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Asthma in adults - InDepth
Bronchial asthma - InDepth; Wheezing - asthma - InDepthAn in-depth report on how asthma is diagnosed, treated, and managed in adults.
Asthma Guidelines
The U.S. National Asthma Education and Prevention Program (NAEPP) guidelines for the diagnosis and management of asthma recommend:
- Assessment and Monitoring. Doctors should use multiple measures to determine a patient's current condition and future risk for worsening of condition. Even patients who show few daily effects of asthma may be in danger of a sudden worsening of symptoms.
- Patient Education. Patients should be taught skills to self-monitor and manage asthma. Doctors should give patients a written asthma action plan, which includes information on daily treatment and ways to recognize worsening asthma.
- Control of Environmental Factors and Other Asthma Triggers. It is important to reduce exposure to allergens. Treating co-existing chronic conditions (such as rhinitis, sinusitis, and obesity) can also help improve asthma control.
- Medications. A stepwise approach is recommended where medication types and doses are increased or decreased based on the level of asthma control.
Exercise-Induced Asthma
A short-acting beta-agonist (like albuterol) is recommended as the first-line treatment for exercise-induced asthma. For patients whose symptoms continue, a leukotriene antagonist (like montelukast) is the second option, along with a daily inhaled corticosteroid.
Newer Medicines
Mepolizumab, benralizumab, and reslizumab are anti-IL-5 monoclonal antibodies. Omalizumab is an anti-IgE monoclonal antibody. These biologic drugs have been approved for use in patients with severe eosinophilic asthma, which is a type of asthma with increased levels of eosinophils (a type of white blood cell) found in the airways.
The word asthma comes from an ancient Greek word meaning panting. Essentially, asthma is an inflammatory lung condition that makes it difficult to breathe properly.
When people inhale, the air travels through the following body structures:
- Air passes through the nose or mouth and then the pharynx (throat) into the lungs through progressively smaller airways called bronchi and then bronchioles. The lungs contain millions of these airways.
- All bronchioles lead to alveoli, which are microscopic sacs where oxygen is taken in and carbon dioxide is expelled.
The major features of the lungs include the bronchi, the bronchioles, and the alveoli. The alveoli are the microscopic sacs lined by tiny blood vessels that take in oxygen and give up carbon dioxide.
Asthma is a chronic condition in which the airways undergo changes that are usually triggered by allergens, other environmental factors, or by infection. Asthma is characterized by two specific responses:
- The hyperreactive response (also called hyperresponsiveness)
- The inflammatory response
These actions in the airway cause coughing, wheezing, and shortness of breath (dyspnea), the classic symptoms of asthma.
Hyperreactive Response
In the hyperreactive response, smooth muscles in the airways of the lungs constrict and narrow excessively in response to inhaled allergens or other irritants. This sudden contraction in the muscle walls of the bronchioles is called bronchospasm. Bronchospasms can result from many different health conditions (allergies, bronchitis, and chronic obstructive pulmonary disease) but asthma is the most common cause.
Everyone's airways constrict when exposed to allergens or irritants, but there are major differences in the hyperreactive response that occurs in people with asthma:
- When people without asthma breathe in and out deeply, the airways relax and open to rid the lungs of the irritant.
- When people with asthma try to exhale, their airways do not relax and instead they narrow, causing hyperinflation of the lungs with unexpelled air. As asthma worsens, less air is able to get to the alveoli and the airways narrow further, causing patients to pant for breath. Smooth muscles in the airways of people with asthma may have a defect, perhaps a deficiency in a critical chemical that prevents the muscles from relaxing. And, during an asthma attack the airways narrow, making breathing difficult.
Inflammatory Response
Hyperreactivity is associated with the inflammatory response, which generally contributes to asthma in the following way:
- In response to allergens or other environmental triggers, the immune system delivers white blood cells and other immune factors to the airways.
- These inflammatory factors cause the airways to swell, to fill with fluid, and to produce thick, sticky mucus.
- This combination results in wheezing, breathlessness, an inability to exhale properly, and a phlegm-producing cough.
Inflammation appears to be present in the lungs of all patients with asthma, even those with mild cases, and plays a key role in all forms of the disease.
Doctors do not fully understand the causes of asthma. They believe the disorder is most likely caused by a combination of genetic (inherited) factors and environmental triggers (such as allergens and infections).
The Allergic Response (Allergens)
Nearly half of adults with asthma have an allergy-related condition, which, in most cases developed first in childhood. (In patients who first develop asthma during adulthood, the allergic response usually does not play a strong causal role.)
In people with allergies, the immune system overreacts when exposed to allergens. Allergic asthma is triggered by inhaling certain substances (allergens) such as:
- Dust mites, specifically mite feces, which are coated with enzymes that contain a powerful allergen. These are the primary allergens in the home.
- Animal dander. Cats harbor significant allergens, which can even be carried on clothing; dogs usually cause fewer problems. People with asthma who already have pets and are not allergic to them probably have a low risk for developing such allergies later on.
- Molds.
- Cockroaches. Cockroach dust is a major asthma trigger and may reduce lung function even in people without a history of asthma.
- Pollen from plants.
Environmental Factors (Irritants)
An asthma attack can also be triggered or aggravated by direct irritants to the lungs. Important irritants involved in asthma include cigarette smoke, indoor chemicals, and air pollution.
Respiratory viral and bacterial infections play a role in some cases of adult-onset asthma. In both children and adults with existing allergic asthma, an upper respiratory tract infection often worsens an attack.
Risk Factors
Before puberty, asthma occurs more often in males, but after adolescence, it is more common in females. In adults, women are more likely to report severe symptoms than men.
Hormonal fluctuations or changes in hormone levels may affect the severity of asthma in women. Many women with asthma experience fluctuations in severity that are associated with their menstrual cycle. Some women first develop asthma during or shortly after pregnancy, while others first develop it around the time of menopause (perimenopause).
Family History
Having a parent with asthma increases the risk of developing asthma by 3 to 6 times.
Race and Ethnicity
Non-Hispanic Black people have higher rates of asthma than non-Hispanic White people or other ethnic groups. They are also more likely to die of the disease. Race and ethnicity are, however, less likely to play a role in these differences in asthma prevalence than socioeconomic factors, such as having less access to optimal health care, and greater likelihood of living in an urban area (another asthma risk factor).
People with allergic conditions like allergic rhinitis or atopic dermatitis have an increased risk of developing asthma.
Exposure to Environmental Factors
People who smoke or are exposed to secondhand smoke have an increased risk of asthma. Exposure to smog and air pollutants common in the urban environment and certain workplaces also increases the risk of developing asthma. [See "Causes" above.]
Studies report a strong association between obesity and asthma. Evidence also suggests that people who are overweight (body mass index greater than 25) have more difficulty getting their asthma under control. Weight loss in anyone who is obese and has asthma or shortness of breath helps reduce airway obstruction and improve lung function.
Weight loss
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Patients with asthma often also have gastroesophageal reflux disease (GERD), which is associated with acid reflux. It is not entirely clear which condition causes the other or whether they are both due to common factors. Acid reflux can worsen asthma symptoms. Treating GERD may help improve asthma control in some patients.
An in-depth report on the causes, diagnosis, treatment, and prevention of GERD.
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Aspirin-Induced Asthma
Aspirin-induced asthma (AIA) is a condition in which asthma gets worse after taking aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). AIA often develops after a viral infection. It is a particularly severe asthmatic condition, associated with many asthma-related hospitalizations. In about 5% of cases, aspirin is responsible for a syndrome that involves multiple attacks of asthma, sinusitis, and nasal congestion. Such patients also often have polyps (small benign growths) in the nasal passages. Patients with aspirin-induced asthma (AIA) should avoid aspirin and other NSAIDs, including ibuprofen (Advil and other brands, generic) and naproxen (Aleve, generic).
NSAIDs known as COX-2 inhibitors, such as Celexicob (Celebrex), are not associated with aspirin-induced asthma.
Doctors classify the severity of asthma into four groups (Intermittent, Mild Persistent, Moderate Persistent, and Severe Persistent) based on:
- Symptom frequency, ranging from fewer than 2 days per week to throughout the day.
- Nighttime awakenings, ranging from none to nightly.
- Short-acting beta2-agonist use for symptom control, ranging from 2 or fewer days per week to several times per day.
- Interference with normal activity, ranging from none to extremely limited activity.
- Lung function as measured by testing at the doctor's office.
- Number of exacerbations (sudden worsening) requiring oral corticosteroids, ranging from none to two or more in the last 6 months.
Persistent asthma is usually chronic, although it occasionally goes into long periods of remission. Long-term outlook generally depends on severity:
- In mild-to-moderate cases, asthma can improve over time, and many adults become symptom free.
- Even in some severe cases, adults may experience improvement depending on the degree of obstruction in the lungs and the timeliness and effectiveness of treatment.
- In about 10% of severe persistent cases, changes in the structure of the walls of the airways lead to progressive and irreversible problems in lung function.
Death from asthma is a relatively uncommon event, and most asthma deaths are preventable. It is very rare for a person who is receiving proper treatment to die of asthma. However, even when it is not life threatening, asthma can be debilitating and frightening. Asthma that is not properly controlled can interfere with school and work, as well as with daily activities.
Asthma symptoms vary in severity from occasional mild bouts of breathlessness to daily wheezing that lasts even when a patient takes large doses of medication. After exposure to asthma triggers, symptoms rarely develop abruptly but progress over a period of hours or days.
The classic symptoms of an asthma attack are:
- Wheezing. Wheezing when breathing out is nearly always present during an attack. Wheezing is a whistling sound caused by narrowed airways.
- Shortness of breath (dyspnea). Shortness of breath is a major source of distress for patients with asthma. Breathing may be shallower and more rapid. Use of the muscles at the base of the neck and between the ribs may be more exaggerated than normal. Shortness of breath may worsen during exercise.
- Coughing. In some people, the first (or only) symptom of asthma is a dry cough. Coughing may worsen at night or in the early morning.
- Chest tightness or pain. Initial chest tightness without any other symptoms may be an early indicator of an asthma attack.
Not all patients experience the same signs or symptoms of asthma or experience them the same way.
The end of an attack is often marked by a cough that produces thick, stringy mucus. After an initial acute attack, inflammation lasts for days to weeks, even if it does not produce symptoms.
