Asthma

Asthma is a lung condition that makes the primary airways—known as the bronchi—in the lungs swollen and inflamed all of the time. People who have asthma are more sensitive than other people to things inhaled from the environment, known as triggers.

These triggers make the muscles in an asthma sufferer’s lungs tighten, constricting the air passages and making breathing difficult. In addition, cells in the lungs produce more mucus in response to a trigger. The mucus can clog the bronchial tubes, which contributes to breathing problems. The airways also swell and become inflamed with white blood cells.

When the lungs react to a trigger, what’s known as an “asthma attack” can occur. Wheezing, coughing and/or tightness in the chest and shortness of breath are all hallmark symptoms of a classic asthma attack. Asthma can be controlled with the proper diagnosis and treatment.

The National Center for Health Statistics (a division of the U.S. Centers for Disease Control and Prevention, or CDC) reported that 18.9 million American adults and 7.1 million children suffered from asthma in 2011. The condition is becoming more common and more severe across all age, sex and racial groups.

Asthma typically develops during childhood. But many people develop the condition in adulthood, after age 20—known as adult onset asthma. Some individuals have their first asthma attack after age 50.

Who’s at Risk?

Obesity significantly increases a person’s risk of developing the condition. Heredity is also thought to play a role. Children of parents with asthma are at greater risk for developing the condition.

Pollution, poor air quality in urban environments, poverty and lack of patient education are also factors contributing to rising asthma and asthma-related complication rates. People who have allergies are at an increased risk of developing asthma, and those raised in environments where they were exposed to cigarette smoke also have a much higher incidence of the condition.

Women and Asthma

Women may first develop asthma during or after pregnancy, though the condition may also improve during pregnancy. There is some evidence that asthma may be affected by hormonal changes during a woman’s cycle and can be triggered prior to or during the menstrual period. Women are also more likely than men to die from asthma.

Researchers aren’t sure why some people’s airways are more sensitive to things in the environment. Asthma sufferers may have allergies to certain proteins, known as allergens, which are usually airborne and can trigger an attack. But not all asthma sufferers have defined allergies. An estimated 70 percent of people with asthma have airborne allergies.

Common Asthma Triggers

Common allergens include: dust mites, mold, pollen, cockroaches, animal dander and certain foods or chemicals commonly used in food processing. Contrary to popular belief, dog and cat fur don’t cause allergies. Rather, a protein found in the pet’s saliva, dander and urine causes allergies in some individuals. Other things can irritate the already-sensitive air passages of asthma or allergy sufferers. Common irritants include cigarette smoke, cold air and pollution. Exercise and stress also can trigger an asthma attack.

Controlling asthma includes short-term relief of symptoms and long-term strategies to prevent attacks from occurring. Medications and behavioral approaches, such as avoiding asthma triggers, for example, are both important to managing asthma successfully. Another critical part of asthma management is education and close consultation with your health care team. Newer medications are available, and older methods are being improved or have been withdrawn from the market.

Asthma symptoms that recur frequently, even when medication is taken regularly, can be a sign that a reassessment with a health care professional is necessary.

Diagnosis

While primary care providers can diagnose and treat asthma, consultation with a specialist, such as an allergist or pulmonary or lung specialist, may be necessary. Asthma symptoms are sometimes mistaken for a bacterial infection. Antibiotics are not usually effective in controlling asthma. Pulmonary or lung function testing is essential to making the proper diagnosis.

Moderate and mild asthma attacks are common for asthma sufferers. During these attacks an asthma sufferer may feel restless, feel her chest tighten, wheeze and/or cough up mucus. Severe attacks interrupt breathing, causing breathlessness, difficulty talking and eventually loss of consciousness, if not treated immediately. Asthma symptoms and their severity can vary greatly, but they should always be taken seriously.

