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Asthma
FromWikipedia,thefreeencyclopedia

Asthmaisacommonlongterminflammatorydiseaseoftheairwaysofthelungs.[2]Itischaracterizedby
variableandrecurringsymptoms,reversibleairflowobstruction,andbronchospasm.[3]Symptomsinclude
episodesofwheezing,coughing,chesttightness,andshortnessofbreath.[4]Theseepisodesmayoccurafew
timesadayorafewtimesperweek.Dependingonthepersontheymaybecomeworseatnightorwith
exercise.[2]

Asthma

Asthmaisthoughttobecausedbyacombinationofgeneticandenvironmentalfactors.[5]Environmental
factorsincludeexposuretoairpollutionandallergens.[2]Otherpotentialtriggersincludemedicationssuchas
aspirinandbetablockers.[2]Diagnosisisusuallybasedonthepatternofsymptoms,responsetotherapyover
time,andspirometry.[6]Asthmaisclassifiedaccordingtothefrequencyofsymptoms,forcedexpiratoryvolume
inonesecond(FEV1),andpeakexpiratoryflowrate.[7]Itmayalsobeclassifiedasatopicornonatopicwhere
atopyreferstoapredispositiontowarddevelopingatype1hypersensitivityreaction.[8][9]
Thereisnocureforasthma.[2]Symptomscanbepreventedbyavoidingtriggers,suchasallergensandirritants,
andbytheuseofinhaledcorticosteroids.[10][11]Longactingbetaagonists(LABA)orantileukotrieneagents
maybeusedinadditiontoinhaledcorticosteroidsifasthmasymptomsremainuncontrolled.[12][13]Treatmentof
rapidlyworseningsymptomsisusuallywithaninhaledshortactingbeta2agonistsuchassalbutamoland
corticosteroidstakenbymouth.[14]Inveryseverecases,intravenouscorticosteroids,magnesiumsulfate,and
hospitalizationmayberequired.[15]
In2013,242millionpeoplegloballyhadasthmaupfrom183millionin1990.[16]Itcausedabout489,000
deathsin2013,[17]mostofwhichoccurredinthedevelopingworld.[2]Itoftenbeginsinchildhood.[2]Therates
ofasthmahaveincreasedsignificantlysincethe1960s.[18]AsthmawasrecognizedasearlyasAncient
Egypt.[19]ThewordasthmaisfromtheGreek,sthmawhichmeans"panting".[20]

Contents
1 Signsandsymptoms
https://en.wikipedia.org/wiki/Asthma

Peakflowmetersareusedtomeasurethepeak
expiratoryflowrate,importantinbothmonitoring
anddiagnosingasthma. [1]
Classificationandexternalresources
Specialty

Pulmonology

ICD10

J45(http://apps.who.int/classifications/
icd10/browse/2016/en#/J45)

ICD9CM

493(http://www.icd9data.com/getICD
9Code.ashx?icd9=493)

OMIM

600807(http://omim.org/entry/60080
7)
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1 Signsandsymptoms
1.1 Associatedconditions
2 Causes
2.1 Environmental
2.2 Genetic
2.3 Medicalconditions
2.4 Exacerbation
3 Pathophysiology
4 Diagnosis
4.1 Spirometry
4.2 Others
4.3 Classification
4.4 Differentialdiagnosis
5 Prevention
6 Management
6.1 Lifestylemodification
6.2 Medications
6.3 Others
6.4 Alternativemedicine
7 Prognosis
8 Epidemiology
9 Economics
10 History
11 References
12 Externallinks

DiseasesDB 1006(http://www.diseasesdatabase.co
m/ddb1006.htm)
MedlinePlus 000141(http://www.nlm.nih.gov/medl
ineplus/ency/article/000141.htm)
eMedicine

article/806890(http://emedicine.medsc
ape.com/article/806890overview)

PatientUK Asthma(http://patient.info/doctor/bro
nchialasthma)
MeSH

D001249(https://www.nlm.nih.gov/cg
i/mesh/2016/MB_cgi?field=uid&term
=D001249)

Signsandsymptoms
Asthmaischaracterizedbyrecurrentepisodesofwheezing,shortnessofbreath,chesttightness,and
coughing.[21]Sputummaybeproducedfromthelungbycoughingbutisoftenhardtobringup.[22]During
recoveryfromanattack,itmayappearpuslikeduetohighlevelsofwhitebloodcellscalledeosinophils.[23]
Symptomsareusuallyworseatnightandintheearlymorningorinresponsetoexerciseorcoldair.[24]Some
peoplewithasthmararelyexperiencesymptoms,usuallyinresponsetotriggers,whereasothersmayhave
markedandpersistentsymptoms.[25]

Wheezing
0:00

MENU

Thesoundofwheezingasheardwitha
stethoscope.
Problemsplayingthisfile?Seemediahelp.

