Bronchial Asthma: Therapy

General measures

• Sitting, calming, slow breathing.
• Severe asthma attack: inpatient treatment; in the emergency ambulance beginning therapy (see below drug therapy).
• Self-help during an asthma attack
  • Breathing facilitating posture: while doing this, the patient sits down, bends her upper body forward and rests her forearms on her thighs; breathing in and out calmly.
  • Lip brake (also dosed lip brake) – breathing technique that helps to relax the respiratory muscles. This allows increased mucus removal and can also be used as an emergency measure in case of shortness of breath, in addition to medication.
  • Procedure: The lips are pointed as if whistling, and the upper lip should be slightly protruded. It should be exhaled as long as possible against the lips open only a crack wide or loosely on top of each other, respectively. This causes the cheeks to inflate slightly. The air should escape slowly and evenly. The air should not be squeezed out. When performed correctly, the exhale lasts longer than the inhale.
• Nicotine restriction (refraining from tobacco use) including passive smoking.
• Aim for normal weight!Determination of BMI (body mass index, body mass index) or body composition by means of electrical impedance analysis and, if necessary, participation in a medically supervised weight loss program.
• Review of permanent medication due topossible effect on the existing disease.
• Avoidance of psychosocial stress:
  • Stress
• Avoidance of allergens (allergen caring) or environmental stress:
  • General abstinence from feather- or fur-bearing pets in persons with allergies.
  • The following allergens can trigger an asthma attack: Pollen, house dust mite droppings, animal allergens, feathers, mold spores, food allergens, insect allergens.
  • Occupational exposure – frequent contact with allergenic, irritant or toxic (poisonous) substances such as metal salts (platinum, chromium, nickel), wood and plant dusts, industrial chemicals. Also known is the so-called baker’s asthma, fungal asthma and also people who work with isocyanates often suffer from asthma.
  • Air and polluted environment – exhaust fumes, particulate matter, smog, ozone, tobacco smoke.
  • Household spray
• Travel recommendations:
  • Low allergen areas: Altitude about 1,500 meters (= lower allergen than the lower-lying Central European areas) (see below rehabilitation).

Measures to be taken in case of pollen allergy

• Keep windows closed – in the morning hours the pollen concentration is highest in the countryside, in the evening hours in the city; therefore ventilate in the countryside in the evening hours (between 7 pm and midnight) and in the city rather in the morning hours (between 6 am and 8 am)
• During the pollen season, do not stay outdoors for too long
• The pollen load increases particularly strongly after a thunderstorm. The reason for this is the so-called osmotic shock. Here, the following effect occurs: In the first 20 to 30 minutes, the osmotic shock causes the pollen grains to swell. When the swollen pollen grains then fall to the ground with the rain, they burst open and release a high concentration of allergens. Allergy sufferers and asthmatics are best not to go outside for about half an hour after a thunderstorm.
• In heavy summer rain, you should put a cloth over your nose and only exhale through your mouth. Rain is basically good, because it cleans the air from pollen. Therefore, in an approaching thunderstorm better stay indoors and close the windows.
• After downpours (after about 30 minutes) go outside and enjoy the pollen-free air.
• Avoid roads with heavy traffic
• Nasal douches daily in the pollen season
• Wash face several times a day
• Do not take off street clothes in the bedroom
• Wash hair before going to bed
• Regularly wash bed linen
• Replace carpets and carpeting with laminate or parquet flooring
• Keep windows closed when driving
• Regularly change the pollen filters in ventilation systems (eg in the car).
• Vacuum cleaners should have special fine dust filters (eg Hepa filter systems).
• Low pollen vacation areas can be found by the sea, on islands or in the high mountains

Conventional non-surgical therapy methods

• In addition to allergen avoidance, specific immunotherapy (SIT; synonyms: allergen-specific immunotherapy, hyposensitization, allergy vaccination) should be performed as early as possible for causative therapy of allergic bronchial asthma (e.g., dust mite allergy, grass pollen allergy).The National Health Care Guideline (NVL) recommends SIT and points out that it is a component of step therapy. SIT is considered an additional therapeutic option for all stages, regardless of severity.
  • Indication: when the allergic component of asthmatic symptoms is well documented (proven sensitization and clear clinical symptoms after allergen exposure).
  • Prerequisite: stable controlled asthma (FEV1 > 70% in adults).
  • There are now good data for both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT).
  • Note: SIT is not a substitute for effective antiasthmatic drug therapy!
• Bronchial thermoplasty – minimally invasive procedure that uses radiofrequency energy to reduce airway smooth muscle.A catheter is inserted through a bronchoscope, and an expandable basket is stretched at the end of the catheter, which contacts the bronchial walls.Radiofrequency waves generate thermal energy of 65° Celsius in the bronchial wall, which spares peribronchial tissue while reducing smooth muscle by approx. 50.According to the study evidence, the procedure is expected to improve morning peak flow values, lead to reduction of on-demand medication, and significantly reduce exacerbations.Treatment duration is 30-60 minutes; three treatments are given 3-6 weeks apart.Treatment is performed under general or local anesthesia. Indication: patients who cannot achieve adequate control with high-dose inhaled steroids (ICS) and two controller medications or systemic corticosteroids.The procedure has been approved in Europe since 2011 for the treatment of patients with severe persistent bronchial asthma who are older than 18 years and whose asthma remains uncontrolled despite maximal therapy.

