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Tuesday, August 31, 2010

Modern inhalers may equal better asthma control

The neat thing about asthma is it can be controlled. At present, the most recommended medicine to control asthma is inhaled corticosteroids. Is it possible, depending on your asthma severity one inhaled corticosteroid might be better than another? Is it possible the new HFA inhalers are better than the old CFC ones?

Recent evidence might suggest this true. While it has been proven that Flovent and Pulmicort work better than inhaled corticosteroids of old, such as Azmacort and Vanceril, mainly because they are stronger. Yet even more recent evidence suggests that a medicine called QVAR might work better if your asthma episodes involve the smaller airways as opposed to the larger airways.

As you may know, your lungs branch out like a tree (as you can see by the picture). You start out in the trachea, and from there air travels to the chorina where air can travel into your left lung or right lung. The chorina would be like the trunk of the tree.

Yet whichever way air travels (to the right or left lung), the next branch is the bronchioles. Air starts out in the large bronchioles, which would would be represented by the larger branches of a tree. As the bronchioles branch out, they get smaller and smaller. Thus, the small bronchioles would be represented by the sticks at the end of larger branches.

Now consider when you are a kid and have inflammation in your airways. This inflammation makes your lungs sensitive to your asthma triggers. When exposed to your triggers, this inflammation worsens, and this causes blockage of your airway that is the asthma attack.

In children and most asthmatics, the worsening inflammation will cause your peak flow readings to decrease. Yet, as you grow older and your airways become larger, the inflammation in your airways becomes smaller in comparison to your now larger airways. Thus, while your lungs grow, the inflammation stays the same.

So, in some asthmatics, some degree of shortness of breath can occur and this not effect the peak flow at all. This is because your peak flow readings represent what your large airways are doing. If inflammation in your large airways increases, your peak flow readings will go down. This is because air is trapped in your larger airways.

However, if your lower airways are blocked and the upper airways are not, your peak flow readings will remain the same. This, according to some asthma experts, might indicate that your asthma symptoms are the result of increased inflammation in your smaller airways.

So, while inhaled corticosteroids have been proven to benefit all asthmatics, what if you take inhaled steroids (like Flovent) and you still have asthma symptoms. Is it possible that there is an inhaled corticosteroid that does a better job of getting down to the smaller airways and reducing inflammation down there.

According to Sally M. Wenzel, MD, who is an asthma expert over at, the answer to this question is yes, or probably. In answer to a question on this topic, she said, "The literature on particle deposition is actually pretty good for Qvar. It does get much better overall delivery to lungs, which means larger amounts to small airways (and alveoli). One small study (Annals Allergy) did show that adding Qvar to Flovent, as opposed to increasing the Flovent, produced slightly better symptom and lung function changes, particularly in measures of small airways. But, OBVIOUSLY each person's disease is slightly different and there are no guarantees that this will work."

Another neat thing I discovered is the following from a book I have called, "Asthma for Dummies," by Dr. William E. Berger. He notes that the U.S. government forced the phaseout of CFC propellants for inhalers like Albuterol.

Berger writes, "As a result... Proventil HFA, Ventolin HFA, and QVAR-HFA are the first oxone-friendly products on the market with this propellant, which delivers medications to the lungs more effectively than CFC propellants developed in the 1950s.

"In most cases," Berger continues, "because of a lower velocity propellant spray and smaller particle size, a non-CFC propelled product allows more of the medication to get into the smaller, more peripheral airways of your lungs."

So this adds to the growing evidence that HFA inhalers, and not just QVAR, are able to get the medicine deeper into the lungs, and to the smaller air passages.

However, it should be noted that studies have been limited, and ongoing research is necessary. Still, it's interesting to note there have indeed been some highly qualified asthma experts thinking along these lines.

So, perhaps, simply going to HFA inhalers may actually benefit chronic lungers using this medication, allowing for better overal asthma, COPD control.


Brittney said...

So, I've got a question. How do you tell if your asthma involves smaller airways more than larger airways? I ask because I monitor my peak flow and FEV1 using a Piko-1 meter and I notice that the majority of time my peak flow is in the low green zone but my FEV1 is way into the yellow zone when I'm doing a lot of coughing but not wheezing but have SOB with walking and am pretty fatigued. I know that peak flow measures larger airways so that makes me think it is my smaller airways causing the problem. I only question it because of the idea that QVAR might be better for small airway inflammation and I've been treated with high doses of pulmicort for years along with singulair, theophylline, and serevent (and albuterol of course) for years. I'd love to drop some of the meds and if changing meds does it I'm game.

Rick Frea said...

To be honest I'm not really sure there truly is a way. Although I'm going to try to find an answer for you. So stay tuned.

lindajadams said...

But, there are some of us that have had adverse reactions to the inhalers left on the market. Severe ones! My doctor has me using drops of Dexem. steroids in the water bottle attached to my liquid oxygen tank. There are the minority group of asthmatics of the four types that have chemically induced reactive airways and other chemically induced asthma and sensitivities that are not allergic reactions. Since 2002, there were no nasal steroids available without antihistamines which cause acute adverse reactions and had to substitute Azmacort canister in an old nasacort holder as the upper respiratory was badly damaged when injured in a terrific chemical/toxic exposure 22+ years ago. Our group is discriminated against by the FDA and they allow the clinical trials on drugs to exclude us. As one major pharmaceutical co. person said to me in 1997 when a waiver was granted for the CFC's by Congress but never addressed the issue of there being 4 kinds of asthma: you're an environmental asthmatic, you don't count. At that time there was less than a million of us in the USA, with the 9/11 toxic fires, etc. estimates are closer to 3 million and in this world of chemicals and toxins sometimes the wrong mix gets inhaled and life time medical care is needed to sustain life. Linda Joy Adams( contacted for 1997 hearings to submit well- documented medical records. This time, no one cared?)

CajunGal said...

So glad I came across this post!
I have been going back and forth with my pulmo about my asthma control. He insists it's mild asthma but my PF readings are always very good, even if I'm symptomatic so he says he doesn't think it's asthma at all. I'll have to bring this article to his attention.

Thanks for all your hard work here! You don't know what a great resource this has been for me. I know you'll always tell it like it is. :-)