Symptoms of a Life Threatening Attack
The following signs and symptoms may indicate a life threatening situation:
- Rapid pulse
- Sweating
- Bluish skin color
- Anxiety or panic
- Grogginess, confusion, or difficulty talking
Asthma often progresses very slowly, but it may sometimes develop to a fatal or near-fatal attack within a few minutes. It is very difficult to predict when an attack will become very serious. Any symptoms that suggest a serious attack should be immediately treated with a rescue bronchodilator. If symptoms persist, call for emergency help.
Exercise-Induced Asthma
Exercise-induced asthma (EIA), also called exercise-induced bronchoconstriction, is a limited form of asthma in which exercise triggers coughing, wheezing, or shortness of breath. This condition usually occurs during intense exercise in cold dry air. Symptoms start 5 to 10 minutes into exercise and then gradually resolve.
EIA is triggered only by exercise and is distinct from ordinary allergic asthma in that it does not produce a long period of airway hyperactivity, as allergic asthma does. Many people who have asthma also have EIA.
Nocturnal Asthma
Many patients experience a worsening of their asthma symptoms during the nighttime, especially during sleep. Attacks often occur between 2 to 4 a.m. Factors that increase the risk for nocturnal asthma include allergen exposure, sinus problems, GERD, chronic obstructive lung diseases, and the sleep-disordered breathing associated with obstructive sleep apnea.
Your doctor will want to know any patterns or triggers associated with your asthma symptoms. Be sure to let your doctor know:
- Any possible allergic triggers.
- Whether symptoms are more frequent during the spring or fall (allergy seasons).
- Whether exercise, a respiratory infection, or exposure to cold air has ever triggered an attack.
- Any family history of asthma or allergic disorders, such as eczema, hives, or hay fever.
- Any occupational or long-term exposure to chemicals. If symptoms improve on weekends and vacation and are worse at work, the job may be the likely source of the asthma.
Lung Function Tests
If symptoms and a patient's history suggest asthma, the doctor will usually perform lung (pulmonary) function tests to confirm the diagnosis and determine the severity of the disease.
A standard test uses a spirometer, an instrument that measures the amount of air taken into and exhaled out from the lungs. The patient breathes into a tube that is connected to a machine. The spirometer can give several measures of airflow:
- Vital capacity (VC) is the maximum volume of air that can be inhaled or exhaled, and is the total lung capacity (TLC). A spirometry test measures the forced vital capacity (FVC), as you breathe into TLC and then do a forced expiration to residual volume.
- Peak expiratory flow rate (PEFR), commonly called the peak flow rate, is the maximum flow rate that can be generated during a forced exhalation.
- Forced expiratory volume (FEV1) is the maximum volume of air expired in 1 second.
Spirometry is a painless study of air volume and flow rate within the lungs. Spirometry is frequently used to evaluate lung function in people with obstructive or restrictive lung diseases such as asthma.
If the airways are obstructed, these measurements will fall. Depending on the results, the doctor will take the following steps:
- If measurements fall, the doctor typically asks the patient to inhale a bronchodilator medication. This drug is used in asthma to open the air passages. The measurements are taken again. If the measurements are more normal, the drug likely has cleared the airways and a diagnosis of asthma is likely.
- If measurement results fail to show airway obstruction, but asthma is still suspected, the doctor may perform a challenge test. This involves administering a specific drug (histamine or methacholine) that usually increases airway resistance only when asthma is present, although some other conditions can cause false positive tests.
Allergy Tests
Your doctor may recommend skin or blood allergy tests, particularly if a specific allergen is suspected. Allergy skin tests may help diagnose allergic asthma, although they are not recommended for people with year-round asthma.
Fractional Exhaled Nitric Oxide (FeNO) Testing
Fractional exhaled nitric oxide (FeNO) tests measure how much nitric oxide is in the air you breathe out. Nitric oxide (NO) is a gas that is considered to be a byproduct of inflammation in the lungs. FeNO can be used when there are doubts about asthma diagnosis in people ages 5 and older.
Ruling out Other Conditions
Many other health conditions have symptoms similar to asthma:
- Asthma and chronic obstructive lung diseases (chronic bronchitis and emphysema) affect the lungs in similar ways and both may be present in the same person. Unlike other chronic lung conditions, asthma usually first appears in patients younger than age 30 and with chest x-rays that are normal.
- Panic or anxiety disorder can coincide with asthma or be confused with it.
- Other conditions that must be considered during diagnosis are pneumonia, aspirin sensitivity, severe allergic reactions, pulmonary embolism, other lung obstructions, cancer, heart failure, tumors, psychosomatic illnesses, sarcoid, and certain rare disorders such as cystic fibrosis.
General Approach for Treating and Managing Asthma
Asthma is often a chronic condition but you can effectively manage it by:
- Working with your doctor to develop a written Asthma Action Plan that addresses daily maintenance treatment, rescue medications, and what to do if your asthma worsens.
- Following appropriate drug treatments and making necessary lifestyle changes.
- Identifying and avoiding allergens and other asthma triggers.
- Doing regular self-monitoring at home, including tracking peak flow meter readings.
- Communicating regularly with your doctor.
Based on your age, symptoms, and asthma severity, your doctor will determine an individualized treatment plan. In general, doctors recommend a stepwise approach for treating asthma. Medications and dosages are increased when needed, and decreased when possible. Your record of peak flow meter readings can help your doctor manage your medications and make necessary adjustments.
These are the signs of well-controlled asthma:
- Asthma symptoms occur twice a week or less
- Rescue bronchodilator medication is used twice a week or less
- Symptoms do not cause nighttime or early morning awakening
- Symptoms do not limit work, school, or exercise activities
- Peak flow meter readings are normal or the patient's personal best
- Both the doctor and the patient consider the asthma to be well controlled
Treating Symptoms Versus Controlling the Disease
It is important to understand the difference between coping with asthma attacks and controlling the disease over time.
Medications for asthma fall into two categories:
- Rescue (Quick-Relief) Medication. Medications that open the airways (bronchodilators) are used to quickly relieve any moderate or severe asthma attack. These drugs are usually short-acting beta-adrenergic agonists (beta2-agonists) taken through an inhaler. Beta2-agonists and other rescue medications do not have any effect on the disease process itself. They are only useful for treating symptoms.
- Long-Term Control (Maintenance) Medication. Long-term control medications focus on controlling the damaging inflammatory response associated with asthma and not simply treating symptoms. For adults and children over age 5 with moderate-to-severe persistent asthma, doctors recommend inhaled corticosteroids, which are sometimes accompanied by long-acting beta2-agonists when corticosteroids alone fail to control the disease.
Unfortunately, many patients do not understand the difference between medications that provide rapid short-term relief and those that are used for long-term symptom control. Make sure your doctor explains how to avoid overusing your short-term bronchodilator medications and underusing your long-term corticosteroid medications. The overuse of bronchodilators can have serious consequences, while not properly using steroids can lead to permanent lung damage.
Inhaler Devices
Most asthma drugs are taken through inhalers. The two basic inhaler devices are the metered-dose inhaler (MDI) and dry powder inhalers (DPIs). In a hospital setting, or when a patient cannot use an inhaler, a nebulizer may be used. A nebulizer is a device that administers the drug in a fine spray that the patient breathes in.
Metered-Dose Inhaler
The metered-dose inhaler (MDI) is the standard device. It allows precise doses to be delivered directly to the lungs. The medicine is contained in a pressurized canister that is placed inside the plastic inhaler. MDIs are often used with a spacer, which is a tube that is attached to the inhaler. The spacer serves as a holding chamber for the medication sprayed by the inhaler. The spacer helps improve the ease and efficiency of medication delivery.
Dry Powder Inhalers
Dry powder inhalers (DPIs) deliver a powdered form of beta2-agonists or corticosteroids directly into the lungs. Unlike an MDI, dry powder inhalers do not contain a propellant and do not require a spacer. Some patients find that they are more difficult to manage than MDIs.
Treatment of Asthma during Pregnancy
Guidelines from the National Asthma Education and Prevention Program (NAEPP) emphasize that most asthma medications are safe for pregnant women. The guidelines recommend that pregnant women with asthma have albuterol available at all times. Inhaled corticosteroids should be used for persistent asthma. Patients whose persistent asthma does not respond to standard dosages of inhaled corticosteroids may need a higher dosage or the addition of a long-acting beta-agonist to their drug regimen.
For severe asthma, oral corticosteroids may be necessary. The NAEPP notes that while it is not clear if oral corticosteroids are safe for pregnant women, uncontrolled asthma poses an even greater risk for a woman and her fetus. Pregnant women with asthma face increased risks for complications including pre-eclampsia (a condition associated with high blood pressure) and preterm delivery.
Treatment of Severe Persistent Asthma
Most patients with asthma respond well to standard medications, but a small percentage of people are treatment-resistant. In these cases, a doctor (preferably an asthma specialist) should confirm the asthma diagnosis and evaluate other conditions that might contribute to severe persistent asthma.
Diseases and lifestyle factors that can worsen asthma include rhinosinusitis, nasal polyps, obesity, smoking, obstructive sleep apnea, thyroid dysfunction, female hormonal fluctuations, and GERD. Medications such as ACE inhibitors, beta-blockers, and aspirin and other nonsteroidal anti-inflammatory drugs can also worsen asthma. Addressing these conditions can help reduce asthma severity.
For patients who are not helped by high-dose inhaled corticosteroids and long-acting beta-agonists, guidelines recommend trying either:
- Omalizumab (Xolair) for patients where allergies play a large role in their asthma
- Mepolizumab (Nucala),benralizumab (Fasenra), or dupilumab (Dupixent) for patients with high levels of eosinophils
- Tiotropium (Spiriva)
Bronchial thermoplasty is an outpatient procedure approved by the FDA in 2010. It is reserved for select adult patients whose severe and persistent asthma has not been helped by inhaled corticosteroids and long-acting beta-agonist medications. The procedure uses radiofrequency energy to heat lung tissue and reduce the thickness of smooth muscle in the airways so that patients can breathe better. Current guidelines recommend against bronchial thermoplasty for most people with uncontrolled moderate to severe asthma due to the risks involved and the modest benefits. Some people who are willing to accept the risks may choose to undergo this therapy after consideration together with their health care provider.
Quick-Relief (Rescue) Medications
Quick-relief (rescue) medications work immediately to relax airways and quickly control acute asthma attacks. They are not useful for preventing attacks or controlling inflammation in the airways.
