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Asthma ˈaz-mə

by Matthew C. Miles, MD, Stephen P. Peters, MD, PhD

Asthma is a condition in which the airways narrow—usually reversibly—in response to certain stimuli.

  • Coughing, wheezing, and shortness of breath that occur in response to specific triggers are the most common symptoms.

  • Doctors confirm the diagnosis of asthma by doing breathing (pulmonary function) tests.

  • To prevent attacks, people should avoid substances that trigger asthma and should take drugs that help keep airways open.

  • During an asthma attack, people need to take a drug that quickly opens the airways.

Asthma affects more than 25 million people in the United States, and it is becoming more common. The reason for the increase in asthma is not known.

Although it is one of the most common chronic diseases of childhood, adults can also develop asthma, even at an old age. Asthma affects more than 6 million children (see Asthma in Children) in the United States and occurs more frequently in boys before puberty and in girls after puberty. Asthma can eventually resolve in children.

Asthma also occurs more frequently in non-Hispanic blacks and Puerto Ricans. Although the number of people affected by asthma has increased, the number of deaths has decreased.

The most important characteristic of asthma is narrowing of the airways that can be reversed. The airways of the lungs (the bronchi) are basically tubes with muscular walls (see Respiratory System). Cells lining the bronchi have microscopic structures, called receptors. These receptors sense the presence of specific substances and stimulate the underlying muscles to contract or relax, thus altering the flow of air. There are many types of receptors, but two main types of receptors are important in asthma:

  • Beta-adrenergic receptors respond to chemicals such as epinephrine and make the muscles relax, thereby widening (dilating) the airways and increasing airflow.

  • Cholinergic receptors respond to a chemical called acetylcholine and make the muscles contract, thereby decreasing airflow.

Did You Know...

  • Coughing may be the only symptom of asthma.

Causes

Affected people usually carry genes that make them susceptible to asthma. Environmental conditions, including conditions before and around the time of birth, can then influence the development of asthma.

Narrowing of the airways is often caused by abnormal sensitivity of cholinergic receptors, which cause the muscles of the airways to contract when they should not. Certain cells in the airways, particularly mast cells, are thought to be responsible for initiating the response. Mast cells throughout the bronchi release substances such as histamine and leukotrienes, which cause smooth muscle to contract, mucus secretion to increase, and certain white blood cells to move to the area. Eosinophils, a type of white blood cell found in the airways of people with asthma, release additional substances, contributing to airway narrowing.

In an asthma attack (sometimes called an exacerbation), the smooth muscles of the bronchi contract, causing the bronchi to narrow (called bronchoconstriction) The tissues lining the airways swell due to inflammation and mucus secretion into the airways. The top layer of the airway lining can become damaged and shed cells, further narrowing the airway. A narrower airway requires the person to exert more effort to breathe. In asthma, the narrowing is reversible, meaning that with appropriate treatment or on their own, the muscular contractions of the airways stop, inflammation resolves so that the airways widen again, and airflow into and out of the lungs returns to normal.

How Airways Narrow

During an asthma attack, the smooth muscle layer goes into spasm, narrowing the airway. The middle layer swells because of inflammation, and excessive mucus is produced. In some segments of the airway, mucus forms plugs that nearly or completely block the airway.

Asthma triggers

In people who have asthma, the airways narrow in response to stimuli (triggers) that usually do not affect the airways in people without asthma. Such triggers include

  • Allergens

  • Infections

  • Irritants

  • Exercise

  • Stress and anxiety

  • Aspirin

Many inhaled allergens, including pollens, particles from dust mites, body secretions from cockroaches, particles from feathers, and animal dander, can trigger an asthma attack. These allergens combine with immunoglobulin E (IgE, a type of antibody) on the surface of mast cells to trigger the release of asthma-causing chemicals. (This type of asthma is called allergic asthma.) Although food allergies induce asthma only rarely, certain foods (such as shellfish and peanuts) can induce severe attacks in people who are sensitive to these foods.

Infectious triggers are usually viral respiratory infections, such as colds, bronchitis, and sometimes pneumonia.

Irritants that can provoke an asthma attack include smoke from tobacco, marijuana, or cocaine, fumes (such as from perfumes, cleaning products, or air pollution), cold air, and stomach acid in the airways caused by gastroesophageal reflux disease (GERD).

