Asthma is a chronic lung disease that causes inflammation and narrowing of the airways in the lungs. Recurring periods of wheezing, chest tightness, shortness of breath, and coughing are all hallmarks of asthma.
Asthma affects people of all ages, but most often starts during childhood.
Asthmatics have inflamed airways in their lungs. Inflamed airways are narrowed and very sensitive, thereby reacting very stronglt to inhaled allergens.
When the airways react, the muscles around them tighten, narrowing the airways causing reduced airflow into the lungs. The swelling can and will progress, farther narrowing the airways. Associated with this process is the increased production of mucus, a thick, sticky fluid that farther narrows the already narrowed airways.
These reactions result in the symptoms of asthma – Wheezing, chest tightness, shortness of breath, and coughing.
Asthmatic symptoms are often mild and spontaneously resolve or are easily treated with minimal treatment. However, in some cases, it can progress and become worse, resulting in what is commonly known as an asthmatic attack.
Hence, treating symptoms of asthma early is paramount. By the time an asthmatic attack ensues, emergency care is required and if left untreated, asthma can be fatal.
There is no cure for asthma.However, with proper and thorough ongoing treatment, asthma can be managed and sufferers of asthma can and will continue to lead normal and active lives.
Populations At Risk
Most often, asthma starts during childhood but it can affect all ages.
Young children who frequently suffer from respiratory infections are at highest risk of developing asthma.Other risk factors influencing the development of asthma include being atopic (having multiple allergies), eczema, or, as mentioned above, having parents who are also asthmatic.
Boys have a higher risk of developing asthma compared to girls. However, once adulthood is reached, there are more female asthmatics compared to their male counterparts. As a sum total, most people with asthma have allergies.
Another significant population with asthma are industrial workers who come into contact with chemical irritants or industrial pollutants in their workplace. This population develops occupational asthma, a contentious disease label.
Causes of Asthma
A multitude of causes for asthma have been documented so far. These include:
- Genetic causes, especially atopic individuals or asthmatic parents
- Childhood Respiratory Infections
- A multitude of airborne allergens have been implicated
Signs and Symptoms of Asthma
Common signs and symptoms of asthma include:
- Chest tightness
- Shortness of breath
Coughing caused by Asthma is often worse at night, disrupting sleep. Wheezing is a squeaky, whooshy sound that is audible with each breath.Chest tightness and shortness of breath can and is often confused with cardiac causes and can result in undue stress to the patient.
Having one or more of the above symptoms do not automatically diagnose asthma. Proper lung function tests, history taking and a physical examination by a health profession is the only way of confirming asthma.
The type and severity of symptoms of asthma suffered by the patients though determines the management of the disease. Because symptoms vary over time, asthmatics need to be aware of their own symptoms and fluctuations thereof, and seek treatment early because while mild symptoms can be simply annoying, severe symptoms can seriously limit daily routines and exercise, and very severe symptoms can potentially cause death if untreated.
Treatment is now available to prevent the onset of asthma in known asthmatics.
Triggers Of Asthma
- Allergens – dust, animal fur, cockroaches, mold, and pollens from trees, grasses, and flowers etc.
- Chemical Irritants – cigarette smoke, air pollution, chemicals, workplace dust, sprays etc.
- Medicines – NSAIDs (eg aspirin) and B-Blockers (eg Atenolol).
- Upper respiratory infections
- Physical activity – exercise can trigger asthma.
This list is not exhaustive. Each asthmatic is unique and it is best if you seek advice from your health professional.
Prevention Of Asthma
Asthma can’t be cured. But you can prevent it. Following these simple steps will go a long way in managing asthma.
- Educate yourself about asthma. Empower yourself.
- Have an Asthma Action Plan and follow through with it.
- Follow your physician’s medicine regime
- Identify the triggers that cause your asthma and avoid them
- Document progression of your asthma
- Regular visits to your treating physician
Asthma is diagnosed in the primary care setting by a comprehensive medical history, family history, a physical examination and lung function tests.
Your primary care physician will determine the severity of your asthma which in turn will affect the treatment you require.
Referral to a Respiratory Specialist in the following situations:
- Subspecialized tests are needed to confirm the diagnosis of asthma
- There is a history of a life threatening asthma attack
- Treatment for specific allergies
- Polypharmacy (Multiple medications) is needed to control your asthma
Important Points To Mention During Your Medical Consult
Important points to bring up during your medical consult include:
- A Family history of asthma and allergies
- Frequency of asthmatic attacks
- Timing of asthmatic attacks, especially if it occurs only during certain times of the year, day, or in certain places.