Short-Acting Beta2-Agonists
The standard quick-relief medication is a beta2-agonist inhaler. Beta2-agonists are bronchodilators. They relax and open constricted airways during an acute asthma attack.
Specific short-acting beta2-agonists include:
- Albuterol (Proventil, Ventolin, ProAir, also called salbutamol outside the U.S.), is the standard short-acting beta2-agonist in the United States.
- Levalbuterol (Xopenex) is a newer type of beta2-agonist.
Short-acting beta2-agonists are usually administered through inhalation and are effective for 3 to 6 hours. They relieve the symptoms of acute attacks, but they do not control the underlying inflammation. They are used alone only for patients with intermittent asthma. Most patients with asthma use a beta2-agonist only for rapid symptom relief during an asthma attack, and use a long-term control medication to prevent attacks and reduce airway inflammation.
Side Effects of Beta2-Agonists
Side effects of all beta2-agonists may include:
- Anxiety.
- Tremor.
- Restlessness.
- Headache.
- Fast and irregular heartbeats. Notify a doctor immediately if this side effect occurs, particularly if you have an existing heart condition.
Beta2-agonists may have serious interactions with certain other drugs, such as beta-blockers. People with diabetes, heart disease, high blood pressure, hyperthyroidism, an enlarged prostate, or a history of seizures should use these drugs with caution.
Short-acting beta2-agonists become less effective when taken regularly over time, which increases the risk for overuse. Overdose can be serious and in rare cases even life threatening, particularly for patients with heart disease.
Oral (Systemic) Corticosteroids
Oral corticosteroids are generally used for asthma flare-ups that do not respond to inhaler medications. Common oral corticosteroids include prednisone, prednisolone, methylprednisolone, and hydrocortisone.
For asthma treatment, oral corticosteroids are typically used for short "bursts" of treatment lasting 5 to 10 days. In some severe cases, they may be used as maintenance therapy.
Short-term side effects of oral corticosteroids include mood changes and irritability, fluid retention and weight gain, and high blood pressure. Oral corticosteroids can cause severe side effects if taken for long periods of time. These side effects include cataracts, glaucoma, osteoporosis, diabetes, osteoporosis, susceptibility to infections, and other serious conditions.
If you need to take oral corticosteroids for more than 5 days, your doctor will gradually taper off the dose. Abruptly stopping oral steroids after using them for a prolonged period of time (30 days or longer) can cause withdrawal symptoms.
Anticholinergic Drugs
Two inhaled drugs, ipratropium bromide (Atrovent) and tiotropium (Spiriva), are bronchodilators that are not approved for asthma treatment but are sometimes used for this purpose. Ipratropium is used as a rescue medication. Tiotropium is being studied for use as a long-term control medication for patients with severe persistent asthma.
Possible benefits of anticholinergics include:
- They may be useful for certain older patients with asthma who also have emphysema or chronic bronchitis.
- Combining with a beta2-agonist might help patients who have not been helped by a beta2-agonist alone.
OTC Rescue Medications
Asthmanefrin is an over-the-counter (non-prescription) rescue bronchodilator that contains a form of epinephrine called racepinephrine. The medication is inhaled through an atomizer. Asthmanefrin came on the market in 2012 as a replacement for Primatene Mist. Primatene Mist was discontinued because its inhaler used chlorofluorocarbon (CFC) propellant. (CFCs are banned because of environmental concerns.)
Asthmanefrin does not use CFC. However, many doctors do not recommend the use of epinephrine products for asthma because the drug can raise heart rate and blood pressure, and may increase the risk for heart attack and stroke. In general, patients are much better off seeing a health care provider and using inhalers that are prescribed.
Long-Term Control (Maintenance) Medications
Long-term control (maintenance) medications are taken on a regular basis to prevent asthma attacks, control inflammation in the airways, and manage chronic symptoms.
Inhaled Corticosteroids
Corticosteroids, also called glucocorticoids or steroids, are powerful anti-inflammatory drugs. Steroids are not bronchodilators (they do not relax the airways) and have little short-term effect on symptoms. Instead, they work over time to reduce inflammation and prevent permanent injury in the lungs. They can also help prevent asthma attacks from occurring.
Taking a corticosteroid drug through an inhaler provides effective local anti-inflammatory activity in the lungs with very few side effects elsewhere in the body. (By contrast, steroids taken by mouth have considerable side effects throughout the body.) Inhaled corticosteroids (ICS) are recommended as the primary therapy for any patient needing long-term control medications for persistent asthma.
The most recent generation of inhaled steroids include beclomethasone (QVAR), budesonide (Pulmicort), ciclesonide (Alvesco), flunisolide (AeroBid), fluticasone (Flovent), mometasone furoate (Asmanex), and triamcinolone (Azmacort and others). These steroids are sometimes combined with a long-acting beta2-agonist in a single inhaler, such as budesonide-formoterol (Symbicort), fluticasone-salmeterol (Advair), or mometasone-formoterol (Dulera). Optimal timing of the dose is important and may vary depending on the medication.
Inhaled steroids are generally considered safe and effective and only rarely cause any of the more serious side effects associated with prolonged use of oral steroids. The following are possible side effects of inhaled steroids:
- Throat irritation, hoarseness, and dry mouth (the most common side effects). Using a spacer device and rinsing the mouth after each treatment can minimize or prevent these effects.
- Oral candidiasis (thrush). A yeast infection in the mouth, tongue, or throat may develop, especially if the mouth is not rinsed after use of the inhaled steroids.
- Rashes, wheezing, facial swelling (edema), fungal infections (thrush) in the mouth and throat, and bruising are also possible but not common with inhalators.
- Inhaled corticosteroids are associated with a higher risk for cataracts in patients over age 40, particularly with higher dosages. (No higher risk is observed in younger people.)
- Some studies report a higher risk for bone loss in patients who take inhaled steroids regularly, a side effect known to occur with oral steroids.
Long-Acting Bronchodilator Inhaled Drugs
There are two types of long-acting bronchodilators:
- Long-acting beta2-agonists (LABAs)
- Long-acting muscarinic antagonists (LAMAs)
Long-acting beta2-agonists (LABAs) are bronchodilator drugs that help to open and relax the airways. Unlike the short-acting Beta2-agonists used for rescue medication, LABAs are used for long-term asthma control. They are not used for treating attack symptoms.
LABAs should never be used alone in the treatment of asthma in adults or children. They can be dangerous when used alone, because they can mask asthma symptoms, and they can increase the risk of asthma death unless paired with an inhaled steroid. LABAs should only be used in combination with another control medication, such as an inhaled corticosteroid. LABAs should be used for the shortest time possible, and should only be used by patients whose asthma is not adequately controlled by other asthma maintenance medications.
Patients may also benefit from as-needed LABA/ICS using formoterol as a LABA for symptom relief. Salmeterol-fluticasone (Advair), formoterol-budesonide (Symbicort), and formoterol-mometasone (Dulera) are long-acting beta2-agonists products combined with a steroid in a single inhaler that are used for treatment of moderate-to-severe asthma. The LABA-only versions of these drugs are salmeterol (Serevent Diskus) and formoterol (Foradil Aerolizer).
Long-acting muscarinic antagonists (LAMAs) are other long-acting bronchodilator drugs. Like LABAs, LAMAs are used to prevent asthma attacks rather than to treat attack symptoms. Also like LABAs, LAMAs are not used by themselves, but in combination with corticosteroids. Although LABAs are preferred over LAMAs when corticosteroids alone do not control asthma, if a LABA cannot be used or is not available, LAMAs can be used instead. LAMAs can also be used in addition to corticosteroids and LABAs when this combination is not sufficient to control asthma symptoms. Examples of LAMAs include umeclidinium (incruse), glycopyrrolate (Seebri), tiotropium (Spiriva) and aclidinium (Tudorza). Combination LAMA/LABA inhalers include umeclidinium/vilanterol (Anoro) and tiotropium/olodaterol (Stiolto).
Leukotriene Antagonists
Leukotriene antagonists (also called anti-leukotrienes or leukotriene modifiers) are pills that block leukotrienes. Leukotrienes are powerful immune system factors that, in excess, produce damaging chemicals that can cause inflammation and spasms in the airways of people with asthma. As with other anti-inflammatory drugs, leukotrienes are used for prevention, NOT for treating acute asthma attacks.
Leukotriene antagonists include montelukast (Singulair, generic) and zafirlukast (Accolate, generic). Zileuton (Zyflo) is a leukotriene inhibitor. These drugs may be used as second-line treatment for asthma control and are sometimes used for preventing exercise-induced asthma.
Side Effects and Complications
Upset stomach, headache, and sore throat are the most common side effects of leukotriene antagonists. Because zafirlukast and zileuton can raise liver enzyme levels, patients may need periodic liver tests.
In rare cases, leukotriene antagonists may cause mental health disturbances and behavioral changes. Mood problems include agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, tremor, and suicidal thinking. Patients who take a leukotriene antagonist drug should be monitored for signs of behavioral and mood changes. Doctors should consider discontinuing the drug if patients exhibit any of these symptoms.
Omalizumab (Xolair) is FDA-approved for patients age 12 and older who have moderate-to-severe persistent asthma related to allergies. Omalizumab is a biologic drug that targets and blocks the antibody immunoglobulin E (IgE), a chemical trigger of the inflammatory events associated with an allergic asthma attack.
Omalizumab is given by injection every 2 to 4 weeks. It is used only to treat patients who have moderate-to-severe persistent asthma related to allergies whose symptoms are not controlled by inhaled corticosteroids.
Side Effects and Complications
About 1 in 1,000 patients who take omalizumab develop anaphylaxis (a life threatening allergic reaction). Patients can develop anaphylaxis after any dose of omalizumab, even if they had no reaction to a first dose. Anaphylaxis may occur up to 24 hours after the dose is given.
Omalizumab should always be injected in a doctor's office, and health care providers should observe patients for at least 2 hours after an injection. Patients should also carry emergency self-treatment for anaphylaxis (such as an Epi-Pen) and know how to use it. With an Epi-Pen, or similar auto-injector device, patients can quickly give themselves a life-saving dose of epinephrine.
Anaphylaxis symptoms include:
- Difficulty breathing
- Chest tightness
- Dizziness
- Fainting
- Itching and hives
- Swelling of the mouth and throat
The FDA is currently reviewing whether omalizumab may be associated with increased risk for heart and vascular problems (ischemic heart disease, arrhythmias, cardiomyopathy, heart failure, pulmonary hypertension, and blood clots).