Additionally, people who have asthma can develop airway narrowing when exercising. Stress and anxiety can trigger mast cells to release histamine and leukotrienes and stimulate the vagus nerve (which connects to the airway smooth muscle), which then contracts and narrows the bronchi.

Crying or hearty laughing may trigger symptoms in some people.

Aspirin is a trigger for almost 30% of people with severe asthma, but it is a trigger in less than 10% of people with asthma.

Reactive airways dysfunction syndrome

Reactive airways dysfunction syndrome (RADS) is a persistent asthma-like disorder that occurs in people with no history of asthma. It is a form of environmental lung disease (see Overview of Environmental Lung Diseases) caused by a single large exposure to nitrogen oxide or volatile organic compounds (such as those in certain bleaches and cleaning products). People have symptoms similar to those of asthma, including cough, wheezing, and shortness of breath. Treatment is similar to usual treatment for asthma (see Asthma : Treatment).

Symptoms

Asthma attacks vary in frequency and severity. Some people who have asthma are symptom-free most of the time, with only an occasional brief, mild episode of shortness of breath. Other people cough and wheeze most of the time and have severe attacks after viral infections, exercise, or exposure to other triggers. Wheezing is a musical sound that occurs when the person breathes out (see Wheezing). Coughing may be the only symptom in some people (cough-variant asthma). Some people with asthma produce a clear, sometimes sticky (mucoid) phlegm (sputum).

Asthma attacks occur most often in the early morning hours when the effects of protective drugs wear off and the body is least able to prevent airway narrowing.

An asthma attack may begin suddenly with wheezing, coughing, and shortness of breath. At other times, an asthma attack may come on slowly with gradually worsening symptoms. In either case, people with asthma usually first notice shortness of breath, coughing, or chest tightness. The attack may be over in minutes, or it may last for hours or days. Itching on the chest or neck may be an early symptom, especially in children. A dry cough at night or while exercising may be the only symptom.

During an asthma attack, shortness of breath may become severe, creating a feeling of severe anxiety. The person instinctively sits upright and leans forward, using the muscles in the neck and chest to help in breathing, but still struggles for air. Sweating is a common reaction to the effort and anxiety. The heart rate usually quickens, and the person may feel a pounding in the chest.

In a very severe asthma attack, a person is able to say only a few words without stopping to take a breath. Wheezing may diminish, however, because hardly any air is moving in and out of the lungs. Confusion, lethargy, and a blue skin color (cyanosis) are signs that the person’s oxygen supply is severely limited, and emergency treatment is needed. Usually, a person recovers completely with appropriate treatment, even from a severe asthma attack. Rarely, some people develop attacks so quickly that they may lose consciousness before they can give themselves effective therapy. Such people should wear identification (such as a medical alert bracelet or necklace) and carry a cellular phone to call for emergency medical assistance.

Diagnosis

  • A doctor's evaluation of symptoms

  • Breathing tests

Doctors suspect asthma based largely on a person’s report of characteristic symptoms. Doctors confirm the diagnosis by doing breathing (pulmonary function) tests (see Pulmonary Function Testing (PFT)). These tests are done before and after giving the person an inhaled drug, called a beta-adrenergic drug (or beta-adrenergic agonist), that reverses airway narrowing. If test results are significantly better after the person receives the drug, asthma is thought to be present. If the airways are not narrowed at the time of the test, a challenge test can help confirm the diagnosis.

In a challenge test, pulmonary function is measured before and after the person inhales a chemical (usually methacholine, but histamine, adenosine, or bradykinin may be used) that can narrow the airways. The chemical is given in doses that are too low to affect a person with healthy lungs but that cause the airways to narrow in a person with asthma.

Repeatedly measuring lung function over time allows doctors to determine the severity of the airway obstruction and the effectiveness of treatment.

Peak expiratory flow (the fastest rate at which air can be pushed out of the lungs) can be measured using a small handheld device called a peak flow meter. This test is used at home to monitor the severity of asthma. Usually, peak flow rates are lowest between 4 am and 6 am and highest at 4 pm . However, more than a 30% difference in rates at these times is considered evidence of moderate to severe asthma.

To test for exercise-induced asthma, an examiner uses pulmonary function tests to measure how much air the person can exhale in 1 second before and after the person exercises on a treadmill or stationary bicycle. If the volume of air decreases more than 15%, the person’s asthma can be induced by exercise.

