Asthma

Definition
Asthma is chronic, reversible, obstructive airway disease.
Asthma occurs when the airways in your lungs (bronchial tubes) become inflamed
and constricted. The muscles of the bronchial walls tighten, and your airways produce
extra mucus that blocks your airways.
Etiology
it is commonly result of hyper responsiveness of the trachea and bronchi to irritant.
Allergy influences both the persistence and severity of asthma, and atopy or the genetic
predisposition of the development of an IgE –mediated response to common airborne
allergens.
Signs and symptoms of asthma
Asthma signs and symptoms range from minor to severe, and vary from person to
person. You may have mild symptoms such as infrequent wheezing, with occasional
asthma attacks. Between episodes you may feel normal and have no trouble breathing.
Or, you may have signs and symptoms such as coughing and wheezing all the time or
have symptoms primarily at night or only during exercise.
Asthma signs and symptoms include:
 Shortness of breath
 Chest tightness or pain
 Trouble sleeping caused by shortness of breath, coughing or wheezing
 An audible whistling or wheezing sound when exhaling
 Bouts of coughing or wheezing that are worsened by a respiratory virus such as a cold
or the flu
Signs that your asthma is probably getting worse include:
 An increase in the severity and frequency of asthma signs and symptoms
 A fall in peak flow rates as measured by a peak flow meter, a simple device used to check how well your
lungs are working
 An increased need to use bronchodilators
Causes
It isn't clear why some people get asthma and others don't, but it's probably due to a
combination of environmental and genetic (inherited) factors.
Asthma triggers are different from person to person including:
 Airborne allergens, such as pollen, animal dander, mold, cockroaches and dust
mites
 Respiratory infections, such as the common cold
 Physical activity (exercise-induced asthma)
 Cold air
 Air pollutants and irritants such as smoke
 Certain medications, including beta blockers, aspirin and other nonsteroidal
anti-inflammatory drugs
 Strong emotions and stress
 Sulfites, preservatives added to some perishable foods
 Gastroesophageal reflux disease (GERD), a condition in which stomach acids
back up into your throat
 Menstrual cycle in some women
 Allergic reactions to foods such as peanuts or shellfish
Risk factors
Asthma is common, affecting millions of adults and children. A growing number of
people are diagnosed with the condition each year, but it isn't clear why. A number of
factors are thought to increase the chances of developing asthma. These include:
 A family history of asthma
 Frequent respiratory infections as a child
 Exposure to secondhand smoke
 Living in an urban area, especially if there's a lot of air pollution
 Exposure to occupational triggers, such as chemicals used in farming,
hairdressing and manufacturing
Low birth weight
 Being overweight

Tests and diagnosis

Diagnosing asthma can be difficult. Signs and symptoms can range from mild to
severe and are often similar to those of other conditions, including emphysema, early
congestive heart failure or vocal cord problems. In children, it can be hard to
differentiate asthma from wheezy bronchitis, pneumonia or reactive airway disease.
In order to rule out other possible conditions, your doctor will do a physical exam and
ask you questions about your signs and symptoms and about any other health problems.
You may also be given lung (pulmonary) function tests to determine how much air
moves in and out as you breathe.
Tests to measure lung function include:
 Spirometry.
Spirometry (meaning the measuring of breath) ,is the most common of the
Pulmonary Function Tests (PFTs).
It will detect
a. Decrease for expiration volume(FEV)
b. Decreased peak expiration flow rate(PEFR)
c. Diminshed forced vital capacity(FVC)
d. Diminshed inspiratory capacity(IC)

The most common parameters measured in spirometry are

Forced Vital Capacity (FVC)

Forced Vital Capacity (FVC) is the volume of air that can forcibly be blown out after full
inspiration, measured in liters. FVC is the most basic maneuver in spirometry tests. A
lower than normal FVC reading indicates restricted breathing.
Forced Expiratory Volume in 1 second (FEV1)
this is how much you can force from your lungs in one second.
Average values for FEV1 in healthy people depend mainly on sex and age, between 80%
and 120% of the average value is considered normal. In obstructive diseases (asthma,
COPD, chronic bronchitis, emphysema) FEV1 is diminished because of increased airway
resistance to expiratory flow.

Forced Expiratory Flow (FEF)

Forced Expiratory Flow (FEF) is the flow (or speed) of air coming out of the lung during
the middle portion of a forced expiration.Average ranges in the healthy population
depend mainly on sex and age, Values ranging from 50-60% and up to 130% of the
average are considered normal.
Forced Expiratory Time (FET)
Forced Expiratory Time (FET) measures the length of the expiration in seconds.
Peak Expiratory Flow (PEF)
The peak expiratory flow (PEF), also called peak expiratory flow rate (PEFR) is
measured with a peak flow meter, a small, hand-held device .Peak expiratory flow is
the maximal flow (or speed) achieved during the maximally forced expiration initiated
at full inspiration, measured in liters per minute.Peak flow readings are higher when
patients are well, and lower when the airways are constricted.
Tidal volume (TV)
Tidal volume (TV) is the specific volume of air drawn into, and then expired out of, the
lungs during normal tidal breathing.
Total Lung Capacity (TLC)
Total Lung Capacity (TLC) is the maximum volume of air present in the lungs
Slow Vital capacity (SVC)
Slow Vital capacity (SVC) is the maximum volume of air that can be exhaled slowly after
slow maximum inhalation.

