Centers of Excellence

The Lung Center

Severe Asthma

Individuals with asthma experience symptoms such as coughing, wheezing, shortness of breath and tightness in the chest. In those with severe asthma, these symptoms persist despite treatment with commonly prescribed medications. Of the approximately 23 million Americans who suffer from asthma, five to 10 percent experience a form of the condition that is difficult to treat.

Learn more about the risk factors, causes, symptoms and classification of asthma.

Severe asthma can be triggered or aggravated by many factors, including improper administration of medication, complicating medical conditions such as sinusitis, cigarette smoking, pet allergens, mold, and dust mites. In some cases, persistent respiratory symptoms may not actually be asthma at all, but rather an unrelated medical condition.

Diagnosis of Severe Asthma

The Severe Asthma Program at Brigham and Women’s Hospital provides sophisticated diagnostic options for patients, such as nitric oxide measurement, pulmonary function testing, and blood and skin testing for allergic sensitivities.

Nitric Oxide Measurement

Two commonly performed tests for diagnosing and evaluating asthma are spirometry and peak flow measurement. These tests assess lung function by measuring the volume and speed of air that is inhaled and exhaled.

In addition to offering spirometry and peak flow measurement, the Severe Asthma Program provides an additional test of pulmonary function that evaluates the level of inflammation within the airways by measuring the concentration of nitric oxide gas in the exhaled breath.

When inflammation is active within the bronchial tubes or inadequately suppressed by medications, more nitric oxide is produced and detected in the exhaled breath. Alternatively, when inflammation is low or suppressed by an anti-inflammatory medication such as inhaled steroids, exhaled nitric oxide concentrations will be low.

Exhaled nitric oxide concentrations are measured with a nitric oxide analyzer. The test takes only a few minutes and involves breathing into a recording device. Knowing nitric oxide concentrations can help medical providers better evaluate a patient’s asthma, or determine whether allergic-type inflammation of the airways has been adequately suppressed with treatment.

Comprehensive Pulmonary Function Testing

Asthma is a disorder of the breathing (bronchial) tubes. Many pulmonary function tests assess the status of these tubes by evaluating whether they are narrow due to constriction of the bronchial muscles, swelling of the walls of the tubes, or accumulation of secretions within the tubes.

While spirometry and peak flow tests can evaluate the bronchial tubes in this regard, patients with severe asthma often require a more comprehensive assessment of lung function. This may be because the diagnosis of asthma is uncertain, or because a patient’s asthma is complicated by other respiratory conditions.

Such patients can undergo a comprehensive pulmonary assessment within the Severe Asthma Program’s Pulmonary Function Laboratory.

Pulmonary functioning tests may include:

  • Lung volume measurement
  • Diffusing capacity of the lungs for carbon monoxide (DLCO)
  • Respiratory muscle strength
  • Measurement of arterial blood gases
  • The 6-minute Walk Test (6MWT), which measures the distance walked and reflects a person’s ability to perform daily physical activities.

In some cases, comprehensive pulmonary function testing can reveal normal lung functioning, and yet a medical provider may still suspect that asthma exists. If so, additional tests, known as bronchoprovocative tests, can be conducted.

Bronchoprovocative challenge testing is used to determine the reactivity or “twitchiness” of the airways. Your physician may use the following to determine the sensitivity of your bronchial tubes.

Methacholine challenge: Methacholine is an agent that, when inhaled, causes the airways to narrow if asthma is present. The test is considered positive, meaning asthma is present, if the lung function drops by at least 20 percent in response to inhaling a relatively low concentration of this chemical.

Eucapnic hyperventilation: A test for exercise-associated asthma which consists of six minutes of rapid and deep breathing through a breathing circuit that delivers dry air with oxygen and carbon dioxide.

Exercise testing: Use of a stationary bike or treadmill to provoke the typical airway narrowing that occurs after exercise in people with asthma.

Asthma symptoms could also be caused by a sensitivity or intolerance to aspirin in which case patients can participate in an outpatient aspirin challenge which is conducted by BWH allergy specialists.

Blood and Skin Testing for Allergic Sensitivities

Many people living with asthma know the allergens to which they are sensitive (e.g., pets, mold or pollen). However, some patients cannot identify which allergens trigger their symptoms (e.g., frequently overlooked allergens include dust and dust mites).

In order to identify what a patient is allergic to, the Severe Asthma Program offers the following tests:

Allergen-specific immunoglobulin E (IgE): Measures the blood level of IgE to assess one’s sensitivity to many allergens, including pollen, mold, animal dander, dust mites, and cockroaches.

Skin testing: Includes prick and intradermal skin tests, during which a small amount of allergen is placed on or below the skin to see if a reaction develops.