Anti-IL-5 monoclonal antibodies
Mepolizumab (Nucala), reslizumab (Cinqair), and benralizumab (Fasenra) are anti-IL-5 monoclonal antibodies FDA-approved for patients who have a high level of eosinophils. These drugs have been shown to reduce exacerbations in patients with severe asthma. They are not meant to be used in acute exacerbations or in patients with status asthmaticus.
Anti-IL-5 antibodies are administered once every 4 weeks and given either via subcutaneous injection or intravenous injection. Injections should be given in a provider's office and patients monitored for allergic reactions or even anaphylaxis. Some patients treated with mepolizumab (Nucala) have experienced opportunistic infections such as shingles or herpes zoster.
Theophylline is a bronchodilator drug. It relaxes the muscles around the bronchioles and also stimulates breathing. Since the introduction of inhaled corticosteroids and long-acting beta2-agonists, theophylline is not used as often for asthma treatment. It may still be used in some circumstances, such as for treating severe or nocturnal asthma. Theophylline is available in tablet, liquid, and injectable forms. Theophylline should not be used by people with peptic ulcers or GERD, and should be used with caution by anyone with heart disease, liver disease, high blood pressure, or seizure disorders.
Other Treatments
Patients with asthma should get an annual flu vaccine, and they should be vaccinated against pneumococcal pneumonia.
Annual flu vaccine
An in-depth report on the diagnosis, treatment, and prevention of colds and flu.
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Treating Seasonal Allergies and Sinusitis
Patients with asthma and chronic allergic rhinitis may need to take medications daily. Patients with severe seasonal allergies may need to start medications a few weeks before the pollen season, and to continue medicine until the season is over. Treatment of allergies and sinusitis can help control asthma.
An in-depth report on the causes, diagnosis, treatment, and prevention of common nasal allergies. Nasal allergies can be associated with sinus infla...
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An in-depth report on the causes, diagnosis, treatment, and prevention of sinusitis.
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Immunotherapy ("allergy shots") may help reduce asthma symptoms, and the use of asthma medications, in patients with known allergies. They may also help prevent the development of asthma in children with allergies. Immunotherapy poses some risk for severe allergic reactions, however, especially for children with poorly controlled asthma.
Especially for children with poorly controlled ...
An in-depth report on how asthma is diagnosed, treated, and managed in children and adolescents.
Read Article Now | Book Mark Article |
An oral form of immunotherapy that uses a sublingual (under-the-tongue) tablet has been researched. Recent reviews indicate that sublingual therapy may be helpful for milder asthma. However, this therapy has not been shown to improve more persistent asthma, and safety has not been well studied in patients with more severe asthma. Furthermore, many questions remain including dosage and duration of treatment. Sublingual therapy has recently been FDA-approved for allergic rhinitis caused by grass and ragweed allergies. At this time, sublingual immunotherapy is not approved or recommended for asthma treatment in the United States.
Preventing and Treating Respiratory Infections
Respiratory infections, including the common cold, can interact with allergies to worsen asthma. People with moderate to severe asthma are at increased risk of developing severe COVID-19 if infected.
People with asthma should try to minimize their risk for respiratory tract infections. Using alcohol-based hand rubs and washing hands are simple but effective preventive measures. Vaccinations for viral respiratory infections are also important.
Treating Gastroesophageal Reflux Disease (GERD)
Asthma and GERD often co-exist. Some patients find that treatment of GERD helps improve their asthma symptoms. GERD treatment includes:
- Avoiding heavy meals and meals with fried food.
- Avoiding caffeine, chocolate, onions, and garlic.
- Avoiding eating or drinking at least 3 hours before bedtime.
- Elevating the head of the bed by 6 inches.
- Taking medications such as proton pump inhibitors (PPIs). Be sure to talk to your doctor before taking these medicines. The use of PPI drugs to improve asthma symptoms is controversial. Studies indicate that these drugs do not help with asthma symptoms.
Managing Hormonal-Related Asthma
Women who suspect that menstrual-related changes may influence asthma severity should keep a diary of their menstrual dates and times of asthma attacks. Sometimes, adjusting medications in anticipation of menstruation may help prevent attacks.
Alternative Therapies
Many people with asthma turn to alternative therapies including high-dose vitamins (such as Vitamin D), homeopathic remedies, probiotics, isoflavone, omega-3 fatty acids, and herbal supplements. There is no evidence that any of these treatments are helpful for asthma.
However, because stress can worsen asthma symptoms and make breathing more difficult, alternative therapies that focus on relaxation and stress reduction may be helpful. These modalities include:
- Breathing and relaxation techniques, including meditation and yoga
- Biofeedback
- Hypnosis
- Acupuncture
- Massage therapy
Managing Asthma at Home
Asthma Action Plans
Asthma action plans create a written document for patients to manage asthma during stable times and to more easily identify when asthma is worsening. Important components of a home program include:
- A clearly written plan for taking asthma medications when condition is stable.
- Instructions for what medications to take if asthma gets worse.
- Education regarding the difference between long-term control medications and quick-relief medications.
- Monitoring of asthma on a daily basis. Symptom monitoring is adequate for patients with intermittent or mild persistent. asthma. Peak flow monitoring should be performed in patients with moderate or severe persistent asthma or those with a history of more severe exacerbations (sudden worsening or increase in severity of symptoms).
- A list of environmental control measures that need to be taken to control exposure to allergens.
- When to seek medical care.
Monitoring Peak Flow
A peak flow meter is a handheld plastic device for measuring peak expiratory flow rate (PEFR). PEFR measures how fast you can expel air out of your lungs and is an indication of lung functioning. Changes in the PEFR may indicate problems with asthma control even before symptoms appear.
It is a good idea to keep a written record of your peak flow meter readings. This data can help your doctor adjust medications and recognize problems before they become serious. Patients who self-manage their asthma with peak air flow measurements and appropriate medication use have fewer hospitalizations and unplanned doctors' visits, and generally have a better quality of life than those who rely only on the occasional doctor or emergency room visit to control symptoms.
To use a peak flow meter, stand or sit upright, set the meter to zero, take a deep breath and exhale hard and fast into the meter. Write down the number that appears on the meter.
Tips for regular peak flow monitoring include:
- Patients with severe asthma should take PEFR readings 2 or 3 times a day. The overall goal should be to achieve less than a 20% (and ideally only 10%) variation in readings between evening and morning rates.
- For mild-to-moderate asthma, a single reading each morning is usually sufficient, but check with your doctor.
- It is important to use the meter at the same times each day and to stand or sit in the same position to keep an accurate record.
- Keep an ongoing record of your readings to help detect any worsening of symptoms.
- Record any asthma attacks, exposure to allergens or triggers, and medications taken.
Peak low measurements are individually tailored to establish your normal range. Readings are then categorized as either being in the green, yellow, or red zone. Peak flows in the green zone are 80% to 100% of your personal best readings, readings in the yellow zone are 50% to 80% of your personal best readings, and peak flows in the red zone are less than 50% of your personal best readings. Patients should seek medical attention when their peak flows fall within the red zone.
Avoiding Environmental Triggers
It is important to avoid and control triggers that lead to asthma attacks.
Controlling Pets
Patients who already have pets and are not allergic to them probably have a low risk for developing allergies. If pets trigger asthma, take the following precautions:
- If possible, keep pets outside.
- If this isn't possible, confine pets to carpet-free areas outside the bedroom. Cats harbor significant allergens, which can even be carried on clothing. Dogs usually cause fewer problems.
- Wash animals once a week to reduce allergens. Dry shampoos, available for both cats and dogs, can remove allergens from the skin and fur and are easier to administer than wet shampoos.
Controlling for Dust
Spray furniture polish is very effective for reducing both dust and allergens. Air purifiers and vacuum cleaners with High Efficiency Particle Arresting (HEPA) filters can help remove particles and small allergens found indoors. Neither vacuuming nor the use of anti-mite carpet shampoo is, however, effective for removing mites in house dust. In fact, vacuuming stirs up both mites and cat allergens. If possible, avoid carpets and rugs.
A High Efficiency Particle Arresting (HEPA) filter can remove the majority of harmful particles, including mold spores, dust, dust mites, pet dander, and other irritating allergens from the air. Along with other methods to reduce allergens, such as frequent dusting, the use of a HEPA filtration system can help control the amount of allergens circulating in the air. HEPA filters can be found in most air purifiers, which are usually small and portable.
Bedding, Curtains, and Bedroom Environment
- Replace curtains with shades or blinds, and wash bedding using the highest temperature setting.
- Encase mattress and pillows in special dust mite proof covers (synthetic pillows may pose a higher risk for asthma attacks than feather pillows, or no pillow at all).
- Wash pillows in water hotter than 130°F (55°C), or in cooler water with detergent and bleach.
- Wash sheets and blankets weekly in hot water.
- Avoid sleeping or lying on cushions or furniture that are cloth covered.
Reducing Humidity in the House
Living in a damp house is counterproductive. Dust mites thrive in humidity and damp houses increase the risk for mold. Humidity levels should not exceed 30 to 50 percent:
- Fix all leaky faucets and pipes, and eliminate collections of water around the outside of the house.
- Dehumidify basements, but empty dehumidifiers and clean them daily with a vinegar solution.
- Clean often any moldy surfaces in the basement or in other areas of the home.
- Avoid prolonged used of vaporizers to manage symptoms during asthma attacks.
Gas Stoves, Kerosene, and Cooking
Electric stoves and ovens are healthier than gas ones for people with asthma. Gas ovens release nitrogen dioxide, a substance that can aggravate asthma symptoms. Even smoky cooking can worsen asthma. Kerosene (used in space heaters and lamps) may also produce allergic reactions.
Exterminating Pests (Cockroaches and Mice)
- Use a professional exterminator to eliminate cockroaches. (Cleaning the house using standard housecleaning techniques may not eliminate the cockroach allergens.)
- Exterminate mice and attempt to remove all dust, which might contain mouse urine and dander.
- Keep food and garbage in closed containers.
- Keep food out of bedrooms.
Avoiding Cigarette Smoke
Cigarette smoke can accelerate the decline in lung function related to asthma. Even exposure to secondhand smoke can double the risk of an asthma-related emergency room visit. Everyone should quit smoking and encourage others around them to quit.