Bronchial challenge test.

A bronchial challenge test is a medical test used to assist in the diagnosis of asthma.
the patient's medical history is taken and possible triggers are discussed. Spirometry
tests are taken. The patient is exposed to whatever triggers the breathing problem,
under controlled conditions. Spirometry tests are again taken, and compared with the
earlier results. In such tests, pharmaceutical agents such as methacholine or histamine
may be used.

 Nitric oxide test. This test is sometimes used to diagnose and monitor asthma.
It measures the amount of a gas called nitric oxide you have in your breath. If
your airways are inflamed — a sign of asthma — you may have higher than
normal levels of nitric oxide. This test isn't widely available.
Asthma classification
Initially asthma is categorized into two: the extrinsic asthma and the intrinsic asthma.
But this classification is elaborated; the extrinsic asthma is renamed as the allergic
asthma while the intrinsic asthma is divided further into exercise induced asthma and
the chemical induced asthma.

Extrinsic asthma
this is triggered by allergens. Hence, it is also termed as allergic asthma. In extrinsic
asthma, immune system which exerts a protective mechanism reacts to simple harmless
substances such as pollen and produces antibodies. This results in symptoms like hay
fever, rhinitis and asthma. In case of asthma, the allergic reaction is observed in lungs
which results in production of huge amounts of mucus that obstructs the air passage.
Symptoms of extrinsic asthma include coughing, wheezing, chest pain due to pressure
and heaviness.There is no permanent cure for extrinsic asthma but the symptoms can be
controlled by avoiding exposure to allergens.
Intrinsic asthma
it is very hard to treat intrinsic asthma as the causative agent is unknown.It is generally
caused by extremes of emotional feelings like laughing, crying, or contact with chemicals
like cigarette smoke, aspirin, cleaning agents or chest infection or exercises. These
agents act by stimulating the response of the nerves in the air passage.

Exercise induced asthma is a subtype of intrinsic asthma. It is generally seen

immediately after exercising.

A subtype of asthma called the nocturnal asthma is observed in the early hours of the
night in between 2 to 4. It is common with both extrinsic and intrinsic asthma patients.
It is essential to treat this type of asthma to prevent deaths due to asthma in sleep.

To classify your asthma severity, your doctor will evaluate your answers to questions about symptoms (such as how
often you have asthma attacks and how bad they are), along with the results of your physical exam and diagnostic
tests. Determining the severity level of your asthma will help your doctor choose the best treatment for you.
Asthma is also classified into four general categories:

classification Signs and symptoms

Mild intermittent up to two days a week and up to two nights a month

Mild persistent Symptoms more than twice a week, but no more than
once in a single day
Moderate persistent Symptoms once a day and more than one night a week

Severe persistent Symptoms throughout the day on most days and

frequently at night

Complications
Asthma may cause a number of complications, including:
 Emergency room visits and hospitalizations for severe asthma attacks
  Permanent narrowing of the bronchial tubes (airway remodeling)
treatment should be flexible and based on changes in symptoms, which should be
assessed thoroughly each time you see your doctor. Then, treatment can be adjusted
accordingly.
For example, if your asthma is well controlled, your doctor may prescribe less
medicine. If your asthma is not well controlled or getting worse, your doctor may
increase your medication and recommend more frequent visits.

Treatments and drugs

Prevention and long-term control is the key to preventing asthma attacks. Treatment
usually involves learning to recognize your triggers and taking steps to avoid them, and
tracking your breathing to make sure your daily asthma medications are keeping
symptoms under control. In case of an asthma flare-up, you may need to use a quick-
relief inhaler such as albuterol.

Medications
The right medications for you depend on a number of things, including your age, your
symptoms, your asthma triggers and what seems to work best to keep your asthma
under control.
Long-term control medications
In most cases, these medications need to be taken every day. Types of long-term control
medications include:

 Inhaled corticosteroids. These medications include

Fluticasone, budesonide, mometasone, flunisolide, beclomethasone and others. They

are the most commonly prescribed type of long-term asthma medication. You may
need to use these medications for several days to weeks before they reach their
maximum benefit. Unlike oral corticosteroids, these corticosteroid medications have a
relatively low risk of side effects and are generally safe for long-term use.

