RiteFlo™ Can Be Combined With Rescue and Controller Inhalers Prescribed For Asthma, Bronchitis, Emphysema and COPD. 

Asthma

• Asthma is a chronic disease involving inflammation of the airways.
• Over 20 million Americans have asthma and over 6 million are children and young adults.
• African Americans are at 4 times the risk compared to Caucasians from dying from an asthmatic attack.
• Approximately 4,500 Americans die each year from asthma.
• Although asthma is often a hereditary disease, many patients develop asthma after a viral respiratory illness.
• Each year, close to 11 billion dollars are spent on asthma care, yet there is no significant improvement in outcomes seen at the national level.
• One of the most important ways to improve asthma outcomes is through proper education. An asthma action plan instructing a patient which medications to use and when to seek immediate care may improve asthma outcomes.
• There are two broad classes of medication for asthma: Controllers and Relievers
• Controllers consist of : Oral Steroids (Prednisone), Inhaled Steroids (Azmacort®, Flovent®, Aerobid®, Qvar®, Advair® {combination drug of Flovent® and Serevent®}), Leukotriene Modifiers (Singulair®, Accolate®), Mast Cell Stabilizers (Intal®, Tilade®), Long-Acting beta₂-adrenergic agonists (Serevent®, Foradil®) and Xolair®, a new injectable therapy (recombinant bioengineered monoclonal antibody that binds to the allergic antibody IgE)
• Relievers consist of : Bronchodilators such as beta₂-adrenergic agonists (Albuterol, Xopenex®, Maxair®, Ventolin®, Proventil®-Hfa), Methylxanthines (Theophylline, Uniphyl®), Anticholinergic drugs (Ipratropium Bromide) and Oral Steroids

Asthma Definition

• Asthma is a disease that affects all age groups and races. It is viewed as a chronic inflammatory disease affecting the airways of the lung. The inflammatory changes result in narrowing of the airways present as: wheezing, shortness of breath, cough and even respiratory arrest and death. Inflammation causes air flow obstruction. Airway hyper-responsiveness may present as a cough due to: cold air, exercise, exposure to dust mites, pollutants, and even stress.

Incidence and Cause of Asthma

• The incidence of asthma in the United States is approximately between 4-5% with 12-14 million asthmatics identified. It appears that asthma is becoming a more severe disease than in earlier periods of time (1970’s-1990’s). The full impact of the disease appears to be more felt by the minority segment of the U.S. population with a special emphasis on inner-city African Americans and Hispanics.
• 50% of all cases of asthma are identified by the age of 10.
• Allergy is the single most important risk factor for developing asthma. Often allergic asthma is associated with a personal or family history of allergic rhinitis (hay fever), urticaria (hives) and or atopic dermatitis (eczema).
• Most patients with allergic asthma will have elevated levels of allergic antibodies (IgE) in their blood and/or a positive skin test to allergens.
• There is still a significant population of asthmatics who are not allergic and these patients usually develop asthma later in life and have a more difficult course.

What are the Inflammatory Changes in An Asthmatic Lung?

• The changes that take place in an asthmatic lung are very complicated and not fully understood at this time. The changes that take place make the lung susceptible and hyper-reactive to various stimuli from the environment. The bronchial tubes and smooth muscle that encircles these breathing tubes during an attack go into spasm narrowing the airway passage. Additionally, the cells of the lining of the airways swell and secrete copious amounts of mucus blocking the airways. This results in an asthmatic having greater difficulty breathing air in and out.
• Mast cells that line the bronchial wall release mediators causing the bronchial muscles to spasm and stimulate the production of mucus.
• The main cell types that contribute to inflammation in the lung are mast cells, T-cells, eosinophils and epithelial cells.
• Leckotrienes are substances that contribute to the inflammatory cascade of events in the lungs. New drugs aimed at these mediators appear to have a role in the management of asthma.
• The epithelial lining of the bronchial tree undergoes change during time, resulting in a process called ‘Airway Remodelling’. Airway remodeling further narrows the airways and makes the lung hyper-responsive. This process appears to be irreversible and steroids do not always appear to halt this effect.