Associatedconditions
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Anumberofotherhealthconditionsoccurmorefrequentlyinthosewithasthma,includinggastroesophagealrefluxdisease(GERD),rhinosinusitis,and
obstructivesleepapnea.[26]Psychologicaldisordersarealsomorecommon,[27]withanxietydisordersoccurringinbetween1652%andmooddisordersin14
41%.[28]However,itisnotknownifasthmacausespsychologicalproblemsorifpsychologicalproblemsleadtoasthma.[29]Thosewithasthma,especiallyifitis
poorlycontrolled,areathighriskforradiocontrastreactions.[30]

Causes
Asthmaiscausedbyacombinationofcomplexandincompletelyunderstoodenvironmentalandgeneticinteractions.[5][31]Thesefactorsinfluencebothitsseverity
anditsresponsivenesstotreatment.[32]Itisbelievedthattherecentincreasedratesofasthmaareduetochangingepigenetics(heritablefactorsotherthanthose
relatedtotheDNAsequence)andachanginglivingenvironment.[33]Onsetbeforeage12ismorelikelyduetogeneticinfluence,whileonsetafter12ismore
likelyduetoenvironmentalinfluence.[34]

Environmental
Manyenvironmentalfactorshavebeenassociatedwithasthma'sdevelopmentandexacerbationincludingallergens,airpollution,andotherenvironmental
chemicals.[35]Smokingduringpregnancyandafterdeliveryisassociatedwithagreaterriskofasthmalikesymptoms.[36]Lowairqualityfromfactorssuchas
trafficpollutionorhighozonelevels,[37]hasbeenassociatedwithbothasthmadevelopmentandincreasedasthmaseverity.[38]Overhalfofcasesinchildreninthe
UnitedStatesoccurinareaswithairqualitybelowEPAstandards.[39]Exposuretoindoorvolatileorganiccompoundsmaybeatriggerforasthmaformaldehyde
exposure,forexample,hasapositiveassociation.[40]Also,phthalatesincertaintypesofPVCareassociatedwithasthmainchildrenandadults.[41][42]
Thereisanassociationbetweenacetaminophen(paracetamol)useandasthma.[43]Themajorityoftheevidencedoesnot,however,supportacausalrole.[44]A
2014reviewfoundthattheassociationdisappearedwhenrespiratoryinfectionsweretakenintoaccount.[45]Usebyamotherduringpregnancyisalsoassociated
withanincreasedriskasispsychologicalstressduringpregnancy.[46][47]
Asthmaisassociatedwithexposuretoindoorallergens.[48]Commonindoorallergensincludedustmites,cockroaches,animaldander(fragmentsoffuror
feathers),andmold.[49][50]Effortstodecreasedustmiteshavebeenfoundtobeineffectiveonsymptomsinsensitizedsubjects.[51][52]Certainviralrespiratory
infections,suchasrespiratorysyncytialvirusandrhinovirus,[20]mayincreasetheriskofdevelopingasthmawhenacquiredasyoungchildren.[53]Certainother
infections,however,maydecreasetherisk.[20]
Hygienehypothesis

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Thehygienehypothesisattemptstoexplaintheincreasedratesofasthmaworldwideasadirectandunintendedresultofreducedexposure,duringchildhood,to
nonpathogenicbacteriaandviruses.[54][55]Ithasbeenproposedthatthereducedexposuretobacteriaandvirusesisdue,inpart,toincreasedcleanlinessand
decreasedfamilysizeinmodernsocieties.[56]Exposuretobacterialendotoxininearlychildhoodmaypreventthedevelopmentofasthma,butexposureatanolder
agemayprovokebronchoconstriction.[57]Evidencesupportingthehygienehypothesisincludeslowerratesofasthmaonfarmsandinhouseholdswithpets.[56]
Useofantibioticsinearlylifehasbeenlinkedtothedevelopmentofasthma.[58]Also,deliveryviacaesareansectionisassociatedwithanincreasedrisk(estimated
at2080%)ofasthmathisincreasedriskisattributedtothelackofhealthybacterialcolonizationthatthenewbornwouldhaveacquiredfrompassagethrough
thebirthcanal.[59][60]Thereisalinkbetweenasthmaandthedegreeofaffluence.[61]

Genetic
Familyhistoryisariskfactorforasthma,withmanydifferentgenesbeingimplicated.[63]Ifoneidenticaltwinis
affected,theprobabilityoftheotherhavingthediseaseisapproximately25%.[63]Bytheendof2005,25genes
hadbeenassociatedwithasthmainsixormoreseparatepopulations,includingGSTM1,IL10,CTLA4,
SPINK5,LTC4S,IL4RandADAM33,amongothers.[64]Manyofthesegenesarerelatedtotheimmunesystem
ormodulatinginflammation.Evenamongthislistofgenessupportedbyhighlyreplicatedstudies,resultshave
notbeenconsistentamongallpopulationstested.[64]In2006over100geneswereassociatedwithasthmainone
geneticassociationstudyalone[64]morecontinuetobefound.[65]

CD14endotoxininteractionbasedonCD14
SNPC159T[62]
Endotoxinlevels CCgenotype TTgenotype
Highexposure