- Triggers of asthma specific to you
- Related conditions when experiencing an asthmatic attack, like a concurrent upper respiratory tract infection, reflux disease, stress, sleep apnoea etc
Physical examination would include:
- Auscultation by your primary physician to listen for wheezing in the lungs
- Examination of the upper airways, sinuses and upper nasal passages for existing upper airway diseases
- Examination for other signs of allergic conditions eg eczema
Diagnostic Tests For Asthma
Lung Function Tests
Lung Spirometry is a type of Lung Function Test that measures the amount of air you inhale and exhale and the speed thereof.
Some respiratory specialists will use medications to “treat” existing asthma and repeat the lung function tests again to see if there is any improvement. This is usually done if chronic asthma is suspected. It is also done when the diagnosis of asthma is unclear.
Associated Tests For Asthma
Other tests performed by respiratory specialists may include:
- Allergy testing
- Perform Bronchoprovocation tests to “trigger” a controlled asthmatic attack
- Chest X-Rays
- Electrocardiograms (ECGs)
Asthma In Young Children
Many children develop asthmatic symptoms before 5 years of age and it is difficult to diagnose asthma in young children because the symptoms often present together with many other childhood diseases.
Reason is because children have small airways to begin with. Any respiratory condition with mucus production, for example, will further narrow their airways causing wheezing to be audible, thereby mimicking asthma. As the child grows older, the airways enlarge, and wheezing no longer becomes audible.
However, asthma should be suspected if:
- One or both parents have asthma
- Other allergic conditions eg eczema is present
- A history of pollen allergy or hay fever is present
- Wheezing is audible even when the child is healthy
Children Below 5 Years of Age
Asthma is difficult to diagnose in children below 5 years of age. As the airways of children are naturally small, wheezing, when audible, can be confused between asthma and simple upper respiratory tract infections.
To add to the confusion, fast acting medications like Beta2 Agonists will relieve wheezing in children irrespective of whether they have asthma or not.
Your primary physician might elect to treat your child with long term medications like inhaled corticosteroids after weighing the risks vs the benefits of the drug. They will do so especially if the asthma proceeds beyond 6 years of age.
Inhaled corticosteroids are the preferred drug of choice for young children, Montelukast and Cromolyn being the other options available. Treatment is usually prescribed over a trial period between 4-6 weeks and stopped if no benefits are seen during that period of time.
Side effects of inhaled corticosteroids in very young children include slow growth across all ages. However, poorly controlled asthma also reduces a child’s growth rate. Hence, your primary physician will discuss the risks and benefits of commencing inhaled corticosteroids with you before commencing the medication.
Polypharmacy in elderly patients makes treatment in this group challenging. Commonly used drugs like Beta Blockers (for hypertension), aspirin and other NSAIDs (for analgesia) are all contraindicated in the treatment of asthma.
All elderly patients are advised to inform the doctor of all the medications currently consumed.
Side effects from asthma treatment like long time consumption of corticosteroids at high doses include development of osteoporosis and diabetes. Discuss management strategies with your primary physician before commencing these medications.
Pregnancy is complicated by asthma because the foetus requires an adequate oxygen supply above and beyond that required by the mother. Asthma also increases the risk of other complications of pregnancy, pre-eclampsia, pre-mature birth and low birth weights notwithstanding.
It is more beneficial to take asthma medicines while pregnant than to risk having an asthma attack. Discuss your Asthma Action Plan with your attending physician if you’re pregnant or planning a pregnancy. Whatever your asthma control may be, continued monitoring and control of your asthma throughout your pregnancy is essential.
Athletes and Growing Children
Physical activities can trigger asthma.
There is a range of medications that may help prevent asthma during exercise. These include:
- Short-acting Beta2-agonists – These are inhaled often before physical activity and have a duration of action up to 2-3 hours.
- Long-acting Beta2-agonists – These are inhaled and have a duration of action up to 12 hours. However, tolerance to these medications can develop and with prolonged use, the duration of action of the drug will be reduced.
- Leukotrienes – These are often consumed orally hours before physical activity and can relieve symptoms of asthma.
It is important to slowly ease into exercise and not to over exert unnecessarily. A simple warm up prior to exercise, proper clothing and warm down post exercise will all aid in controlling asthma.
