Asthma

Asthma is a disease that affects the breathing passages of the lungs (bronchioles). Asthma is caused by chronic (ongoing, long-term) inflammation of these passages. This makes the breathing tubes, or airways, of the person with asthma highly sensitive to various "triggers."
  • When the inflammation is "triggered" by any number of external and internal factors, the walls of the passages swell, and the openings fill with mucus.
  • Muscles within the breathing passages contract (bronchospasm), causing even further narrowing of the airways.
  • This narrowing makes it difficult for air to be breathed out (exhaled) from the lungs.
  • This resistance to exhaling leads to the typical symptoms of an asthma attack.

Because asthma causes resistance, or obstruction, to exhaled air, it is called an obstructive lung disease. The medical term for such lung conditions is chronic obstructive pulmonary disease or COPD. COPD is actually a group of diseases that includes not only asthma but also chronic bronchitis and emphysema. Some people with asthma do not have COPD. These are the individuals whose lung function returns to normal when they are not having an attack. Others will have a process of lung airway remodeling from chronic, long-standing inflammation, usually untreated. This results in permanent abnormalities of their lung function with symptoms of obstructive lung disease occurring all the time. These people are categorized as having one of the class of diseases known as COPD.

Like any other chronic disease, asthma is a condition you live with every day of your life. You can have an attack any time you are exposed to one of your triggers. Unlike other chronic obstructive lung diseases, asthma is reversible.

  • Asthma cannot be cured, but it can be controlled.
  • You have a better chance of controlling your asthma if it is diagnosed early and treatment is begun right away.
  • With proper treatment, people with asthma can have fewer and less severe attacks.
  • Without treatment, they will have more frequent and more severe asthma attacks and can even die. Ongoing persistent airway inflammation can lead to progressive deterioration of lung function and can result in disability and even death.

Asthma is on the rise in the United States and other developed countries. We are not sure exactly why this is, but these factors may contribute.

  • We grow up as children with less exposure to infection than did our ancestors, which has made our immune systems more sensitive.
  • We spend more and more time indoors, where we are exposed to indoor allergens such as dust and mold.
  • The air we breathe is more polluted than the air most of our ancestors breathed.
  • Our lifestyle has led to our getting less exercise and an epidemic of obesity. There is some evidence to suggest an association between obesity and asthma.

Asthma is a very common disease in the United States, where more than 17 million people are affected. A third of these are children. Asthma affects all races and is slightly more common in African Americans than in other races.

  • Asthma affects all ages, although it is more common in younger people. The frequency and severity of asthma attacks tend to decrease as a person ages.
  • Asthma is the most common chronic disease of children.

Asthma has many costs to society as well as to the individual affected.

  • Many people are forced to make compromises in their lifestyle to accommodate their disease.
  • Asthma is a major cause of work and school absence and lost productivity.
  • Asthma is one of the most common reasons for emergency department visits and hospitalization.
  • Asthma costs the U.S. economy nearly $13 billion each year.
  • Approximately 5,000 people die of asthma each year in the U.S. These numbers may not take into account those individuals who have developed severe COPD from inadequately treated asthma.

The good news for people with asthma is that you can live your life to the fullest. Current treatments for asthma, if followed closely, allow most people with asthma to limit the number of attacks they have. With the help of your health-care provider, you can take control of your care and your life.

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The exact cause of asthma is not known.
  • What all people with asthma have in common is chronic airway inflammation and excessive airway sensitivity to various triggers.
  • Research has focused on why some people develop asthma while others do not.
  • Some people are born with the tendency to have asthma, while others are not. Scientists are trying to find the genes that cause this tendency.
  • The environment you live in and the way you live partly determine whether you have asthma attacks.

An asthma attack is a reaction to a trigger. It is similar in many ways to an allergic reaction.

  • An allergic reaction is a response by the body's immune system to an "invader."
  • When the cells of the immune system sense an invader, they set off a series of reactions that help fight off the invader.
  • It is this series of reactions that results in inflammation of the lining of the air passages. This can result in a modification of the cell types lining these airways. More glandular-type cells develop, which can cause the production of mucus. This mucus, along with irritation to muscle receptors in the airways, can cause bronchospasm. These responses cause the symptoms of an asthma attack.
  • In asthma, the "invaders" are the triggers listed below. Triggers vary among individuals.
  • Because asthma is a type of allergic reaction, it is sometimes called reactive airway disease.