A chest x-ray is usually not helpful in diagnosing asthma. Doctors use chest x-rays when considering another diagnosis. However, a chest x-ray is often obtained when a person with asthma needs to be hospitalized for a severe attack.

Identifying asthma triggers

Determining what triggers a person’s asthma is often difficult. Allergy testing is appropriate when there is a suspicion that some avoidable substance (for example, exposure to cat dander) is provoking attacks. Skin testing can help identify allergens that may trigger asthma symptoms. However, an allergic response to a skin test does not necessarily mean that the allergen being tested is causing the asthma. The person still has to note whether attacks occur after exposure to this allergen. If doctors suspect a particular allergen, a blood test that measures the level of antibody produced in response to the allergen (the radioallergosorbent test [RAST]) can be done to determine the degree of the person's sensitivity to the allergen.

Evaluating an asthma attack

Because people who are having a severe asthma attack commonly have low blood oxygen levels, doctors may check the level of oxygen by using a sensing monitor on a finger or ear. In severe attacks, doctors also need to measure levels of carbon dioxide in the blood, and this test typically requires obtaining a sample of blood from an artery or, occasionally, a vein (see Arterial Blood Gas (ABG) Analysis). However, carbon dioxide levels can sometimes be monitored in the person's breath using a sensor placed in front of the nose or mouth. Doctors may also check lung function, usually with a spirometer (a mouthpiece and tubing connected to a recording device that is used to measure air flow in the lungs) or with a peak flow meter. Usually, a chest x-ray is needed only when asthma attacks are severe, in order to rule out other serious conditions (such as a lung collapse).

Treatment

  • Drugs to reduce inflammation

  • Drugs to widen the airways

An array of drugs can be used to prevent and treat asthma in adults or in children (see Asthma in Children : Treatment). Doctors may use the term "rescue treatment" to describe treatment of an acute attack and "maintenance treatment" to describe treatments aimed at preventing attacks. Most of the drugs used to prevent asthma attacks are also used to treat an asthma attack but in higher doses or in different forms. Some people need to use more than one drug to prevent and treat their symptoms.

Therapy is based on two classes of drugs:

  • Anti-inflammatory drugs

  • Bronchodilators

Anti-inflammatory drugs suppress the inflammation that narrows the airways. Anti-inflammatory drugs include corticosteroids (which can be inhaled, taken by mouth, or given intravenously), leukotriene modifiers, and mast cell stabilizers.

Bronchodilators help to relax and widen (dilate) the airways. Bronchodilators include beta-adrenergic drugs (both those for quick relief of symptoms and those for long-term control), anticholinergics, and methylxanthines.

Other types of drugs that directly alter the immune system (called immunomodulators) are sometimes used for people with severe asthma, but most people do not need immunomodulators.

Education about how to prevent and treat asthma attacks is beneficial for all people who have asthma and often for their family members. Proper use of inhalers is essential for effective treatment. People should know

  • What can trigger an attack

  • What helps to prevent an attack

  • How to use drugs properly

  • When to seek medical care

Many people use a handheld peak flow meter to evaluate their breathing and determine when they need intervention, before their symptoms become severe. People who experience frequent, severe asthma attacks should know how to reach help quickly.

All people with asthma should have a written treatment plan that was devised in collaboration with their doctor. Such a plan allows them to take control of their own treatment and has been shown to decrease the number of times people need to seek care for asthma in the emergency department.

Preventing Attacks

Asthma is a chronic condition that cannot be cured, but individual attacks can often be prevented. Prevention efforts depend on the frequency of attacks and the stimuli that trigger the attacks.

Identifying and eliminating or avoiding stimuli that trigger asthma attacks may commonly prevent them. People who have asthma should avoid cigarette smoke and try to avoid exposure to people with upper respiratory infections. Often, attacks triggered by exercise can be blocked by taking asthma drugs beforehand. When dust and allergens are triggers, air filters, air conditioners, and other types of barriers (such as mattress covers, which reduce the amount of particles from dust mites that are in the air) can help considerably.

Avoiding aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) helps prevent attacks in people whose asthma is triggered by these drugs. Drugs that block the beneficial effects of beta-adrenergic drugs (called beta-blockers) may worsen asthma.

