Summertime, when the breathing is not so easy

For most of us summer means more rest and relaxation, but for millions of Americans with asthma, summertime can also mean greater respiratory problems. During the summer, sudden changes in weather such as extreme humidity or sudden cooling can trigger an asthma attack. Winds can spread pollens and molds that affect asthmatics who have grass, tree pollen or mold allergies. And the Environmental Protection Agency (EPA) states that levels of ozone — a gas responsible for smog/hazy conditions — is increased in the summer due to more sunlight and decreased winds. As the temperatures rise, so do levels of ozone, and ozone can trigger asthma.

What is asthma?There are at least 25 million Americans who have asthma, representing approximately eight percent of the population, affecting more than seven million children up to age 17. Asthma is associated with intermittent symptoms of shortness of breath, cough and wheezing. A patient with asthma may have one to all of the above symptoms. Since these symptoms can be mimicked by other conditions, the diagnosis is confirmed following a complete medical history, physical examination and from diagnostic tests such as pulmonary function tests, which may show variable, and reversible airway obstruction. Asthma is diagnosed by age seven in 75 percent of patients. Asthma severity varies in intensity and may be triggered by diverse stimuli, resulting in an excessive narrowing of the airways, resulting in inflammation of the airways and asthma symptoms.

So what can an asthmatic do?Avoiding triggers, such as environmental allergens like pollens and grasses, molds, cold air, exercise, house dust mites, animal dander, respiratory infections and occupational exposures, will help to reduce the need for medication. However, some triggers such as viral respiratory infections, and significant or occupational exercise, may be difficult to avoid. If you have asthma, make sure to check local weather sources that provide pollen count reports. Staying in a cooler room that is less humid and air conditioned will reduce asthma symptoms in hot sticky weather. Significant exercise in hot, humid weather should be avoided as it can also trigger an asthma attack, although swimming may prevent the usual rapid cooling and drying of the airways during exercise. If you cannot afford an air conditioner, the state Medicaid program may pay for one, so call 311 for details. If an air conditioner is unavailable, there are “cooling centers” in schools, libraries or civic centers.

Managing your asthmaTreatment with medication is the cornerstone of managing asthma. The National Asthma Education and Prevention Program (NAEPP) and the Global Initiative for Asthma (GINA) guidelines provide guidance on how to best treat asthma. Asthma severity is determined by the frequency of a patient’s symptoms, and changes in lung function, as well as by a recent history of hospitalizations for what are known as asthma attacks, or a recent requirement for oral steroid therapy. Intermittent, infrequent symptoms are treated with short-acting symptom relievers/rescue therapy, and anti-inflammatory medication, including inhaled steroids which are used if a patients’ symptoms are persistent and increasingly severe.

Oral steroids are reserved for severe persistent symptoms. Patients should be evaluated in the ER, and may even be admitted if the severity of the patient’s asthma exacerbation requires intravenous steroids. As symptoms of asthma improve, the patients’ medication can be reduced in a step-wise fashion. National and international guidelines on asthma management have been have been validated in clinical trials, ensuring that the treating physician can follow established and tested treatment regimens tailored to the severity of the symptoms.

Some patients may benefit from new advanced medical treatment with “biologics” for severe, difficult to control steroid-dependent asthma. Biologics include omalizumab for patients who have evidence of severe allergic asthma. In addition, injectable medications are now available for a subtype of asthma called “eosinophilic asthma,” which is characterized by an increase in eosinophils — white blood cells that are a normal part of the immune system, which increase in number following certain triggers and are responsible for significant airway inflammation.

In general, a patient with asthma should be referred to pulmonary and allergy clinics when the patient has been to the hospital for asthma, or has required frequent courses of oral steroids for unstable asthma. If the patient is not responding to treatment, the diagnosis of asthma may be incorrect, so be sure to see a specialist.

If you think you have asthma or have been diagnosed with it, talk to your doctor to develop strategies to minimize your risks of suffering asthma attacks during the summer months, and limiting certain exposures and taking corrective action. Be sure to follow your doctor’s recommendations to best manage your symptoms and asthma conditions this summer.

David Steiger, MD, is the chief of the Division of Pulmonary, Critical Care and Sleep Medicine at Mount Sinai Beth Israel.