What Is Asthma?
The word asthma is derived from Greek and is literally translated as “panting” or “shortdrawn breath”. If you or your child has ever experienced an asthma attack, this translation seems quite appropriate. Yet asthma specialists are quick to point out that most asthma patients have more subtle symptoms and, only rarely, experience asthma “attacks”.
It is now recognized that the one thing that all asthmatics have in common is airway inflammation, resulting in hyper-responsiveness of the lungs to allergic and/or non-allergic stimuli. This inflammation occurs primarily in the medium to smaller bronchial tubes and, if untreated and persistent, can create a pattern of obstruction throughout the lungs. This obstruction is caused by swelling of the lining of the bronchial tubes and mucous production within the bronchial tubes themselves, and/or by bronchial constriction, which is caused by the muscles around the bronchial tubes tightening and squeezing. Both of these phenomena – the swelling and mucous production inside the tubes and the muscular tightening on the outside of the tubes – lead to airway obstruction, with subsequent wheezing, tightness in the chest, and difficulty breathing.
However, it is extremely important to recognize that all asthmatic patients will not present with signs and symptoms of airway obstruction. Patients with mild asthma, especially children, may present with a cough, and no other symptoms. Asthma represents a spectrum of severity, from mild to severe. The presenting symptoms can vary from an exercise induced cough or a frequent night time cough in the mildest asthmatics, to severe breathing difficulties requiring hospitalizations in the most severe asthmatics.
Rescue medications, often referred to as bronchodilators, are designed to provide immediate relief of bronchial constriction. Examples of these medications include albuterol, xopenex, adrenaline/epinephrine, and ipratropium. They may be given as inhalers or aerosolized to be used in a nebulizer.
The best way to determine if you or your child has asthma is to speak with your doctor. Your doctor, or an allergy and asthma specialist, will take a careful history looking for symptoms of airway inflammation. A careful exam of the entire respiratory and cardiac systems will also be performed. The asthma specialist will often have you or your child perform a lung function test by blowing into a spirometer to measure any airway obstruction.
Asthma is a common disease. In the United States, about 20 million people have been diagnosed with asthma; nearly 9 million of them are children.
What Triggers Asthma Symptoms?
Because of the inflammation which occurs in the lining of the bronchial tubes, the airways of asthmatics tend to be highly reactive to a variety of stimuli, both allergic and non-allergic.
Allergies are one of the primary causes of asthma symptoms, especially in children. Although we tend to think of asthma as a disease of the lungs, physicians now realize our immune system is truly the driving force behind this condition. If a person has a genetic tendency for allergies and asthma, then any number of environmental triggers can play a role. Common allergic triggers of asthma include dust mites, mold and mildew, pet dander, feathers, cockroach, as well as weed, tree, and grass pollens. Occasionally, certain foods may trigger asthma symptoms.
The response to allergens can be immediate (within minutes to hours), with the primary symptoms being caused by constriction by the bronchial smooth muscles. Exposure to allergens can also cause a slow build up of symptoms (days or weeks) as they fuel the inflammatory process. Often the springtime or autumn will bring exposure to large amounts of pollen that cause acute symptoms such as coughing or wheezing, which may be short lived or persistent throughout the season. Patients also commonly report a worsening of preexisting asthma weeks or months after they purchase a new pet.
Approximately one half of all asthmatics have non-allergic asthma, i.e., their symptoms are brought on not by allergens, but by exposure to non-allergic triggers, or irritants. The classic non-allergic triggers would include: an upper respiratory viral infections (the common cold), exercise, laughter, cold air, exposure to cigarette smoke and other strong smells (perfumes, aerosols, cleaning products, etc.), and changes in the weather.
Recent research has shown more allergic asthma in urban versus rural areas. Some scientists believe the migration of people from farms and away from the tough and dirty environment of agricultural living has left our immune systems soft and unchallenged. They hypothesize that the “allergic” side of our immune systems has been allowed to over react since we no longer have to fight off other infectious diseases such as TB, or be exposed to the germs from the farm.
How Can You Be Certain You or Your Child Has Asthma?
Since allergies play a large role in asthma, allergy testing will be indicated in many cases.
Your doctor may also need to rule out other causes of breathing difficulties by checking on the health of your lungs and heart with X-rays or an EKG. Sometimes other conditions may induce asthma-like symptoms such as pneumonia, bronchitis, sinus infections, gastroesophageal reflux (GERD), or heart disease, just to name a few.
The diagnosis of asthma in infants and young children can be especially challenging, due to the fact that lung function testing in young children is difficult. Therefore, the diagnosis of asthma may become evident only with the passage of time. Commonly, infants and young children are often diagnosed with “reactive airways disease” (RAD), which may eventually be confirmed as asthma. A strong family history may lead doctors to diagnosis asthma at an earlier age.
How Do I Best Treat My Asthma?
Allergy and asthma specialist should be actively involved in formulating a comprehensive program to best manage your asthma. Depending on several factors, such as the frequently and severity of symptoms, and the objective measurement of lung function, your asthma specialist will decide whether one needs to be on daily (controller or preventative) medication(s), or, on an as needed (rescue) medication.
Controller medications are usually prescribed for patients who have asthma symptoms consistently at least two or three days per week. Patients who require rescue medication to control night time cough or daily shortness of breath are commonly placed on these preventative medications. Physicians have found inhaled corticosteroids (ICS) to be the most effective controller medications. They are effective in controlling symptoms of asthma and improve lung function by reducing the inflammatory component of asthma. Due to the fact that these are prophylactic medications, they must be taken daily, exactly as prescribed. They are NOT to be used to treat an acute or sudden attack of symptoms. They have a very good safety profile and are appropriate even for young children and senior citizens.
There are also non-steroidal anti-inflammatory medications available, but they are generally less effective than ICS in preventing symptoms. These include leukotriene blockers, theophylline, cromolyn, nedocromil, and long acting bronchodilators. All of these medications are given on a daily basis and some may be taken in combination with ICS to provide additional control.
Oral or injectable steroids are often prescribed to rapidly reduce the airway inflammation during acute or chronic asthma. Contrary to popular belief, corticosteroids are extremely safe if given for short periods of time, even for several weeks. Long term use of steroids, on the other hand, can be associated with significant side effects. The use of these, and all medications, should be discussed with the prescribing physician.
An allergy and asthma specialist may recommend immunotherapy therapy for patients who have difficulty controlling their allergies and/or asthma. Allergy injection therapy works making the immune system more tolerant to the allergen(s) and thus decreasing the hyper responsiveness of the airway to allergens in the environment. Studies suggest that immunotherapy can be effective in preventing an allergic individual from developing asthma, or, by preventing asthma from getting worse.
Xolair (Omilazimub) is a new treatment for asthma that is designed to help patients with the most severe asthma. It works by blocking the body’s overproduction of allergy antibodies. This form of therapy is generally reserved for the most severe asthma patients and usually is prescribed by an asthma or lung specialist.
Finally, a team approach with your physician may include an asthma action plan. Your doctor may give you a list of symptoms with corresponding recommendations about when to start medications, or when to seek medical attention. In addition, the action plan may include monitoring lung function at home with a peak flow meter. Peak flow meters are simple tube devices that measure airway obstruction by quantifying how much air a patient can blow out of his/her lungs.
This information may reveal worsening air flow, and acting on this information could likely prevent worsening asthma or an acute asthma attack.