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Asthma
What is asthma?
Asthma is a complex clinical syndrome of chronic airway inflammation characterized by
recurrent, reversible, airway obstruction. Airway inflammation also leads to airway
hyperreactivity, which causes airways to narrow in response to various stimuli.
Asthma is a common chronic condition, affecting approximately 8% to 10% of Americans, or an
estimated 23 million Americans as of 2008. Asthma remains a leading cause of missed work
days. It is responsible for 1.5 million emergency department visits annually and up to 500,000
hospitalizations. Over 3,300 Americans die annually from asthma. Furthermore, as is the case
with other allergic conditions, such as eczema (atopic dermatitis), hay fever(allergic rhinitis), and
food allergies, the prevalence of asthma appears to be on the rise.

What causes asthma?

Asthma results from complex interactions between an individual's inherited genetic make-up
and their interactions with the environment. The factors that cause a genetically predisposed
individual to become asthmatic are poorly understood. The following are risk factors for asthma:

Family history of allergic conditions

Personal history of hay fever (allergic rhinitis)

Viral respiratory illness, such as respiratory syncytial virus (RSV), during childhood

Exposure to cigarette smoke

Obesity

Lower socioeconomic status

What are the signs and symptoms of asthma?

The classic signs and symptoms of asthma areshortness of breath, cough (often worse
at night), and wheezing(high-pitched whistling sound produced by turbulent airflow
through narrow airways, typically with exhalation). Many patients also report chest
tightness. It is important to note that these symptoms are episodic, and individuals with
asthma can go long periods of time without any symptoms.
Common triggers for asthmatic symptoms include exposure to allergens (pets, dust
mites, cockroach, molds, and pollens), exercise, and viral infections. Tobacco use or
exposure to secondhand smoke complicates asthma management.
Many of the symptoms of asthma are nonspecific and can be seen in other conditions as
well. Symptoms that might suggest conditions other than asthma include new symptom
onset in older age, the presence of associated symptoms (such as chest discomfort,
light headedness,palpitations, and fatigue), and lack of response to appropriate
medications for asthma.

The physical exam in asthma is often completely normal. Occasionally, wheezing is

present. In an asthma exacerbation, the respiratory rate increases, the heart rate
increases, and the work of respiration increases. Individuals often require accessory
muscles to breathe, and breath sounds can be diminished. It is important to note that the
blood oxygen level typically remains fairly normal even in the midst of a significant
asthma exacerbation. Low blood oxygen level is therefore concerning for impending
respiratory failure.

How is asthma diagnosed?

The diagnosis of asthma begins with a detailed history and physical examination. A typical
history is an individual with a family history of allergic conditions or a personal history of allergic
rhinitis who experiences coughing, wheezing, and difficulty breathing, especially with exercise or
during the night. There may also be a propensity towards bronchitis or respiratory infections. In
addition to a typical history, improvement with a trial of appropriate medications is very
suggestive of asthma.
In addition to the history and exam, the following are diagnostic procedures that can be used to
help with the diagnosis of asthma:

Lung function testing with spirometry: This test measures lung function as the patient
breathes into a tube. If lung function improves significantly following the administration of a
bronchodilator, such asalbuterol, this essentially confirms the diagnosis of asthma. It is
important to note, however, that normal lung function testing does not rule out the possibility
of asthma.

Measurement of exhaled nitric oxide (FeNO): This can be performed by a quick and
relatively simple breathing maneuver, similar to spirometry. Elevated levels of exhaled nitric
oxide are suggestive of "allergic" inflammation seen in conditions such as asthma.

Skin testing for common aeroallergens: The presence of sensitivities to environmental

allergies increases the likelihood of asthma. Of note, skin testing is generally more useful
than blood work (in vitro testing) for environmental allergies. Testing for food allergies is not
indicated in the diagnosis of asthma.

Other potential but less commonly used tests include provocation testing such as a
methacholine challenge, which tests for airway hyperresponsiveness. Hyperresponsiveness
is the tendency of the breathing tubes to constrict or narrow in response to irritants. A
negative methacholine challenge makes asthma much less likely. Specialists sometimes
also measure sputum eosinophils, another marker for "allergic" inflammation seen in
asthma. Chest imaging may show hyperinflation, but is often normal in asthma. Tests to rule
out other conditions, such as cardiac testing, may also be indicated in certain cases.

What is the treatment for asthma?

As per widely used guidelines, the treatment goals for asthma are to:

adequately control symptoms,

minimize the risk of future exacerbations,

maintain normal lung function,

maintain normal activity levels, and

use the least amount of medication possible with the least amount of potential side
effects.

