Asthma: Causes, Symptoms, Diagnosis, Treatment

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Bronchial asthma is a chronic, inflammatory disease of the respiratory tract, which is characterized by bronchial hyperreactivity and respiratory obstruction which is reversible (spontaneously or under influence of bronchodilater) marked by wheezing ,shortness of breath,chest tightness and coughing.



    For many asthma sufferers, timing of these symptoms is closely related to physical activity. And, some otherwise healthy people can develop asthma symptoms only when exercising. This is called exercise-induced bronchoconstriction (EIB), or exercise-induced asthma (EIA). Staying active is an important way to stay healthy, so asthma shouldn't keep you on the sidelines. Your physician can develop a management plan to keep your symptoms under control before, during and after physical activity.

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    People with a family history of allergies or asthma are more prone to developing asthma. Many people with asthma also have allergies. This is called allergic asthma.

    Occupational asthma is caused by inhaling fumes, gases, dust or other potentially harmful substances while on the job.

    Childhood asthma impacts millions of children and their families. In fact, the majority of children who develop asthma do so before the age of five.

    There is no cure for asthma, but once it is properly diagnosed and a treatment plan is in place you will be able to manage your condition, and your quality of life will improve.

    ETIOLOGY

    The development of bronchial asthma is a multicausal process, which is caused by exogenic factors (environmental factors), and also by genetic dispositions. In addition, the course of the disease can be influenced by climatic changes and mental factors. Important exogenic activators are: · Allergens or Environmental allergens (house dust mites, pollen) Allergenic work substances (flour) or Food allergens · Toxins or chemical irritants ·Respiratory diseases · Pseudoallergic reactions (PAR) to analgesics (analgesic-induced asthma) · Physical exertion (mainly in children) Patients with allergic asthma or other atopical diseases show a polygenic inherited trait for an overshooting immune response of IgE. If both parents suffer from atopy, the children have an atopical disease as well in 40-50% of the cases.

    Asthma

    CLASSIFICATION

    1. Allergic or Extrinsic Asthma

    This generely begins earlier in life and is associated with atrophy-the presence of immediate hypersensitivity to external allergens associated with positive skin-prick tests. These patients show a high incidence of seasonal rhinitis and flexural eczema. There is usually a strong family history of asthma,hay fever or eczema.

    In patients with the extrinsic asthma episodes may be precipitated by exposure to antigenic materials, including pollens, house dust, animal furs and feathers.Foodstuffs including milk,eggs,fish and chocolate may, very occasionally,be incriminated. Patients with extrinsic asthma may also react adversely to non-allergic provoking factors including air temperature changes, emotional disturbances, exercise laughter and respiratory tract infection(RTI).

    2. Non-allergic or Intrinsic Asthma

    This occur later in life and allewrgic featurs are usually absent so that the skin-prick test to common allergens are negetive.This is common in women than men.

    3. Mixed Form

    Worsening symptoms of the both types include bronchial irritation by the streneous exercise ,exposure to cold air,dust,tobbaco smoke,fumes, emotional stress and respiratory infections.


    Airway narrowing in an asthma attack. The image on the left shows the location of the lungs in the body. The middle image is a close-up of a normal airway, and the image on the right shows a narrowed, inflamed airway typical of an asthma attack. Medical Illustration Copyright © 2020 Nucleus Medical Media, All rights reserved.


    According to Degree of Severity

    Grade 1: Intermittent
    Grade 2: Persistent, Mild
    Grade 3: Persistent, Moderate
    Grade 4: Persistent, Severe


    According to Clinical Types

    1. Episodic Asthma

    May occur at any time by feeling of chest tightness with breathlessness and wheezing. Expiration becomes difficult with short gasping inspiration,and wheezes are usually expiratory and often audible without the aid of a stethoscope. A troublesome cough is common with scanty viscid mucus.

    In severe episodes there will be a tachycardia,pulsus paradoxus and central cyanosis.