With proper control, asthmatics can participate in any physical activity or sport they wish.
Asthma is a significant risk factor for general anaesthesia.Tracheal intubation, for example, can trigger an asthmatic attack.
Patients are advised to inform the surgeon and anaesthesia team prior to surgery to pre-empt problems.
There is no cure for asthma. Aim of management is to achieve control of the disease. This includes the following:
- Prevent chronic and recurrent symptoms like nocturnal coughing
- Reduce the use of medications
- Maintenance of lung function
- Maintenance of regular activities
- Preventing severe asthmatic attacks requiring hospital stays or visits to the Emergency Room
Practical tips to control asthma:
- Control other conditions that can aggravate asthma
- Avoid known allergens
- Maintain an active lifestyle
- Have an action plan in the event of asthma attacks
The asthma action plan should include the medications regime, avoidance of triggers, tracking of asthma attacks, and actions to be taken if asthmatic symptoms become more severe despite treatment. Eg When to proceed to the Hospital Emergency Department for treatment
Medications for Asthma
Asthmatic medications can be broadly divided into medications that exert long term control and medications that provide rapid relief from asthmatic symptoms.
Both types of medications aim at reducing airway inflammation to control asthma.
Initial treatment depends on how severe your asthma is. Follow up treatment depends on how well the patient follows the asthma action plan and how effective the action plan is.
Note though that the asthma action plan will vary with changes in your lifestyle and social environment because different social exposures result in exposure to different allergens in your environment.
Adjustment of medication dosage should be at the discretion of your primary physician. If you have adjusted the dose of medication on your own, you should let your primary physician know immediately to facilitate proper titration of medication dosing with each visit to the doctor.
The doctor will always aim to use the least amount of medicine necessary to achieve control of your asthma so it is imperative that the doctor be made aware of how much medications you have been using.
Certain groups of patients require more intensive titration regimes – these include pregnant women, young children, or patients with special needs.
Asthma Action Plan
Every Asthma Action plan should be crafted to the individual patient. The plan should include the medication regime, avoidance of triggers, tracking of asthma attacks and actions to be taken should symptoms of asthma become progressively severe.
It is best to work with your primary physician to draft your asthma action plan. The plan should describe all the above in detail.
In the case of children, parents and caregivers should know the child’s asthma action plan. This should include babysitters, workers at day care centers, parents, schools and organizers of outdoor children activities.
Avoidance of Triggers
An entire multitude of allergens have been documented to be linked to asthma. To the individual patient, the most important thing is to know what triggers asthma in you. Following that, know what steps to take when asthma is triggered.
Simple common sense is essential. For example, if you have a known allergy or sensitivity to pollen, please limit your exposure to pollen and stay indoors if needed. If you are sensitive to pets, or pet fur, please do not keep pets at home or allow pets to enter your bedroom.
Of note, physical activity can also trigger asthmatic attacks. However, it is recommended that asthmatics exercise on a regular basis because in the long run, exercise will help with control of asthma.Speak with your primary physician if you experience asthmatic attacks when engaging in physical activities. There are medications available to control asthma during exercise.
In the event your asthma correlates strongly to allergens that cannot be avoided (eg dust), your primary physician might advise on use of medications against allergies.
Medications for Asthma
Please consult with your primary physician for medications suitable for control of your asthma. Your primary physician will adjust the dose of medications as needed. If you have self adjusted the dose, you must inform your primary physician on your next visit.
Generally speaking, medications for asthma can either be in the form of a pill, an injectable, or as a nebulized drug consumed via use of an inhaler. Nebulized drugs are inhaled directly into the lungs where it exerts its effects.
Please note that use of inhalers will require a certain technique and should be taught by a doctor or a trained health care provider.
Medications targeting Long Term Control
Chronic asthmatics will need medications to achieve long term control of their asthma. These medications work slowly and reduces airway inflammation.
Inhaled corticosteroids are most commonly used for long term control of asthma. They act by reducing inflammation in the airways of the lungs. Use of inhaled corticosteroids daily will greatly reduce the severity and frequency of symptoms.
The most common side effect of inhaled corticosteroids is oral thrush. Use of a spacer when using the inhaled corticosteroid can reduce the incidence of oral thrush.Check with your primary physician if you are unsure of how to use a spacer. Simple rinsing of the mouth after cosuming inhaled corticosteroids can also reduce the incidence of oral thrush.