Common symptoms of asthma include:

dry cough, especially at night or as a response to certain “triggers” or allergens, such as dust or pets
a feeling of tightness or pressure in your chest
difficulty breathing
wheezing—which sounds like a whistling sound—when you exhale
shortness of breath after exercise
colds that migrate to your chest or don’t go away for 10 days or more
waking up at night with shortness of breath
Common asthma triggers include the following:

dust mites
pollens
molds
pet dander (protein in pet fur, saliva and urine)
cockroaches
viral respiratory infections
certain medications, such as aspirin and other nonsteroidal anti-inflammatories, and beta blockers
exercise
stress
menstrual cycles in some women
irritants (tobacco smoke and some scented products and chemicals)
food allergies
If you are experiencing one or more of the symptoms associated with asthma and have never received treatment or medication for it, it is very important that you make an appointment with a health care professional soon. To accurately diagnose your condition, your health care professional will ask you questions about your symptoms, perform a physical exam and conduct lung function tests.

Asthma symptoms are often associated with other illnesses in older adults, such as chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD) and sinusitis. COPD is a persistent blockage of the air passages caused by emphysema or chronic bronchitis. Emphysema occurs when the walls of the alveoli—or tiny air sacs—in the lungs are damaged. This damage makes the aveoli less elastic and, therefore, less effective at passing oxygen into the blood and removing carbon dioxide from the blood, leading to shortness of breath. It is most common among people who have smoked the equivalent of one pack of cigarettes per day or more for 10 years.

Chronic bronchitis, which produces a persistent cough not related to a cold or other medical condition, causes inflammation of the airways, which produces mucus and causes muscle spasms.

It is estimated that more than 75 percent of people with asthma also experience GERD, which causes the stomach’s digestive juices to back up or “reflux” into the esophagus—the passageway for food from the mouth to the stomach. Over time, the esophagus becomes inflamed or permanently damaged. Chronic heartburn, cough, snoring, wheezing and hoarseness are some symptoms of GERD.

Asthma and sinusitis frequently coexist, and many patients with asthma won’t improve unless their sinusitis is treated. Additionally, many only get asthma when their sinusitis worsens. Thus, a complete assessment of asthma always requires a review of the upper airway, including the sinuses.

Tests that measure your airflow are a primary tool in the diagnosis of asthma. Specialists and some primary health care professionals will use a spirometer, which is a machine that measures how much air you blow out each second. Another test employs a peak flow meter to measure how much air you can breathe out in a fast blast. These tests are simple and painless, but offer revealing information about your airflow. Your health care professional might also measure your airflow before and after treatment with a bronchodilator, a medicine that relaxes tight muscles in the airways, to judge reversibility or improvement with a bronchodilator, the hallmark of asthma.

Other tests may be administered to assess your sensitivity to specific allergens that may be triggering your asthma. Often skin tests are used to determine which allergens you are allergic to. Diluted extracts from allergens such as particular foods, pollens, dust mites and molds are injected under your skin or into a tiny scratch or puncture on your arm or back. If you have a positive reaction (meaning you are allergic), a small, raised, reddened area with a surrounding flush will appear at the test site, indicating antibodies to that specific allergen are present in the skin. These reactions can be modest or very large depending on how allergic you are.

Your health care professional might also conduct a blood test, which is not as sensitive as a skin test, to look for allergies. Using a sample of your blood, the test looks for levels of antibodies to particular allergens present in the home and outdoors in various parts of the United States.

Treatment
Asthma requires continuous medical care and treatment. Asthma treatment focuses on opening airways by reducing inflammation and swelling of the bronchial tubes, both large and small—the lung structures affected by asthma. Once inflammation and swelling are reduced, the lungs may become less sensitive to triggers. Many medications are available to treat symptoms and prevent attacks from recurring. Nonmedical management strategies also are recommended: asthma sufferers are encouraged to identify triggers in their environment and avoid them, when possible, or at least be prepared for them by having and using medication, both control and reliever types.

