selective, long-acting beta-2 adrenergic receptor agonist (beta-2 agonist) that has 2-fold greater potency than racemic formoterol (which contains both [S, S] and [R, R]-enantiomers). The pharmacologic effects of beta-2 adrenoceptor agonist drugs, including arformoterol, are at least in part attributable to stimulation of intracellular adenyl cyclase, the enzyme that catalyzes the conversion of adenosine triphosphate to cyclic-3',5'-adenosine monophosphate (cyclic AMP). Increased intracellular cyclic AMP levels cause relaxation of bronchial smooth muscle and inhibition of the release of mediators of immediate hypersensitivity from cells, especially from mast cells.

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Beta2-Agonist/Corticosteroid Combinations

Class Summary

These combinations (budesonide and formoterol [Symbicort]; fluticasone and salmeterol [Advair HFA, Advair Diskus]; mometasone and formoterol [Dulera]) may decrease asthma exacerbations when inhaled short-acting beta2 agonists and corticosteroids have failed.

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Budesonide/formoterol (Symbicort)

 

Formoterol relieves bronchospasm by relaxing the smooth muscles of the bronchioles in conditions associated with asthma. Budesonide is an inhaled corticosteroid that alters the level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing the production of cytokines and other mediators involved in the asthmatic response.

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Mometasone and formoterol (Dulera)

 

Combination corticosteroid and long-acting selective beta-2 agonist (LABA) metered-dose inhaler. Mometasone elicits local anti-inflammatory effects to respiratory tract with minimal systemic absorption. Formoterol elicits bronchial smooth muscle relaxation. Indicated for prevention and maintenance of asthma symptoms in patients inadequately controlled with other asthma controller medications (eg, low- to medium-dose inhaled corticosteroids) or whose disease severity clearly warrants initiation of treatment with 2 maintenance therapies, including a LABA. Available in 2 strengths; each actuation delivers mometasone/formoterol 100 mcg/5 mcg or 200 mcg/5 mcg.

Fluticasone and salmeterol (Advair)

 

Fluticasone inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, and may decrease the number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. It also has vasoconstrictive activity. Salmeterol relaxes the smooth muscles of the bronchioles in conditions associated with bronchitis, emphysema, asthma, or bronchiectasis, and can relieve bronchospasms. Its effects may also facilitate expectoration. Adverse effects are more likely to occur when the agent is administered at high or more frequent doses than recommended.

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5-lipoxygenase Inhibitor

Class Summary

Like leukotriene receptor antagonists, 5-lipoxygenase inhibitors (Zileuton) act on leukotrienes.

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Zileuton

 

Zileuton inhibits leukotriene formation, which, in turn, decreases neutrophil and eosinophil migration, neutrophil and monocyte aggregation, leukocyte adhesion, capillary permeability, and smooth muscle contractions.

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Methylxanthines

Class Summary

These agents (theophylline [Theo-24, Theochron, Uniphyl]) are used for long-term control and prevention of symptoms, especially nocturnal symptoms.

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Theophylline (Theo-24, Theochron, Uniphyl)

 

Theophylline is available in short- and long-acting formulations. Because of the need to monitor the drug levels, this agent is used infrequently. The dose and frequency of administration depend on the particular product selected.

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Mast cell stabilizers

Class Summary

These agents (cromolyn sodium [Intal]) block early and late asthmatic responses, interfere with chloride channels, stabilize the mast cell membrane, and inhibit the activation and release of mediators from eosinophils and epithelial cells. They inhibit acute responses to cold air, exercise, and sulfur dioxide.

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Cromolyn sodium (Intal)

 

Cromolyn sodium inhibits the release of histamine, leukotrienes, and other mediators from sensitized mast cells exposed to specific antigens. It has no intrinsic anti-inflammatory, antihistamine, or vasoconstrictive effects.

