Asthma
Asthma is a condition in which the airways narrow—usually reversibly—in response to certain stimuli. Allergies and asthma are highly correlated.
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Coughing, wheezing, and shortness of breath that occur in response to specific triggers are the most common symptoms.
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Doctors confirm the diagnosis of asthma by doing pulmonary function tests.
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To prevent attacks, people should avoid substances that trigger asthma and should take drugs that help keep airways open.
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During an asthma attack, people need to take a drug that quickly opens the airways.
Asthma affects more than 20 million people in the US, and it is becoming more common. Although it is one of the most common chronic diseases of childhood, adults can also develop asthma, even at an old age. Asthma affects more than 6 million children and occurs more frequently in boys before puberty and in girls after puberty. It also occurs more frequently in blacks and Puerto Ricans. Although the number of people affected by asthma has increased, the number of deaths has decreased.
The reason for the increase in asthma in children is not known, but it may relate to more widespread use of vaccines and antibiotics, to the fact that children are spending more time indoors, or to both. Increased use of vaccines and antibiotics may have shifted the activity of a special subgroup of white blood cells (called lymphocytes) in the body from fighting infection to releasing chemical substances that promote the development of allergies. Alternatively, because children are spending more time indoors and living in better-insulated homes than they were in the past, the exposure to potentially allergic substances is increased. There are few data to support either theory.
The most important characteristic of asthma is narrowing of the airways that can be reversed. The airways of the lungs (the bronchi) are basically tubes with muscular walls. Cells lining the bronchi have microscopic structures, called receptors. There are two main types of receptors: beta-adrenergic and cholinergic. These receptors sense the presence of specific substances and stimulate the underlying muscles to contract and relax, thus altering the flow of air. Beta-adrenergic receptors respond to chemicals such as epinephrine and make the muscles relax, thereby widening (dilating) the airways and increasing airflow. Cholinergic receptors respond to a chemical called acetylcholine, making the muscles contract, thereby decreasing airflow.
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Causes
Narrowing of the airways is often caused by abnormal sensitivity of cholinergic receptors, which cause the muscles of the airways to contract when they should not. Certain cells in the airways, particularly mast cells, are thought to be responsible for initiating the response. Mast cells throughout the bronchi release substances such as histamine and leukotrienes, which cause smooth muscle to contract, mucus secretion to increase, and certain white blood cells to migrate to the area. Eosinophils, a type of white blood cell found in the airways of people with asthma, release additional substances, contributing to airway narrowing.
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In an asthma attack, the smooth muscles of the bronchi contract, causing the bronchi to narrow (called bronchoconstriction), and the tissues lining the airways swell from inflammation and mucus secretion into the airways. The top layer of the airway lining can become damaged and shed cells, further narrowing the diameter of the airway. A narrower airway requires the person to exert more effort to move air in and out of the lungs. In asthma, the narrowing is reversible, meaning that with appropriate treatment or on their own, the muscular contractions of the airways stop, the airways widen again, and the airflow into and out of the lungs returns to normal.
In people who have asthma, the airways narrow in response to stimuli that usually do not affect the airways in normal lungs. The narrowing can be triggered by many inhaled allergens, such as pollens, particles from dust mites, body secretions from cockroaches, particles from feathers, and animal dander. These allergens combine with immunoglobulin E (a type of antibody) on the surface of mast cells to trigger the release of asthma-causing chemicals from these cells. (This type of asthma is called allergic asthma.) Although food allergies induce asthma only rarely, certain foods (such as shellfish and peanuts) can induce severe attacks in people who are sensitive to these foods.
Cigarette smoke, cold air, and viral infections can also provoke asthma attacks. Additionally, people who have asthma can develop bronchoconstriction when exercising. Stress and anxiety can trigger mast cells to release histamine and leukotrienes and stimulate the vagus nerve (which connects to the airway smooth muscle), which then contracts and narrows the bronchi. Gastroesophageal reflux disease (GERD) is a common trigger of asthma.
