Asthma Treatment: New Guidelines 

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It's good that the guidelines are reflecting what we've come to learn about asthma over the past few years that much of it is eosinophil-driven (driven by the immune-system), meaning that it responds to immune suppression much more than we had appreciated before. It's not just a handful of people with high eosinophil counts who get the specialty drugs, but patients more broadly who can benefit. This is a good thing for patients. As Dr. Seheult rightly points out, the severe exacerbations can be fatal. This will save lives. Thank you, Doctor, for the clear and succinct update.

As your friendly neighborhood Respiratory Therapist, please use your spacers with inhalers! Not all inhalers need them, but things like Albuterol inhalers MUST have them. You're not doing anything wrong by using one, nor are they just for kids. Without the spacer holding the medicine for you, the vast majority of the medicine gets squirted out into the back of your throat and doesn't really get down to your lungs.

As always, Dr Seheult is pure gold. Succinct, clear, and a wealth of information. Thank you.

This is needed more than ever, now that the air has been inundated with particulates from all these fires.

Concise as well highly informative and will be useful for all the clinicians who have background knowledge of Asthma and COPD. With a few slides you explained the treatment so well.Thanks

I've never had asthma, so I knew nothing about these medicines...until covid. Lung clotting was a major cause of death for covid. Nebulized albuterol treatments knocked out covid in my 80 year old mother and myself (60 y/o male) 3 years ago. I'm talking 6 treatments, 3-4 hours apart, and the next day we were not just better...we were cured...it was a huge improvement).... so THANK YOU to everyone who keeps trying to figure out what does work and what works even better on these medical issues...and then shares it with the world. We may not need it right now, but who knows what's next....

This is super helpful, thank you! Now I know why my insurance is suddenly denying coverage for my Ventolin, and all generics. Time to have a chat with the pulmonologist.

What an amazing presentation on the new Asthma guidelines. It had visuals, it had evidence based medicine and it had a great narration. Thank you so much for providing such an amazing video!!!

I was diagnosed with asthma last year and use an albuterol inhaler PRN. I am not having actual “I Can’t Breathe” attacks more than twice a year but my daily shortness of breath is getting much worse, especially since my last round of COVID last fall. If it hadn’t been for my inhaler I probably would have been hospitalized. I appreciated this video because it gives me more of an understanding about future medications my doctor might prescribe to manage my asthma and to look at possible COPD. That’s not paranoia, I was a heavy smoker for 20 years. I quit 20 years ago but somehow it doesn’t seem to matter.

Thank you. I have 9/11 COPD/Asthma/GERDs/Cancer(s) and your synthesis of GINA Report and research articles extremely well done. Sent to my physicians.

I'm definitely thank you all for putting this on RU-vid for people to learn about asthma I have asthma and I am learning a lot by looking at your RU-vid I know what to ask my doctor once again I thank you and I thank you so much for putting this out for people to learn and educate them

Thank you for your informative video. I have had athsma for many years. I have found the reformulated version of Abuterol with the new inhaler barely effective, when the old version was effective for decades.

Thank you so much for this informative video.

Air purifiers, diet change and lose dose antigen therapy for allergies has practically eliminated my asthma attacks.

thanks for the info

Excellent video Doc! My wife has Asthma & has been taking Advair daily for quite some time now. She also takes Albuterol as a rescue inhaler. I will have her watch this video. Thanks for this important medical information! Hope that all is well with you & your family.

Super helpful video, thanks.

Thank you. This is very good information.

People who don't have asthma, or have a minor case of it, don't realize how bad it can get. About 4k people die from asthma attacks every year in the USA. I used to go to emergency about every 6 months, until I got on Advair too. I don't think I have ever been to emergency since using Advair. If you have a child who gets severe asthma, check with their school to see if they are allowed to carry their inhaler on them. About a year ago, a student died in Riverside, Ca, because he was playing soccer during recess, and his rescue inhaler was in the Nurses office. He may have been so low on oxygen, he may not even had been able to tell someone to go get it from the Nurse, or call 911. He may have had to try and use hand signals. I think a child should be able to keep a nebulizer and albuterol liquid in their home room class too, in case he can't get to the nurse, or they not in their office.

