Online Health Chat with Dr. Sumita Khatri
May 26, 2011
Cleveland_Clinic_Host: Asthma is a common chronic disease that affects the airways of the lungs and ultimately results in the inflammation of the air passages, making it very difficult to breath. It affects about 5 percent to 10 percent of children in the United States and is the most common chronic condition of childhood. Asthma symptoms can begin at any age, from infancy through adulthood; and although the prevalence is increasing, the death rate from asthma is on the decline.
A person with asthma has very sensitive airways that react to a variety of external factors, or "triggers." These triggers cause the airways to tighten and become inflamed and blocked with mucus, resulting in difficulty breathing. An acute asthma attack can begin immediately after exposure to a trigger or several hours or days later. Some people are affected by numerous triggers; others may not be able to identify any. Recognizing and avoiding triggers, when possible, is an important way to control asthma. While it can be controlled, asthma cannot be cured. It is not normal to have frequent symptoms, trouble sleeping, or trouble completing tasks. Appropriate asthma care will prevent symptoms, and visits to the emergency room and hospital. However, asthma can also be life-threatening, especially when serious cases are not effectively managed by use of an inhaler or medication.
Sumita Khatri, MD, is a Staff Physician in the Department of Pulmonary, Allergy, and Critical Care Medicine and Co-Director of the Asthma Center at Cleveland Clinic. Her clinical and research interests include the effects of air pollution and environmental triggers on asthma, evaluating biomarkers of asthma, and community engagement with respect to asthma and lung health.
To make an appointment with Sumita Khatri, MD, or any of the specialists in the Respiratory Institute at Cleveland Clinic, please call 866.ccf.lung or email us at email@example.com. You may also visit us online at my.clevelandclinic.org/.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Sumita Khatri. We are thrilled to have her here today for this chat. Let’s begin with some of your questions.
Willis: My son (5 years old) was just diagnosed with asthma. We are devastated! What can we do to prevent him from having an attack? I'm so scared that he will have one when we are not around and he won't know what to do.
Dr__Sumita_Khatri: If you haven't already, I would have an honest conversation with his doctor on how to manage and control his asthma and its triggers. You can also request a referral to a pediatric pulmonologist or allergist, who can give you more information. Also, request an appointment with an asthma educator. This would probably be the most helpful and educational approach to learn the day-to-day management and understanding of asthma.
going_places: I was diagnosed with asthma, but I have no wheezing or coughing. My chest gets tight and uncomfortable, and I am short of breath. Is this typical or can something else be wrong?
Dr__Sumita_Khatri: If you have not been tested for asthma or if there is some uncertainty, I suggest you get breathing tests to confirm the diagnosis. Most of the time, the clinical picture of symptoms and what causes your flares can give the doctor confidence in the diagnosis. Symptoms can be quite variable and occur in episodes, usually prompted by a trigger -- be it allergies, exercise, temperature, stress, etc. The symptoms can be cough or wheeze, but as you have mentioned, chest tightness, even fatigue, can be part of the picture. Visit the American Lung Association Web site (www.lungusa.org) or the Global Initiative for Asthma Web site (www.ginaasthma.com) for more information. Knowledge is power!
Triggers and set-backs
game_over: I had minor asthma for a couple of years when I was around 8 to 10 years old. However, it has now returned in my 20s more severely. I thought I was going to have an asthma attack last week. I have gone to my general practitioner and was given the blue inhaler, which seems to help. I would like to know why this has returned, and can it be that asthma is related to stress?
Dr__Sumita_Khatri: Asthma is really a condition that has no cure. There are times that it flares up and times that there are fewer symptoms and is not active at all. Childhood asthma is quite common. More often, boys grow out of it than girls, but it is hard to predict if anyone completely will grow out of it. Asthma has many triggers and these can change over time. Perhaps now you are encountering new triggers in your environment, daily life, work, etc. that are flaring up your asthma, so our task is to really pay attention to the things that may be related time-wise to your asthma flares (such as colds, perfumes, humidity, air pollution, dust, etc.). And definitely, STRESS can make asthma worse. Controlling our response to stress and being on proper controller medications will help you get over that hurdle. If your asthma requires frequent use of your blue inhaler, which sounds like albuterol or a short-acting bronchodilator, you may need to be on a regular asthma controller/anti-inflammatory inhaler. Please bring this up to your primary care physician or ask for a referral to an allergist/pulmonologist.
Jeanne1986: My 19-year-old son was diagnosed with asthma as an infant. At his last chest X-ray, it was noticed that there was a rippling in the left lung. His doctor said this was common, fluffed it off, and said that many asthmatics have this. Can you shed any more information on what causes this rippling and should we be more concerned?
Dr__Sumita_Khatri: I can understand that a word like that can be alarming, but one thing I know from being a lung doctor is that there are many variations of normal, as well as chronic findings of no clinical concern on chest X-rays. If there is an area of prior inflammation, or an area where there might have been an infection in the past, there can be a small leftover effect on the chest X-ray. The important issue is to make sure that it is stable and unchanged, and that the patient feels good at the present time.