    2. Chronic Asthma

    There is persistence wheezing with breathlessness.cough with mucoid sputum and recurrent episodes of respiratory infections.

    3. Childhood Asthma

    Wheeziness is common with the minor respiratory infections.Non-asthmatic wheeziness usually resolves as the child grows.childhood asthma is commener in boys than girls and usually accompnies atopy.

    4. Adult Asthma

    Asthma may persist into adult life from childhood. Irritanta including smog,ciggarette smoke, and pollens.

    5. Status Asthmaticus

    These has been supersedes by ”SEVERE ACUTE ASTHMA” refers to episodes of severe wheezing and breathlessness lasting more than 24 hours not responding to normal medication and potentially threatning”PULSUS PARADOXUS ”and very quite breath sounds on auscultation.

    PATHOPHYSIOLOGY

    Genetic disposition and exogenous noxa trigger three pathophysiological processes which characterize bronchial asthma:

    1. Inflammation of the Bronchi

    Allergens or infections elicit an infectious reaction of the bronchial mucous membrane. In allergic asthma, an IgE-induced reaction of the immediate type (Type 1 reaction) occurs immediately after inhalation of the allergen. The mast cells in the mucous membrane degranulate and thereby release inflammation mediators like histamine, ECF-A, bradykinin and leukotrienes (“immediate reaction”). Apart from this immediate reaction, there also exists an IgG-induced late reaction after 6-12 hours or a combination of both reaction types (“dual reaction”). As a rule, the triggering allergen can only be identified at the early stage of the disease. In the course of years, the range of allergens often becomes wider, thereby making it more difficult or even impossible for the patient to avoid allergens.

    2. Bronchial Hyperreactivity

    An unspecific bronchial hyperreactivity can be detected in almost all asthmatics. In case of the inhalation of irritants, the hyperreactivity manifests as a very strong constriction of the bronchial tubes, and can be objectified by the methacholine test.

    3. Endobronchial Obstruction

    The endobronchial obstruction is the first clinically discernible “end product” of the pathophysiological processes of bronchial asthma. It develops through the shift of the bronchial lumen as a consequence of mucosal edema, increased mucus secretion (dyscrinism) and bronchospasms.


    Asthma Symptoms

    According to the leading experts in asthma, the symptoms of asthma and best treatment for you or your child may be quite different than for someone else with asthma.

    The most common symptom is wheezing. This is a scratchy or whistling sound when you breathe. Other symptoms include:
    • Shortness of breath
    • Chest tightness or pain
    • Chronic coughing
    • Trouble sleeping due to coughing or wheezing

    Asthma symptoms, also called asthma flare-ups or asthma attacks, are often caused by allergies and exposure to allergens such as pet dander, dust mites, pollen or mold. Non-allergic triggers include smoke, pollution or cold air or changes in weather.

    Asthma symptoms may be worse during exercise, when you have a cold or during times of high stress.

    Children with asthma may show the same symptoms as adults with asthma: coughing, wheezing and shortness of breath. In some children chronic cough may be the only symptom.

    If your child has one or more of these common symptoms, make an appointment with an allergist / immunologist:
    • Coughing that is constant or that is made worse by viral infections, happens while your child is asleep, or is triggered by exercise and cold air
    • Wheezing or whistling sound when your child exhales
    • Shortness of breath or rapid breathing, which may be associated with exercise
    • Chest tightness (a young child may say that his chest “hurts” or “feels funny”)
    • Fatigue (your child may slow down or stop playing)
    • Problems feeding or grunting during feeding (infants)
    • Avoiding sports or social activities
    • Problems sleeping due to coughing or difficulty breathing

    Patterns in asthma symptoms are important and can help your doctor make a diagnosis. Pay attention to when symptoms occur:
    • At night or early morning
    • During or after exercise
    • During certain seasons
    • After laughing or crying
    • When exposed to common asthma triggers

    Asthma Diagnosis

    An allergist diagnoses asthma by taking a thorough medical history and performing breathing tests to measure how well your lungs work.