An in-depth report on the health risks of smoking and how to quit.
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Avoiding Outdoor Allergens
- Avoid scheduling camping and hiking trips during times of high pollen count (generally, May and June for grass pollen and mid-August to October for ragweed in the eastern United States).
- Avoid strenuous activity when ozone levels are highest, which usually occur in early afternoon, particularly on hot hazy summer days. Levels are lowest in early morning and at dusk.
- Asthma attacks are often triggered by thunderstorms, perhaps because storms stir up pollen and spores or because of the build-up of ozone that accompanies such storms.
- Patients who are allergic to mold should avoid barns, hay, raking leaves, and mowing grass. Exposure to automobile fumes may worsen asthma. Fungi in car air conditioners can also be a problem.
- Air pollution can worsen asthma.
Asthma is no reason to avoid exercise. Historically, about 10% of Olympic athletes have asthma. Some studies indicate that long-term exercise even helps control asthma and reduce hospitalization. Exercise can help control weight, which can help with asthma symptoms. Patients should consult their doctors before starting any exercise program, however.
People who enjoy running should probably choose an indoor track to avoid pollutants and to avoid cold, dry air in the cold months. Swimming is excellent for people with asthma. Yoga, which uses stretching, breathing, and meditation techniques, may also have particular benefits.
Hints for Reducing Exercise Induced Asthma (EIA)
EIA occurs only after exercise and is more likely to happen during regular paced activities in cold, dry air. The following are some suggestions for reducing its impact:
- Warm-up and cool-down before and after exercise.
- Choose activities that do not require exposure to cold, dry air.
- Participate in activities with short bursts of exercise (such as tennis and football) rather than exercises involving long-duration pacing (such as cycling, soccer, and distance running).
- Breathe through a scarf or through the nose. This helps warm up the airways when exercising in cold air.
- Use any prescribed medications as directed.
Treatment guidelines for exercise-induced asthma recommend:
- A short-acting beta2-agonist (albuterol) taken 15 minutes before exercise is the first choice, and lasts for 2 to 3 hours.
- A leukotriene antagonist drug taken daily is the second choice for patients who continue to have exercise asthma symptoms. These patients should also use daily an inhaled steroid for maintenance control.
- American Lung Association -- www.lung.org
- American College of Allergy, Asthma & Immunology -- acaai.org
- American Academy of Allergy, Asthma & Immunology -- www.aaaai.org
- National Heart, Lung, and Blood Institute -- www.nhlbi.nih.gov
- Asthma and Allergy Foundation of America -- www.aafa.org
Bardin PG, Price D, Chanez P, Humbert M, Bourdin A. Managing asthma in the era of biological therapies. Lancet Respir Med. 2017;5(5):376-378. PMID: 28463176 pubmed.ncbi.nlm.nih.gov/28463176/.
Beasley R, Holliday M, Reddel HK, et al; Novel START Study Team. Controlled trial of budesonide-formoterol as needed for mild asthma. N Engl J Med. 2019;380(21):2020-2030. PMID: 31112386 pubmed.ncbi.nlm.nih.gov/31112386/.
Boulet LP, O'Byrne PM. Asthma and exercise-induced bronchoconstriction in athletes. N Engl J Med. 2015;372(7):641-648.PMID: 25671256 pubmed.ncbi.nlm.nih.gov/25671256/.
Boulet LP, Godbout K. Diagnosis of asthma in adults. In: Burks AW, Holgate ST, O'Hehir RE, et al, eds. Middleton's Allergy: Principles and Practice. 9th ed. Philadelphia, PA: Elsevier; 2020:chap 51.
Brozek JL, Bousquet J, Agache I, et al. Allergic rhinitis and its impact on asthma (ARIA) guidelines-2016 revision. J Allergy Clin Immunol. 2017;140(4):950-958. PMID: 28602936 pubmed.ncbi.nlm.nih.gov/28602936/.
Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J. 2014;43(2):343-373. PMID: 24337046 pubmed.ncbi.nlm.nih.gov/24337046/.
Cloutier MM, Dixon AE, Krishnan JA, Lemanske RF Jr, Pace W, Schatz M. Managing asthma in adolescents and adults: 2020 asthma guideline update from the National Asthma Education and Prevention Program. JAMA. 2020;324(22):2301-2317. PMID: 33270095 pubmed.ncbi.nlm.nih.gov/33270095/.
Del Giacco SR, Bakirtas A, Bel E, et al. Allergy in severe asthma. Allergy. 2017;72(2):207-220. PMID: 27775836 pubmed.ncbi.nlm.nih.gov/27775836/.
Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), Cloutier MM, Baptist AP, Blake KV, et al. 2020focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020;146(6):1217-1270. PMID: 33280709 pubmed.ncbi.nlm.nih.gov/33280709/.
Farne HA, Wilson A, Powell C, Bax L, Milan SJ. Anti-IL5 therapies for asthma. Cochrane Database Syst Rev. 2017;9:CD010834. PMID: 28933516 pubmed.ncbi.nlm.nih.gov/28933516/.
Fuchs O, Bahmer T, Rabe KF, von Mutius E. Asthma transition from childhood into adulthood. Lancet Respir Med. 2017;5(3):224-234. PMID: 27666650 pubmed.ncbi.nlm.nih.gov/27666650/.
Israel E, Reddel HK. Severe and difficult-to-treat asthma in adults. N Engl J Med. 2017;377(10):965-976. PMID: 28877019 pubmed.ncbi.nlm.nih.gov/28877019/.
Jolliffe DA, Greenberg L, Hooper RL, et al. Vitamin D supplementation to prevent asthma exacerbations: a systematic review and meta-analysis of individual participant data. Lancet Respir Med. 2017;5(11):881-890. PMID: 28986128 pubmed.ncbi.nlm.nih.gov/28986128/.
Lemière C, Vandenplas O. Asthma in the workplace. In: Broaddus VC, Mason RJ, Ernst JD, et al, eds. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 72.
Lugogo N, Que LG, Gilstrap DL, Kraft M. Asthma: clinical diagnosis and management. In: Broaddus VC, Mason RJ, Ernst JD, et al, eds. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 42.
Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleve Clin J Med. 2020;87(9):569-575. PMID: 32868307 pubmed.ncbi.nlm.nih.gov/32868307/.
McCracken JL, Veeranki SP, Ameredes BT, Calhoun WJ. Diagnosis and management of asthma in adults: a review. JAMA. 2017;318(3):279-290. PMID: 28719697 pubmed.ncbi.nlm.nih.gov/28719697/.
Nasim F, Iyer VN. Bronchial thermoplasty-an update. Ann Thorac Med. 2018;13(4):205-211. PMID: 30416591 pubmed.ncbi.nlm.nih.gov/30416591/.
Parsons JP, Hallstrand TS, Mastronarde JG, et al. An official American Thoracic Society clinical practice guideline:exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013;187(9):1016-1027. PMID: 23634861 pubmed.ncbi.nlm.nih.gov/23634861/.
Smith LJ, Kalhan R, Wise RA, et al; American Lung Association Asthma Clinical Research Centers. Effect of a soy isoflavone supplement on lung function and clinical outcomes in patients with poorly controlled asthma: a randomized clinical trial. JAMA. 2015;313(20):2033-2043. PMID: 26010632 pubmed.ncbi.nlm.nih.gov/26010632/.
Sobieraj DM, Weeda ER, Nguyen E, et al. Association of inhaled corticosteroids and long-acting ß-agonists as controller and quick relief therapy with exacerbations and symptom control in persistent asthma: a systematic review and meta-analysis. JAMA. 2018;319(14):1485-1496. PMID: 29554195 pubmed.ncbi.nlm.nih.gov/29554195/.
Sobieraj DM1, Baker WL1, Nguyen E, et al. Association of inhaled corticosteroids and long-acting muscarinic antagonists with asthma control in patients with uncontrolled, persistent asthma: a systematic review and meta-analysis. JAMA. 2018;319(14):1473-1484. PMID: 29554174 pubmed.ncbi.nlm.nih.gov/29554174/.
van de Griendt EJ, Tuut MK, de Groot H, Brand PLP. Applicability of evidence from previous systematic reviews on immunotherapy in current practice of childhood asthma treatment: a GRADE (Grading of Recommendations Assessment, Development and Evaluation) systematic review. BMJ Open. 2017;7(12):e016326. PMID: 29288175 pubmed.ncbi.nlm.nih.gov/29288175/.
Viswanathan RK, Busse WW. Management of asthma in adolescents and adults. In: Burks AW, Holgate ST, O'Hehir RE, et al, eds. Middleton's Allergy: Principles and Practice. 9th ed. Philadelphia, PA: Elsevier; 2020:chap 52.von Mutius E, Smits HH. Primary prevention of asthma: from risk and protective factors to targeted strategies for prevention. Lancet. 2020;396(10254):854-866. PMID: 32910907 pubmed.ncbi.nlm.nih.gov/32910907/.
Wechsler ME, Yawn BP, Fuhlbrigge AL, et al; BELT Investigators. Anticholinergic vs long-acting ß-agonist in combination with inhaled corticosteroids in black adults with asthma: the BELT randomized clinical trial. JAMA. 2015;314(16):1720-1730. PMID: 26505596 pubmed.ncbi.nlm.nih.gov/26505596/.
Woodruff PG, Bhakta NR, Fahny JV. Asthma: pathogenesis and phenotypes. In: Broaddus VC, Mason RJ, Ernst JD, et al, eds. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 41.
Asthma - description
Your lungs: The inflammatory response
The inflammatory response: Symptoms and causes of airflow limitation
Asthma symptoms, triggers, and management
Asthma - description
Your lungs: The inflammatory response
The inflammatory response: Symptoms and causes of airflow limitation
Asthma symptoms, triggers, and management
Related Information
ecReview Date: 5/31/2021
Reviewed By: Stuart I. Henochowicz, MD, FACP, Clinical Professor of Medicine, Division of Allergy, Immunology, and Rheumatology, Georgetown University Medical School, Washington, DC. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.


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Grow something on your keys
I came across these pics on the net of a recent fad in Japan. Apparently the pocket pet crazy has extended into living things. You can grow these little plants on your key chain in these mini terrariums, and once they get to be too big you can just pot them up into a larger pot and start all over. These pics seem to be of some Cacti and Succulents. I wonder how easy it would be to make something like this, in Japan they retail for about 1000 yen.