Three groups of asthma medications are available: quick-relief medications, long-term controller medications and medications for allergy-induced asthma. They are available under many brand names and in a variety of forms: sprays, pills, powder, liquids and injections. Some are short acting and are administered directly to the lining of the lungs to immediately relieve symptoms. Controller medications are meant to have longer-term effects—preventing attacks from occurring. The longer-acting medications take a while to help symptoms subside. Some asthma medications are meant to be taken daily, while others are intended only for symptom relief, as symptoms develop.

Quick-relief medications:

Quick relief (or “rescue”) medications are used to provide short-term relief during an asthma attack or, for some people, before physical activity to prevent exercise-induced asthma or after exposure to a known allergen like cats or dust.

In a class of medications known as short-acting beta agonists, asthma medications called bronchodilators are typically designed to act quickly to stop an asthma attack once it has started by relaxing and opening—”dilating”—the bronchial tubes so more air is available. For this reason, they are in the quick-relief medications—or “rescue medications”—category. Coughing, wheezing and breathing difficulties are quickly relieved, and the effects of these medications last for several hours.

The most commonly used bronchodilator in the United States is albuterol (Ventolin, Proventil, ProAir), and the preferred method of taking bronchodilators is through inhalation with a metered dose inhaler. Other short-acting beta agonists used for asthma include levalbuterol (Xopenex HFA) and pirbuterol (Maxair Autohaler). Both albuterol and levalbuterol are available in a solution form to be delivered by a nebulizer.

Another bronchodilator—ipratropium (Atrovent)—works to relax the airways and make breathing easier. Although it is primarily used for chronic bronchitis and emphysema, ipratropium is also sometimes used to treat acute asthma attacks.

Also in the rescue medications category, corticosteroids work to relieve airway inflammation caused by severe asthma. Corticosteroids are not the same type of steroids used by some athletes. These performance-enhancing drugs are called anabolic steroids. In inhaled form in standard doses, there are fewer side effects from corticosteroids used to treat asthma, though the risk of side effects may increase if you take this medication orally (in liquid or pill form) over a long time. Side effects may include hoarseness and thrush, a surface (throat) fungal infection, though rinsing the throat with water after inhaling reduces this risk.

Prednisone and methylprednisolone are two of the most commonly prescribed oral steroid drugs. They are available as liquids or pills for short-term use. Side effects include weight gain, menstrual irregularities, increased appetite and loss of energy, among others. Long-term effects of the drug include decreased bone density, bone fractures, ulcers, cataracts, high blood pressure, elevated blood sugar and many other potential problems.

In their inhaled form, corticosteroids are also frequently prescribed for long-term asthma control, discussed below.

Long-term controller medications:

Most long-term controller medications for asthma need to be taken every day for asthma prevention.

Inhaled corticosteroids, including fluticasone (Flovent Diskus, Flovent HFA), mometasone (Asmanex), beclomethasone (Qvar), budesonide (Pulmicort Flexhaler), ciclesonide (Alvesco) and others, are the most commonly prescribed long-term asthma remedy. Compared to oral corticosteroids, inhaled corticosteroids have a relatively low risk of side effects and are usually safe for long-term use in normal doses. It usually takes several days or weeks for these medications to start working.

Salmeterol (Serevent Diskus) and formoterol (Foradil Aerolizer) are two bronchodilators in a class of medications known as long-acting beta agonists (LABAs). When used with an inhaled corticosteroid, these drugs help control asthma symptoms. There are also devices available that contain both a LABA and an inhaled (anti-inflammatory) corticosteroid (Advair, Symbicort, Dulera).

Theophylline (Uniphyl), another type of slow-acting bronchodilator, is prepared in a slow-release form taken by mouth. Although not used as frequently as it used to be in the past, theophylline is sometimes used for persistent asthma symptoms, particularly nighttime asthma. Side effects of bronchodilators can include nervousness, shakiness and a rapid heart rate. There also may be interaction with other medications or reduced effectiveness caused by other factors.

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