    One of these tests is called spirometry. You will take a deep breath and blow into a sensor to measure the amount of air your lungs can hold and the speed of the air you inhale or exhale. This test diagnoses asthma severity and measures how well treatment is working.

    A FeNO Test or Exhaled Nitric Oxide Test

    In patients with allergic or eosinophilic asthma, is a way to determine how much lung inflammation is present and how well inhaled steroids are suppressing this inflammation. With allergic or eosinophilic asthma, sometimes you may feel your breathing is fine, but when you measure your exhaled nitric oxide, it may still be significantly elevated, and you might do better in the long-term using slightly more of your inhaled steroid to suppress this inflammation.

    Spirometry : This test estimates the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath and how fast you can breathe out.
    Peak flow. A peak flow meter is a simple device that measures how hard you can breathe out. Lower than usual peak flow readings are a sign your lungs may not be working as well and that your asthma may be getting worse. Your doctor will give you instructions on how to track and deal with low peak flow readings.

    Lung function tests often are done before and after taking a medication called a bronchodilator , such as albuterol, to open your airways. If your lung function improves with use of a bronchodilator, it’s likely you have asthma.

    Asthma
    Other tests to diagnose asthma include:


    1. Methacholine challenge : Methacholine is a known asthma trigger that, when inhaled, will cause mild constriction of your airways. If you react to the methacholine, you likely have asthma. This test may be used even if your initial lung function test is normal.

    2. Nitric oxide test : This test, though not widely available, measures the amount of the gas, nitric oxide, that you have in your breath. When your airways are inflamed — a sign of asthma you may have higher than normal nitric oxide levels.

    3. Imaging tests : A chest X-ray and high-resolution computerized tomography (CT) scan of your lungs and nose cavities (sinuses) can identify any structural abnormalities or diseases (such as infection) that can cause or aggravate breathing problems.

    4. Allergy testing : This can be performed by a skin test or blood test. Allergy tests can identify allergy to pets, dust, mold and pollen. If important allergy triggers are identified, this can lead to a recommendation for allergen immunotherapy.

    5. Sputum eosinophils : This test looks for certain white blood cells (eosinophils) in the mixture of saliva and mucus (sputum) you discharge during coughing. Eosinophils are present when symptoms develop and become visible when stained with a rose-colored dye .

    6. Provocative testing : for exercise and cold-induced asthma. In these tests, your doctor measures your airway obstruction before and after you perform vigorous physical activity or take several breaths of cold air.

    PREVENTIVE TREATMENT OF BRONCHIAL ASTHMA

    USE YOUR AIR CONDITIONER

    Air conditioning reduces 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.

    DECONTAMINAT YOUR DECOR

    Minimize dust that may worsen nighttime symptoms by replacing certain items in your bedroom. For example, encase pillows, mattresses and box springs in dustproof covers. Remove carpeting and install hardwood or linoleum flooring. Use washable curtains and blinds.

    MAINTAIN OPTIMAL HUMIDITY

    If you live in a damp climate, talk to your doctor about using a dehumidifier.

    PREVENT MOLD SPORES

    Clean damp areas in the bath, kitchen and around the house to keep mold spores from developing. Get rid of moldy leaves or damp firewood in the yard.

    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 regular 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.
    Cover your nose and mouth if it’s cold out. If your asthma is worsened by cold or dry air, wearing a face mask can help.

    TREATMENT

    Prevention and long-term control are key in stopping asthma attacks before they start. Treatment usually involves learning to recognize your triggers, 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 your age, symptoms, asthma triggers and what works best to keep your asthma under control.

    Preventive, long-term control medications reduce the inflammation in your airways that leads to symptoms. Quick-relief inhalers (bronchodilators) quickly open swollen airways that are limiting breathing. In some cases, allergy medications are necessary.