Symptoms
Asthma attacks vary in frequency and severity. Some people who have asthma are symptom-free most of the time, with only an occasional, brief, mild episode of shortness of breath. Other people cough and wheeze most of the time and have severe attacks after viral infections, exercise, or exposure to allergens or irritants, including cigarette smoke. Coughing may be the only symptom in some people (cough-variant asthma). Crying or hearty laughing may bring on symptoms in some people. Some people with asthma produce a clear, sometimes sticky (mucoid) phlegm (sputum). Asthma attacks occur most often in the early morning hours when the effects of protective drugs wear off and the body is least able to prevent bronchoconstriction.
An asthma attack may begin suddenly with wheezing, coughing, and shortness of breath. Wheezing is particularly noticeable when the person breathes out. At other times, an asthma attack may come on slowly with gradually worsening symptoms. In either case, people with asthma usually first notice shortness of breath, coughing, or chest tightness. The attack may be over in minutes, or it may last for hours or days. Itching on the chest or neck may be an early symptom, especially in children. A dry cough at night or while exercising may be the only symptom. Symptoms of asthma can also be caused by other disorders. Symptoms are reversible with timely treatment and typically occur after exposure to one or more triggers.
During an asthma attack, shortness of breath may become severe, creating a feeling of severe anxiety. The person instinctively sits upright and leans forward, using the neck and chest muscles to help in breathing, but still struggles for air. Sweating is a common reaction to the effort and anxiety. The pulse usually quickens, and the person may feel a pounding in the chest.
In a very severe asthma attack, a person is able to say only a few words without stopping to take a breath. Wheezing may diminish, however, because hardly any air is moving in and out of the lungs. Confusion, lethargy, and a blue skin color (cyanosis) are signs that the person's oxygen supply is severely limited, and emergency treatment is needed. Usually, a person recovers completely with appropriate treatment, even from a severe asthma attack. Rarely, some people develop attacks so quickly that they may lose consciousness before they can give themselves effective therapy. Such people should wear a medical alert bracelet and carry a cellular phone to call for emergency medical assistance.
Diagnosis
Doctors suspect asthma based largely on a person's report of characteristic symptoms. Doctors confirm the diagnosis by doing pulmonary function tests. These tests are done before and after giving the person an inhaled drug, called a beta-adrenergic agonist, that reverses bronchoconstriction. If test results are significantly better after the person receives the drug, asthma is thought to be present. If the airways are not narrowed at the time of the test, a diagnosis can be confirmed by doing a challenge test. In a challenge test, pulmonary function is measured before and after the person inhales a chemical (usually methacholine but histamine may be used) that can narrow the airways. The chemical is given in doses that are too low to affect a person with healthy lungs but that cause the airways to narrow in a person with asthma. If the challenge test shows airway narrowing, asthma is thought to be present.
An abbreviated form of pulmonary function testing, spirometry, is used in people known to have asthma. Spirometry can help assess the severity of the airway obstruction and monitor effectiveness of treatment.
Peak expiratory flow (the fastest rate at which air can be exhaled) can be measured using a small handheld peak flow meter. Often, this test is used at home to monitor the severity of asthma. Usually, peak flow rates are lowest between 4 am and 6 am and highest at 4 pm. However, more than a 30% difference in rates at these times is considered evidence of moderate to severe asthma.
Determining what triggers a person's asthma is often difficult. Allergy testing is appropriate when there is a suspicion that some avoidable substance is stimulating attacks (for example, exposure to cat dander). Skin testing can help identify allergens that may trigger asthma symptoms. However, an allergic response to a skin test does not necessarily mean that the allergen being tested is causing the asthma. The person still has to note whether attacks occur after exposure to this allergen. If doctors suspect a particular allergen, a blood test that measures the level of antibody produced in response to the allergen (the radioallergosorbent test [RAST]) can be done to determine the degree of sensitivity.
To test for exercise-induced asthma, an examiner uses spirometry before and after exercise on a treadmill or stationary bicycle to measure how much air the person can exhale in 1 second (forced expiratory volume in 1 second). If the forced expiratory volume in 1 second decreases more than 15%, the person's asthma can be induced by exercise.
A chest x-ray is not generally helpful in diagnosing asthma. Doctors use chest x-rays when considering another diagnosis. However, a chest x-ray is often obtained when a person with asthma needs to be hospitalized for severe asthma.