Lowrisk

Highrisk

Lowexposure

Highrisk

Lowrisk

Somegeneticvariantsmayonlycauseasthmawhentheyarecombinedwithspecificenvironmentalexposures.[5]Anexampleisaspecificsinglenucleotide
polymorphismintheCD14regionandexposuretoendotoxin(abacterialproduct).Endotoxinexposurecancomefromseveralenvironmentalsourcesincluding
tobaccosmoke,dogs,andfarms.Riskforasthma,then,isdeterminedbybothaperson'sgeneticsandthelevelofendotoxinexposure.[62]

Medicalconditions
Atriadofatopiceczema,allergicrhinitisandasthmaiscalledatopy.[66]Thestrongestriskfactorfordevelopingasthmaisahistoryofatopicdisease[53]with
asthmaoccurringatamuchgreaterrateinthosewhohaveeithereczemaorhayfever.[67]Asthmahasbeenassociatedwitheosinophilicgranulomatosiswith
polyangiitis(formerlyknownasChurgStrausssyndrome),anautoimmunediseaseandvasculitis.[68]Individualswithcertaintypesofurticariamayalso
experiencesymptomsofasthma.[66]
Thereisacorrelationbetweenobesityandtheriskofasthmawithbothhavingincreasedinrecentyears.[69][70]Severalfactorsmaybeatplayincludingdecreased
respiratoryfunctionduetoabuildupoffatandthefactthatadiposetissueleadstoaproinflammatorystate.[71]

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Betablockermedicationssuchaspropranololcantriggerasthmainthosewhoaresusceptible.[72]Cardioselectivebetablockers,however,appearsafeinthosewith
mildormoderatedisease.[73][74]Othermedicationsthatcancauseproblemsinasthmaticsareangiotensinconvertingenzymeinhibitors,aspirin,andNSAIDs.[75]

Exacerbation
Someindividualswillhavestableasthmaforweeksormonthsandthensuddenlydevelopanepisodeofacuteasthma.Differentindividualsreacttovariousfactors
indifferentways.[76]Mostindividualscandevelopsevereexacerbationfromanumberoftriggeringagents.[76]
Homefactorsthatcanleadtoexacerbationofasthmaincludedust,animaldander(especiallycatanddoghair),cockroachallergensandmold.[76][77]Perfumesare
acommoncauseofacuteattacksinwomenandchildren.Bothviralandbacterialinfectionsoftheupperrespiratorytractcanworsenthedisease.[76]Psychological
stressmayworsensymptomsitisthoughtthatstressalterstheimmunesystemandthusincreasestheairwayinflammatoryresponsetoallergensand
irritants.[38][78]

Pathophysiology
Asthmaistheresultofchronicinflammationoftheconductingzoneoftheairways(mostespeciallythebronchiandbronchioles),whichsubsequentlyresultsin
increasedcontractabilityofthesurroundingsmoothmuscles.Thisamongotherfactorsleadstoboutsofnarrowingoftheairwayandtheclassicsymptomsof
wheezing.Thenarrowingistypicallyreversiblewithorwithouttreatment.Occasionallytheairwaysthemselveschange.[21]Typicalchangesintheairwaysinclude
anincreaseineosinophilsandthickeningofthelaminareticularis.Chronicallytheairways'smoothmusclemayincreaseinsizealongwithanincreaseinthe
numbersofmucousglands.Othercelltypesinvolvedinclude:Tlymphocytes,macrophages,andneutrophils.Theremayalsobeinvolvementofothercomponents
oftheimmunesystemincluding:cytokines,chemokines,histamine,andleukotrienesamongothers.[20]

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FigureAshowsthe
locationofthelungs
andairwaysinthe
body.FigureBshowsa
crosssectionofa
normalairway.Figure
Cshowsacross
sectionofanairway
duringasthma
symptoms.

Obstructionofthe
Diagramofasthma
lumenofabronchiole
bymucoidexudate,
gobletcellmetaplasia,
andepithelialbasement
membranethickening
inapersonwith
asthma.

Diagnosis
Whileasthmaisawellrecognizedcondition,thereisnotoneuniversalagreedupondefinition.[20]ItisdefinedbytheGlobalInitiativeforAsthmaas"achronic
inflammatorydisorderoftheairwaysinwhichmanycellsandcellularelementsplayarole.Thechronicinflammationisassociatedwithairwayhyper
responsivenessthatleadstorecurrentepisodesofwheezing,breathlessness,chesttightnessandcoughingparticularlyatnightorintheearlymorning.These
episodesareusuallyassociatedwithwidespreadbutvariableairflowobstructionwithinthelungthatisoftenreversibleeitherspontaneouslyorwithtreatment".[21]
Thereiscurrentlynoprecisetestforthediagnosis,whichistypicallybasedonthepatternofsymptomsandresponsetotherapyovertime.[6][20]Adiagnosisof
asthmashouldbesuspectedifthereisahistoryofrecurrentwheezing,coughingordifficultybreathingandthesesymptomsoccurorworsenduetoexercise,viral
infections,allergensorairpollution.[79]Spirometryisthenusedtoconfirmthediagnosis.[79]Inchildrenundertheageofsixthediagnosisismoredifficultasthey
aretooyoungforspirometry.[80]