 Leukotriene modifiers. These oral medications include

montelukast, zafirlukast and zileuton. They help prevent asthma symptoms for up to
24 hours. In rare cases, these medications have been linked to psychological reactions
such as agitation, aggression, hallucinations, depression and suicidal thinking. Seek
medical advice right away for any unusual reaction.

 Long-acting beta agonists (LABAs). These inhaled medications include

salmeterol and formoterol . LABAs open the airways and reduce inflammation.
 However, they've been linked to severe asthma attacks. LABAs should be taken only in
combination with an inhaled corticosteroid.

 Combination inhalers such as fluticasone and salmeterol and budesonide and

formoterol. These medications contain a LABA along with a corticosteroid. Like other
LABA medications, these medications may increase your risk of having a severe
asthma attack.

 Theophylline. This is a daily pill that helps keep the airways open. Theophylline
relaxes the muscles around the airways to make breathing easier. It's not used as often
now as in past years.

Quick-relief medications
Quick-relief medications are used as needed for rapid, short-term symptom relief
during an asthma attack — or before exercise if your doctor recommends it. Types of
quick-relief medications include:

 Short-acting beta agonists. These inhaled, quick-relief bronchodilators can

rapidly ease symptoms during an asthma attack. They include albuterol ,levalbuterol
and pirbuterol . These medications act within minutes, and effects last several hours.

 Ipratropium. Your doctor might prescribe this inhaled medication for

immediate relief of your symptoms. Like other bronchodilators, ipratropium relaxes
the airways, making it easier to breathe. Ipratropium is mostly used for emphysema
and chronic bronchitis, but it's sometimes used to treat asthma attacks.

 Oral and intravenous corticosteroids. These medications relieve airway

inflammation caused by severe asthma. Examples include prednisone and
methylprednisolone. They can cause serious side effects when used long term, so
they're used only on a short-term basis to treat severe asthma symptoms.

Treatment for allergy-induced asthma

If your asthma is triggered or worsened by allergies, you may benefit from allergy
treatment as well. Allergy treatments include:

 Allergy shots (immunotherapy). Immunotherapy injections are generally

given once a week for a few months, then once a month for a period of three to five
years. Over time, they gradually reduce your immune system reaction to specific
allergens.
 Omalizumab (Xolair). This medication is specifically for people who have
allergies and severe asthma. It acts by altering the immune system. Omalizumab is
delivered by injection every two to four weeks.

 Allergy medications. These include oral and nasal spray antihistamines and
decongestants as well as corticosteroid, cromolyn and ipratropium nasal sprays.

Don't rely on quick-relief medications

Long-term asthma control medications — such as inhaled corticosteroids — are the
cornerstone of asthma treatment. These medications keep asthma under control on a
day-to-day basis and make it less likely you'll have an asthma attack.

If you do have an asthma flare-up, a quick-relief inhaler can ease your symptoms right
away. But if your long-term control medications are working properly, you shouldn't
need to use your quick-relief inhaler very often. Keep a record of how many puffs you
use each week. If you need to use your quick-relief inhaler more often than your doctor
recommends, see your doctor. You probably need to adjust your long-term control
medication.

Bronchial thermoplasty
This treatment is used for severe asthma that doesn't improve with inhaled
corticosteroids or other long-term asthma medications. Generally done in three
outpatient visits, bronchial thermoplasty heats the insides of the airways in the lungs
with an electrode, reducing the smooth muscle inside the airways. This limits the ability
of the airways to tighten, making breathing easier and may reduce asthma attacks.
Bronchial thermoplasty isn't widely available. More research is needed to determine
whether the benefits of this treatment outweigh the possible risks and potential side
effects.

Treatment by severity for better control: A stepwise approach

Treatment based on asthma control can help you manage your asthma. Asthma
treatment should be flexible and based on changes in symptoms, which should be
assessed thoroughly each time you see your doctor. Then, treatment can be adjusted
accordingly. For example, if your asthma is well controlled, your doctor may prescribe
less medicine. If your asthma is not well controlled or getting worse, your doctor may
increase your medication and recommend more frequent visits.
Asthma action plan
Work with your doctor to create an asthma action plan that outlines in writing when to
take certain medications, or when to increase or decrease the dose of your medications
based on your symptoms. Your asthma action plan should also list your triggers and the
steps you need to take to avoid them. Your asthma plan may also involve tracking your
asthma symptoms or using a peak flow meter on a regular basis to monitor how well
your treatment is controlling your asthma.

Prevention

Working together, you and your doctor can design a step-by-step plan for living with your condition and
preventing asthma attacks.