Sammy:My asthma is getting more severe. Before, I was able to control it pretty well with my daily inhaler and allergy pills. Now, I am finding that I need to use my emergency inhaler almost every day. What are my options?
Dr__Sumita_Khatri: Your asthma is not well-controlled, and gaining control is the key. There are multiple medications available to gain control of your asthma, and it is very important that you do that. The goal of asthma therapy is to maintain a normal active life and perform daily activities without difficulty. Also, as asthma can be variable based on time, health, and environment, partnering with a health care provider to use and adjust medications to control asthma with minimal side effects is the hallmark of good asthma care.
nystrom: My husband has exercise-triggered asthma symptoms. His primary care physician has given him an albuterol inhaler but has not suggested anything further (i.e., a pulmonary evaluation.) Should he seek one on his own or just use the medication when needed unless he gets really bad?
Dr__Sumita_Khatri: If symptoms occur only during exercise and are controlled with a couple puffs of albuterol 15 minutes prior to activity, then that is probably enough. However, if the minimal use of albuterol does not allow best performance during athletic activity, other supplemental medications can be used. Again, the goal is not to let asthma interfere with daily life and goals! We are particularly interested in exercise-induced asthma here at Cleveland Clinic.
chill_out: Does cold (temperature) aggravate asthma?
Dr__Sumita_Khatri: Yes, cold temperatures can aggravate asthma in some individuals. Covering your mouth and nose during exercise or when outside during cold weather may be helpful.
happy_r_we: Is there anything new in allergy/asthma treatment?
Dr__Sumita_Khatri: The hallmark of asthma treatment today is anti-inflammatory/inhaled steroid therapy. There are newer inhaled steroids available, as are combination medications with long-acting bronchodilators. There is also interest in the use of exercise and nutrition in asthma treatment, and in taking a comprehensive lifestyle approach to asthma care.
The newest therapeutic modality for asthma is an adjunctive non-drug therapy that has been released for use in patients who are not controlled with maximal medical therapy. This is called bronchial thermoplasty. It is a three-session procedure performed through a bronchoscope that applies thermal energy to the smooth muscle of visible airways.
Frank_EY: I have been hearing a lot about bronchial thermoplasty to treat severe asthma. Is anyone eligible for the procedure or do you have to meet a select criterion?
Dr__Sumita_Khatri: The way it is currently approved allows for a select group of asthmatics to be considered. It is meant to be a therapy for patients in whom the best medical therapies have not allowed stability of asthma. On the other hand, the eligible patients must be able to tolerate the procedure, which requires three bronchoscopies and the main side effect, which is a temporary asthma flare. So you see it is a window where you have to be sick enough to qualify for the procedure but well enough to tolerate it. We have people available to discuss the detailed criteria for those who are interested.
Cant_breathe: Is bronchial thermoplasty covered by insurance? How serious is the procedure and what does it really do?
Dr__Sumita_Khatri: Insurance companies are a bit slow to come around to pay for this, but there is more demand for it, and hopefully with time, pre-authorization will become easier. Since it is a relatively new procedure, more experience will likely help this cause. We are one of the institutions in which bronchial thermoplasty is available for those who qualify, and we are studying patients to help determine who seems to have the best outcomes. Also, if one is not a candidate, our comprehensive severe asthma management program can help find other possible therapies and approaches, as we are trying to make more clinical trials available. Other conditions such as significant sinusitis, reflux, vocal cord/upper airway abnormalities, bronchiectasis, and chronic
infections can either make asthma worse or mimic asthma. Therefore a good diagnostic workup is often helpful.
SandyD45: What's anti-IgE therapy?
Dr__Sumita_Khatri: IgE is the abbreviation for immunoglobulin E. This is an antibody we make that fights against certain infections, but also revs up with exposure to allergies. Using anti-IgE medications, which is an injection given monthly or every two weeks, has been demonstrated to reduce emergency visits for asthma care. The criteria for being eligible are specific. If you are interested in being considered for this therapy, it is available here at the Asthma Center. You can call for an appointment at 866.ccf.lung or email us at firstname.lastname@example.org.
pigsfly: I have heard that Singulair® has been found to be more helpful to adults and really not as likely to help youth patients. Is there any truth to this?
Dr__Sumita_Khatri: Each patient is different. I am not aware of such a finding. Some pediatric pulmonologists, in fact, try to use Singulair® (montelukast) if possible. A therapeutic trial is the only way to know.
pigsfly: The only control medication my 9-year-old severe asthmatic is on is Symbicort® (budesonide/formoterol fumarate dihydrate) 160. She has had three asthma flare ups this year alone, the first two requiring 21 days of prednisone, the third a five day burst. Is there another control medication you suggest other than Singulair®?