Spirometry

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Spirometryisrecommendedtoaidindiagnosisandmanagement.[81][82]Itisthesinglebesttestforasthma.IftheFEV1measuredbythistechniqueimprovesmore
than12%followingadministrationofabronchodilatorsuchassalbutamol,thisissupportiveofthediagnosis.Ithowevermaybenormalinthosewithahistoryof
mildasthma,notcurrentlyactingup.[20]Ascaffeineisabronchodilatorinpeoplewithasthma,theuseofcaffeinebeforealungfunctiontestmayinterferewiththe
results.[83]SinglebreathdiffusingcapacitycanhelpdifferentiateasthmafromCOPD.[20]Itisreasonabletoperformspirometryeveryoneortwoyearstofollow
howwellaperson'sasthmaiscontrolled.[84]

Others
Themethacholinechallengeinvolvestheinhalationofincreasingconcentrationsofasubstancethatcausesairwaynarrowinginthosepredisposed.Ifnegativeit
meansthatapersondoesnothaveasthmaifpositive,however,itisnotspecificforthedisease.[20]
Othersupportiveevidenceincludes:a20%differenceinpeakexpiratoryflowrateonatleastthreedaysinaweekforatleasttwoweeks,a20%improvementof
peakflowfollowingtreatmentwitheithersalbutamol,inhaledcorticosteroidsorprednisone,ora20%decreaseinpeakflowfollowingexposuretoatrigger.[85]
Testingpeakexpiratoryflowismorevariablethanspirometry,however,andthusnotrecommendedforroutinediagnosis.Itmaybeusefulfordailyself
monitoringinthosewithmoderatetoseverediseaseandforcheckingtheeffectivenessofnewmedications.Itmayalsobehelpfulinguidingtreatmentinthose
withacuteexacerbations.[86]

Classification
Asthmaisclinicallyclassifiedaccordingtothefrequencyof
symptoms,forcedexpiratoryvolumeinonesecond(FEV1),
andpeakexpiratoryflowrate.[7]Asthmamayalsobeclassified
asatopic(extrinsic)ornonatopic(intrinsic),basedonwhether
symptomsareprecipitatedbyallergens(atopic)ornot(non
atopic).[8]Whileasthmaisclassifiedbasedonseverity,atthe
momentthereisnoclearmethodforclassifyingdifferent
subgroupsofasthmabeyondthissystem.[87]Findingwaysto
identifysubgroupsthatrespondwelltodifferenttypesof
treatmentsisacurrentcriticalgoalofasthmaresearch.[87]

Severity

Clinicalclassification(12yearsold)[7]
FEV1
Symptom
Nighttime %FEV1of
frequency
symptoms
predicted Variability

SABAuse

Intermittent

2/week

2/month

80%

<20%

2days/week

Mildpersistent

>2/week

34/month

80%

2030%

>2days/week

Moderate
persistent

Daily

>1/week

6080%

>30%

daily

Severepersistent

Continuously

Frequent
(7/week)

<60%

>30%

twice/day

Althoughasthmaisachronicobstructivecondition,itisnot
consideredasapartofchronicobstructivepulmonarydiseaseasthistermrefersspecificallytocombinationsofdiseasethatareirreversiblesuchasbronchiectasis,
chronicbronchitis,andemphysema.[88]Unlikethesediseases,theairwayobstructioninasthmaisusuallyreversiblehowever,ifleftuntreated,thechronic

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inflammationfromasthmacanleadthelungstobecomeirreversiblyobstructedduetoairwayremodeling.[89]Incontrasttoemphysema,asthmaaffectsthe
bronchi,notthealveoli.[90]
Asthmaexacerbation
Anacuteasthmaexacerbationiscommonlyreferredtoasanasthmaattack.The
classicsymptomsareshortnessofbreath,wheezing,andchesttightness.[20]The
wheezingismostoftenwhenbreathingout.[92]Whilethesearetheprimary
symptomsofasthma,[93]somepeoplepresentprimarilywithcoughing,andin
severecases,airmotionmaybesignificantlyimpairedsuchthatnowheezingis
heard.[91]Inchildren,chestpainisoftenpresent.[94]
Signswhichoccurduringanasthmaattackincludetheuseofaccessorymusclesof
respiration(sternocleidomastoidandscalenemusclesoftheneck),theremaybea
paradoxicalpulse(apulsethatisweakerduringinhalationandstrongerduring
exhalation),andoverinflationofthechest.[95]Abluecoloroftheskinandnails
mayoccurfromlackofoxygen.[96]
Inamildexacerbationthepeakexpiratoryflowrate(PEFR)is200L/minor
50%ofthepredictedbest.[97]Moderateisdefinedasbetween80and200L/min
or25%and50%ofthepredictedbestwhilesevereisdefinedas80L/minor
25%ofthepredictedbest.[97]
Acutesevereasthma,previouslyknownasstatusasthmaticus,isanacute
exacerbationofasthmathatdoesnotrespondtostandardtreatmentsof
bronchodilatorsandcorticosteroids.[98]Halfofcasesareduetoinfectionswith
otherscausedbyallergen,airpollution,orinsufficientorinappropriatemedication
use.[98]