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subset: commoncrawl


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I have seen the Halloween Treat Challenge of Trumoo on Facebook and thought, it's a fun thing to experiment in my kitchen. I went to the store yesterday and looked for the Trumoo Orange Scream milk but could not find one so I just got the Trumoo Chocolate flavored one. I decided to make some candied carrots since I have many carrots that I harvested from my garden. I have never done this before but I had a feeling that it is going to be good so I went for it. Here's the recipe that I came up with:
You will need:
- 3 medium size carrots
- 2 tbsp butter
- 1 glass of trumoo chocolate milk
- 2 tbsp cream cheese
- 1 cup mini marshmallows
- 2 tbsp. honey
- 1 tsp corn starch
- Orange zest
- Peel the carrots and slice them up. You can make some heart-shape ones out of the small part of the carrots but that's optional
- I decided to incorporate an orange zest since I did not find the orange scream flavored milk.
- In a medium size pan, melt the butter.
- Add the marshmallows and let it melt.
- Mix the cornstarch to the glass of chocolate milk. Then add the mixture to the melted butter and marshmallows.
- Add the orange zest, honey, and cream cheese
- Stir it until the mixture is thick then add the carrots.
- Cook it in a medium high heat for 25 minutes.
- Let it cool a little bit before stacking them up and putting a lunch pick on it.
- The sauce tasted so good so I didn't want to throw it out. I added food coloring to eat and put it in a ziploc bag. Cut the corner of the ziploc bag and squirt the sauce around the candied carrot.
I can't wait til my kids comes home from school. They love trying new treats like this. I love it when company challenges Moms like me because it gets the creativity out of you. You can try my recipe and see if you like it. Preparation is very easy and it tastes so good. It's delicious and nutritious at the same time. You can visit their website for more delicious TruMoo Halloween recipes or check them out through Pinterest for more fun Halloween treat ideas using Trumoo Orange Scream and chocolate flavored milk.


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Scholarships are gifts. They don't need to be repaid. There are thousands of them, offered by schools, employers, individuals, private companies, nonprofits, communities, religious groups, and professional and social organizations.
What kinds of scholarships are available?
Some scholarships for college are merit-based. You earn them by meeting or exceeding certain standards set by the scholarship-giver. Merit scholarships might be awarded based on academic achievement or on a combination of academics and a special talent, trait, or interest. Other scholarships are based on financial need.
Many scholarships are geared toward particular groups of people; for instance, there are scholarships for women or graduate students. And some are available because of where you or your parent work, or because you come from a certain background (for instance, there are scholarships for military families).
A scholarship might cover the entire cost of your tuition, or it might be a one-time award of a few hundred dollars. Either way, it's worth applying for, because it'll help reduce the cost of your education.
How do I find scholarships?
You can learn about scholarships in several ways, including contacting the financial aid office at the school you plan to attend and checking information in a public library or online. But be careful. Make sure scholarship information and offers you receive are legitimate; and remember that you don't have to pay to find scholarships or other financial aid. Check out our information on how to avoid scams.
Try these free sources of information about scholarships:
the financial aid office at a college or career school
a high school or TRIO counselor
the U.S. Department of Labor's FREE scholarship search tool
your state grant agency
your library's reference section
foundations, religious or community organizations, local businesses, or civic groups
organizations (including professional associations) related to your field of interest
ethnicity-based organizations
your employer or your parents' employers
When do I apply for scholarships?
That depends on each scholarship's deadline. Some deadlines are as early as a year before college starts, so if you're in high school now, you should be researching and applying for scholarships during the summer between your junior and senior years. But if you've missed that window, don't give up! Look at scholarship information to see which ones you can still apply for now.
How do I apply for scholarships
Each scholarship has its own requirements. The scholarship's website should give you an idea of who qualifies for the scholarship and how to apply. Make sure you read the application carefully, fill it out completely, and meet the application deadline.
How do I get my scholarship money?
That depends on the scholarship. The money might go directly to your college, where it will be applied to any tuition, fees, or other amounts you owe, and then any leftover funds given to you. Or it might be sent directly to you in a check. The scholarship provider should tell you what to expect when it informs you that you've been awarded the scholarship. If not, make sure to ask.
How does a scholarship affect my other student aid?
A scholarship will affect your other student aid because all your student aid added together can't be more than your cost of attendance at your college or career school. So, you'll need to let your school know if you've been awarded a scholarship so that the financial aid office can subtract that amount from your cost of attendance (and from certain other aid, such as loans, that you might have been offered). Then, any amount left can be covered by other financial aid for which you're eligible. Questions? Ask your financial aid office.


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Sunday, April 18, 2010
Red Heart Super Saver [100% acrylic; 364yds/333m per 7oz/198g skein]; small amount in #0321 Gold, small amount in #0312 Black
US #4/3.5mm circular needle, 40-in/100-cm long for magic loop
Tapestry needle
Two snap-on black plastic toy eyes
Small amount of polyfil or scrap yarn
Not terribly important, but about 20sts = 4in /10cm in stst
Finished Size:
About 4in/10cm tall
Click here for Abbreviations
With Black, CO 10 sts, using long tail method.
Rows 1-7, odd: sl1, p9.
Rows 2-8 even: sl1, k9.
Row 9: sl1, p6, p2tog, p1.
Row 10: sl1, k5, ssk, k1.
Row 11: sl1, p4, p2tog, p1.
Row 12: sl1, k3, ssk, k1.
Row 13: sl1, p2, p2tog, p1.
Row 14: sl1, k1, ssk, k1.
BO all 4 sts and cut yarn.
Rotate piece so that CO edge is up with RS facing. With Black, pick up and knit 10 sts through front loops of CO.
Repeat Rows1-14. BO and cut yarn.
With Gold, beginning where CO tails are, with RS facing, pick up and knit 40 sts evenly around.
Purl 1 rnd.
You'll only be working with half of these sts, leaving the rest on hold for later.
Wedge 1:
Row 1: k18, w&t.
Row 2: p16, w&t.
Row 3: k15, w&t.
Row 4: p14, w&t.
Row 5: k13, w&t.
Row 6: p12, w&t.
Row 7: k11, w&t.
Row 8: p10, w&t.
Row 9: k9, w&t.
Row 10: p8, w&t.
Row 11: k14, picking up wraps (insert right needle up through wrap, then through st and knit together), turn.
Row 12: sl1, p19, picking up wraps (insert right needle up through back of wrap, then through st and purl together), turn.
Wedge 2:
Row 1: sl1, k17, w&t.
Repeat Rows 2-12 of Wedge 1.
Repeat Wedge 2 until there are a total of 5 yellow wedges. Do not BO. Cut yarn, leaving 20in/50cm tail.
Attach eyes and stuff. With tapestry needle, thread tail through selvage sts of edge and pull tight to cinch closed. Graft 20 sts just worked with 20 sts on hold. Stuff more if needed. Thread tail through selvage sts on other side and cinch closed. Tie off and hide end inside.
Feel free to comment here with questions.
This pattern is intended for personal use only. Please do not try to sell it or any product made from it. Thank you.
10 comments:
- Jennifer Updyke1/14/12, 9:41 AM
This is great! You just made one little boy very happy. :)
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Kandahar International Airport - Bisha flight ticket
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Transportation form City Center to Kandahar International Airport Airport
Things you need to know to reach to Kandahar International Airport from city centre
Kandahar International Airport
Kandahar International Airport is the other international airport of Afghanistan. The airport is approximately 16 km away from Kandahar city centre. Kandahar International Airport has large capacity for instance flight schedule and there is one method to reach to Kandahar International Airport from city centre.
To reach to Kandahar International Airport from city centre or other central destinations, you can use taxi or rent a car services. You can reach to the airport in approximately 20 minutes with taxi or car.
Transportation from Bisha Airport to City Center
Things you need to know to reach to city centre from Bisha Airport
Bisha Airport
Bisha is in the Asir administrative region, south of the Saudi Arabian Peninsula. Bisha Airport, which welcomes domestic flights, only accepts limited international flights. There are two options you can choose from Bisha Airport to the city centre.
Aerobilet transfer services
Aerobilet is there for you in Bisha. To transfer to your hotel from Bisha Airport in secure and comfortable way, you can check individual transfer prices of Aerobilet and select among different options. You can call Aerobilet support line for more information and tell us about alternatives or your demands.
You can easily find taxis at the exit of Bisha Airport arrival terminal. City centre will approximately take 6 minutes from Bisha Airport.


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June 20, 2011
Oxford, England
Late last week, Thomas James Ball reached his breaking point. Driven to desperation by a system that bankrupted him and destroyed his family, Ball walked up to the main door of the Keene County, New Hampshire courthouse, doused himself with gasoline, and lit himself ablaze.
Hardly anyone seems to have noticed.
Conversely, when a 26-year old Tunisian man lit himself on fire a few months ago after police confiscated the fruits and vegetables he had been selling without a proper permit, it launched a wave of revolution across the Middle East.
People were shocked into taking action… protests and riots swept the region and one regime after another crumbled.
Rather than sparking an "American spring" and shocking US citizens into taking their country back, though, Mr. Ball's act of self-immolation seems to have been largely ignored. There has been scant coverage (and scant is being extremely generous) of Mr. Ball in the mainstream media, and what little coverage there is generally discredits the man as a troublemaker.
This is how the system's gatekeepers have been so adroit at maintaining the status quo– by suppressing dissent, marginalizing the detractors, and distracting the populace with meaningless, irrelevant drivel.
Mr. Ball left behind a lengthy missive prior to his suicide, which covers a range of topics from political corruption to why the family court system in America is utterly disgraceful. He was, to put it mildly, a staunch advocate of violent change, and it's clear he hoped a great deal of others would follow in his footsteps to literally burn the system down.
(Ball even left instructions for how to make a proper Molotov cocktail along with specific vulnerabilities of police stations in his area…)
Perhaps the most interesting part of his final post, however, was the observation that the United States is no longer a nation of laws; Ball described what he calls the 'second set of books,' which is essentially the collection of policies, procedures, and protocols that courts and executive agencies rely upon.
This includes police departments and other 'enforcers' across the country that come up with standardized responses to take judgment out of the equation. TSA agents, for instance, are only following procedure when they fondle children at airport checkpoints. Even the guys who drove the trains to the concentration camps were just following procedures.