Dr__Sumita_Khatri: Sounds frustrating, and as a mother myself, I can imagine how hard that must be. I am not a pediatric pulmonologist and treating kids is a bit different. My biggest suggestion would be for you to see a pediatric allergist or pulmonologist who sees a lot of severe asthma patients. Going to a tertiary referral site for pediatric asthma may be necessary.
Katherine: My husband and I are planning for a baby. I take Advair® (fluticasone propionate and salmeterol) daily. Do I need to stop it while I am pregnant?
Dr__Sumita_Khatri: Your best bet would be to use the minimal necessary medication to control your asthma, but the asthma must be controlled for the health of your baby. Please see your asthma doctor, and your current regimen can be evaluated. If you still need inhaled steroids, your doctor may choose to change the medications based on your status.
peyton456: I have COPD and asthma. My doctor wants me to go on Xolair®. I am worried about getting these injections. What are your thoughts on Xolair®?
Dr__Sumita_Khatri: This question relates to a prior question. Xolair® (omalizumab) is an anti-IgE therapy. As with any treatment, there are risks and benefits. If you have any specific concerns, it is important that you discuss them openly with your provider. Your doctor may feel that your asthma is severe enough to warrant a trial of it, and it is usually in six months or so that you may notice a difference; but most individuals who start it go on for 12 months before determining whether it is helpful or not.
pigsfly: My 9-year-old is a severe asthmatic. Whenever any illness starts along with a decrease in her pulmonary function, her doctor puts her on zithromax as a preventive measure. With so many viruses now becoming antibiotic resistant, is this a wise move?
Dr__Sumita_Khatri: Since I am not aware of the details of your daughter's condition, it is difficult to state a position strongly on this. You are right, though, that viruses are a big trigger in this age group; and in most cases, asthma treatments for flare-ups are the way to go. However, bacterial infections can also trigger asthma flares and it is based on clinical examination and peak flow rates together, whether antibiotics should be prescribed. Also, if she usually gets better with that treatment, your doctor may feel that is a worthwhile approach.
pigsfly: Are any asthma treatment or control medications known to cause an increased risk to bone strength?
Dr__Sumita_Khatri: Higher doses of inhaled steroids do allow for some systemic absorption of steroids, such that the side effect of decreased bone density can be a concern. This is not usually the case with the ranges currently prescribed for asthma. However, in severe asthma cases, where extra steroids are used or if higher-dose steroids are used for a sustained time, monitoring of bone density becomes necessary. That is why it is very important to step down and decrease the strength of your asthma medications when asthma is controlled. In other words, finding the best therapeutic/risk ratio. These decisions should be made in partnership with your physician/caregiver.
JDSmith: Is research currently being conducted to find a cure for asthma, or is this a forgotten disease?
Dr__Sumita_Khatri: There are many of us trying to find a 'cure' for asthma, or at the very least trying to understand the different forms of asthma so we can better help people on an individual level. This is part of the mission of Cleveland Clinic, because patient care as well as patient-based research is supported and encouraged. Asthma has long been an area of research here. I do need to emphasize that if this is an important issue for you that you consider being involved in research trials, not only for possible new medications, but also in studies where we are better trying to profile different asthmatic types.
tommy: Do you know anything about the Buteyko method?
Dr__Sumita_Khatri: Yes. I have heard of it and looked into it a bit. It is certainly a good adjunctive consideration in the comprehensive management of asthma. There are other approaches that are also helpful, including meditation and yoga breathing. Be mindful that you are also managing the airway inflammation of asthma with currently available and appropriate inhaled medications, because inflammation control is the cornerstone of asthma management. Breathing techniques should be a complement to such management.
wild_times: Is there any relationship between asthma and sleep apnea?
Dr__Sumita_Khatri: There is growing evidence that some patients with asthma, as well as COPD (both in the obstructive lung disease category), have abnormal breathing patterns with sleep. This may be due to upper airway obstruction, as is obstructive sleep apnea, or even variability in ventilation with position. Your physician can perform a screening questionnaire and determine whether you should be tested for such sleep disorders.
jerrk: I’m 25 years old and have asthma, I’m about 5'8 weigh 135. What are the ranges for a peak flow meter?
Dr__Sumita_Khatri: You gave all the right information to figure this out, except your gender. If you are a woman, your normal predicted peak flow rates are within 450 to 490. If you are a man, your normal predicted peak flow rates are within 590 to 635. For more details about monitoring your asthma, you can look up the American Lung Association Web site www.lungusa.org or the Global Initiative for Asthma Web site www.ginaasthma.com.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Sumita Khatri is now over. Thank you again, Dr. Khatri for taking the time to answer your questions about Asthma.
Dr__Sumita_Khatri: We appreciate your time and your very good questions. Please do refer to the resources mentioned above, and if you would like to have an asthma evaluation, do contact us.
To make an appointment with Sumita Khatri, MD, or any of the specialists in the Respiratory Institute at Cleveland Clinic, please call 866.ccf.lung or email us at email@example.com. You may also visit us online at
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This chat occurred on May 26, 2011
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