Inhaled corticosteroids (ICS) are the most effective anti-inflammatory agents available for the
chronic treatment of asthma and are first-line therapy per most asthma guidelines. It is well
recognized that ICS are very effective in decreasing the risk of asthma exacerbations.
Furthermore, the combination of a long-acting bronchodilator (LABA) and an ICS has a
significant additional beneficial effect on improving asthma control.
The most commonly used asthma medications include:

Short-acting bronchodilators (albuterol [Proventil, Ventolin, ProAir, Maxair, Xopenex])

provide quick relief and can be used in conjunction for exercise-induced symptoms.

Inhaled steroids (budesonide, fluticasone,beclomethasone, mometasone, ciclesonide)

are first-line anti-inflammatory therapy.
Long-acting bronchodilators (salmeterol, formoterol) can be added to ICS as additive
therapy. LABAs should never be used alone for the treatment of asthma.
Leukotriene modifiers (montelukast, zarirlukast) can also serve as anti-inflammatory
agents.
Anticholinergic agents (ipratropium, tiotropium) can help decrease sputum production.
Anti-IgE treatment (omalizumab) can be used in allergic asthma.
Chromones (cromolyn, nedocromil) stabilize mast cells (allergic cells) but are rarely used
in clinical practice.
Theophylline also helps with bronchodilation (opening the airways), but again is rarely
used in clinical practice due to an unfavorable side effect profile.
Systemic steroids (prednisone, prednisolone, methylprednisone, dexamethasone) are
potent anti-inflammatory agents that are routinely used to treat asthma exacerbations but
pose numerous unwanted side effects if used repeatedly or chronically.
Numerous other monoclonal antibodies are currently being studied but none are
currently commercially available for routine asthma therapy.

There is often concern about potential long-term side effects of inhaled corticosteroids.
Numerous studies have repeatedly shown that even long-term use of inhaled corticosteroids
has very few if any sustained, clinically-significant side effects, including changes in bone
health, growth, or weight. However, the goal always remains to treat all individuals with the least
amount of medication that is effective. Patients with asthma should be routinely reassessed for
any appropriate changes to their medical regimen.
Asthma medications can be administered via inhalers either with or without an AeroChamber or
nebulized solution. It is important to note that if an individual has proper technique with an
inhaler, the amount of medication deposited in the lungs is no different than that when using a

nebulized solution. When prescribing asthma medications, it is essential to provide the

appropriate teaching on proper delivery technique.
Smoking cessation and/or minimizing exposure to secondhand smoke are critical when treating
asthma. Treating concurrent conditions such as allergic rhinitis andgastroesophageal reflux
disease (GERD) may also improve asthma control. Vaccinations such as the annual influenza
vaccination are also indicated.
Although the vast majority of individuals with asthma are treated as outpatients, treatment of
severe exacerbations can require management in the emergency department or inpatient
hospitalization. These individuals typically require use of supplemental oxygen, early
administration of systemic steroids, and frequent or even continuous administration of
bronchodilators via a nebulized solution. Individuals at high risk for poor asthma outcomes are
referred to a specialist (pulmonologist or allergist). The following factors should prompt
consideration or referral:

History of ICU admission or multiple hospitalizations for asthma

History of multiple visits to the emergency department for asthma

History of frequent use of systemic steroids for asthma

Ongoing symptoms despite the use of appropriate medications

Significant allergies contributing to poorly-controlled asthma

What is an asthma action plan?

Patient education is a critical component in the successful management of asthma. An asthma
action plan provides an individual with specific directions for daily management of their asthma
and for adjusting medications in response to increasing symptoms or decreasing lung function,
as usually measured by a peak flow meter.

What is the prognosis for asthma?

The prognosis for asthma is generally favorable. Children experience complete remission more
often than adults. Although adults with asthma experience a greater rate of loss in their lung
function as compared to age-controlled counterparts, this decline is usually not as severe as
seen in other conditions, such as chronic obstructive pulmonary disease (COPD) or
emphysema. Asthma in the absence of other comorbidities does not appear to shorten life
expectancy. Risk factors for poor prognosis from asthma include:

History of hospitalizations, especially ICU admissions or intubation

Frequent reliance on systemic steroids

Significant medical comorbidities

Can asthma be prevented?

With the increasing prevalence of asthma, numerous studies have looked for risk factors and
ways to potentially prevent asthma. It has been shown that individuals living on farms are
protected against wheezing, asthma, and even environmental allergies. The role of air pollution
has been questioned in both the increased incidence of asthma and in regards to asthma
exacerbations.
Climate change is also being studied as a factor in the increased incidence of asthma. Maternal
smoking during pregnancy is a risk factor for asthma and poor outcomes. Tobacco smoke is
also a significant risk factor for the development and progression of asthma. The development
of asthma is ultimately a complex process influenced by many environmental and genetic
factors, and currently there is no proven way to decrease an individual's risk of developing
asthma.