Ball argued that the nation is now ruled by such procedures, even in such institutions as family court where judges (by policy) pass the buck down the line to mental health case workers.
His anger and desperation for this system, which tore apart his family and bankrupted his finances, led Ball to light himself ablaze at the local courthouse in a state whose motto is "Live Free or Die." Ball chose the latter.
The next day, life went on in America. There was no shocking front-page cover story or award-winning photograph to spark a national debate… let alone propel droves of fed-up citizens to flood the streets demanding change.
Rather, the New Hampshire courthouse cleaned up his charred remains and meticulously scrubbed the floors to eliminate all trace of the event. 24-hour news networks ran a quick blurb in their scrolling tickers amid more important coverage of the Miss USA beauty pageant and President Obama's Father's Day plans.
In other words, business as usual… suggesting that if there is, in fact, going to be a fight for the soul of the country, it's a long way off, and many more degrees for the boiling frogs who are stuck in the pot.
My assessment of this situation, however controversial it may be, remains very clear: the great faceless enemy that opposes us, irrespective of our country of origin, is the institution of government.
Over time, this institution has inserted itself into nearly all aspects of life, such that a man cannot so much as enjoy a pint of beer, discipline his children, ride on the train, go to the doctor, open a bank account, apply for a job, go fishing, or watch a sporting event without the heavy hand of government being involved.
This is a beast that feeds on citizens; the more it feeds, the larger it becomes and the hungrier it gets. Of all the solutions out there, including armed conflict, civil disobedience, self-immolation, active democracy, etc., the only one that truly destroys the beast is starving it– take away the feast of productive citizens and accelerate its collapse.


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One more dead after contracting hantavirus at Yosemite National Park
(CNN) -- More than a week after announcing two vacationers had contracted hantavirus -- one of them fatally -- Yosemite National Park said Monday, August 27th that authorities have determined another person died after contracting the disease while visiting the park.
In addition to this fatality, Yosemite said in a news release that officials had identified "a probable fourth case of hantavirus."
All four cases involve people who stayed at the park's popular Curry Village in mid-June. The park said its officials are trying to reach those who vacationed in these "tent cabins" from June through this month, when the accommodations were thoroughly cleaned, and urge them to get medical help if they show any symptoms of hantavirus.
Hantavirus cardiopulmonary syndrome is a rare but often fatal lung disease that kills about a third of those who get infected. Don Neubacher, Yosemite's superintendent, noted that people typically don't fall ill with hantavirus until between one and six weeks after they are exposed.
"The health of our visitors is our paramount concern, and we are making every effort to notify and inform our visitors of any potential illness," Neubacher said.
In the United States, the carriers of hantavirus are deer mice, cotton rats, rice rats and white-footed mice, according to the U.S. Centers for Disease Control and Prevention. The virus can be present in the rodents' urine, droppings and saliva, and is spread to people when they breathe in air contaminated with the virus, the CDC says.
The virus is not communicable from person to person.
Earlier this month, the California Department of Public Health said two state residents who came down with the disease may have been exposed to mice droppings or urine that contained hantavirus while staying at the park.
An unidentified 37-year-old man from the San Francisco Bay area died in late July, said Dr. Vicki Kramer, chief of the department's vector-borne disease section.
A Southern California woman in her 40s survived and is recovering, Kramer told CNN.
The two stayed in separate locations at the village, which contains about 400 canvas tent and wooden cabins. Yosemite ranger and spokesman Scott Gediman described the cabins as "very sparse but comfortable."
Park officials have not given details about the one new confirmed case or the "probable" one.
Officials have focused on deer mice, common in the high-elevation eastern Sierra Nevada region. The mice are gray or brown on top, with white bellies. Their ears have no fur.
"Rodents can infest a whole range of these structures," Kramer said. "Deer mice can get in a hole one-quarter inch in diameter."
In addition to cleaning the 400 camp structures, park officials have said they've increased routine measures to reduce the hantavirus risk.
"You cannot eliminate all the mice," Kramer said. "There are a lot of people and snacks that people bring into their tents or cabins."
Prior to this year, Yosemite National Park saw one hantavirus case each in 2000 and 2010.
There is no specific treatment for a hantavirus infection, according to the CDC, but the earlier a patient is brought to intensive care, the better.
Diagnosis is difficult, because early symptoms of fever, muscle aches and fatigue often are confused with the flu.
"However, if the individual is experiencing fever and fatigue, and has a history of potential rural rodent exposure, together with shortness of breath, (that) would be strongly suggestive of HPS," the CDC says.


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A Jamaica Plain man will serve a year and a day in state prison after pleading guilty yesterday to owning and sharing child pornography videos, according to the state Attorney General's Office.
Jose Guzman, 42, was arrested at his JP home by State Police on Jan. 31, 2011 after a search found numerous child porn videos, some of which he had distributed on the Internet via a file-sharing network, according to the AG's Office.
"This defendant will be serving time in state prison for exploiting children, a serious and disturbing offense," state Attorney General Martha Coakley said in a press statement.
Guzman pleaded guilty on Dec. 10 to charges of dissemination of obscene matter, dissemination of child pornography and possession of child pornography. He was sentenced today in Suffolk County Superior Court.
After he is released from prison, Guzman will serve five years of probation, which will include undergoing sex offender evaluation and treatment. For those five years, he will banned from having contact with children under 16 years old; from loitering in areas where children tend to gather; from using the Internet except for work-related reasons; and from using any online chat room, social networking site or similar service.
From press materials.


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by MSR
This smaller, lighter version of our popular Groundhog tent stake saves weight while offering the reliable performance of the original. The proven Y-beam design penetrates and holds in medium to firm soil, while the 7000-series aluminum provides years of strength and durability. A pull loop allows for easy removal. Sold individually and as a kit of 6 stakes.


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Small component with a large impact. A poorly constructed or unsuitable tyre rim tape can be the cause of many punctures. It is especially important with hollow section rims to use a pressure-resistant rim band which covers the entire rim. The fabric-reinforced Continental Easy Tape rim protector is designed for use under high air pressure conditions. The various widths enable a perfect fit for all standard rims. The high pressure design for racing cyclists withstands up to 220 psi, without becoming deformed. The flat construction type also significantly eases the job of tyre fitting.
Part Numbers
Option | UPC | MPN |
27.5 x 20 | 04019238621525 | C1600330 |
29 x 20 | 04019238445176 | C1600440 |


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In his satirical horror novel Breed, Chase Novak has hit upon the perfect blend of terrifying real-life topics: genetic engineering and the mating habits of New York's wealthy 1 percent. The story of two rich but barren Manhattanites, the novel begins as a snarky tour of fertility treatment chic among the city's moneyed classes. But it quickly gets a lot weirder.
On the recommendation of another couple, blue-blood attorney Alex Twisden and his editor wife, Leslie, have one last go at baby making in the bizarre clinic of a creepy Slovenian doctor. The treatment works. They become incredibly fertile — but unfortunately they become feral, too.
Novak is the pen name of Scott Spencer, author of the 1970s classic Endless Love, and here he has repurposed his literary flair for observation into grisly narrative schadenfreude. Every disgusting detail ends with a sarcastic barb, a nasty little stinger aimed at the well-toned bodies of our high-toned protagonists. One of the immediate side effects of the mad doctor's treatment is that Alex and Leslie get incredibly hairy and lose their inhibitions about things like hygiene and chewing on the furniture. They devote most of their time to rutting, eating increasingly grotesque slabs of meat and (in Leslie's case) seeking out people willing to do all-over body waxing once a day.
The bulk of Breed is told from the perspective of the Twisden twins, Alice and Adam, who at the age of 10 have realized there is something deeply wrong with their parents. Through the children's eyes, we see that Alex's family manse has fallen into ruin. There is a clever fable about class here, as the Twisdens' tumble down the evolutionary tree mirrors their fall down the economic ladder. No longer able to work, they've sold off their antique furniture to pay for the twins' expensive schooling. They are the monstrous embodiment of downward mobility, struggling to keep up appearances with their rich neighbors.
Fearing that they're about to become their parents' next meal, Alice and Adam flee their home one night — Adam running to his saintly, gay teacher's house, and Alice into the clutches of a group of feral children like herself who live in Central Park. Novak imagines that the homeless kids who haunt the park are all the spawn of rich New Yorkers who were patients of the mad Slovenian fertility doctor. Again, it's an interesting metaphor for downward mobility and gives us a glimpse of a genetic-engineering nightmare future. In other words, it's scientifically implausible but symbolically rich.
The main problem with Breed is Novak's clumsy effort to offer us a kind of civilized antidote to the Twisdens in Adam's gay teacher, whose main attributes are kindness, selflessness and about-to-be-lunchmeat-ness. Novak also struggles to depict Adam and Alice vividly; they come across as automatons or placeholders, rather than real children who are discovering that they aren't like any other humans they know.
Still, the book is a delightfully nauseating read. And it's the perfect dark fairy tale for these times, when more than a few readers might secretly find themselves wishing that the world's elites would be brought so low as to start pooping in their own posh living rooms.
Annalee Newitz writes about the intersection of science and culture. She's the editor-in-chief of io9.com and the author of a forthcoming book about how humans will survive a mass extinction.
Copyright 2023 NPR. To see more, visit https://www.npr.org.


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21 April, 2010
Grand Cru 110bcd Crank
Here is a sneak peak of the Grand Cru 110bcd crank due in mid-summer. This rendering is not 100% accurate, but it's very close. The rings will be 48/34 and there will also be a triple version later. The crank is cold forged and the rings are full CNC 7075 alloy, so the rings should be super durable. The Q-factor is about 139mm and weight is around 670g. The price will be around $190. This crank will be one of two Grand Cru cranks; the other is the 50.4 bcd version. You like?
Posted by Velo Orange at 1:29:00 PM 45 comments
14 April, 2010
Leather Touring Shoes
The SRT707's uppers are full grain leather and the sole is rubber for easy walking. The midsole is fiberglass-reinforced nylon for comfort on long rides. They are SPD cleat compatible.
Posted by Velo Orange at 2:18:00 PM 57 comments
13 April, 2010
Velo Orange Saddle Care
For many years I've been wearing hiking boots made by Peter Limmer and Sons. Since 1919 this small New Hampshire company has been creating what are among the finest custom-made boots in the world. In fact, I used to live a few miles from their Intervale, NH shop and remember when they also had a climbing shop on the premises.
