Asthma in adults: treatment, inhalers and video visits in Puerto Rico

Asthma is a lung disease in which the airways become inflamed and narrow, which makes it harder to breathe. It is a long-term condition: symptoms can come and go, and flare suddenly during an asthma attack. With the right treatment, most people keep it under control.

For your safety, call 911 or go to the nearest emergency room if you have any of these signs. See also when to go to the ER.

• Your rescue inhaler does not help or breathing is still very hard
• Trouble talking or walking because you are short of breath
• Lips, nails or skin with a bluish tint

Asthma causes wheezing, shortness of breath, chest tightness and coughing, especially at night or early in the morning. Symptoms can come and go, and get suddenly worse during an attack. For some people, a dry cough that won't go away, worse at night or with exercise, is the main sign of asthma.

You see Dr. Diana Nieves Castro, MD, a general practice physician licensed in Puerto Rico (verify her license) with several years of emergency-department experience, so she knows what well-controlled and poorly controlled asthma look like. She sees you in English or Spanish. We evaluate, diagnose and treat; if needed, we give you a lab order for a lab near you.

As part of our chronic care, the doctor can:

• Ask about your symptoms, how often you use your rescue inhaler and whether you wake up at night.
• Check your inhaler technique on camera.
• Write or update your asthma action plan with you.
• Adjust your treatment and refill your inhalers. If appropriate, the doctor prescribes and we send your prescription to your pharmacy.

There are two kinds of asthma medicine. The doctor evaluates which is right for you; this information does not replace her evaluation.

Rescue inhaler (albuterol). Albuterol, also called salbutamol (one well-known brand is Ventolin), is a common rescue inhaler. It is a short-acting bronchodilator: it relaxes and opens the airways when you have wheezing, shortness of breath, coughing or chest tightness, and is sometimes used before exercise. It can cause shakiness, nervousness and headache; if it gives you a racing heartbeat or chest pain, or you need it more than usual, tell the doctor: your asthma is not well controlled.

Inhaled corticosteroid controller (budesonide). It is used every day, even when you feel well, so you have fewer and milder attacks; it does not stop an attack that has already started. Rinse your mouth with water and spit it out after each use to reduce hoarseness and yeast infection in the mouth. MedlinePlus lists hoarseness, especially with hives or swelling of the face or throat, among the serious effects of inhaled budesonide: call your doctor right away or get emergency care. Budesonide also comes combined with formoterol, a long-acting bronchodilator, in a single inhaler. For young children, budesonide also comes as a suspension for a nebulizer; see the visit for children.

Montelukast (leukotriene modifier). A pill taken every day to prevent symptoms (one well-known brand is Singulair); it does not work for a sudden attack. Since 2020, the FDA requires a boxed warning about serious mental health side effects: mood or behavior changes, agitation or aggression, depression, sleep problems or vivid dreams, and suicidal thoughts or actions. They can appear while you take it or after you stop. If you notice changes like these, stop taking it and call your doctor right away; if you have thoughts of harming yourself, call or text 988 or call Línea PAS at 1-800-981-0023, open 24 hours. Before starting it, tell the doctor if you have had depression or another mental health condition; she weighs those risks and benefits before prescribing it.

Oral steroids for a flare. If you have an asthma flare that your inhalers do not control, the doctor may prescribe a steroid pill such as prednisone for a few days. If the flare is severe, do not wait: call 911.

Other options include long-acting bronchodilators and biologic medicines for severe asthma, usually managed by a specialist. None of these medicines is a controlled substance.

Spirometry. The lung function test that measures how much air you breathe out and how fast; it helps confirm the diagnosis. If you need it, the doctor gives you an order to have it done at a pulmonary function lab near you.

It works the same from anywhere in Puerto Rico:

A doctor visit has the same price for every age, with no membership and no insurance needed. You are charged when you request the visit, and you get a full refund if the clinic can’t see you. A doctor's note after your visit is included at no extra charge. See all prices.

A review of lab results is also a follow-up visit, for existing patients. If a follow-up or forms visit turns out to need a full visit, the doctor explains why and, with your consent, you pay the difference.

An action plan is a written document that tells you:

• Which triggers to avoid.
• How to recognize an asthma attack and what to do.
• Which medicines to take and when.
• When to call the doctor and when to go to the emergency room.
• Who to call in an emergency.

Avoiding what sets off your symptoms is part of treatment. The CDC lists these common triggers:

• Cigarette smoke, including secondhand smoke. If you smoke, quitting is one of the best things you can do for your asthma: the doctor can help you quit smoking
• Dust mites
• Air pollution, including smoke from fires
• Cockroaches and other pests
• Furry pets
• Mold, which grows in damp places such as kitchens and bathrooms
• Infections such as the flu, colds and respiratory syncytial virus (RSV)
• Sinus infections, allergies and pollen
• Strong chemicals and fragrances
• Acid reflux
• Bad weather, exercise and strong emotions

The Puerto Rico Department of Health BRFSS trends report (2011 to 2021) found that adult asthma stayed stable over those years and was about twice as common in women as in men.

In a warm, humid climate, mold and dust mites are triggers worth controlling at home. And because storms can cut off access to a pharmacy, keep a supply of your inhalers: see medications and hurricanes.

Every summer, clouds of Saharan dust reach Puerto Rico. According to NOAA, the Saharan Air Layer usually ramps up in mid-June, peaks from late June to mid-August, and subsides quickly after that. The EPA lists aggravated asthma among the health effects of particle pollution.

NOAA advises people with asthma to keep their condition under control and limit time outdoors during dust events. Keep your rescue inhaler handy, follow your action plan and, if you need your rescue inhaler more than usual, get checked. More in our Saharan dust guide.

We see children of all ages. If your child has asthma, the doctor evaluates them by video, checks their inhaler and action plan, and helps with refills: see our online doctor visits for kids. For their safety, if a child is breathing fast, the skin between the ribs pulls in, the lips look bluish or they cannot talk, call 911.