Nearfatal

Lifethreatening
(anyoneof)

Severityofanacuteexacerbation[91]
HighPaCO2and/orrequiringmechanicalventilation
Clinicalsigns

Measurements

Alteredlevelofconsciousness

Peakflow<33%

Exhaustion

Oxygensaturation<92%

Arrhythmia

PaO2<8kPa

Lowbloodpressure

"Normal"PaCO2

Cyanosis
Silentchest
Poorrespiratoryeffort
Peakflow3350%
Acutesevere
(anyoneof)

Respiratoryrate25breathsperminute
Heartrate110beatsperminute
Unabletocompletesentencesinonebreath
Worseningsymptoms

Moderate

Peakflow5080%bestorpredicted
Nofeaturesofacutesevereasthma

Brittleasthmaisakindofasthmadistinguishablebyrecurrent,severeattacks.[91]Type1brittleasthmaisadiseasewithwidepeakflowvariability,despiteintense
medication.Type2brittleasthmaisbackgroundwellcontrolledasthmawithsuddensevereexacerbations.[91]
Exerciseinduced

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Exercisecantriggerbronchoconstrictionbothinpeoplewithorwithoutasthma.[99]Itoccursinmostpeoplewithasthmaandupto20%ofpeoplewithout
asthma.[99]Exerciseinducedbronchoconstrictioniscommoninprofessionalathletes.Thehighestratesareamongcyclists(upto45%),swimmers,andcross
countryskiers.[100]Whileitmayoccurwithanyweatherconditionsitismorecommonwhenitisdryandcold.[101]Inhaledbeta2agonistsdonotappearto
improveathleticperformanceamongthosewithoutasthma[102]howeveroraldosesmayimproveenduranceandstrength.[103][104]
Occupational
Asthmaasaresultof(orworsenedby)workplaceexposures,isacommonlyreportedoccupationaldisease.[105]Manycaseshoweverarenotreportedor
recognizedassuch.[106][107]Itisestimatedthat525%ofasthmacasesinadultsareworkrelated.Afewhundreddifferentagentshavebeenimplicatedwiththe
mostcommonbeing:isocyanates,grainandwooddust,colophony,solderingflux,latex,animals,andaldehydes.Theemploymentassociatedwiththehighestrisk
ofproblemsinclude:thosewhospraypaint,bakersandthosewhoprocessfood,nurses,chemicalworkers,thosewhoworkwithanimals,welders,hairdressersand
timberworkers.[105]
Aspirininducedasthma
Aspirinexacerbatedrespiratorydisease,alsoknownasaspirininducedasthma,affectsupto9%ofasthmatics.[108]Reactionsmayalsooccurtoother
NSAIDs.[109]Peopleaffectedoftenalsohavetroublewithnasalpolyps.[109]InpeoplewhoareaffectedlowdosesparacetamolorCOX2inhibitorsaregenerally
safe.[110]
Alcoholinducedasthma
Alcoholmayworsenasthmaticsymptomsinuptoathirdofpeople.[111]ThismaybeevenmorecommoninsomeethnicgroupssuchastheJapaneseandthose
withaspirininducedasthma.[111]Otherstudieshavefoundimprovementinasthmaticsymptomsfromalcohol.[111]
Nonallergicasthma
Nonallergicasthma,alsoknownasintrinsicornonatopicasthmamakesupbetween10and33%ofcases.Thereisnegativeskintesttocommoninhalantallergens
andnormalserumconcentrationsofIgE.Oftenitstartslaterinlifeandwomenaremorecommonlyaffectedthanmen.Usualtreatmentsmaynotworkaswell.[112]

Differentialdiagnosis

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Manyotherconditionscancausesymptomssimilartothoseofasthma.Inchildren,otherupperairwaydiseasessuchasallergicrhinitisandsinusitisshouldbe
consideredaswellasothercausesofairwayobstructionincluding:foreignbodyaspiration,trachealstenosisorlaryngotracheomalacia,vascularrings,enlarged
lymphnodesorneckmasses.[113]Bronchiolitisandotherviralinfectionsmayalsoproducewheezing.[114]Inadults,COPD,congestiveheartfailure,airway
masses,aswellasdruginducedcoughingduetoACEinhibitorsshouldbeconsidered.Inbothpopulationsvocalcorddysfunctionmaypresentsimilarly.[113]
Chronicobstructivepulmonarydiseasecancoexistwithasthmaandcanoccurasacomplicationofchronicasthma.Aftertheageof65,mostpeoplewith
obstructiveairwaydiseasewillhaveasthmaandCOPD.Inthissetting,COPDcanbedifferentiatedbyincreasedairwayneutrophils,abnormallyincreasedwall
thickness,andincreasedsmoothmuscleinthebronchi.However,thislevelofinvestigationisnotperformedduetoCOPDandasthmasharingsimilarprinciplesof
management:corticosteroids,longactingbetaagonists,andsmokingcessation.[115]Itcloselyresemblesasthmainsymptoms,iscorrelatedwithmoreexposureto
cigarettesmoke,anolderage,lesssymptomreversibilityafterbronchodilatoradministration,anddecreasedlikelihoodoffamilyhistoryofatopy.[116][117]