So informative, thank you!

Pure gold doc

nice thank you very much I have mild asthma so this is very helpful

Great info!! I’ve been hitting the albuterol more than usual with this smoke in the PNW. So this will be helpful! Thanks!

I'm so glad I caught this. I've moved and need to find a doctor. I want to have this info handy. Now, if only I could find a doctor who doesn't try to treat my asthma like an allergy problem. They always start with that and don't usually listen to me... even when armed with my records. It has never been an allergy issue, and I've known about my asthma since my first major attack in 1976.

very helpful , thanks sir

Excellent video thank you..

Thanks for t his. This is quite interesting.

I LOVE the lectures....love medicine....thank u Dr!

I had asthma for nearly 50 years. It has disappeared completely since I started following a keto diet 4 years ago.

Thank you

Very interesting. My doc gave me different meds for my last asthma flare. No explanation for why. Would be nice if it was explained. Thank you.

Thank you for this video, its the most informative video on asthma I've ever watched.

Cigarette smoking I believe is the greatest cause of COPD. My father gave up a life time of cigarette smoking in his late 30s. He was a fit strong man till his late 70s. Then he got COPD as a result of his history of smoking. He could barely walk to the toilet and was on O2 nasal feed where ever he tried to go. Pneumonia killed him in his late 80s. Damn cigarettes. Don't smoke folks

Learning this for my abim boards haha. Thanks!

People with asthma really need to look into their vitamin D levels. As a kid, I only had mild asthma around cats and dogs. But when I got closer to 40, I began having persistent mild asthma and was put on a HFA twice daily maintenance plan (two puffs in the morning, two at night). I was working night shift in the Pacific Northwest, getting virtually no sunlight for years. I was taking a multivitamin, but it only had 1000 IU's of vitamin D3. I recently started taking more vitamin D3 (5000 IU's at breakfast, 5000's at dinner) and now I only have to use ONE puff of HFA per day. It was a huge difference. Sometimes I don't even need HFA at all. Obviously this is anecdotal, but there are some studies out there showing vitamin D deficiency can affect asthma. Hope this helps someone.

What about side effects of a corticosteroid. I took it for years and had significant problems with throat irritation, and I’m wondering if it would increase the chance of getting respiratory infections in the long term?

Adding magnesium to my daily supplements has radically improved my asthma. Just an FYI for anyone watching.

This is needed more than ever. Long Covid has triggered so much lung inflammation. Is it asthma after acute covid is declared over? It often responds to inhaled steroids.

It will be interesting to see how long it takes for this to impact practice

Dr.: this is interesting. Thank you for posting! I have more serious asthma now. 20 years ago when it was more mild, when I was sick I was sometimes given inhaled steroid two to three times a day plus continue albuterol daily until the illness resolved. I imagine the above is somewhat similar. This makes sense and I still get good results, now that I am on a biologic when I have an exacerbation, I do that combo approach still, and it resolves more quickly, as long as I am not very ill, and then I drop it. Asthma Tx is also an art. An excellent doctor who understands human and asthma variability is a must.

please make a video about myofascial pain (it's not taken seriously even though it prevents millions of people from sleeping (e.g. more than 20 minutes or 1h in a row, for years). There are a lot of misconceptions and misinformation about it and the way to treat it (such as "correct your posture" or "stretch your muscles" etc.).

Please can you do a video on red light, collagen, exercise and diet recommendations/research for osteoarthritis?

This is interesting and very helpful information. I appreciate the GINA assessment of asthma control. As I've aged my asthma is worse than the mild it was for years. A Dr. Rx Symbicort b.i.d when wheezing became obnoxious. I could not tolerate it because of suspected allergy to it with increased mucous, worsened throat clearing symptoms. Now I'm on a break from Flovent with occasional use of Albuterol. Finally, is there any known (nonitchy) rash associated with inhaled corticosteroids?