Child-onset Asthma

• When asthma begins in childhood, it is usually due to genetic reasons. Asthma in these children is often closely related to allergy.
• Allergy is one of the strongest pre-disposing risk factors for developing asthma.
• A significant number of children develop asthma after exposure to certain viral infections that have been shown to cause wheezing in children.
• Large epidemiology studies revealed that children with recurrent wheezing during the first three years of life have a 76% probability of developing asthma. Two major risk factors for developing asthma are:(1) Parental history of asthma or (2) Physician diagnosed case of eczema.
• Two of the following three minor risk factors are required for the diagnosis of asthma: (1) Wheezing apart from colds (2) Increased blood count of eosinophils (3) Physician diagnosed case of allergic rhinitis (Hay Fever).

Adult-onset Asthma

• Allergy may play a role in the development of adult asthma. Adults who develop asthma may have had it when they were children. In addition, adults who develop asthma usually have a more severe form of asthma compared to children.
• Many adults have other associated risk factors for developing asthma despite no history of allergy. These individuals may have: sinusitis, nasal polyps, sensitivity to aspirin, exposure to fumes from the workplace (occupational asthma), sensitivity to wood dust (cedar) and even sensitivity to NSAID (non-steroidal anti-inflammatory) drugs, such as naprosyn or ibuprofen. These patients have intrinsic or nonallergic asthma. Even after the inciting cause of asthma is removed from the workplace, many of these patients continue to have symptoms of asthma.

Asthma Triggers

• Most asthmatic attacks are related to well-known triggers. These asthma triggers usually will set off a chain of bio-chemical and cellular events that lead to tissue changes resulting in airway inflammation and bronchoconstriction. Avoiding these triggers are an effective management tool for asthma. Many allergists are trained to help you identify the triggers that may cause your asthma. If avoidance of these triggers is not possible, then your allergist can develop an effective desensitization program to help you. Multiple clinical trials have shown that allergy therapy is an effective tool in the management of asthma.
• Common asthma triggers are: (1) respiratory viruses, (2) exercise, (3) allergic reactions to animal dander, pollens, molds, dust, cockroaches, food, drugs, and rapid changes in outdoor temperature, (4) cigarette smoke (5) pollution (6) emotional stress.
• Most asthmatic attacks are obvious because of either shortness of breath, cough or wheezing. Some patients have attacks that are not obvious in the early phases. Some children will complain of an itching in their back or neck at the start of an attack. Other children or adults will only complain of a tightness in their chest.
• Wheezing is often loudest on expiration (breathing out). Many patients are free of symptoms during the day and only complain of asthmatic episodes in the evening or early morning hours. These symptoms should never be ignored. Severe episodes of asthma often occur after viral infections or after exposure to heavy concentration of allergens (cats, hay, molds, etc.).

How to Diagnose Asthma

• The first and most important step in diagnosing asthma is obtaining a careful and accurate medical history. Some of the most important parts of the medical history is looking for the risk factors for asthma. One of the major risk factors for asthma in a child is allergy. Parental history of asthma is a major risk factor for asthma. A previous diagnosis of allergic rhinitis and/or eczema are major risk factors for developing asthma.
• The major symptoms a doctor looks for are: wheezing, evening or early morning cough or shortness of breath.
• Factors that worsen asthma include:(1) acute or chronic sinusitis (2) reflux esophagitis or GERD (Gastrointestinal Esophageal Reflux Disease) (3) viral infections (4) allergen exposure, i.e. cats, dust mites, cockroach exposure.
• Other causes of bronchospasm that may complicate making a diagnosis of asthma include:(1) exercise induced bronchospasm (2) rapid changes in outside temperature causing cough (cold air induced bronchospasm) (3) exposure to cigarette smoke or other forms of smoke (4) exposure to workplace chemicals or fumes.
• The physical exam is an important part of the evaluation phase. In the early stages of asthma, the physical exam can be totally normal. Some of the key features that a physician examines for are: listening with a stethoscope for wheezing in different lung zones and seeing whether the wheezing occurs in only expiration (breathing out) or also with inspiration (breathing in). If a patient has prolonged expiration, that tends to suggest more advanced asthma. During the lung exam, a doctor will check for hyper-inflation syndrome (depressed diaphragms), another sign of more advanced asthma disease. Other complicating signs your doctor will look for are nasal polyps, evidence for sinusitis or reflux esophagitis.