Allergy immunotherapy (desensitization—see Allergen immunotherapy (desensitization)) through the use of allergy shots may help prevent attacks in people whose asthma is triggered by allergies. A doctor-supervised desensitization program may also be used for people whose asthma is triggered by aspirin or NSAIDs.

Drugs, such as inhaled or oral corticosteroids, leukotriene modifiers, long-acting beta-adrenergic drugs, methylxanthines, antihistamines, or mast cell stabilizers, are used to prevent attacks in most people with asthma.

Treating Attacks

An asthma attack can be frightening, both to the person experiencing it and to others around. Even when relatively mild, the symptoms provoke anxiety and alarm. A severe asthma attack is a life-threatening emergency that requires immediate, skilled, professional care. If not treated adequately and quickly, a severe asthma attack can cause death.

Mild attacks

People who have a mild asthma attack are usually able to treat it without assistance from a health care practitioner. Typically, they use an inhaler to deliver a dose of a short-acting beta-adrenergic drug such as albuterol, move into fresh air (away from cigarette smoke or other irritants), and sit down and rest. They can use the inhaler 3 times 20 minutes apart if needed. An attack usually subsides in 5 to 10 minutes. An attack that does not subside after using an inhaler 3 times or that gets worse is likely to require additional treatment supervised by a doctor.

Severe attacks

People who have severe symptoms should typically go to an emergency department. For severe attacks, doctors give frequent (or sometimes continuous) treatment using inhaled beta-adrenergic drugs and sometimes anticholinergic drugs. For people who are having great difficulty breathing, beta-adrenergic drugs may be given by injection. People are also given a corticosteroid, such as prednisone, by mouth. Supplemental oxygen may be given during attacks.

Generally, people who have a severe asthma attack are admitted to the hospital if their lung function does not improve after they have received an inhaled beta-adrenergic drug and corticosteroids by mouth or vein. People also are hospitalized if they have a seriously low blood oxygen level or a high blood carbon dioxide level.

Antibiotics may be needed if a doctor suspects a lung infection. However, most such infections are due to viruses for which (with a few exceptions) no treatment exists.

People experiencing very severe asthma attacks may need to have an artificial airway passed through their mouth and throat (intubation) and be placed on a mechanical ventilator (see Mechanical Ventilation).

Drugs for Preventing or Treating Attacks

Drugs allow most people with asthma to lead relatively normal lives. Most of the drugs used to treat an asthma attack can be used (often in lower doses) to prevent attacks.

Beta-adrenergic drugs

Short-acting beta-adrenergic drugs are usually the best drugs for relieving asthma attacks. They also are used to prevent exercise-induced asthma. These drugs are referred to as bronchodilators because they stimulate beta-adrenergic receptors to widen (dilate) the airways. Bronchodilators that act on all beta-adrenergic receptors throughout the body (such as epinephrine ) cause side effects such as rapid heartbeat, restlessness, headache, and muscle tremors. Bronchodilators (such as albuterol) that act mainly on beta 2 -adrenergic receptors, which are found primarily on cells in the lungs, have less effect on other organs and thus cause fewer side effects. Most short-acting beta-adrenergic drugs, especially the inhaled ones, act within minutes, but the effects last only 2 to 6 hours.

Long-acting bronchodilators are available, but they are used to prevent rather than to treat asthma attacks. The long-acting beta-adrenergic drugs are not used alone because people using only long-acting beta-adrenergic drugs may have a slightly higher risk of death. Thus, doctors always give them together with inhaled corticosteroids.

Metered-dose inhalers (handheld cartridges containing gas under pressure) are the most commonly used method for giving inhaled beta-adrenergic drugs. The pressure turns the drug into a fine spray containing a measured dose of drug. Inhalation deposits the drug directly in the airways, so that it acts quickly, but the drug may not reach airways that are severely narrowed. For people who have difficulty using a metered-dose inhaler, spacers or holding chambers can be used. These devices increase the amount of drug delivered to the lungs. With any type of inhaler, proper technique is vital. If the device is not used properly, the drug will not reach the airways.

A dry powder drug formulation is also available for many bronchodilators. The powder formulation is easier for some people to use, in part because it requires less coordination with breathing.

How to Use a Metered-Dose Inhaler

  • Shake the inhaler after removing the cap.