Many years ago I had a long discussion with Peter about leather care. I thought the latest high-tech treatments were the way to go, but Peter patiently explained how they broke down the leather and shortened the leather's useful life. He had developed a natural leather treatment that would not over-soften or break down the leather over the years. I've used it on my boots and saddles and briefcases ever since.
So when we decided to make a VO leather treatment we called Peter Limmer. It turns out that Peter rides a Brooks saddle (we're sending him a VO saddle ) and agreed to make a leather saddle treatment for us. It contains natural hydrocarbons, lanolin, silicone, oils, and a just little white camphor oil. That camphor oil was added because Peter's dog tried to eat the original mix, plus camphor oil smells nice.
A four ounce (118g) jar costs $8.50 and will last for many years. Compare that to $9.75 for 28g of Proofide!
By the way, I have a size
Posted by Velo Orange at 2:44:00 PM 10 comments
09 April, 2010
Odds and Ends
A few new products and miscellaneous notes.
We have a small quantity of the new Kool Stop 4-bump Mafac-style brake pads. This style of pad has been very hard to find and we think it's great that they are being made again. So you can now rejuvenate those great old Mafac Raid brakes and put them on your new VP Rando or Mixte frame. We have only a small quantity now, but more are on the way.
Our VO brake pads are now brick red (except the MTB straight-post). They are the same compound as the black and stop equally well; we simply like the look of the red pads.
Simplex retro-friction shifters may well be the best downtube shifters of all time, but they used an odd cylinder-shaped cable end. And replacement cables have been hard to find. Fortunately the new VO shift cables have a Simplex and and a standard end; cut off the one you don't need. Simplex produced shifters for several other companies, so if you have old shifters that require funny cable ends, try these. BTW, this was Tom's idea so all of us Simplex fans should thank him.
We have three new VO wheels, a 650b Diagonale/Formula fixie rear wheel, 700c Diagonale/Novatech dynamo, and 650b Diagonale/Shimano Nexus 8-speed. Several of you asked for the fixie wheel; let us know how you like them.
We are working to post better photos of our components. Kyle shot new VO and Grand Cru headset photos that I think are are a big improvement over the originals. There are also photos of the headsets dissembled so you can see the bearing and races. Now he'll have to shoot the rest of our components; see what happens when you do a good job.
On another subject, communication with VO, there have been some small changes of late. As we keep growing my duties here are shifting. For example, I no longer have time to personally answer technical and product information e-mails. That task has fallen to Kyle, Perry, and Pat. I think you'll find that they can take more time and provide a more thorough answer. Also, if you have questions specific to your bike, rather than general questions/comments related to a blog post, please e-mail rather than asking in the comments section.
That's all for now.
Posted by Velo Orange at 11:18:00 AM 20 comments
07 April, 2010
VO Mixte Frames Now Available
While mixte frames are traditionally though of as woman's frames in the US, in Europe they are often ridden as city bikes by men who values quick mounting and dismounting.
The Mixte has full braze-ons for fenders and racks, including douple drop-out eyelets. There is one bottle cage mount.
It is brass brazed from 4130 double-butted chrome-moly tubing. The wheels are 700c and maximum tire size is 38mm. It uses extra-long reach caliper brakes. Note that the rear caliper is elegantly mounted on the mid-stay, so there is no awkward cable routing as with many mixte frames. The rear dropouts are horizontal so either internally-geared or derailleur drive trains work perfectly. Frame geometry can be found here.
The headset is 1" threaded (ISO), brakes are extra long reach (55-73mm), BB is standard ISO (or British) with a spindle length to match your choice of crank, 27.2mm seat post, we suggest 45-55mm fenders, 132.5mm rear spacing so both road and MTB hubs fit.
Posted by Velo Orange at 11:52:00 AM 25 comments
05 April, 2010
Polyvalent Mini Build Kit
We are introducing a mini build kit for the Polyvalent. It includes:
- A Polyvalent frame set
- VO Diagonale/Shimano 105 Front Wheel
- VO Diagonale/ Shimano 105 Rear Wheel
- Grand Cru sealed bearing headset
- Grand Cru seat post
- Roberto Components Canti Brakes in black
And any other parts ordered at the same time are 10% off.
Posted by Velo Orange at 1:07:00 PM 23 comments
01 April, 2010
Gran Rapide Components
It's funny how companies don't always follow our well considered road maps. For example, we seem to be selling more VO seat post to racers and triathletes than to randonneurs and "country riders". Hardly a day goes by without an e-mail asking for a 31.8mm and/or carbon version. The reason is that all those folks riding too-small frames find benefit in increased set back. We see a similar interest in our stems. So we'll be introducing a new component line called Gran Rapide to meet this need.
Our first product will be an aero seat post. We'll introduce aero stems next, then a deep-V version of our PBP rim. It's a new direction for VO, but we think it has great potential for expansion. Any ideas for new Gran Rapide products?
Posted by Velo Orange at 10:04:00 AM 37 comments


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The LaserWriter 8500, introduced in August 1997, was the end of the line for Apple LaserWriters. Although Apple stopped introducing new printers in 1997 and discontinued most immediately, the 8500 remained available until January 1999.
Category Archives: Printers
The LaserWriter 12/640 PS was one of Apple's last LaserWriter printers.
The LaserWriter 4/600 PS was the last low-end LaserWriter; it supports 600 dpi resolution. Its only connection is for LocalTalk networking.
The Color LaserWriter 12/600 PS was a no compromise color laser printer with 600 dot-per-inch output, 110 lb. of weight, and gorgeous output. It uses four separate toner cartridges – black, cyan, yellow, and magenta.
The LaserWriter 16/600 PS was the low end of the second generation LaserWriter 600 family. It includes a parallel port for use with PCs. It was part of the first family of LaserWriters to support 600 dpi resolution, following the LaserWriter Pro 600 and 630 from 1993.
The LaserWriter Pro 810 was a beast – 19.5″ tall, 81 lb., and with three paper trays, this one was designed for heavy use. It prints pages "sideways" compared to most laser printers, which also allows it to print on 11″ x 17″ paper.
Unlike the serial-only Personal LaserWriter 300 introduced earlier in 1993, the Personal LaserWriter 320 was an affordable laser printer with LocalTalk support.
The LaserWriter Select 360 was the only networkable model in the LaserWriter Select family. Unlike earlier LaserWriter Select models, the 360 uses a Fuji Xerox Pro printer engine, which is twice as fast and has 600 dot per inch resolution (vs. 300).
Earlier in 1993, Apple had introduced its low-end LaserWriter Select line, which seemed like a replacement for the Personal LaserWriter family – but here was the Personal LaserWriter 300, another low cost 4-page-per-minute serial-only QuickDraw printer similar to the Personal LaserWriter LS. Color me confused by two competing product lines!
The LaserWriter Select 310 was something of an anomaly for Apple, a PostScript printer without network support. The 310 is part of Apple's low end 5 page-per-minute LaserWriter Select family that replaced the earlier Personal LaserWriter series.
The LaserWriter Select 300 was a QuickDraw laser printer without network support and part of Apple's low end 5 page-per-minute LaserWriter Select family that replaced the earlier Personal LaserWriter series.
The LaserWriter Pro 630 was the high end of LaserWriter 600 family, which brought the LaserWriter to 600 dpi resolution.
The LaserWriter Pro 600 was the low end of LaserWriter 600 family and the second LaserWriter with a parallel port (the 1992 Personal LaserWriter NTR was the first).
The Personal LaserWriter NTR was a networkable 4-page-per-minute Postscript laser printer designed to work with PCs (via parallel port) as well as Macs. It was the first LaserWriter to use an AMD CPU instead of a Motorola 68000 or 68030.
Introduced in 1991, the LaserWriter IIf was a big step forward from the LaserWriter IINTX. It had a much more powerful CPU, a 20 MHz 68030 instead of a 16 MHz 68000, and its 2 MB of memory could be expanded as high as 32 MB. It was one of the first printers with Postscript […]
Although the LaserWriter IIf was a big step forward from the LaserWriter IINTX., the IIg was also a big step forward from the IIf. It was the first LaserWriter with ethernet, and it included two technologies to improve output. FinePrint reduced jaggies on text while PhotoGrade supported over 65 levels of gray in printed output. […]
The Personal LaserWriter LS was a low cost 4-page-per-minute QuickDraw printer similar to the Personal LaserWriter SC, but it connected to Apple's serial port instead of usings SCSI and retailed for $700 less. It is not networkable and does not have Postscript. As a QuickDraw printer, it depends on the host computer to render the […]
The Personal LaserWriter SC was a lower speed, lower cost replacement for the LaserWriter IISC. Like the IISC, it connects to a single Mac using SCSI. It is not networkable and does not have Postscript. It is a QuickDraw printer that depends on the host computer to render the page before sending it to the […]
The Personal LaserWriter NT was a networkable 4-page-per-minute Postscript laser printer designed as a lower cost alternative to the LaserWriter IINT.
The LaserWriter IINTX was the top end of Apple's first generation LaserWriter II family and a more powerful successor to the LaserWriter Plus. It was considered the best laser printer on the market at the time. The LaserWriter II family of printers all used the same 8 page-per-minute 300 dot-per-inch Canon LBP-SX engine, but each […]
The LaserWriter IINT the core of Apple's LaserWriter II family and a worthy successor to the LaserWriter Plus. The LaserWriter II family of printers all used the same 8 page-per-minute 300 dot-per-inch Canon LBP-SX engine, but each model had a different logic board. The LaserWriter IINT was the middle of the line and the least […]
The LaserWriter IISC was a bit of an oddity. It was the low end of the LaserWriter II family, and to keep costs down Apple left out LocalTalk networking and Postscript. The IISC connects to a single Mac using a SCSI cable. QuickDraw images are rendered in the computer and then sent to the printer.
The LaserWriter Plus, introduced on January 16, 1986 along with the Mac Plus, built on the success of the networkable, Postscript-based, 300 DPI LaserWriter by adding 22 more fonts to the 13 included with the original LaserWriter.
The original Apple LaserWriter was the 77 pound beastie that helped launch the desktop printing revolution in 1985, along with Aldus (later Adobe) PageMaker and the Fat Mac. Three things helped it make inroads: its 300 dot-per-inch resolution, the Postscript page description language (which Apple was the first to license), and the fact that the […]