Patients who have severe asthma might need to consume oral corticosteroids instead of inhaled corticosteroids to achieve sufficient control of their asthma. Unlike inhaled corticosteroids, which can be taken for years, oral corticosteroids will have significant side effects if used for prolonged periods.
Long term use of oral corticosteroids increases the risk of diabetes, osteoporosis, cataracts, and abnormal metabolic activity.
Consult with your primary physician to measure the risks and benefits before consuming oral corticosteroids.
Other long term medications:
- Cromolyn – This drug prevents airway inflammation and is used as a nebulized drug delivered via an inhaler.
- Omalizumab – This drug is a form of immunotherapy and acts against Immunoglobulin E (anti-IgE) which triggers narrowing of airways. This medication is usually given as an injection once or twice a month and prevents the immune system from reacting to triggers of asthma. It is, however, not a first line treatment for asthma and might not be offered upfront by your primary physician.
- Inhaled long-acting beta2-agonists – These medications are usually taken together with inhaled corticosteroids to achieve a synergistic effect on expanding the lumen of the lung airways.
- Leukotriene modifiers – These are oral medications that reduce airway inflammation.
- Theophylline – Theophylline can be consumed orally or via an injection and acts to open the lung airways.
Please note that there is a likelihood of symptoms rebounding if long term medications are suddenly ceased. Also, all long term medications will have side effects. Please discuss with your primary physician before commencing long term treatment regimes
Rapid Acting Medications
Short acting Beta 2 – Agonists are usually the first line medications in this group. They are often delivered in the nebulized form through an inhaler. They act by relaxing the muscles in the airways, thereby allowing more air passage through.
Rapid acting medications should be consumed as soon as symptoms appear.
Should the medication be required for more than 2 days a week, you should inform your doctor to formulate more strategies for your asthma action plan.
Asthmatics are advised to carry their quick relief inhaler with them at all times.
Of note, these medications do not reduce inflammation of the airways and hence cannot replace long acting medications.
Documentation of Asthma Progression
Regular use of the peak flow and regular visits to your primary physician will be the primary means of documenting progression of Asthma.
As a rule of thumb, asthma is well controlled if:
- Symptoms occur no more than 2 days a week
- Symptoms do not disturb sleep more than twice a month.
- There are no limitations to your daily activities.
- Quick-relief medicines are required less than 2 days a week.
- Less than one severe asthma attack a year requiring oral steroids
- Peak Flow Meter readings remain at 80% of baseline level
Peak Flow Meter
Your primary care physician will instruct on the use of the peak flow meter.
When used, the peak flow meter measures the maximum rate of flow of air out of the lungs during exhalation. Regular measurements will allow documentation of asthma progression and it is recommended that patient record their peak flow every morning.
During the initial phase after diagnosis, it is important to ascertain baseline peak flow. This is often touted as the patient’s “Personal Best” peak flow reading. Future control of asthma relies on this baseline. Good asthma control being maintenance of peak flow to at least 80% of baseline.
Regular peak flow readings also help predict impending asthmatic attacks. Progressively deteriorating peak flow readings often indicate an impending attack and should be incorporated into the Asthma Action Plan.
Frequent medical reviews with your primary physician every fortnightly is the norm during the initial phase of treatment. Once asthma is controlled, your primary physician might elect to see you across a longer stretch of time.
During the medical reviews, important information required by your primary physician include:
- Frequency of Asthma Attack
- Changes in Symptoms
- Changes in Peak Flow Readings
- Changes in daily activities like exercise tolerance
- Difficulties with adherence to the Asthma Action Plan
- Problems with current medications
Seek Medical advice if:
- Regular medications fail to treat an asthma attack.
- Peak flow readings falls to less than 50% of baseline
Proceed immediately to the nearest Hospital Emergency Room if:
- You experience severe shortness of breath to the stage where walking becomes difficult
- Your lips and tongue turn bluish
Asthma – A Lifelong Issue
There is no cure for asthma. Successful management of asthma requires the patient to take an active role in the control of asthma by conforming to an asthma action plan.
Your primary physician is your best partner to develop your asthma action plan. The action plan will keep you reminded of your medication regime, triggers, and protocols to follow when asthmatic symptoms develop or worsen. Even children should be involved in the creation of their action plan because it is the individual effort that counts in the long term care of asthma.
Asthma will not be going away. But it can be controlled.
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