  • Breathe out for 1 or 2 seconds.

  • Put the inhaler in your mouth or 1 to 2 inches from it and start to breathe in slowly, like sipping hot soup.

  • While starting to breathe in, press the top of the inhaler.

  • Breathe in slowly until your lungs are full. (This should take about 5 or 6 seconds.)

  • Hold your breath for 10 seconds (or as long as you can).

  • Breathe out and, if a second dose is required, repeat the procedure after 1 minute.

  • If you find it difficult to coordinate breathing using this method, a spacer can be used.

A nebulizer can be used to deliver beta-adrenergic drugs directly to the lungs. A nebulizer uses pressurized air or ultrasonic sound waves to create a continuous mist of drug that is inhaled without having to coordinate dosing with breathing. Nebulizers are often portable, and some units can even be plugged into a power outlet in a car. Nebulizers and metered-dose inhalers often deliver different amounts of drug with a single dose, but both are capable of delivering sufficient amounts of drug to the lungs.

Other bronchodilators, including ipratropium delivered through a nebulizer, may be combined with beta-adrenergic drugs for acute attacks. A combination of ipratropium plus albuterol given in a metered-dose inhaler is also available.

Other forms are also available. Beta-adrenergic drugs can be taken in liquid or tablet form or injected. However, the oral drugs tend to work more slowly than the inhaled or injected ones and are more likely to cause side effects. Side effects include abnormal heart rhythms, which may suggest excessive use.

Quick medical attention should be sought when a person who has asthma feels the need to use more of a beta-adrenergic drug than is recommended. Overusing these drugs can be very dangerous. The need for continuous use indicates severe bronchoconstriction, which can lead to respiratory failure and death.

Methylxanthines

Theophylline, a methylxanthine, is another drug that causes bronchodilation. It is now used less frequently than in the past. Theophylline is usually taken by mouth. Oral theophylline comes in many forms, from short-acting tablets and syrups to longer-acting sustained release capsules and tablets. Theophylline is used mainly for prevention of asthma.

The amount of theophylline in the blood can be measured in a laboratory and must be closely monitored by a doctor. Too little drug in the blood may provide little benefit, and too much drug may cause life-threatening abnormal heart rhythms or seizures. When first taking theophylline, a person who has asthma may feel slightly jittery and may develop headaches. These side effects usually disappear as the body adjusts to the drug. Larger doses may cause a rapid heartbeat, nausea, or palpitations. A person may also experience insomnia, agitation, vomiting, and seizures. Occurrence of these side effects is one of the reasons that theophylline is used less often than other drugs.

Anticholinergic drugs

Anticholinergic drugs, such as ipratropium, block acetylcholine from causing smooth muscle contraction and from producing excess mucus in the bronchi. These drugs are inhaled. These drugs further widen (dilate) the airways in people who have already been given beta-adrenergic drugs.

Leukotriene modifiers

Leukotriene modifiers, such as montelukast, zafirlukast, and zileuton, also help control asthma. They are anti-inflammatory drugs that prevent the action or synthesis of leukotrienes. Leukotrienes are chemicals made by the body that cause bronchoconstriction. These drugs, which are taken by mouth, are used more to prevent asthma attacks than to treat them.

Mast cell stabilizers

Mast cell stabilizers, which are inhaled, include cromolyn and nedocromil. These drugs are thought to inhibit the release of inflammatory chemicals from mast cells and make the airways less likely to narrow. Thus, they are also anti-inflammatory drugs. They are useful for preventing but not treating an attack. Mast cell stabilizers may be helpful for children who have asthma and for people who develop asthma due to exercise. These drugs are very safe and must be taken regularly even when a person is free of symptoms.

Corticosteroids

Corticosteroids block the body’s inflammatory response and are exceptionally effective at reducing asthma symptoms. They are the most potent form of anti-inflammatory drugs and have been an important part of asthma treatment for decades. They are given in the inhaled form to prevent attacks and improve lung function. They are given by mouth in higher doses for people experiencing severe attacks. Corticosteroids given by mouth are generally continued for at least several days after a severe attack.