Vaccinations

The following vaccinations are advised, as infection can often lead to worsening of the present disease:

• Flu vaccination
• Pneumococcal vaccination

Regular checkups

• Regular medical checkups

Nutritional medicine

• Nutritional counseling based on nutritional analysis
• Nutritional recommendations according to a mixed diet taking into account the disease at hand. This means, among other things:
  • A total of 5 servings of fresh vegetables and fruit daily (≥ 400 g; 3 servings of vegetables and 2 servings of fruit).
  • Once or twice a week fresh sea fish, i.e. fatty marine fish (omega-3 fatty acids) such as salmon, herring, mackerel.
  • High-fiber diet (whole grain products).
• Observance of the following specific nutritional recommendations:
  • Sufficient fluid intake (2-3 liters per day).
  • Diet rich in:
    • Vitamin D – Regular vitamin D supplementation (duration of intake at least six months) may reduce both the risk of significant exacerbation of asthma symptoms and the frequency of asthmatic attacks in people with mild to moderate asthma attacks.
• Selection of appropriate food based on the nutritional analysis
• See also under “Therapy with micronutrients (vital substances)” – if necessary, taking a suitable dietary supplement.
• Detailed information on nutritional medicine you will receive from us.

Sports Medicine

• Note: In effort asthma (exercise asthma), it is better to exert yourself to near maximum in intervals of variable intensity than to try to warm up before exercise.
• Endurance training (cardio training) and strength training.
  • Suitable endurance sports are running, swimming, cycling or inline skating.
• Strength training two to three times a week in addition to endurance training, ie muscle building to strengthen the respiratory support muscles and back muscles. This facilitates breathing.It also leads to better thoracic spine rotation, which maintains mobility.
• Warm-up is required before exercise (see above on effort asthma) and at the end the load should be slowly reduced. During exercise, the anaerobic threshold should not be exceeded.
• Regular sports activities (twice a week aerobic exercise of 35 minutes) are better than occasional excessive exercise. They mitigate symptoms and allow successful asthma management.
• Aerobic exercise of patients with moderate to severe asthma has positive influence on:
  • Bronchial hyperresponsiveness (exaggerated airway responsiveness to an exogenous stimulus (e.g., cold air, inhalation toxins), leading to pathological airway narrowing (bronchoobstruction))
  • Inflammatory markers in the blood (number of eosinophilic granulocytes in the sputum ↓ and the FeNo value ↓, especially in patients with a high degree of inflammation)
  • Quality of life
  • Exacerbations (significant worsening of the clinical picture).
• Establishment of a fitness plan with appropriate sports disciplines based on a medical check (health check).
• Detailed information on sports medicine you will receive from us.

Psychotherapy

• Stress management (e.g. autogenic training), if applicable.
• Yoga – can relieve symptoms of bronchial asthma, but has no effect on lung function.
• Detailed information on psychosomatic medicine (including stress management) is available from us.

Complementary treatment methods

• Breathing exercises (yoga, breathing retraining, methods such as Buteyko or Papworth, or even deep diaphragmatic breathing) – have a positive effect on quality of life, hyperventilation symptoms (symptoms due to increased breathing beyond what is needed) and lung function in patients with mild to moderate asthma.
• Biofeedback training with a capnometer (measuring device to monitor carbon dioxide levels in exhaled air) – can improve breathing technique and prevent hyperventilation (excessive breathing).
• Note: According to the current national care guideline, acupuncture, homeopathy, and hypnosis should not be recommended for the treatment of asthma.

Education

The first purpose of patient education is to inform the patient about the nature and individual severity of the asthma disease. Furthermore, it is/will:

• The handling of the inhalation systems explained (correct inhalation technique).
• Smoking cessation performed
• Allergen avoidance (see above “General measures”) explained
• The peak flow measurement for self-monitoring of the disease explained
• The individual triggering factors determined and strategies for avoiding these so-called triggers elaborated
• Trained with the patient the correct behavior in the event of an acute attack, to give him the confidence to deal with his disease in any situation.

Rehabilitation

• High-altitude asthma therapy as medical rehabilitation at alpine altitudes (>1,500 m) significantly improved all clinical parameters, including FEV1 and FeNO, within 21 days. Furthermore, the type 2 immune response of asthma patients decreased under altitude therapy.