    Long-term asthma control medications, generally taken daily, 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. Types of long-term control medications include:

    INHALED CORTICOSTEROIDS

    These anti-inflammatory drugs include fluticasone , budesonide , flunisolide , ciclesonide , beclomethasone , mometasone and fluticasone furoate . Read more about inhaled corticosteroids for asthma management.

    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.

    LEUCOTRIEN MODIFIERS

    These oral medications including montelukast, zafirlukast and zileuton help relieve 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 AGONIST

    These inhaled medications, which include salmeterol and formoterol , open the airways.

    Some research shows that they may increase the risk of a severe asthma attack, so take them only in combination with an inhaled corticosteroid. And because these drugs can mask asthma deterioration, don’t use them for an acute asthma attack.

    COMBINATION INHALERS

    These medications such as fluticasone-salmeterol , budesonide-formoterol and formoterol-mometasone contain a long-acting beta agonist along with a corticosteroid. Because these combination inhalers contain long-acting beta agonists, they may increase your risk of having a severe asthma attack.

    THEOPHYLIN

    Theophylline is a daily pill that helps keep the airways open (bronchodilator) by relaxing the muscles around the airways. It’s not used as often now as in past years.
    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-AGONIST

    These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack. They include albuterol and levalbuterol .

    IPRATROPIUM

    Like other bronchodilators, ipratropium acts quickly to immediately relax your 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 which include prednisone and methylprednisolone relieve airway inflammation caused by severe asthma. 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.

    If you 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.

    Allergy medications may help if your asthma is triggered or worsened by allergies. These include:

    ALLERGY SHOTS ( Immunotherapy )

    Over time, allergy shots gradually reduce your immune system reaction to specific allergens. You generally receive shots once a week for a few months, then once a month for a period of three to five years. Read more about immunotherapy in our fact sheet.

    OMALIZUMAB (Xolair)

    This medication, given as an injection every two to four weeks, is specifically for people who have allergies and severe asthma. It acts by altering the immune system.

    ASTHMA-MANAGEMENT

    PHYSIOTHERAPY MANAGEMENT

    The majority of patients suffering from asthma will seek physiotherapy for dyspnoea and hyperventilation . Physiotherapists treatment in a variety of ways with the aim to improve breathing technique. Physiotherapy techniques for asthma are in addition to medication and should never be used as a replacement to prescribed medication, however may reduce the dosage required.

    Breathing Techniques

    BREATHING RETRAINING TECHNICS

    Breathing techniques may have more benefit on mild – moderate asthma . The aim of breathing retraining is to normalise breathing patterns by stabilising respiratory rate and increasing expiratory airflow. Instructions are given from the physiotherapist on how to complete this technique, with the following components:
    • Decreasing Breaths Taken (Reducing Respiratory Rate)
    • Taking Smaller Breaths (Reducing Tidal Volume)
    • Deep Breathing (Diaphragmatic breathing through use of abdominal muscles and lower thoracic chest movement)
    • Breathing through the Nose (Nasal Breathing)
    • Relaxation (Relaxed, controlled breathing)
    • Decreasing Air Leaving (Decreased expiratory flow through pursed lip breathing)
    • These retraining techniques help control breathing and reduce airflow turbulence, hyperinflation, variable breathing pattern and anxiety.

    BUTEYKO BREATHING TECHNIQUE

    The Buteyko breathing technique is another breathing retraining technique; however it is specific to reducing hyperinflation. It was developed based on the theory that asthmatic bronchospasm is caused by hyperventilation, leading to a low PaCO2 and therefore all asthmatic symptoms are due to this. The narrowed airways induce an “air hunger” causing a switch to mouth-breathing and an increased respiratory rate leading to hyperinflation. Buteyko believes that this hyperinflation then also contributes to bronchoconstriction. The Buteyko technique aims to reduce ventilation and subsequently lung volume, as a treatment for asthma and other respiratory diseases. A qualified practitioner is necessary to train the patient.

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