Prevention and Treatment
An array of drugs can be used to prevent and treat asthma. Most of the drugs used to prevent asthma are also used to treat an asthma attack but in higher doses or in different forms. Some people need to use more than one drug to prevent and treat their symptoms.
Therapy is based on two classes of drugs: anti-inflammatory drugs and bronchodilators. Anti-inflammatory drugs suppress the inflammation that narrows the airways. Bronchodilators help to relax and widen (dilate) the airways. Anti-inflammatory drugs include corticosteroids (which can be inhaled, taken by mouth, or given intravenously), leukotriene modifiers, and mast cell stabilizers. Bronchodilators include beta-adrenergic agonists (both those for quick relief of symptoms and those for long-term control), drugs with anticholinergic effects, and methylxanthines.
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Education about how to prevent and treat asthma attacks is beneficial for all people who have asthma and often for their family members. Proper use of inhalers is essential for effective treatment. People should know what can stimulate an attack, what helps to prevent an attack, how to use drugs properly, and when to seek medical care. Many people use a handheld peak flow meter to evaluate their breathing and determine when they need intervention, before their symptoms get extreme. People who experience frequent, severe asthma attacks should know how to reach help quickly.
Many people have a written treatment plan that was devised in collaboration with their doctor. Such a plan allows them to take control of their own treatment and has been shown to decrease the number of times people need to seek care for asthma in the emergency department.
Preventing Attacks
Asthma is a chronic condition that cannot be cured, but individual attacks can often be prevented. Asthma attacks may commonly be prevented if the factors that trigger them are identified and eliminated or avoided. People who have asthma should avoid cigarette smoke. Often, attacks triggered by exercise can be blocked by taking medication beforehand. When dust and allergens are the problem, air filters, air conditioners, and other types of barriers (such as mattress covers, which reduce the amount of particles from dust mites that are in the air) can help considerably. For people whose asthma is stimulated by allergies, desensitization through the use of allergy shots may prevent attacks.
Some people who have asthma may have a sensitivity to aspirin Some Trade Names
BAYER
or other nonsteroidal anti-inflammatory drugs (NSAIDs) and must avoid using these drugs. Drugs that block the beneficial effects of beta-adrenergic agonists (called beta-blockers) may worsen asthma.
Most people with asthma take drugs, such as inhaled or oral corticosteroids, leukotriene modifiers, long-acting beta-adrenergic agonists, methylxanthines, antihistamines, or mast cell stabilizers to prevent attacks. Prevention efforts are individualized according to the frequency of attacks and the stimuli that trigger the attacks.
Treating Attacks
An asthma attack can be frightening, both to the person experiencing it and to others around. Even when relatively mild, the symptoms provoke anxiety and alarm. A severe asthma attack is a life-threatening emergency that requires immediate, skilled, professional care. If not treated adequately and quickly, a severe asthma attack can cause death.
People who have asthma are generally able to treat most attacks without assistance from a health care practitioner. Typically, they use an inhaler to deliver a dose of a short-acting beta-adrenergic agonist, move into fresh air (away from cigarette smoke or other irritants), and sit down and rest. An attack usually subsides in 5 to 10 minutes. An attack that does not subside in 15 minutes or that gets worse is likely to require additional treatment supervised by a doctor.
Because people with severe asthma commonly have low blood oxygen levels, doctors may check the level of oxygen by using a sensing monitor on a finger or ear. Supplemental oxygen may be given during attacks. However, in severe attacks, doctors also need to monitor levels of carbon dioxide in the blood, and this test requires a sample of blood from an artery. Doctors may also check lung function, usually with a spirometer or a peak flow meter. Usually, a chest x-ray is needed only in severe asthma attacks. People experiencing very severe asthma attacks may need to have an artificial airway passed through their mouth and throat (intubation) and be placed on a mechanical ventilator.
Generally, people who have severe asthma are admitted to the hospital if their lung function does not improve after they have received an inhaled beta-adrenergic agonist and corticosteroids by mouth or vein. People also are hospitalized if they have a seriously low blood oxygen level or a high blood carbon dioxide level.
Intravenous fluids may be needed if the person is dehydrated. Antibiotics also may be needed if a doctor suspects a lung infection; however, most such infections are due to viruses for which (with a few exceptions) no treatment exists.
ENT & Allergy
Physicians:
06/23/2010
