Breath In, Breath Out, All Is Good

An average breath rate is 16 to 20 breaths per minute. I pulled out my abacus and calculated that I breathe 23,040 times daily. This fantastic process occurs without me thinking I need to breathe. My one exception is when I practice yoga. Yoga is all about the breath.

Yoga is all about the breath. At the end of class, I often hear, “You know you are breathing in, and you know you are breathing out.” Many of us take this for granted. If diagnosed with asthma, the breath does not come so automatically.

The CDC’s most recent national asthma data for 2021 reports there are 24,963,874 asthmatics in the U.S., which accounts for 7.7% of the U.S. population. Children under 18 years of age account for 6.5% of asthmatics, and those over 18 years of age account for 18% of current asthma patients. The highest percentage groups of asthmatics, based on race and ethnicity, are American Indians/Alaska Natives at 13.3%, Blacks at 10.7%, and Whites at 8.0%. The percentage of asthma attacks is almost 39% for children under 18 and nearly 40% for ages those over 18. The highest asthma-related death rates based on age, sex, and ethnicity are 22.3 deaths per million for Blacks. The asthma-related death rate per million for Whites is 7.4 and for Hispanics, 8.4. According to the Asthma and Allergy Foundation of America, on average, ten people in the U.S. die from asthma every day. In 2021, 3,517 people died from asthma. Nearly all of these deaths are avoidable with evidence-based treatment and care.

The common triggers of asthma attacks are indoor allergens (dust mites, mold, pet dander, and fur), outdoor allergens (mold, industrial pollutants, and pollens), emotional stress (crying, anger, laughing), and physical activity. I have shown new asthmatics blown-up pictures of dust mites and their excrement in bed linen. This discussion, as disgusting as it sounds, has made a significant impact on awareness of triggers for my asthmatic folks.

The pathophysiology of asthma involves the lungs, bronchioles, and alveoli. The respiratory system consists of a conducting zone and a respiratory zone. The conducting zone extends from the nose to the bronchioles, and the respiratory zone, where gas exchange occurs, is from the alveolar duct to the alveoli. Asthma is primarily involved in the bronchial tree, with its primary job being to distribute air throughout the lungs until it reaches the alveolar sacs. The bronchi contain smooth muscle and elastic fibers to maintain their wall integrity. The asthma triggers are the culprits that constrict the smooth muscle and elastic fibers. This inflammatory process causes a hyperreactive constrictive response. Asthma is inflammation, inflammation, and inflammation. The antibodies most commonly seen in asthma are IgE, which respond to specific triggers in the asthmatic environment. IgE antibodies bind to high-affinity inflammatory mast cells and basophils. When a pollutant or allergen gets inhaled, the mast cells release cytokines, histamine, prostaglandins, and leukotrienes. These cells, in turn, contract the smooth muscle and cause airway constriction. The medication therapies reverse bronchoconstriction and antagonize the inflammatory response.

The drug delivery system of asthma medications differs from your run-of-the-mill tablets and capsules. The drug delivery systems utilized in asthma are metered dose inhalers, dry powder inhalers, and nebulizers. The perfection of these devices is the medications go directly into the lungs. The inhalers have propellants to expel the medication to be inhaled into the lungs. The dry powder inhaler disperses the medication in powder form into a chamber in the device and is inhaled into the lungs. The nebulizer aerosolizes a liquid solution and is sent to an oxygen-like mask to deliver the medication.

The Global Initiative for Asthma (GINA) was established in 1993 by the World Health Organization and the U.S. National Heart Lung and Blood Institute to improve asthma awareness, prevention, and management worldwide. The GINA guidelines recommend a combination inhaler regimen of an inhaled corticosteroid (ICS) plus long-acting beta 2 agonists (LABA) for rescue asthma attacks and if the patient is continuing to have asthma attacks to use the ICS and LABA as a maintenance dose daily. The best inhaler regimen is an ICS and LABA in one inhaler.

Beta 2 agonist inhalers open up the constricted bronchioles. Beta 2 receptors are situated in the lung tissue and are overwhelmed by inflammation and bronchoconstriction during an asthma attack. Before the change in the asthma guidelines, beta 2 agonists alone were recommended for all asthma attacks. The patient would administer a beta 2 agonist and if no relief was seen, another dose was given one minute later. The beta 2 agonist may cause tachycardia, jitteriness, and hypokalemia (low potassium) if administered too often. Hypokalemia could lead to an arrhythmia called ventricular tachycardia. Examples of beta 2 agonists are formoterol (Foradil ä), albuterol (Proventil ä, Pentolin ä), and salmeterol xinafoate (Serevent ä)

The best option for asthma patients for rescue and maintenance therapy is budesonide/formoterol (Symbicortä) Budesonide is an ICS and formoterol is a long-acting beta 2 agonist. Budesonide/formoterol (Symbicort ä) is the most efficient and cost-effective inhaler because it is also generic. The generic price went from over $200 to $50, while the brand-name inhalers remain expensive.

The spacer and peak flow meter are essential tools that must be used with the inhalers for the best clinical outcomes for the asthmatic patient. A spacer is a chamber that attaches to the opening of the inhaler. The other end of the spacer is inserted into the mouth of the patient. The inhaler is actuated, the aerosolized asthma medication goes into the chamber, and the patient inhales the medication. The proper amount of the medication is sent directly into the lungs. The peak flow meter is a device that is used every morning before inhaler use. It can show a patient how well their asthma is controlled. The peak flow meter is free and accessible from the patient’s clinic. The patient breathes in and forces as much air as possible into the peak flow meter. There are green, yellow, and red zones marked on the meter. Green is 80-100% of forced air out and is normal. Yellow is 60-80% of forced air out and says to be cautious of future attacks. Red is 50% or less expelled air than usual and says to be aware that an attack is imminent.

For patients that have allergic asthma, other medications can be added to their inhaler therapy. Non-sedating antihistamines, like loratadine (Claritin ä), fexofenadine (Allegra ä), and cetirizine (Zyrtec ä), are recommended. Montelukast (Singular ä) is another medication prescribed for patients to block an inflammatory substance called leukotrienes. Corticosteroid sprays, such as fluticasone (Flonase ä), which is over the counter, work very well for patients with allergic asthma.

Following the asthma guidelines, being prescribed evidence-based asthma medications, using the inhaler and spacer as prescribed, daily peak flow meter readings, and knowing your triggers are paths to a highly efficient breath, quality of life, and longevity. Be happy and fly safe.

Larry M. Diamond, PharmD, CFII

Larry Diamond has a Doctor of Pharmacy Degree and has been a pharmacist for 37 years. Larry’s pharmacy practice has been as a Clinical Pharmacy Specialist in Cardiology, Orthopedic Surgery Specialist and most recently Clinical Pharmacy Coordinator. He is a CFII, a pilot for 33 years and has been an AOPA member since 1984.

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