Laboratory Tests Helpful in Making a Diagnosis of Asthma

• Pulmonary Function Testing- This is the most widely used test that helps to make a diagnosis of asthma. It is a computer that measures the volume of air flow over several seconds usually during exhalation. Spirometry may reveal airway obstruction. One of the important aspects of making a diagnosis of asthma is if there is airway reversibility. Airway reversibility is measured by giving a subject a short-acting bronchodilator (usually albuterol) waiting 15-30 minutes and redoing the spirogram. If there is a 12% improvement or greater after inhaling the bronchodilator, the subject has airway reversibility and may have asthma. Spirometry may be normal between asthma attacks or even normal during the day. However, spirometry may be abnormal only in the early morning or evening hours.
• Serial Peak Flow Readings- A peak flow meter is a simple portable handheld device that measures maximum airflow in the first second of exhaling. This device measures the Peak Expiratory Flow Rate (PEFR). As the large airways in asthmatics narrow, the PEFR declines. Peak flow variability (differences between A.M. and P.M.) aids in the diagnosis of asthma. Peak flow variability usually indicates asthma that is not under control or airway hyper-responsive syndrome. Patients may be on steroids and continue to have airway hyper-responsiveness. This can be assessed with the use of a peak flow meter.
• Bronchoprovocative Tests- Some patients may give a very clear-cut history of asthma,yet their pulmonary function tests may be normal or show no reversibility. Bronchoprovocative tests measure airway responsiveness. Patients are given, via inhalation, either histamine or a drug called methacholine. A 20% drop in FEV₁ (Forced Expiratory Volume in One Second) aids in making the diagnosis of asthma. A normal bronchoprovocative challenge helps to exclude the diagnosis of asthma.
• Allergy Skin Testing- It is now established that over 75% of patients with asthma have allergy. Avoidance of allergens can be helpful in the management of asthma. New therapies (Xolair®) are directed at the allergic antibody (IgE). A positive skin/blood test for allergies with an elevated IgE level may make a patient a candidate for Xolair®. Clinical trials have shown that immunotherapy has been helpful to patients with asthma.
• Tests That May Uncover Other Causes of Asthma- Rhinoscopy is an invasive test using a flexible tube with a camera on its end. It is used by ENT and allergists to look for evidence of nasal polyps or sinusitis. A pH probe is more commonly used in pediatrics or in certain adults suspected of having GERD (gastrointestinal esophageal reflux disease). Reflux has been associated with asthma.

Stages of Asthma Severity

• The National Asthma Education Program (NAEP) and the National Heart Lung and Blood Institute (NHLBI) with their expert panel have developed a classification system to stage the severity of asthma and the appropriate therapy for each stage. Patients are staged based on the severity of symptoms (complaints) and signs (measurable findings) of their asthma. Patients in any stage can have mild to severe exacerbations.
• The 2007 NHLBI Guidelines now divide asthma assessment into Components of Severity and a separate Component of Control. Additionally, there are now three age groups based on age. The ages are grouped as follows: 0-4, 5-11, and Youths > 12 Years and Adults.
• Asthma Severity is then divided in to Impairment and Risk Domains. Impairment is defined as abnormal spirometry and symptoms such as: Nighttime Awakenings, Use of short-acting rescue drugs (albuterol) and Interference with Normal Activity.
• Asthma Risk is defined as “Exacerbations Requiring Oral Steroids”.
• Class I-    Intermittent Asthma– Symptoms of asthma less that 2/week, evening symptoms (cough) less than 2/month, Normal FEV₁ equal or greater than 80%
• Class II-   Mild Persistent Asthma – Symptoms of asthma occur greater than 2 times/week but not daily, evening symptoms (cough) 3-4/month, but not nightly, FEV₁ 80%
• Class III- Moderate Persistent Asthma– Daily symptoms of asthma, evening symptoms (cough) greater than 1/week, but not nightly, FEV₁ 60%-80% predicted, use of albuterol (rescue inhaler) daily
• Class IV-  Severe Persistent Asthma – Continual symptoms of asthma during the day, frequent evening symptoms (cough) 7 times/week, FEV₁ less than 60% predicted,

Management Goals For Asthma

• Goals for the management of asthma include: (1) Maintain a normal active lifestyle (2) Understand asthma (3) Be involved in making decisions with your doctor or healthcare professional (4) Know when your asthma is out of control (5) Know when to seek medical advice (6) Understand how your medications work (7) Learn how to prevent asthma attacks.
• The goal for everyone diagnosed with asthma is to be able to lead an active lifestyle. In fact, many top athletes have been diagnosed with asthma and are able to compete both in U.S. National and Olympic meets. There are guidelines for which medications are allowed to be used in athletic meets. Check with your physician for information on the list of approved medications.
• The key to controlling asthma is education. Many studies have shown that when parents of children with asthma or adult asthmatics understand their disease, the cost of care, duration of symptoms and the morbidity and mortality of asthma is reduced.