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Monoclonal Antibody

Class Summary

Omalizumab [Xolair] is a recombinant DNA-derived humanized immunoglobulin G monoclonal antibody that binds selectively to human immunoglobulin E on the surface of mast cells and basophils. The drug reduces mediator release, which promotes an allergic response. It is indicated for moderate-to-severe persistent asthma in patients who react to perennial allergens, in whom symptoms are not controlled by inhaled corticosteroids.

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Omalizumab (Xolair)

 

Omalizumab is a recombinant, DNA-derived, humanized IgG monoclonal antibody that binds selectively to human IgE on the surface of mast cells and basophils. It reduces mediator release, which promotes an allergic response. It is indicated for moderate-to-severe persistent asthma in patients who react to perennial allergens in whom symptoms are not controlled by inhaled corticosteroids.

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Corticosteroid, Inhalant

Class Summary

Inhaled steroids include ciclesonide (Alvesco), beclomethasone (QVAR), triamcinolone, flunisolide (Nasalide), fluticasone (Flovent Diskus, Flovent HFA), budesonide (Pulmicort Flexhaler or Respules), and mometasone furoate inhalation powder (Asmanex Twisthaler). Steroids are the most potent anti-inflammatory agents. Inhaled forms are topically active, poorly absorbed, and least likely to cause adverse effects.

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Ciclesonide (Alvesco)

 

Ciclesonide is an aerosol inhaled corticosteroid indicated for maintenance treatment of asthma as prophylactic therapy in adult and adolescent patients aged 12 years and older. It is not indicated for relief of acute bronchospasm. Corticosteroids have a wide range of effects on multiple cell types (eg, mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (eg, histamines, eicosanoids, leukotrienes, cytokines) involved in inflammation.

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Beclomethasone (QVAR, Beclovent)

 

This agent inhibits bronchoconstriction mechanisms; causes direct smooth muscle relaxation; and may decrease the number and activity of inflammatory cells, which, in turn, decreases airway hyperresponsiveness. It is available as a 40- or 80-mcg/actuation.

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Fluticasone inhaled

 

Fluticasone has extremely potent vasoconstrictive and anti-inflammatory activity. It has a weak HPA-axis inhibitory potency when applied topically. It is available as a metered-dose inhaler aerosolized product (HFA) or DPI (Diskus).

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Budesonide inhaled (Pulmicort Flexhaler or Respules)

 

Fluticasone has extremely potent vasoconstrictive and anti-inflammatory activity. It has a weak HPA-axis inhibitory potency when applied topically. It is available as a DPI in 90-mcg/actuation (delivers about 80 mcg/actuation) or 180-mcg/actuation (delivers about 160 mcg/actuation). A nebulized suspension (ie, Respules) is also available for young children.

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Mometasone (Asmanex Twisthaler)

 

Mometasone is a corticosteroid for oral inhalation. It is indicated for asthma as prophylactic therapy.

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Triamcinolone inhaled (Azmacort)

 

Triamcinolone alters the level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing the production of cytokines and other mediators involved in the asthmatic response.

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Flunisolide (Aerobid, AeroSpan, Nasalide)

 

Flunisolide inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, and may decrease the number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. It does not depress the hypothalamus. AeroBid (flunisolide CFC) delivers about 250 mcg per actuation. AeroSpan (flunisolide HFA) delivers about 80 mcg per actuation.

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Leukotriene Receptor Antagonist

Class Summary

Knowledge that leukotrienes cause bronchospasm, increased vascular permeability, mucosal edema, and inflammatory cell infiltration leads to the concept of modifying their action by using pharmacologic agents. These are either 5-lipoxygenase inhibitors or leukotriene-receptor antagonists (zafirlukast [Accolate]; montelukast [Singulair]).

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Zafirlukast (Accolate)

 

Zafirlukast is a selective competitive inhibitor of LTD4 and LTE4 receptors.

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Montelukast

 

Montelukast is the last agent introduced in its class. The advantages are that it is chewable, it has a once-a-day dosing, and it has no significant adverse effects.