I have had severe asthma since childhood.. many icu admissions. Finally got onto laba/ics (Pulmicort/Oxis.. like symbicort but I have them in separate inhalers as I can’t get the right combo in symbicort.. have used these for approx 25 years now.. it has been the only thing that has treated it effectively.. I increase the dose when I get asthma symptoms eg when I get a cold and it stops it most times without any other meds.. it’s the business! Of course every new GP I’ve had tries to get me back on other inhalers.. but I have managed to stand firm.. have not had any hospital admissions and rarely take corticosteroids now.. as a young person I ended up with a tricky prednisone addiction as I couldn’t get any meds that actually worked until I found Pulmicort/Oxis.. I agree completely with what you are saying.. thanks for the info!

What do you think about patients who use a SABA prophylactically before exercise? Should they also use an inhaled steroid at that time?

So are insurers going to evaluate what they're covering? I work in asthma and spend ridiculous amounts of time on Prior auths for combination inhalers. Insurance is always wheeling and dealing with drug manufacturers to make their formulary. One year, a patient is stable on generic advair. Next year that's not preferred on the insurers formulary so gotta switch or pay 500 a month to breathe. I hate the way we do things in the US.

Hopefully Kaiser will put this medication back on their formulary!

Yeah I’ve kind of noticed that if I do my steroid and the albuterol at the same time, I get better long-term results. However for long-term steroid users please please make sure you get regular eye exams. And add in some nasal washes to prevent asthma if post-nasal drip is a trigger (exercise-induced.)

My asthma doc presecribed Dulera for me in 2012, and I have not needed the rescue inhaier albuterol since. Also only have to take the Dulera as needed. This study seems to confirm he knew what he was doing back then. I am still taking the Dulera, although my insurance doesn't normally cover it, and we have to get pre authorization for Dulera every year.

I didn't hear anything about vitamin d. Is there any mention of vitamin d levels in the studies? You should look for the studies of vitamin d and asthma. Checking vitamin d levels seems to be anathema in asthma. I wonder why.

Wow, I have been doing this without even knowing there was a research and it does work. This is because the ICS affected my eyesight so i only take it when I'm using my albuterol pump

I was told I had asthma as an elderly person, and given inhalers including that combination inhaler. All I can tell you is the inhalers made the problem MUCH worse; the inhalers turned the problem from an occasional one into a constant daily one, and greatly increased the severity. I could not get enough air because I could not breathe OUT when I used the inhalers. I really felt like I was going to suffocate and die. No, I have never smoked, and no, per the lung function tests I don't have COPD. I couldn't walk a couple hundred feet uphill to my garden without stopping to pant for air. Finally in desperation I threw them all in the trash and started using a Chinese traditional asthma tea, and only when having problems. The whole shortness-of-breath problem just disappeared except for very mild symptoms a couple of weeks a year (allergies???) and then I take the tea. After all of this, I really question how "asthma" is diagnosed, and I think way too many drugs are prescribed for "mild" asthma without regard to side effects on different people. I have read for example that these treatments work very poorly for many black patients, which seems to point at genetics having a lot of influence on their effectiveness/safety. At any rate, their effects frightened me enough that I'll never use them again.

4:33 That's how I deal with my asthma as well, I only use it if I feel some trouble breathing or in case of an exacerbation like coughing and stuff.. Thankfully I almost never use it, perhaps a couple times a month... sometimes I go months without needing it.

i was always taking symbicort as needed even though the doctors always said i should take it every morning/evening, it seemed to work fine for me just taking it sometimes, interesting it has been validated now

He I see you are in California I always wanted to take a trip out there see the redwood trees

I have my asthma pretty much completely controlled by diet and supplements. I take stinging nettle and NAC. When I did take a rescue inhaler I would get a rebound effect a few hours later- even though I would get a few hours of relief.

65% reduction 😮 That is amazing! It's about time they "upped" the standard medicines. Later in life, I was diagnosed with Chronic bronchitis and use combivent. It opens the asthma tubes, firstly and then opens the bronchial tubes. It is Ipatropium and albuterol. Albuterol, alone, is ineffective. For my needs, it is 100% effective. Somewhere I read that we are all born with emphysema but what we do in life is what stimulates it. This lecture is well needed. Thank you, Dr Hansen

This is devastating for me, I can take albuterol and it really helps. I literally cannot take inhaled corticosteroids without a giant Candida flare up, that in the past has caused 60 pounds of weight gain in 3 months. Forcing me on a corticosteroid steroid will cause me harm. I'm really glad I got the heads up from you here, because I now have a mountain of research to do to figure out how to avoid being forced on a corticosteroid steroid.