Corticosteroids can be taken in several different forms. Often, inhaled versions are best because they deliver the drug directly to the airways and minimize the amount sent throughout the body. They come in several strengths and are generally used twice a day. People should rinse their mouth after use to decrease the likelihood that a fungal infection of the mouth (thrush—see Symptoms) develops. Oral or injected corticosteroids may be used in high doses to relieve a severe asthma attack and are generally continued for 1 to 2 weeks. Oral corticosteroids are prescribed on a long-term basis only when no other treatments can control the symptoms.

If taken for long periods, corticosteroids gradually reduce the likelihood of an asthma attack by making the airways less sensitive to a number of provocative stimuli. Long-term use of corticosteroids, especially larger doses taken by mouth, can cause side effects including obesity, osteoporosis, cataracts, easy bruisability, skin thinning, insomnia, elevated blood sugar levels, and, very rarely, psychosis. Some studies have suggested that growth may be delayed when children use corticosteroids for an extended period. However, most children who use inhaled corticosteroids eventually reach their predicted adult height.

Immunomodulators

Omalizumab is a drug that is an antibody directed against a group of other antibodies called immunoglobulin E (IgE). Omalizumab is used in people with asthma who also have severe allergies and high levels of IgE in their blood. Omalizumab prevents IgE from binding to mast cells and thus prevents the release of inflammatory chemicals that can narrow the airways. It can decrease requirements for oral corticosteroids and help relieve symptoms. The drug is injected subcutaneously every 2 to 4 weeks. Severe allergic reactions (anaphylaxis) sometimes occur after this drug is given. Newer immunomodulators are being investigated that target other substances involved in asthma, such as inflammatory molecules called interleukins.

Drugs Commonly Used to Treat Asthma

Drug

Some Side Effects

Comments

Short-acting beta-adrenergic drugs

Albuterol

Levalbuterol

Pirbuterol

Increased heart rate

Shakiness

For immediate relief of acute attack

Long-acting beta-adrenergic drugs

Arformoterol

Formoterol

Salmeterol

Increased heart rate

Shakiness

For ongoing treatment, not for acute relief

Not recommended for use alone (without other asthma drugs)

Methylxanthines

Theophylline

Increased heart rate

Shakiness

Stomach upset

Seizures (if the blood level is high)

Serious heartbeat irregularities (if the blood level is high)

Can be used for prevention and treatment

Taken by mouth but can be given intravenously in a hospital

Anticholinergics

Ipratropium

Dry mouth

Rapid heart rate

Usually used in combination with a beta-adrenergic drug

Mast cell stabilizers

Cromolyn

Coughing or wheezing

Useful for preventing attacks, often related to exercise, but not for treatment of an acute attack

Corticosteroids (inhaled)

Beclomethasone

Budesonide

Flunisolide

Fluticasone

Mometasone

Triamcinolone

Fungal infection of the mouth (thrush)

A change in the voice

Inhaled for prevention (long-term control) of asthma

Corticosteroids (oral)

Methylprednisolone

Prednisolone

Prednisone

Weight gain

Elevated blood sugar levels

Rarely, psychosis

Osteoporosis

Cataracts

Skin thinning and easy bruising

Insomnia

Used for acute attacks and for asthma that cannot be controlled with inhaled therapy

Leukotriene modifiers

Montelukast

Zafirlukast

Zileuton

Eosinophilic granulomatosis with polyangiitis (formerly called Churg-Strauss syndrome)

With zileuton, elevated liver enzymes

Used more for prevention (long-term control) than for treatment

Immunomodulator

Omalizumab

Discomfort at the injection site

Rarely, anaphylactic reactions

Used in people with severe asthma to decrease use of oral corticosteroids

More Information

Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • ADRENALIN
  • No US brand name
  • ADENOCARD
  • PROVENTIL-HFA, VENTOLIN-HFA
  • RAYOS
  • ATROVENT
  • ELIXOPHYLLIN
  • ZYFLO
  • ACCOLATE
  • SINGULAIR
  • CROLOM
  • ALOCRIL
  • XOPENEX
  • XOLAIR
  • ORAPRED, PRELONE
  • PULMICORT, RHINOCORT
  • KENALOG
  • CUTIVATE, FLONASE
  • MEDROL
  • SEREVENT
  • BECONASE
  • BROVANA
  • FORADIL AEROLIZER, PERFOROMIST
  • MAXAIR
  • AEROSPAN HFA
  • ELOCON, NASONEX