General Principles In Asthma Care

• The main therapy for asthma is anti-inflammatory medications. The most commonly prescribed anti-inflammatory drugs are either oral or inhaled corticosteroids (ICS) and/or antileukotriene drugs. Studies have shown that the chronic use of inhaled steroids significantly improves outcomes in asthma. The use of inhaled steroids has been shown not only to control asthma but also prevent attacks. The use of inhaled steroids is now considered the gold standard of care for asthma. The goal for a patient is to get the best control of asthma with the lowest tolerated steroid dose.
• It is critical to understand the difference between controller medications and reliever medications. These are two different classes of medications that have very different roles in the management of asthma. Many patients unfortunately make errors in the use and timing of their medications which lead to unnecessary doctor visits, ER visits and even hospitalizations. Many uninformed patients make the common mistake to use their albuterol or reliever for all their asthma symptoms. Since relievers work within minutes and do help patients breath better, many patients prefer not to use their controller medications. Many of these patients only rely on their albuterol or other reliever and usually get into trouble. By only using a reliever, a patient is not addressing the underlying problem of inflammation in the lung. Patients who only rely on their reliever or albuterol are at risk for fatal asthma. Controller medications take days to make a significant impact in asthma care. Many asthmatics prefer not to wait for their controller to take effect and prefer to only rely on their reliever. RELYING ONLY ON YOUR RELIEVER MAY BE FATAL.
• List of Controller Medications– {1} Inhaled corticosteroids (Flovent®, Pulmicort Turbohaler®, Pulmicort Respules®, Azmacort®, Qvar®, Vanceril®, Beclomethasone), {2} Oral Steroids (Prednisone, Medrol, Prednisolone, Orapred®, Prelone®, Pediapred®),{3} Antileukotriene Modifiers (Singulair®, Accolate®, Zyflo®) {4} Methylxanthines (Theophylline, Uniphyl®, Slobid®, Theodur®) {5} Long-Acting Beta₂-Agonists (Serevent®, Foradil®) {6} Combination Dry Powder Inhalers (Advair® is the only combination drug in the United States, Symbicort® in Europe only) {7} Mast Cell Stabilizing Drugs (Intal®, Tilade®)
• List of Reliever Medications– {1} Beta₂-Agonists (Albuterol, Proventil®, Ventolin®, Terbutaline, Pirbuterol, Maxair®, Levalbuterol or Xopenex®) {2} Long-Acting Beta Agonist(Foradil® is both a long-acting and quick onset beta₂-agonist, Serevent® or Salmeterol has an onset of 60 minutes and should not be used as a quick reliever) {3} Anticholinergics- Ipatroprium Bromide, Atrovent® may have a role in emergency room care for asthma, (Spiriva® or Tiotropium Bromide Monohydrate is a new drug that has been approved for the use in COPD and should not be used for acute bronchospastic attacks) {4} Oral steroids are also used to rapidly gain control of asthma over a period of hours to days.
• Spacers– It is the general consensus, both in the United States and European guidelines and treatment algorithms, that spacers should be used with all MDI’s (metered-dose inhalers) to aid in coordination of medication technique, lower inhaled steroid side effects and potentially increase medication to the lower lung.
• Written Action Plans- Patients can benefit from having a written action plan. These plans help to detail what to do when asthma worsens or if a patient is having an attack. Action plans: (1) help to reinforce the proper use of medications (which medications should be increased),(2) explain the importance of using a peak flow meter to determine air way flow variability and (3) when a patient should contact their doctor or health professional for help.
• Monitoring- Patients with more than just mild intermittent asthma should have periodic visits with their doctors or healthcare professionals. Many patients find it difficult to assess their own condition and need to monitor their asthma with peak flow meter readings as well as office-based spirometry.
• The purpose of good asthma management is to avoid symptoms of asthma. Your asthma is uncontrolled if you:(1) develop evening symptoms of cough, wheeze or shortness of breath or (2) increase the use of inhaled beta₂-agonists such as Albuterol (more than 3 uses/week or more than one canister per month)