Allergists and asthma educators can help patients interpret the results of these tests as well offer ways to eliminate exposure to allergens at home, work or school.

In addition, because smoking and respiratory infections can worsen asthma symptoms, the Severe Asthma Program offers a cigarette smoking cessation program, as well as vaccines against common respiratory infections.

Radiologic Imaging of Respiratory Tract

X-rays and computed tomography (CT) of the chest do not typically help to evaluate asthma. These radiographic tests usually reveal normal lungs, or benign thickening of the walls of the bronchial tubes.

However, with severe asthma, such imaging is often quite useful for identifying possible complicating or co-morbid illnesses, including:

  • Sinusitis: inflammation or an infection of the sinuses near the nose.
  • Bronchiectasis: abnormal enlargement of the bronchial tubes with susceptibility to chronic infection when bronchial tubes are dilated or injured.
  • Tracheomalacia: a syndrome that involves abnormal collapse and narrowing of the central breathing tubes.
  • Oropharyngeal aspiration: abnormal swallowing with food and drink entering the lungs is a potential cause of cough and chest congestion mimicking asthma.

For example, if a patient’s asthma is complicated by tracheomalacia, a CT scan of the lungs and airways can be performed, as well as real-time imaging via magnetic resonance. If aspiration is suspected, videofluoroscopic imaging can be performed while swallowing. The results will be interpreted by swallowing therapists who can then initiate “safe swallowing” training, if necessary.

The Severe Asthma Program draws on the resources of the Radiology Department at Brigham and Women’s Hospital for expert performance of state-of-the-art imaging techniques and interpretation of results.

Laryngoscopic and Bronchoscopic Evaluation

An integral part of the Severe Asthma Program is the Voice Program within the BWH Division of Otolaryngology. The throat and vocal cords can be inspected using a fiberoptic camera (“laryngoscopy”) to evaluate for the following:

  • Hoarseness
  • Altered voice quality
  • A sense of fullness or closure in the throat

The 10-minute long laryngoscopic procedure is made painless with the use of a numbing spray.

Speech therapists in the Voice Program also work with patients suffering from disorders of the throat. These patients are taught breathing exercises and vocal hygiene techniques, which can improve breathing and voice quality. Such techniques are especially useful for patients with “vocal cord dysfunction,” a syndrome that can be mistaken for severe asthma or can co-exist with and complicate severe asthma.

Occasionally, in cases of treatment-resistant asthma, direct inspection of the airways is necessary with a procedure called a bronchoscopy. This test is routinely performed by pulmonologists within the Severe Asthma Program, and takes place in an endoscopy suite under light sedation.

During a bronchoscopy, a patient’s airways are viewed during normal breathing and coughing to identify abnormal collapsibility of the central airways. Samples are often collected during the examination to check for infection or inflammation. A bronchoscopy takes approximately 15 to 20 minutes, and includes a one-hour period of recovery while sedating medications wear off.

Treatment of Severe Asthma

Watch this video about Severe Asthma.

The Severe Asthma Program also offers state-of-the-art therapeutic solutions, including aspirin desensitization, bronchial thermoplasty, biologic medicines (monoclonal antibodies) that have recently become available for the treatment of severe asthma, and programs focused on exercising and breathing techniques.

Aspirin Desensitization

Approximately three to four percent of patients with asthma cannot tolerate aspirin or non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen. Up to 25 percent of people with severe asthma may be completely intolerant or allergic to these medications.

With these patients, ingesting even small amounts of these drugs can trigger an asthma attack, nasal or gastrointestinal symptoms. Persons with aspirin-intolerant asthma, known as “aspirin-exacerbated respiratory disease,” must avoid all medications that contain aspirin or NSAIDs, including many over-the-counter cold remedies.

However, many patients need to take aspirin or NSAIDs for certain health conditions, such as those with cardiovascular risk factors, or patients with arthritis who take aspirin or NSAIDs to control inflammation.

Through a program known as Aspirin Desensitization and Maintenance Therapy patients can overcome their intolerance of anti-inflammatory medications. Aspirin desensitization is conducted in a medical office by specialists within the Severe Asthma Program. Over a period of several hours, a patient is given a very small dose of aspirin, followed by increasingly larger amounts, until a full dose no longer triggers asthma symptoms. At this point, the patient is tolerant of aspirin.

After aspirin desensitization, patients who take aspirin daily also typically experience benefits such as:

  • Improvement of nasal and sinus disease
  • Reduced activity of asthma symptoms
  • Decreased chance of nasal polyp re-growth after surgical treatment

The Aspirin Desensitization and Maintenance Therapy Program is especially useful for those persons suffering from triad asthma: asthma, nasal polyposis and aspirin sensitivity.