SYMBICORT can also cause other serious side effects, such as increased blood pressure, increases in heart rate, and changes in heart rhythm. These are not all the possible side effects of SYMBICORT - there is a number of them. Ventolin was very effective, but it was being over used and was less efficient with controlling chronic symptoms. An asthmatic should ALWAYS have Ventolin (Salbutamol) for a back up reliever because it is VERY efficient at relieving mild attacks. Just a note: Symbicort is unpleasant to take. I've written this as an long-term chronic asthmatic and a lay person.

Alright, this is based on my own life experience... and I know that medicine/science can evolve over time... but: I've always associated "asthma" as having the need of having an inhaler with you at all times in case of flair-ups. My daughter was born in 2001 and suffered greatly as a child due to seasonal allergies from spring to fall. Her symptoms would be red, itchy, watery eyes, runny nose, irritated throat, etc. and many times severe enough that she needed to stay home indoors for a few days to alleviate her symptoms. Maybe once a year it would be severe enough that she would also be prescribed albuteral to help the symptoms. So here's my issue: I've grown to understand that there was a difference between having asthma-like "symptoms" from a condition/sickness and having "asthma" AS a condition in its own that COULD be aggravated by external conditions (air impurities) and/or internal conditions (stress). Although my daughter still suffers from seasonal allergies, sometimes badly, in general it's nowhere near as bad as when she was younger. She was prescribed albuteral maybe once in the past 8 years as opposed to 1 to 2 times a year when she was little. The problem arose when she was in high school and needed a yearly physical exam before being allowed to join athletic teams at her schools. The doctors would say she "has" asthma and that she needs to have a rescue breather just because she "used" albuteral in her past. It was always a yearly issue arguing with the doctor and school nurse about how the albuteral was only for the severe allergy attacks when she was younger. It's like saying if I were ever sick enough to need hospital care and if they gave me oxygen either through a canula or mask, then that means I have COPD. That simply does not make any sense and quite frankly would sound like the doctor for his credentials from a cereal box. Isn't there a clear distinction of having a sign/symptom of asthma due to having your airways restricted from a sickness/severe-allergic reaction as opposed to "having" asthma AS a condition in and of itself that COULD be exasperated from other factors? Again, if I ever needed oxygen in my past, that DOESN'T mean I have COPD type disease... so WHY are every pediatrician nowadays declaring that if a child EVER needed albuteral, than it means the child HAS asthma for life and SHOULD always have a rescue breather??? It seems to me that many doctors blindly go through medical literature without any critical thinking. Kinda brings to mind my past benadryl use... the active ingredient is also very common for sleep aid. In my younger years I needed over the counter antihistamines to help my seasonal allergies. I also have always had insomnia issues. And whenever I mentioned to a doctor that I took a benadryl to help me sleep because I ran out of my unisom, they'd be completely puzzled and question the action and say, "but that's for allergies, not for sleeping" and then if have to educate the doctors that benadryl's active ingredient IS the new norm in over the counter sleep aids... to which they'd still give a disbelief reaction to. I simply can't understand how the medical community can be so narrow-minded sometimes. Side note... benadryl never worked well enough for me, and as a sleep aid was terrible for me. For allergies I now use daily types such as Claritin, and only sleep aids (as needed) with the older more useful doxylamine succinate as the active ingredient. TL:DR Isn't there a difference of having asthma symptoms from an underlying condition as opposed to having asthma as a condition??

Online comments acting as amateur online pharmacists is incredibly dangerous. Everyone is absolutely different from another. PLEASE check with YOUR Pharmacy Pharmacist if not in person face to face then call them, if you have to hold the phone for a few minutes it is still way shorter time than spent in an ER room, and to call your Pharmacy pharmacist is FREE.

uhm, you need to include what c 1 9er did to our lungs on top of these issues. since i got the original c 1 9er back in 2019 (last week of) before THEY said it was started to spread in late jan/feb, i have to have asthma and copd inhaler's and i take primatene tabs on top, to me the primetabs work great sometimes better than the inhalers but not alone, i have to have all 3 every day and night. all i can say is that the o.g. c 1 9 er ravaged my lungs and i have a harder time breathing now, before that, i was fine with just a saba and or prime tabs seasonally or couple of times a year.