Prevention
Theevidencefortheeffectivenessofmeasurestopreventthedevelopmentofasthmaisweak.[118]Someshowpromiseincluding:limitingsmokeexposurebothin
uteroandafterdelivery,breastfeeding,andincreasedexposuretodaycareorlargefamiliesbutnonearewellsupportedenoughtoberecommendedforthis
indication.[118]Earlypetexposuremaybeuseful.[119]Resultsfromexposuretopetsatothertimesareinconclusive[120]anditisonlyrecommendedthatpetsbe
removedfromthehomeifapersonhasallergicsymptomstosaidpet.[121]Dietaryrestrictionsduringpregnancyorwhenbreastfeedinghavenotbeenfoundtobe
effectiveandthusarenotrecommended.[121]Reducingoreliminatingcompoundsknowntosensitivepeoplefromtheworkplacemaybeeffective.[105]Itisnot
clearifannualinfluenzavaccinationseffectstheriskofexacerbations.[122]Immunizationhowever,isrecommendedbytheWorldHealthOrganization.[123]
Smokingbansareeffectiveindecreasingexacerbationsofasthma.[124]

Management
Whilethereisnocureforasthma,symptomscantypicallybeimproved.[125]Aspecific,customizedplanforproactivelymonitoringandmanagingsymptoms
shouldbecreated.Thisplanshouldincludethereductionofexposuretoallergens,testingtoassesstheseverityofsymptoms,andtheusageofmedications.The
treatmentplanshouldbewrittendownandadviseadjustmentstotreatmentaccordingtochangesinsymptoms.[126]
Themosteffectivetreatmentforasthmaisidentifyingtriggers,suchascigarettesmoke,pets,oraspirin,andeliminatingexposuretothem.Iftriggeravoidanceis
insufficient,theuseofmedicationisrecommended.Pharmaceuticaldrugsareselectedbasedon,amongotherthings,theseverityofillnessandthefrequencyof
symptoms.Specificmedicationsforasthmaarebroadlyclassifiedintofastactingandlongactingcategories.[127][128]
Bronchodilatorsarerecommendedforshorttermreliefofsymptoms.Inthosewithoccasionalattacks,noothermedicationisneeded.Ifmildpersistentdiseaseis
present(morethantwoattacksaweek),lowdoseinhaledcorticosteroidsoralternatively,anoralleukotrieneantagonistoramastcellstabilizerisrecommended.
Forthosewhohavedailyattacks,ahigherdoseofinhaledcorticosteroidsisused.Inamoderateorsevereexacerbation,oralcorticosteroidsareaddedtothese
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treatments.[14]

Lifestylemodification
Avoidanceoftriggersisakeycomponentofimprovingcontrolandpreventingattacks.Themostcommontriggersincludeallergens,smoke(tobaccoandother),
airpollution,nonselectivebetablockers,andsulfitecontainingfoods.[129][130]Cigarettesmokingandsecondhandsmoke(passivesmoke)mayreducethe
effectivenessofmedicationssuchascorticosteroids.[131]Lawsthatlimitsmokingdecreasethenumberofpeoplehospitalizedforasthma.[132]Dustmitecontrol
measures,includingairfiltration,chemicalstokillmites,vacuuming,mattresscoversandothersmethodshadnoeffectonasthmasymptoms.[51]Overall,exercise
isbeneficialinpeoplewithstableasthma.[133]Yogacouldprovidesmallimprovementsinqualityoflifeandsymptomsinpeoplewithasthma.[134]