Novel Biologic Therapeutics (Monoclonal Antibodies)

Despite diligent use of first-line asthma medications, some patients with severe asthma still struggle with cough, difficulty breathing and frequent asthma attacks. However, medications known as biologics can now help treat this difficult-to-control form of asthma.

Historically, biologics have been used to treat inflammatory diseases, such as rheumatoid arthritis, ulcerative colitis, and psoriasis. These medications are known as monoclonal antibodies.

The Severe Asthma Program prescribes two of these medications for patients with severe asthma and others will be available soon.

Omalizumab (Xolair): This monoclonal antibody removes immunoglobulin-E (IgE) from the blood. IgE is a protein that plays a crucial role in some patients with severe allergic asthma. Omalizumab is administered by injection every two to four weeks with few side effects.

Mepolizumab (Nucala) and reslizumab (Cinqair): These two monoclonal antibodies block interleukin-5, a protein that attracts allergy-type cells (eosinophils), to the breathing tubes. For patients in whom eosinophils cause severe asthma, these medications can be very effective. Mepolizumab is given monthly by injection under the skin, and reslizumab requires an infusion once monthly.

Medical providers within the Severe Asthma Program are familiar with these new medications and will determine when they are appropriate for a patient.

Bronchial Thermoplasty

Most asthmatics share two characteristics with regard to their bronchial tubes. First, the smooth muscles surrounding these tubes usually contract excessively in response to a trigger. Secondly, there is typically more muscle surrounding their bronchial tubes. More muscles that contract excessively account for the dramatic symptoms of an asthma attack.

Bronchial thermoplasty is a procedure that reduces the amount of smooth muscle within the walls of the bronchial tube by applying heat to the bronchial muscles. The following is a short description of the procedure:

  • A bronchoscope (a tube with a camera) is passed through the mouth and into the bronchial tubes.
  • A catheter is channeled through the bronchoscope and into the bronchial tubes.
  • Heat is passed from the metal prongs at the end of the catheter to weaken the bronchial muscles.
  • The procedure takes approximately one hour and is repeated three times, each procedure separated by three weeks.
  • The bronchial thermoplasty procedure can be effective in relieving symptoms in those with severe asthma. Patients are advised that the procedure can occasionally cause a transient increase in asthma symptoms.

Patients with severe asthma who are candidates for bronchial thermoplasty typically receive an evaluation and consultation from interventional pulmonologist, Hisashi Tsukada, MD.

Breathing Exercises and Alternative Medicine Approaches

The Severe Asthma Program is committed to returning patients with difficult-to-control asthma back to a full, active lifestyle. Specialists in the Program employ the most advanced technologies and medicines for the diagnosis and treatment of severe asthma.

In addition, many nontraditional or complementary therapies exist that can help promote healing in those with severe asthma. Patients interested in alternatives treatments have easy access to the Brigham and Women’s Hospital Osher Center for Integrative Health.

Under the direction of Donald Levy, MD. The Osher Center at Brigham and Women’s Hospital offers a variety of services that may offer relief to patients with difficult-to-control asthma, including:

  • Acupuncture
  • Chiropractic therapies
  • Therapeutic massage
  • Cranial sacral massage
  • Tai Chi
  • Yoga
  • Mindfulness-based stress reduction (MBSR)
  • Special breathing training

Severe Asthma Clinical Trials

For over 20 years, the Asthma Research Center at Brigham and Women's Hospital has been engaged in groundbreaking research on the biology and treatment of asthma. The National Institutes of Health (NIH)-funded research conducted at the Center has been published in leading national and international journals, and has shaped the practice of asthma care worldwide.

If interested, patients can participate in asthma research by voluntarily enrolling in one of the many ongoing clinical trials being conducted at the Asthma Research Center. A number of these trials may involve new asthma medications, some of which may be indicated for severe asthma.

The Severe Asthma Program’s close relationship with the Asthma Research Center also affords patients that meet certain criteria to access to newly-developed medications that have not been approved for general use.

What to Expect

When you become a patient of the Severe Asthma Program, a team of specialists will carefully review your medical history. In addition, you will receive a thorough diagnostic evaluation and a recommendation for a therapy based on your specific diagnosis and circumstances. Your primary care provider and other members of your medical team will receive a detailed summary of your assessment and plan. You will be offered close medical follow-up at the Severe Asthma Program or periodic consultation, as you wish.

Multidisciplinary Care

Severe asthma patients benefit from the care of a wide range of specialists within the Severe Asthma Program, including allergists, pulmonologists, otolaryngologists (including Voice Program physicians and speech therapists), gastroenterologists (including experts in gastroesophageal reflux disease), and psychiatrists (with expertise in the psychological aspects of complex medical problems). This collaboration ensures that patients with severe asthma will receive optimal, comprehensive care and a pathway to restored respiratory health.

Appointments and Locations


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