Have to admit I had not heard faba until today. Had to turn my phone over and look

What is OCS? As in avoid maintenance OCS. Does that refer to occasional chronic systems, and using a rescue inhaler when occasionally needed?

A common error in modern American medicine is the idea that guidelines are laws, and must never be deviated from. This flies in the face of patient-centered medicine.

Is ICS-Formoterol also recommended for exercise-induced asthma, and if so, can it be given hours before (rather than 5-20 minutes in SABA) because it has LABA? (Formoterol half life is 7 hours).

Advair 250/110 works great no more fast acting inhaler

good luck getting Symbicort covered

My son has asthma since childhood and during his 30 years he has had the same medication. I have wondered why nothing has changed, but maybe it will now.

GINA 2019 already suggested using ICS-formeterol or ICS single inhaler + SABA as needed for treatment in mild asthma instead of using just SABA as needed. This was revolutionary for clinical pracitce at least in EU as we never prescribe SABA as only asthma treatment anymore since then. Over the years another problem occured as many patients don’t feel the decline in lung function especially if the symptoms appear gradually and they don’t know when to use ICS-formeterol inhaler that is only perscribed to be used as needed. This approach is therefore appropriate only for a small number of patients. I believe this is the main issue for GINA to address in the future.

Do you know if these new protocols are coming to the UK?

I am so thrilled I have managed my asthma with herbs and homeopathy. My gf has been off her inhaler for 4 months using the same remedies. My inhaler was making me worse and it had terrible side effects for me. I now feel much better and breathe so much better and have very little episodes; and when I do have one, it is quite mild (compared to before) and the remedies work fast for me. I was talking to my gf one day and she happened to mention her inhaler was making her worse too so I told her about the remedies. She got on them and said they have been life changing. Too bad more people do not know about these.

Thanks for posting. We are trying to nail down whether my shortness of breath and feelings of chest pressure is due to my mild Pulmonary Hypertension (40 on echo / 40/25 RHC) or if COPD or Asthma. My doc wants everything to be about COPD - I am pushing back because my DLCO score is normal (86) and so is my FEV1. Doc is pushing for COPD because FEF increased by 16 points from 5.01 Since everything else was normal, shouldn't the diagnosis lead more to Asthma? And... even with that - are my symptoms more of a Pulmonary Hypertension nature ? They classify my PH as being in class 3 based on my docs interpretation leading to COPD. Any help understanding this would be appreciated.

Asthma and copd are caused by right side vegophaty ,neurophaty witch is due to exotoxins ,chemotoxis ,biotoxins and poor detoxification or lack of hot climate . Despite cigarette ,allegens and toxins here in hottest place on earth ,afar ,Ethiopia no asthama and copd case .even those patient who come from cold climate in ethiopia ,they recover the atack within few hours .thanks to near infrared radiation ! The best detox and antiinflammatory !

This is confusing 😔 I am due my asthma review in a few weeks. I used to be on the brown maintenance inhaler but a year ago they suggested the pink fostair. But I still find the blue (ventolin?) as a reliever as and when needed. I believe I overused the blue one during my Covid cough and I think that’s why I ended up with pins and needles in my fingers on outbreath. It’s still there a bit nine months on.

as an asthmatic i can attest to the importance of saba and ics treatment, ive had flareups that felt like breathing thru a pen tube, maybe worse, always at times ive forgotten my inhaler at home.

This is great information, thanks. I've had asthma since I was a young boy. For the last 10 years, I've been well-controlled with a 1x/day ICS and SABA (Albuterol) as needed. I find I have to use the SABA for exercise, and on a few rare times getting into bed at night.

I used to use an inhaler, but my breathing only got better in the short run, and it got worse in the long run.

Duoneb always seems to be on back order. We are still using albuterol in our urgent care.