Medications
Medicationsusedtotreatasthmaaredividedintotwogeneralclasses:quickreliefmedicationsusedtotreatacutesymptomsandlongtermcontrolmedications
usedtopreventfurtherexacerbation.[127]Antibioticsaregenerallynotneededforsuddenworseningofsymptoms.[135]
Fastacting
Shortactingbeta2adrenoceptoragonists(SABA),suchassalbutamol(albuterolUSAN)arethefirstlinetreatmentforasthmasymptoms.[14]Theyare
recommendedbeforeexerciseinthosewithexerciseinducedsymptoms.[136]
Anticholinergicmedications,suchasipratropiumbromide,provideadditionalbenefitwhenusedincombinationwithSABAinthosewithmoderateor
severesymptoms.[14]AnticholinergicbronchodilatorscanalsobeusedifapersoncannottolerateaSABA.[88]Ifachildrequiresadmissiontohospital
additionalipratropiumdoesnotappeartohelpoveraSABA.[137]
Older,lessselectiveadrenergicagonists,suchasinhaledepinephrine,havesimilarefficacytoSABAs.[138]Theyarehowevernotrecommendeddueto
concernsregardingexcessivecardiacstimulation.[139]
Longtermcontrol
Corticosteroidsaregenerallyconsideredthemosteffectivetreatmentavailableforlongtermcontrol.[127]Inhaledformssuchasbeclomethasoneareusually
usedexceptinthecaseofseverepersistentdisease,inwhichoralcorticosteroidsmaybeneeded.[127]Itisusuallyrecommendedthatinhaledformulationsbe
usedonceortwicedaily,dependingontheseverityofsymptoms.[140]
Longactingbetaadrenoceptoragonists(LABA)suchassalmeterolandformoterolcanimproveasthmacontrol,atleastinadults,whengivenin
combinationwithinhaledcorticosteroids.[141]Inchildrenthisbenefitisuncertain.[141][142]Whenusedwithoutsteroidstheyincreasetheriskofsevereside
effects[143]andevenwithcorticosteroidstheymayslightlyincreasetherisk.[144][145]
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Leukotrienereceptorantagonists(suchasmontelukastandzafirlukast)maybeusedinadditiontoinhaled
corticosteroids,typicallyalsoinconjunctionwithaLABA.[13][127]Evidenceisinsufficienttosupportuseinacute
exacerbations.[146][147]Inchildrentheyappeartobeoflittlebenefitwhenaddedtoinhaledsteroids,[148]andthesame
appliesinadolescentsandadults.[149]Theyareusefulbythemselves.[150]Inthoseunderfiveyearsofage,theywere
thepreferredaddontherapyafterinhaledcorticosteroidsbytheBritishThoracicSocietyin2009.[151]Asimilarclass
ofdrugs,5LOXinhibitors,maybeusedasanalternativeinthechronictreatmentofmildtomoderateasthmaamong
olderchildrenandadults.[13][152]Asof2013thereisonemedicationinthisfamilyknownaszileuton.[13]
Mastcellstabilizers(suchascromolynsodium)areanothernonpreferredalternativetocorticosteroids.[127]
Deliverymethods
Medicationsaretypicallyprovidedasmetereddoseinhalers(MDIs)incombinationwithanasthmaspacerorasadry
powderinhaler.Thespacerisaplasticcylinderthatmixesthemedicationwithair,makingiteasiertoreceiveafulldoseof
thedrug.Anebulizermayalsobeused.Nebulizersandspacersareequallyeffectiveinthosewithmildtomoderate
symptoms.However,insufficientevidenceisavailabletodeterminewhetheradifferenceexistsinthosewithsevere
disease.[153]
Adverseeffects
Longtermuseofinhaledcorticosteroidsatconventionaldosescarriesaminorriskofadverseeffects.[154]Risksincludethe
developmentofcataractsandamildregressioninstature.[154][155]

Salbutamolmetereddoseinhaler
commonlyusedtotreatasthma
attacks.

Others
Whenasthmaisunresponsivetousualmedications,otheroptionsareavailableforbothemergencymanagementandpreventionofflareups.Foremergency
managementotheroptionsinclude:
Oxygentoalleviatehypoxiaifsaturationsfallbelow92%.[156]
Corticosteroidbymoutharerecommendedwithfivedaysofprednisonebeingthesame2daysofdexamethasone.[157]
Magnesiumsulfateintravenoustreatmentincreasesbronchodilationwhenusedinadditiontoothertreatmentinmoderatesevereacuteasthma
attacks.[15][158][159]Inadultsitresultsinareductionofhospitaladmissions.[160]
Heliox,amixtureofheliumandoxygen,mayalsobeconsideredinsevereunresponsivecases.[15]
Intravenoussalbutamolisnotsupportedbyavailableevidenceandisthususedonlyinextremecases.[156]
Methylxanthines(suchastheophylline)wereoncewidelyused,butdonotaddsignificantlytotheeffectsofinhaledbetaagonists.[156]Theiruseinacute
exacerbationsiscontroversial.[161]
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Thedissociativeanestheticketamineistheoreticallyusefulifintubationandmechanicalventilationisneededin
peoplewhoareapproachingrespiratoryarresthowever,thereisnoevidencefromclinicaltrialstosupportthis.[162]It
isunclearifnoninvasivepositivepressureventilationinchildrenisofuseasithasnotbeensufficientlystudied.[163]
ForthosewithseverepersistentasthmanotcontrolledbyinhaledcorticosteroidsandLABAs,bronchialthermoplastymay
beanoption.[164]Itinvolvesthedeliveryofcontrolledthermalenergytotheairwaywallduringaseriesof
bronchoscopies.[164][165]Whileitmayincreaseexacerbationfrequencyinthefirstfewmonthsitappearstodecreasethe
subsequentrate.Effectsbeyondoneyearareunknown.[166]Evidencesuggeststhatsublingualimmunotherapyinthosewith
bothallergicrhinitisandasthmaimproveoutcomes.[167]

