DEEP BREATHS: Asthma and Controller Medications

by Melissa Rodriguez, MD (’21)
Teaching Resident Capstone Project
reviewed by Alison Heinly, MD (Pediatric Primary Care)

Asthma is an episodic and reversible airway constriction (secondary to smooth muscle constriction and airway narrowing) as well as inflammation. It can be seen in response to infection, environmental allergens, and irritants. $80 billion a year is spent between medical care, missed school, and work secondary to asthma exacerbations. They also represent a leading cause of ED visits and hospitalizations in children. Proper identification of asthma severity along with optimization of treatment in the outpatient setting becomes paramount to help maintain a healthy lung function,  preserve children’s abilities to carry out their daily activities, and decrease ED visits and hospitalizations.

Routine asthma visits usually occur every 3-6 months depending on the patient’s symptoms and clinicians concerns. It’s a place for pediatricians to explain the difference between quick-relief medications and controller medications, demonstrate spacer use if indicated, and treat any comorbidities (OSA, obesity, allergic rhinitis, GERD). It’s also the time to reassess a patient’s symptoms and determine the correct asthma classification and if medications need to be adjusted along with it. During the visit, physicians can ask about the past 4 weeks of symptoms, focusing on daytime symptom frequency, nighttime awakenings, SABA use, and activity limitation as well as the number of exacerbations requiring systemic steroids in the past year. Based on the worst symptom frequency, asthma severity is classified as follows:


Medications can then be adjusted according to severity as seen below:

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Controller medications can be stored in multiple forms such as:

Metered Dose Inhaler (MDI): a pressurized canister that uses a chemical propellant (HFA – hydrofluoroalkane) to deliver medication when the canister is pushed. Has a built-in dose counter and requires spacer use. 

Dry Powder Inhaler (DPI): medication is released by taking a deep, fast breath. Comes in one time/single dose devices (refilled pre each treatment) up to 200 doses containers. 

Soft Mist Inhaler: these are propellant free-devices that release low-velocity aerosol mist. They are Inhaled over longer periods than MDI/DPI. Requires spacer use

Nebulizer: utilized for people who cannot use inhalers ((infants, young children, very ill or need large doses of medications). It comes off as a fine mist that is breathed in through a mouthpiece or mask worn over the nose and mouth

Controller medications utilized in asthma as seen above include the following:

Leukotriene Receptor Antagonist (LTRA): block the action of leukotriene D4 in the lungs resulting in decreased inflammation and relaxation of smooth muscle.
Forms: Tablets (including chewable) and Granules
Names: Montelukast (Singulair)

Inhaled Corticosteroids (ICS): inhibits the recruitment of inflammatory cells into the airway as well as inhibits survival in the airways of inflammatory cells, T-lymphocytes, and mast cells.
Forms: DPI, MDI, nebulizers
Names:  Beclomethasone (Qvar), Budesonide (Pulmicort), Flunisolide (Aerospan), Fluticasone (Flovent), Mometasone (Asmanex)

Inhaled Corticorticosteroids can be combined with Long-Acting Beta Agonists (LABA) to combine anti-inflammatory properties with the relaxation of smooth muscle around the airways.
Forms: DPI, MDI
Names: Fluticasone/Salmaterol (Advair or AirDuo), Budesonide/Formoterol (Symbicort), Mometasone/Formoterol (Zenhale or Dulera)

Omalizumab: one of the oldest and most used biologic agents on the market for asthma. Targets IgE, the main Ig involved in binding and degranulation of mast cells. In essence, this is an antibody against another antibody.
Forms: Subcutaneous injection
Names: Xolair