Classes of Asthma Medications

Controllers

• Oral Corticosteroids– This is the most potent class of medication for use in asthma. Steroids have strong anti-inflammatory properties that are needed for control of severe asthma or asthma attacks. These drugs should only be given under the care of a physician or healthcare professional due to the many potential severe side effects. These drugs are often life-saving and must be appropriately administered and tapered. If long-term use is required, your physician or healthcare professional will need to monitor you for potential side effects. Some patients unfortunately become “steroid-dependent” and need to be monitored by subspecialists, such as pulmonologists or allergists. Those patients who become steroid-dependent are at risk for fatal asthma. Recent research appears to indicate that patients who become steroid-dependent have a genetic predisposition to this condition.
• Inhaled Corticosteroids– This class of medications are the mainstay for treatment of patients in all forms of asthma, except mild intermittent asthma. Inhaled corticosteroids (ICS) allow this form of steroids to go directly to the lung. ICS allows lower doses of steroids to control your asthma. These medications come in three formulations: (1) CFC-MDI (chlorofluorocarbon metered-dose inhaler) (2) HFA-MDI (hydrofluoroalkane metered- dose inhaler and (3) DPI (dry powdered inhaler). Inhaled corticosteroids come in different potency’s. These different potency’s allow your doctor or health professional to select the ideal dose exactly to your needs based on your complaints and spirometry results. ICS do not work immediately nor can you detect their benefit directly when first prescribed. Only after several weeks when you are not coughing or needing quick relief medications (albuterol) can you begin to feel the benefits of this class of medication.
• Antileukotriene Modifiers- This is a new class of medicines introduced in the last 8 years. Currently, there are only 2 antileukotriene modifiers available (Singulair®, Accolate®) in the United States. Singulair® is the most frequently prescribed of the two antileukotriene modifiers. These drugs, when used regularly in conjunction with other asthma medications, will reduce the inflammation in the lung and reduce the number of asthma attacks. Unfortunately, these medications do not work on every asthmatic and there is no way to predict who could benefit from these drugs. Leukotrienes are chemicals that occur naturally in the body. Leukotrienes tighten the airways, increase lung inflammation, increase mucus production and increase the sensitivity of the airways in patients with long-term chronic asthma. These drugs are not relievers and should not be used to relieve acute attacks of asthma. Singulair® and Accolate® do not work like prednisone and should not be a replacement for oral steroids. However, these drugs are viewed as steroid-sparing agents and may allow for lower doses of steroids to be used. Singulair® should be given in the evening (as recommended by the manufacturer) while Accolate® is given twice daily. When to add this class of drug to the wide range of medications used for asthma is still evolving. These drugs may have a role in exercise-induced asthma as well as aspirin sensitive asthmatics (patients with nasal polyps, asthma and aspirin sensitivity). The consensus of opinion is that inhaled steroids are superior to antileukotriene modifiers, but the role of antileukotriene modifiers as monotherapy is still being investigated. The final decision on whether to use these drugs must be left to your doctor.
• Mast Cell Stabilizing Drugs- Mast cells are found in the respiratory tract (nose-trachea-bronchi-terminal areas of the lung) and are important in allergic rhinitis and asthma. Intal® (Cromolyn) and Tilade® (Nedocromil) are nonsteroidal anti-inflammatory drugs often used as initial therapy to prevent asthma attacks in children. These drugs, when used in combination with acute relievers (albuterol, pirbuterol) before exercise, may prevent asthma attacks. Intal® and Tilade® are very safe, but must be used very regularly to be effective in long-term control of chronic asthma. These drugs may be used alone in children less than 5 years who have mild persistent asthma (although children may have difficulty with the taste of Tilade®, this can be corrected with the use of a spacer). Tilade® has been shown to be effective in controlling cough after respiratory viral illness in adults.
• Methylxanthine Drugs-This class of drugs has been around for over forty years. They originally were commonly used both for acute attacks and control of chronic asthma. This class of drugs has fallen out of favor except for special circumstances. Early on, patients with asthma received some benefit from coffee and this is because methylxanthines are found in coffee. Theophylline may add additional long-term control to asthmatics but these medications have serious side effects and must be carefully monitored with blood tests. Some experts recommend their use for nocturnal asthma. Theophylline is now viewed as a third-line agent for control of chronic asthma behind inhaled corticosteroids and long-acting beta-agonists.
• Long-Acting Beta-Agonist Drugs- All beta-agonist drugs affect both the heart (Beta 1) and lung (Beta 2) receptors. These drugs were designed to be more selective for the lung and therefore called selective beta 2-agonists. Even with this in mind, patients taking these drugs can develop symptoms of palpitations (rapid heart beat) and need to tell their doctor if this side-effect occurs. These drugs are similar in potency to albuterol (or in Europe, albuterol is called salbutamol), but have a longer duration of activity. Serevent® has an onset of action between 30-60 minutes and Foradil® of 3-10 minutes. As opposed to albuterol’s duration of activity of approximately 4 hours, the long-acting selective beta-agonists have a duration of activity of approximately 12 hours. This long duration of action makes this class of drug helpful to patients who have nocturnal or evening asthma or exercise-induced asthma. Additionally, clinical trials have shown that the addition of this class of drug (studies were done with Serevent®) allowed patients to have better control of their asthma and lower the dose of inhaled steroid they were using. Serevent® and other long-acting beta-agonist inhalers should not be used alone, but only in combination with an inhaled steroid. These drugs should not be used to relieve an acute asthma attack.
• Anti-IgE Monoclonal Antibody Therapy- This is the newest class of medication approved for patients with moderate to severe persistent asthma. The drug is called Xolair® (Omalizumab). A large majority of asthmatic patients have a history of allergy and thereby have elevated levels of IgE. IgE was first discovered by Drs. Kimishege and Teruko Ishizaka in the early 1960’s. Scientists have developed an anti-IgE molecule using genetic techniques. This is an injectable drug and can cost from $500-$3000/month. Xolair® is indicated for adults and adolescents (12 years of age and older) with moderate to severe persistent asthma who have a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids. Xolair® has been shown to decrease the incidence of asthma exacerbations in these patients. This drug does not alleviate acute asthma attacks and should not be used for the treatment of acute bronchospasm or near fatal asthma. Oral or inhaled steroids should not be abruptly stopped upon initiation of Xolair® therapy. This drug is dosed either once or twice a month. If you are thinking of starting this medication, review carefully the adverse events reported in the product information sheet. This is an exciting time for patients with asthma. Newer drugs are being developed in the hope of getting away from the potential side effects of steroids. Hopefully this drug and other newly developed drugs will deliver better and safer therapy to patients with asthma.