So if Symbicort is too expensive, a combo of taking fluticasone and and salbutamol would be a good affordable alternative?

Are long term ICS side effects a concern? My 6 y/o is starting symbicort, I worry about long term effects (osteoporosis, growth suppression, infections)

Albuterol never did a thing for my asthma, but maybe I'll talk to my doctor about this to see if it helps!

When I was working in the ER as an RT about a decade ago we would do an 2mg budesonide neb with high dose albuterol for acute exacerbations. Don't know if they still do that.

Any estimate on costs involved for the inhaler with ICS/Formoterol? I ask because my insurance isn’t covering the inhaler that works for me. My out of pocket cost for it is $880. This is not sustainable.

I am suffering from inhaler induced eczema (like topical steroid withdrawal). All symptoms are the same as I have already been through 4.5 years of topical steroid withdrawal, and am aware of the symptoms - its not eczema. I was assured that inhalers with steroid in would not cause the same red skin syndrome/tsw like side effects. I dont really have anywhere to turn as i need the long acting inhaler (which contains the steroid), yet i am suffering so much from the side effects on my skin.

How about Leukotriene inhibitors

Thoughts on the biologics as a final step in the GINA guidelines?

Dr. Have you looked at herbal meds like Mullein?

Would that apply to exercise-enduced asthma, too?

Side effects if take according to guidelines?

Who paid for the study and how much more is the combo medicine? Albuterol on good rx is $17 doesnt say how much puffs. If 30 then times by 4. Symbicort on good rx is $105 for 120 puffs of the lower dose then $150 for the higher dose. I always have a but of skepticism when rules change

What would the commercially available inhaler names be that have the ICS and albuterol as a combination inhaler?

Lifestyle also comes into play, would be interested to see if they factored it in As a child I had severe asthma, so did my sister (nebulisers etc the works ) We lived in a house with 2 smoking parents and lots of mould. Once we moved out of home both of us went from frequent attacks to rare attacks My dad used just ventolin when he wasn't smoking attacks were mild once he started smoking again severe pass out fits returned Currently in Australia they recommend ventolin as needed then what they call a preventer routinely

0:05: 📚 The video discusses the treatment of asthma and COPD, with a focus on the new guidelines for asthma treatment. 2:58: ✅ A study published in the New England Journal of Medicine found that combining an inhaled corticosteroid and a long-acting beta agonist as routine treatments, or using an inhaled corticosteroid alone as routine treatment, can be effective for managing mild asthma. 5:27: 💡 Using an inhaler with an inhaled corticosteroid as a rescue inhaler is more effective in reducing urgent medical care usage and systemic glucocorticoid use compared to using albuterol alone. 8:20: 💨 New asthma guidelines recommend combining short-acting beta Agonists with inhaled corticosteroids for rescue inhalers. 11:05: 📚 Risk factors for asthma flare-ups and exacerbations include obesity, food allergies, smoking, and other medical conditions. Recap by Tammy AI

This is awesome information. Question, my 6 y/o has multiple food allergies, and have had to give albuterol for cough from food allergies.. He occasionally has exercise induced coughing. Does this also sound like asthma, how would I get him tested?

Oh, coverage 😢 This will be the biggest problem in my setting.

This new idea to treat a conundrum of chronic bronchitis leading to lasting changes in the bronchial mucosa due to remodelling and changes in the pharmacological response e.g. loss of response to coricosteroids, must also consider the last point : weakened response to corticosteroids necessitating to add amino/ theophyllin to reverse the NON RESPONSE TO CORTICOIDS, otherwhile the brillant GINA hypothesis would be inefficient. REMEMBER Gina !: add AMINOPHYLLIN to restitute response to the antiinflammatory effect of CST. F de Clari MD..

My wife has the most severe form of asthma. She's been in the ICU, on a ventilator, in a medically-induced coma, 8 times. She crashes if she gets a respiratory infection. She lives on Albuterol on a nebulizer, with 20 treatments per day. It's life altering.

Here in Australia we have leant toward combination therapy with a beta agonist and an inhaled steroid for 30 years. Only the very mildest asthmatics are managed with beta agonist only As an aside think budesonide is a poor ICS. Fluticasone is my go-to ICS