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Contributor Information and Disclosures
Author

Michael J Morris, MD  Clinical Assistant Professor, Pulmonary Disease/Critical Care Service, Department of Medicine, Brooke Army Medical Center; Associate Program Director, Internal Medicine Residency, San Antonio Uniformed Services Health Education Consortium

Michael J Morris, MD is a member of the following medical societies: American Association for Respiratory Care, American College of Chest Physicians, American College of Physicians, American Thoracic Society, and Association of Military Surgeons of the US

Disclosure: Pfizer/Boehringer-Ingelheim Honoraria Speaking and teaching

Coauthor(s)

Gregory J Argyros Col, MD  Director, Education, Training, and Research, 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.

Stephen G Batuello, MD  Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society

Disclosure: Nothing to disclose.

Edward Bessman, MD, MBA  Chairman and Clinical Director, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Paul Blackburn, DO, FACOEP, FACEP  Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Praveen Buddiga, MD  Physician, Allergy, Asthma and Immunology, Baz Allergy, Asthma and Sinus Center, Fresno, California

Praveen Buddiga, 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: Meda Honoraria Speaking and teaching; Teva Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching

Robert K Bush, MD  Professor of Medicine (CHS, Emeritus), University of Wisconsin School of Medicine and Public Health; Chief of Allergy (retired), William S Middleton Veterans Affairs Hospital

Robert K Bush, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology and American College of Physicians

Disclosure: University of WI- Madison Emeritus- Reitred; Wm S. Middleton VA Hospital Retired Retired; Teva Pharmaceuticals IRA Holding None; Associate Editor Journal Allergy Clinical Immunology Honoraria None

Michael R Bye, MD  Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Charles Callahan, DO  Professor, Deputy Chief of Clinical Services, Walter Reed Army Medical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Peter G Canaday, MD  Private Practice, Consultant Radiologist, Dakota Dunes, SD

Peter G Canaday, MD is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Medical Association, American Roentgen Ray Society, Nebraska Medical Association, Radiological Society of North America, Society of Breast Imaging, and Society of Thoracic Radiology

Disclosure: Nothing to disclose.

G Patricia Cantwell, MD, FCCM  Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Lanny Garth Close, MD  Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons

Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, American Society for Head and Neck Surgery, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Cheryl D Courtlandt, MD  Faculty, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine; Medical Director, Pediatric Asthma Program, Attending Physician, Department of Pediatrics, Levine Children's Hospital, Carolinas Medical Center

Cheryl D Courtlandt, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and National Medical Association

Disclosure: Nothing to disclose.

Stephen C Dreskin, MD, PhD  Professor of Medicine, Departments of Internal Medicine, Director of Allergy, Asthma, and Immunology Practice, 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 College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology

Disclosure: Genentech, Inc. Consulting fee Consulting; Clinical Immunization and Safety Assessment (CISA) Network (CDC) administered by America's Health Insurance Plans (AHIP) Consulting fee Consulting; Genentech, Inc. Grant/research funds Other; Medical Expert Panel, Department of Health and Human Services, Division of Vaccine Injury Compensation None Independent contractor; American Board of Allergy and Immunology Honoraria Board membership; Novartis, Inc Consulting fee Review panel membership

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Barry J Evans, MD  Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Michael R Filbin, MD  Clinical Instructor, Department of Emergency Medicine, Massachusetts General Hospital

Michael R Filbin, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Joseph P Garry, MD, FACSM, FAAFP  Associate Professor, Department of Family and Community Medicine, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Heart Association, American Medical Society for Sports Medicine, and Minnesota Medical Association

Disclosure: Nothing to disclose.

Murray Grossan, MD  Consulting Staff, Tower Ear, Nose and Throat

Murray Grossan, MD is a member of the following medical societies: American Medical Association, American Tinnitus Association, California Medical Association, and Los Angeles County Medical Association

Disclosure: Hydro Med Inc Ownership interest Management position

Payel Gupta, MD  Department of Allergy and Immunology, ENT Faculty Practice

Payel Gupta, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

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.

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Eugene C Lin, MD  Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine

Disclosure: Nothing to disclose.