 Develop a written asthma plan. With your doctor and health care team, write a detailed plan for taking
maintenance medications and managing an acute
attack. Then be sure to follow your plan. Asthma is an ongoing condition that
needs regular monitoring and treatment. Taking control of your treatment can
make you feel more in control of your life in general.  Identify and
avoid asthma triggers. A number of outdoor allergens and irritants — ranging from pollen and mold to
cold air and air pollution — can
trigger asthma attacks. Find out what causes or worsens your asthma, and take
steps to avoid those triggers.  Monitor
your breathing. You may learn to recognize warning signs of an impending attack, such as slight coughing,
wheezing or shortness of breath.But because your lung function may decrease before you notice any signs
or symptoms, regularly measure your peak airflow with a home peak flow meter.
 Identify and treat attacks early. If you act quickly, you're less likely to have a severe attack. You also
won't need as much medication to control your symptoms. When your peak flow measurements decrease
and alert you to an impending attack, take your medication as instructed and immediately stop any
activity that may have triggered the attack. If your symptoms don't improve, get medical help as directed
in your action plan.  Don't let up on your medication program. Just because your asthma seems to
be improving, don't change anything without first talking to your doctor. It's a good idea to bring your
medications with you to each doctor visit, so your doctor can double-check that you're using your
medications correctly and taking the right dose.

Lifestyle and home remedies

Although many people with asthma rely on medications to relieve symptoms and control inflammation,
you can do several things on your own to maintain overall health and lessen the possibility of attacks.
Avoid your triggers
Taking steps to reduce your exposure to things that trigger asthma symptoms is a key
part of asthma control. Here are some things that may help:
 Use your air conditioner. Air conditioning helps reduce the amount of
airborne pollen from trees, grasses and weeds that finds its way indoors. Air
conditioning also lowers indoor humidity and can reduce your exposure to
dust mites. If you don't have air conditioning, try to keep your windows closed
during pollen season.
 Decontaminate your decor. Minimize dust that may aggravate nighttime
symptoms by replacing certain items in your bedroom. For example, encase pillows, mattresses and box
springs in dust-proof covers. Remove carpeting and install hardwood or linoleum flooring. Use washable
curtains and blinds.
 Maintain optimal humidity. Keep humidity low in your home and office. If
you live in a damp climate, talk to your doctor about using a dehumidifier.
 Keep indoor air clean. Have a utility company check your air conditioner and
furnace once a year. Change the filters in your furnace and air conditioner
according to the manufacturer's instructions. Also consider installing a small-
particle filter in your ventilation system. If you use a humidifier, change the
water daily.
 Reduce pet dander. If you're allergic to dander, avoid pets with fur or
feathers. Having pets regularly bathed or groomed also may reduce the amount
of dander in your surroundings.
 Clean regularly. Clean your home at least once a week. If you're likely to stir
up dust, wear a mask or have someone else do the cleaning.
 If it's cold out, cover your face. If your asthma is worsened by cold, dry air,
wearing a face mask can help.
Stay healthy
Taking care of yourself and treating other conditions linked to asthma will help keep
your asthma under control. A few things you can do include:
 Exercise. Having asthma doesn't mean you have to be less active. Treatment
can prevent asthma attacks and control symptoms during activity. Regular exercise can strengthen your
heart and lungs, which helps relieve asthma symptoms. Aim for 30 minutes of exercise on most days. If
you've been inactive, start slowly and try to gradually increase your activity over time.
 Maintain a healthy weight. Being overweight can worsen asthma symptoms,
and it puts you at higher risk of other health problems.
 Control heartburn and gastroesophageal reflux disease (GERD).It 's
possible that the acid reflux that causes heartburn may damage lung airways
and worsen asthma symptoms. If you have frequent or constant heartburn, talk
to your doctor about treatment options. You may need treatment for GERD
before your asthma symptoms improve.
Coping and support
Asthma can be challenging and stressful. You may sometimes become frustrated,
angry or depressed because you need to cut back on your usual activities to avoid
environmental triggers. You may also feel hampered or embarrassed by the symptoms
of the disease and by complicated management routines. Children in particular may
be reluctant to use an inhaler in front of their peers.
But asthma doesn't have to be a limiting condition. The best way to overcome anxiety and a feeling of
helplessness is to understand your condition and take control of your treatment. Here are some
suggestions that may help:
 Identify the things that trigger your symptoms. This can be one of the most
important ways to take control of your life. Also take peak flow measurements
regularly and follow your action plan for using medications and managing
attacks.
 Pace yourself. Take breaks between tasks and avoid activities that make your
symptoms worse.
 Make a daily to-do list. This may help you avoid feeling overwhelmed.
Reward yourself for accomplishing simple goals.
 Talk to others with your condition. Chat rooms and message boards on the
Internet or support groups in your area can connect you with people facing
similar challenges and let you know you're not alone.
 If your child has asthma, be encouraging. Focus attention on the things your
child can do, not on the things he or she can't. Involve teachers, school nurses,
coaches, friends and relatives in helping your child manage asthma.