Counseling Guide for Avoiding Asthma Triggers

Asthma is a chronic inflammatory disorder of the lungs that is characterized by hyperresponsiveness of the airways to physical, chemical, and pharmacologic stimuli.¹ The inflammatory response results in bronchial obstruction, which can vary in severity from mild shortness of breath to fatal airway obstruction. Avoidance of substances that can trigger asthma exacerbations can significantly reduce inflammation, asthmatic symptoms, and the need for medications. Pharmacists can play a role in helping patients control their asthma by educating them about potential triggers and how such triggers can be avoided.

What Are Asthma Triggers?

Asthma triggers are anything that can cause an asthma attack. They can be classified into 4 categories:

• Inhalant allergens
• Irritants
• Occupational exposures
• Other factors

How Can Asthma Triggers Be Avoided?

The first step in avoidance of asthma triggers is to identify them. Patients with asthma should be evaluated for exposure to possible triggers and should be advised to avoid triggers that aggravate their asthma symptoms.

Inhalant Allergens

Dust mites are the most common source of indoor allergenic material.² They are microscopic mites that feed on human dander and moisture. They are commonly found in mattresses, pillows, bedding, carpets, upholstered furniture, clothes, and stuffed animals. To help control exposure to dust mites, the patient should be instructed to encase the mattress and pillows in allergen-impermeable covers. Bedding and stuffed animals also should be washed weekly in hot water. Carpeting should be removed, if possible, from the bedroom or at least vacuumed frequently with a vacuum containing a high-efficiency particulate air filter.

Pets are another common source of allergenic materials. All warm-blooded animals produce dander, saliva, urine, and feces that can induce an allergic response in sensitive patients. Removal of the offending pet is the best way to avoid the allergens but is often not acceptable to the owner. Options available for pet lovers are to keep the pet out of the bedroom and away from carpets and upholstered furniture that can harbor the allergens.

Cockroaches are another potential asthma trigger. The droppings and body parts of cockroaches have been shown to induce asthma attacks in sensitive patients. Patients should be advised not to leave food or garbage exposed and to keep dishes, sinks, tables, and floors clean. Bait or traps can be set, or an exterminator can be called if needed.

Another potential asthma trigger is indoor mold. To reduce exposure, the patient should be advised to reduce moisture in the home with a dehumidifier. If patients tend to get asthma symptoms only at certain times of the year, outdoor allergens may be the cause. Keeping windows shut and staying indoors on high-pollen-count days can reduce exposure to pollens and outdoor molds.

Irritants

Not all asthma triggers are allergenic in nature. Triggers such as smoke, air pollution, and strong odors can be classified as irritants. Exposure to cigarette smoke can trigger an asthma attack, as well as having a negative impact on overall health. Patients who smoke should be advised to quit. Patients who do not smoke should be advised to prohibit smoking in their home and to avoid situations where smoking occurs.

Both outdoor and indoor air pollution also can aggravate asthma. Patients who live in cities where pollution is an issue should be advised to keep windows closed and to stay indoors on days when smog levels are high. Indoor pollution can come from wood-burning stoves, fireplaces, and kerosene heaters. Patients should be advised to make sure that these heat sources are properly vented or, preferably, try a cleaner form of heat.

Occupational Exposures

Patients may be exposed to various triggers in the workplace, such as dust, chemicals, and plant or animal products. Occupational asthma may be suspected if patients' symptoms tend to improve when they are away from work for several days. In such instances, issues concerning avoidance, ventilation, and respiratory protection need to be addressed in the workplace.

Other Factors

Patients may not be aware that several other factors can trigger asthma attacks. Patients with seasonal allergic rhinitis may be at an increased risk of asthma attacks, because inflammation of the upper airways has been shown to contribute to lower airway hyperresponsiveness.¹ Intranasal corticosteroids can be beneficial in treating these patients. Colds and other illnesses also can make asthma symptoms worse. Patients should be reminded to wash their hands frequently and to receive a flu shot each year.

Another factor that can aggravate asthma is gastroesophageal reflux disease (GERD). Controlling symptoms of GERD has been associated with improvement in asthma symptoms. Pharmacists should counsel patients with GERD about lifestyle modifications to help reduce symptoms. Pharmacologic therapy also may be necessary.

Certain foods have been known to trigger asthma attacks. Sensitive patients should be aware of the ingredients in all the foods they eat.

Cold air is another factor that can aggravate asthma. Patients should be advised to stay indoors on very cold, windy days and to use a scarf to cover their mouth if they need to go out.

Exercise is a fairly common asthma trigger. Patients can reduce symptoms by warming up before exercising and pretreating with an albuterol inhaler prior to exercise, if needed.

In addition, certain medications have been implicated in the worsening of asthma symptoms. Asthmatic patients with allergies to aspirin or nonsteroidal anti-inflammatory drugs are at risk for potentially severe asthma exacerbations and should avoid these medications. Nonselective betablockers also can worsen asthma symptoms and should be avoided in patients with asthma.¹

What Is the Pharmacist's Role?

Pharmacists can play an important role in helping to prevent asthma exacerbations by educating patients about asthma triggers and how they can be avoided. Many patients are not aware of common triggers and therefore may be unwittingly exposed to factors that are aggravating their asthma symptoms. Through education on avoidance of triggers, pharmacists can help patients gain better control of their asthma.

Dr. Bohn is currently completing a primary care specialty residency with Wilkes University Nesbitt School of Pharmacy in affiliation with the Wilkes-Barre VA Medical Center and the Wyoming Valley Family Practice Residency.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: astahl@ascendmedia.com.