Each person with asthma has his or her own unique set of triggers. Most triggers cause attacks in some people with asthma and not in others. Common triggers of asthma attacks include

  • exposure to tobacco or wood smoke;
  • breathing polluted air;
  • inhaling other respiratory irritants such as perfumes or cleaning products;
  • exposure to airway irritants at the workplace;
  • breathing in allergy-causing substances (allergens) such as molds, dust, or animal dander;
  • an upper respiratory infection, such as a cold, flu, sinusitis, or bronchitis;
  • exposure to cold, dry weather;
  • emotional excitement or stress;
  • physical exertion or exercise;
  • reflux of stomach acid known as gastroesophageal reflux disease, or GERD;
  • sulfites, an additive to some foods and wine; and
  • menstruation. (In some, not all, women, asthma symptoms are closely tied to the menstrual cycle.)

A number of factors are thought to increase your chances of developing asthma. These include:

  • Having a blood relative (such as a parent or sibling) with asthma
  • Having another allergic condition, such as atopic dermatitis or allergic rhinitis (hay fever)
  • Being overweight
  • Being a smoker
  • Exposure to secondhand smoke
  • Exposure to exhaust fumes or other types of pollution
  • Exposure to occupational triggers, such as chemicals used in farming, hairdressing and manufacturing

When the breathing passages become irritated or infected, an attack is triggered. The attack may come on suddenly or develop slowly over several days or hours. The main symptoms that signal an attack are as follows:

  • wheezing,
  • breathlessness,
  • chest tightness,
  • coughing, and
  • difficulty speaking.

Symptoms may occur during the day or at night. If they happen at night, they may disturb your sleep.

Wheezing is the most common symptom of an asthma attack.

  • Wheezing is a musical, whistling, or hissing sound with breathing.
  • Wheezes are most often heard during exhalation, but they can occur during breathing in (inhaling).
  • Not all asthmatics wheeze, and not all people who wheeze are asthmatics.

Current guidelines for the care of people with asthma include classifying the severity of asthma symptoms, as follows:

  • Mild intermittent: This includes attacks no more than twice a week and nighttime attacks no more than twice a month. Attacks last no more than a few hours to days. Severity of attacks varies, but there are no symptoms between attacks.
  • Mild persistent: This includes attacks more than twice a week, but not every day, and nighttime symptoms more than twice a month. Attacks are sometimes severe enough to interrupt regular activities.
  • Moderate persistent: This includes daily attacks and nighttime symptoms more than once a week. More severe attacks occur at least twice a week and may last for days. Attacks require daily use of quick-relief (rescue) medication and changes in daily activities.
  • Severe persistent: This includes frequent severe attacks, continual daytime symptoms, and frequent nighttime symptoms. Symptoms require limits on daily activities.

Just because a person has mild or moderate asthma does not mean that he or she cannot have a severe attack. The severity of asthma can change over time, either for better or for worse.

If you go to the emergency department for an asthma attack, the health care provider will first assess how severe the attack is. Attacks are usually classified as mild, moderate, or severe. This assessment is based on several factors:

  • symptom severity and duration,
  • degree of airway obstruction, and
  • the extent to which the attack is interfering with regular activities.

Mild and moderate attacks usually involve the following symptoms, which may come on gradually:

  • chest tightness,
  • coughing or spitting up mucus,
  • restlessness or trouble sleeping, and
  • wheezing.

Severe attacks are less common. They may involve the following symptoms:

  • breathlessness,
  • difficulty talking,
  • tightness in neck muscles,
  • slight gray or bluish color in your lips and fingernail beds,
  • skin appear "sucked in" around the rib cage, and
  • "silent" chest (no wheezing on inhalation or exhalation).

If you are able to speak, the health-care provider will ask you questions about your symptoms, your medical history, and your medications. Answer as completely as you can. He or she will also examine you and observe you as you breathe.

If this is your first attack, or the first time you have sought medical attention for your symptoms, the health-care provider will ask questions and perform tests to search for and rule out other causes of the symptoms.