Markus Little, MD  Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Jeffrey A Miller, MD  Associate Adjunct Professor of Clinical Radiology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Faculty, Department of Radiology, Veterans Affairs of New Jersey Health Care System

Jeffrey A Miller, MD is a member of the following medical societies: American Roentgen Ray Society, Society for Health Services Research in Radiology, and Society of Thoracic Radiology

Disclosure: Nothing to disclose.

Daniel R Neuspiel, MD, MPH, FAAP  Director of Ambulatory Pediatrics, Levine Children's Hospital, Carolinas Medical Center; Adjunct Clinical Professor of Pediatrics, University of North Carolina School of Medicine

Daniel R Neuspiel, MD, MPH, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Physician Executives, American Public Health Association, New York Academy of Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

John D Newell Jr, MD  Professor of Radiology, Head, Division of Radiology, National Jewish Health; Professor, Department of Radiology, University of Colorado School of Medicine

John D Newell Jr, MD is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, American Thoracic Society, Association of University Radiologists, Radiological Society of North America, and Society of Thoracic Radiology

Disclosure: Siemens Medical Grant/research funds Consulting; Vida Corporation Ownership interest Board membership; TeraRecon Grant/research funds Consulting; eMedicine Honoraria Consulting; Humana Press Honoraria Other

John J Oppenheimer, MD  Clinical Associate Professor, Department of Medicine, University of Medicine and Dentistry of New Jersey; Director of 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 Consulting fee Consulting; AZ Grant/research funds Independent contractor; Glaxo Consulting fee Consulting; Glaxo Grant/research funds Independent contractor; Merck Consulting fee Consulting; Merck Grant/research funds Independent contractor; SRXA Consulting

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: Nothing to disclose.

Constantine K Saadeh, MD  President, Allergy ARTS, LLP; Principal Investigator, Amarillo Center for Clinical Research, Ltd

Constantine K Saadeh, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Rheumatology, American Medical Association, Southern Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Anthony J Saglimbeni, MD  President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School; Team Physician, Santa Clara University; Consultant, University of San Francisco, Academy of Art University, Skyline College, Foothill College, De Anza College

Anthony J Saglimbeni, MD, is a member of the following medical societies: California Medical Association and Santa Clara County Medical Association

Disclosure: South Bay Sports and Preventive Medicine Associates, Inc Ownership interest Other

Assaad J Sayah, MD  Chief, Department of Emergency Medicine, Cambridge Health Alliance

Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians

Disclosure: Nothing to disclose.

Thomas Scanlin, MD  Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of Pediatrics, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School

Thomas Scanlin, MD is a member of the following medical societies: American Association for the Advancement of Science, American Society for Biochemistry and Molecular Biology, American Thoracic Society, Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Adam J Schwarz, MD  Consulting Staff, Critical Care Division, Pediatric Subspecialty Faculty, Children's Hospital of Orange County

Adam J Schwarz, MD is a member of the following medical societies: American Academy of Pediatrics and Phi Beta Kappa

Disclosure: Nothing to disclose.

Girish D Sharma, MD  Professor of Pediatrics, Rush Medical College; Senior Attending, Department of Pediatrics, Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush University Medical Center

Girish D Sharma, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

Richard H Sinert, DO  Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

William W Storms, MD  Clinical Professor, University of Colorado Health Sciences Center; Private Practice, The William Storms Allergy Clinic, Colorado Springs, Colorado

Disclosure: AstraZeneca Honoraria Speaking and teaching; Merck Grant/research funds None; Merck Honoraria Consulting; Merck Honoraria Speaking and teaching; Strategic Pharmaceutical Advisors Honoraria Consulting; TEVA Honoraria Consulting; TEVA Speaking and teaching; TREAT Foundation Honoraria Consulting; TEVA Grant/research funds Other; Alcon Labs Grant/research funds Other

Russell D White, MD  Professor of Medicine, Professor of Orthopedic Surgery, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Craig C Young, MD  Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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: Alcon Consulting fee Consulting; Teva Consulting fee Consulting; Meda Honoraria Speaking and teaching; Ista Consulting fee Consulting; sunovian Consulting fee Consulting; dey Honoraria Review panel membership

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA  Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Michael Goldman, MD, Jan Malacara, PA-C, Rohit K Katial, MD, A Antoine Kazzi, MD, Araz Marachelian, MD, and Jannette Collins, MD, MEd, FCCP, to the development and writing of the source articles.