Relievers

• Short-Acting Beta-Agonist Drugs– This class of drugs for the treatment of bronchospasm go back over 3,000 years. The first reports of use were in China with the drug called Ma Huang. Over the last 100 years, this class of drugs has been further refined to be more selective for the beta₂ receptor in the lung (the beta₁ receptor is found in the heart). Many patients can develop symptoms of palpitations with this class of drug and should notify their doctor or healthcare professional if this occurs. It is frowned upon if patients use these drugs in a daily scheduled manner. Patients who use these drugs daily develop tolerance (drug loses its effect). If these drugs are used only on an as needed basis, these drugs are more effective. These drugs are very effective in relieving acute bronchospastic attacks and preventing episodes of exercise-induced asthma if used 20-30 minutes before exercise. Within the medical community, there is a controversy whether levalbuterol (Xopenex®) is superior to racemic albuterol (Generic albuterol). We urge you to seek the advice of your physician or healthcare professional for advice on selection of which drug is best for you or your child. Frequent use of this class of drug (more than 3/week) is a sign that asthma is not under good control.
• Anticholinergics- This class of drug acts on the smooth muscles surrounding the bronchial tube. These drugs relax the smooth muscles that are in spasm. The vagus nerve, which comes from the brain, sends signals to the lung through a chemical called acetylcholine. By inhibiting the effects of acetylcholine, ‘vagal tone’ is diminished. Reduced vagal tone results in bronchodilation. This drug has been shown to be quite helpful in conjunction with beta-agonists. Many ER’s use this medication with other short-acting beta-agonists when patients are in immediate need of relief in an emergency situation. There is no established situation where anticholinergics are used in a regular manner for the treatment of asthma. This class of drug has an important role for patients with COPD (Chronic Obstructive Pulmonary Disease) or emphysema.