Measurements of how well you are breathing include the following:

  • Spirometer: This device measures how much air you can exhale and how forcefully you can breathe out. The test may be done before and after you take inhaled medication. Spirometry is a good way to monitor your lung function, but this forced maneuver during an attack can worsen your symptoms. This test is a more accurate measurement of your baseline lung function.
  • Peak flow meter: This is another way of measuring how forcefully you can breathe out during an attack. This is a useful tool for monitoring the severity of an attack as well as the adequacy of maintenance therapy. It is a less forceful maneuver and therefore can be used during an attack.
  • Oximetry: A painless probe, called a pulse oximeter, will be placed on your fingertip to measure the amount of oxygen in your bloodstream.

There is no blood test than can pinpoint the cause of asthma.

  • Your blood may be checked for signs of an infection that might be contributing to this attack.
  • In severe attacks, it may be necessary to sample blood from an artery to determine exactly how much oxygen and carbon dioxide are present in your body.

A chest X-ray may also be taken. This is mostly to rule out other conditions that can cause similar symptoms.

If your asthma has just been diagnosed, you may be started on a regimen of medications and monitoring. You will be given two types of medications:

  • Controller/maintenance medications: These are for long-term control of persistent asthma. They help to reduce the inflammation in the lungs that underlies asthma attacks. You take these every day regardless of whether you are having symptoms or not.
  • Rescue medications: These are for short-term control of asthma attacks. You take these only when you are having symptoms or are more likely to have an attack -- for example, when you have an infection in your respiratory tract. Some feel that the term rescue medication means that you only use it in an emergency. Actually, these medications should be used for any asthma symptoms, like cough, wheezing, chest tightness, or shortness of breath. They can also be used in anticipation of an activity that causes shortness of breath. It is important to keep track of the frequency that these inhalers are used for unplanned symptoms (that is, not when used in anticipation of symptoms for an activity). Asthma is considered well-controlled when rescue therapy is used less than five times per week. If asthma is not well controlled, then your provider can add additional medications. This concept is important because it helps in overall control and patient understanding of their asthma management. As is described below, medication can be added (step-up therapy) when rescue inhaler use increases for a period of time. Similarly, medications can be reduced (step-down therapy) when rescue use is minimum or nonexistent.

Your treatment plan will also include other components:

  • awareness of your triggers and avoiding the triggers as much as possible;
  • recommendations for coping with asthma in your daily life;
  • regular follow-up visits to your health care provider; and
  • use of a peak flow meter.

At your follow-up visits, your health-care provider will review how you have been doing.

  • He or she will ask you about frequency and severity of attacks, use of rescue medications, and peak flow measurements.
  • Lung function tests may be done to see how your lungs are responding to your treatment.
  • This is a good time to discuss medication side effects or any problems you are having with your treatment.

The peak flow meter is a simple, inexpensive device that measures how forcefully you are able to exhale.

  • Ask your health-care provider or an assistant to show you how to use the peak flow meter. He or she should watch you use it until you can do it correctly.
  • Keep one in your home and use it regularly. Your health-care provider will make suggestions as to when you should measure your peak flow.
  • Checking your peak flow is a good way to help you and your health-care provider assess what triggers your asthma and its severity.
  • Check your peak flow regularly and keep a record of the results. Over time, your health-care provider may be able to use this record to determine appropriate medications, reducing dose or side effects.
  • Peak flow measures fall just before an asthma attack. If you use your peak flow meter regularly, you may be able to predict when you are going to have an attack.
  • It can also be used to check your response to rescue medications.

Together, you and your health-care provider will develop an action plan for you in case of asthma attack. The action plan will include the following:

  • how to use the controller medication;
  • how to use rescue medication in case of an attack;
  • what to do if the rescue medication does not work right away;
  • when to call the health-care provider; and
  • when to go directly to the hospital emergency department.
Asthma is an incurable illness. However, with good treatment and management there is no reason why a person with asthma cannot live a normal and active life.
Get vaccinated for influenza and pneumonia. Staying current with vaccinations can prevent flu and pneumonia from triggering asthma flare-ups. 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.

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