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Asthma treatment. Asthma causes and symptoms. Antigen presentation by the dendritic cell with the lymphocyte and cytokine response leading to airway inflammation and asthma symptoms.
Asthma treatment. Asthma symptoms and severity. Recommended guidelines for determination of asthma severity based on clinical symptoms, exacerbations, and measurements of airway function. Adapted from Global Strategy for Asthma Management and Prevention: 2002 Workshop Report.
Asthma treatment. Stepwise approach to pharmacological management of asthma based on asthma severity. Adapted from Global Strategy for Asthma Management and Prevention: 2002 Workshop Report.
Asthma. High-resolution CT scan of the thorax obtained during inspiration in a patient with recurrent left lower lobe pneumonia shows a bronchial mucoepidermoid carcinoma (arrow).
Asthma. High-resolution CT scan of the thorax obtained during expiration in a patient with recurrent left lower lobe pneumonia shows a bronchial mucoepidermoid carcinoma. Note the normal increase in right lung attenuation during expiration (right arrow). The left lung remains lucent, especially the upper lobe, secondary to bronchial obstruction with airtrapping (left upper arrow). The vasculature on the left is diminutive, secondary to reflex vasoconstriction. Left pleural thickening and abnormal linear opacities are noted in the left lower lobe; these are the result of prior episodes of postobstructive pneumonia (left lower arrow).
High-resolution CT scan of the thorax obtained during inspiration demonstrates airtrapping in a patient with asthma. Inspiratory findings are normal.
High-resolution CT scan of the thorax obtained during expiration demonstrates a mosaic pattern of lung attenuation in a patient with asthma. Lucent areas (arrows) represent areas of airtrapping.
Posteroanterior chest radiograph demonstrates a pneumomediastinum in bronchial asthma. Mediastinal air is noted adjacent to the anteroposterior window and airtrapping extends to the neck, especially on the right side.
Lateral chest radiograph demonstrates a pneumomediastinum in bronchial asthma. Air is noted anterior to the trachea (same patient as in the previous image).
High-resolution CT scan of the thorax obtained during inspiration demonstrates airtrapping in a patient with asthma. Inspiratory findings are normal.
High-resolution CT scan of the thorax obtained during expiration demonstrates a mosaic pattern of lung attenuation in a patient with asthma. Lucent areas (arrows) represent areas of airtrapping (same patient as in the previous image).
Asthma. High-resolution CT scan of the thorax obtained during inspiration in a patient with recurrent left lower lobe pneumonia shows a bronchial mucoepidermoid carcinoma (arrow).
Asthma. High-resolution CT scan of the thorax obtained during expiration in a patient with recurrent left lower lobe pneumonia shows a bronchial mucoepidermoid carcinoma (same patient as in the previous image). Note the normal increase in right lung attenuation during expiration (right arrow). The left lung remains lucent, especially the upper lobe, secondary to bronchial obstruction with airtrapping (left upper arrow). The vasculature on the left is diminutive, secondary to reflex vasoconstriction. Left pleural thickening and abnormal linear opacities are noted in the left lower lobe; these are the result of prior episodes of postobstructive pneumonia (left lower arrow).
Asthma. High-resolution CT scan of the thorax demonstrates mild bronchial thickening and dilatation in a patient with bilateral lung transplants and bronchial asthma.
Asthma. High-resolution CT scan of the thorax demonstrates central bronchiectasis, a hallmark of allergic bronchopulmonary aspergillosis (right arrow), and the peripheral tree-in-bud appearance of centrilobular opacities (left arrow), which represent mucoid impaction of the small bronchioles.
 
 
 
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