Alternativemedicine
Manypeoplewithasthma,likethosewithotherchronicdisorders,usealternativetreatmentssurveysshowthatroughly
50%usesomeformofunconventionaltherapy.[168][169]Thereislittledatatosupporttheeffectivenessofmostofthese
therapies.EvidenceisinsufficienttosupporttheusageofVitaminC.[170]Thereistentativesupportforitsuseinexercise
inducedbrochospasm.[171]Inpeoplewithmildtomoderateasthma,treatmentwithvitaminDsupplementationislikelyto
reducetheriskofasthmaexacerbations.[172]
Acupunctureisnotrecommendedforthetreatmentasthereisinsufficientevidencetosupportitsuse.[173][174]Airionisers
shownoevidencethattheyimproveasthmasymptomsorbenefitlungfunctionthisappliedequallytopositiveand
negativeiongenerators.[175]

Fluticasonepropionatemetereddose
inhalercommonlyusedforlongterm
control.

Manualtherapies,includingosteopathic,chiropractic,physiotherapeuticandrespiratorytherapeuticmaneuvers,haveinsufficientevidencetosupporttheirusein
treatingasthma.[176]TheButeykobreathingtechniqueforcontrollinghyperventilationmayresultinareductioninmedicationusehowever,thetechniquedoesnot
haveanyeffectonlungfunction.[128]Thusanexpertpanelfeltthatevidencewasinsufficienttosupportitsuse.[173]

Prognosis
Theprognosisforasthmaisgenerallygood,especiallyforchildrenwithmilddisease.[178]Mortalityhasdecreasedoverthelastfewdecadesduetobetter
recognitionandimprovementincare.[179]In2010thedeathratewas170permillionformalesand90permillionforfemales.[180]Ratesverybetweencountriesby
100fold.[180]

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Globallyitcausesmoderateorseveredisabilityin19.4millionpeopleasof2004(16millionofwhichareinlowand
middleincomecountries).[181]Ofasthmadiagnosedduringchildhood,halfofcaseswillnolongercarrythediagnosis
afteradecade.[63]Airwayremodelingisobserved,butitisunknownwhethertheserepresentharmfulorbeneficial
changes.[182]Earlytreatmentwithcorticosteroidsseemstopreventoramelioratesadeclineinlungfunction.[183]
Asthmainchildrenalsohasnegativeeffectsonqualityoflifeoftheirparents.[184]

Epidemiology

Asthmadeathspermillionpersonsin2012

Asof2011,235330millionpeopleworldwideareaffectedbyasthma,[185][186][187]andapproximately250,000
345,000peopledieperyearfromthedisease.[21][188]Ratesvarybetweencountrieswithprevalencesbetween1and
18%.[21]Itismorecommonindevelopedthandevelopingcountries.[21]OnethusseeslowerratesinAsia,Eastern
EuropeandAfrica.[20]Withindevelopedcountriesitismorecommoninthosewhoareeconomicallydisadvantaged
whileincontrastindevelopingcountriesitismorecommoninthe
affluent.[21]Thereasonforthesedifferencesisnotwellknown.[21]Low
andmiddleincomecountriesmakeupmorethan80%ofthe
mortality.[189]

Ratesofasthmaindifferentcountriesofthe
worldasof2004.
nodata

67%

<1%

78%

12%

810%

Whileasthmaistwiceascommoninboysasgirls,[21]severeasthma
occursatequalrates.[190]Incontrastadultwomenhaveahigherrateof
asthmathanmen[21]anditismorecommonintheyoungthanthe
old.[20]Inchildren,asthmawasthemostcommonreasonforadmission
tothehospitalfollowinganemergencydepartmentvisitintheUSin
2011.[191]

Globalratesofasthmahaveincreasedsignificantlybetweenthe1960s
and2008[18][192]withitbeingrecognizedasamajorpublichealth
34%
12.515%
problemsincethe1970s.[20]Ratesofasthmahaveplateauedinthe
45%
>15%
developedworldsincethemid1990swithrecentincreasesprimarilyin
56%
thedevelopingworld.[193]Asthmaaffectsapproximately7%ofthe
populationoftheUnitedStates[143]and5%ofpeopleintheUnited
Kingdom.[194]Canada,AustraliaandNewZealandhaveratesofabout1415%.[195]
23%

1012.5%

https://en.wikipedia.org/wiki/Asthma

010

2432

6795

1113

3343

96251

1417

4450

1823

5166

Disabilityadjustedlifeyearforasthmaper
100,000inhabitantsin2004. [177]
nodata

350400

<100

400450

100150

450500

150200

500550

200250

550600

250300

>600

300350

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Economics
From2000to2010,theaveragecostperasthmarelatedhospitalstayintheUnitedStatesforchildrenremainedrelativelystableatabout$3,600,whereasthe
averagecostperasthmarelatedhospitalstayforadultsincreasedfrom$5,200to$6,600.[196]In2010,Medicaidwasthemostfrequentprimarypayeramong
childrenandadultsaged1844yearsintheUnitedStatesprivateinsurancewasthesecondmostfrequentpayer.[196]Amongbothchildrenandadultsinthelowest
incomecommunitiesintheUnitedStatesthereisahigherrateofhospitalstaysforasthmain2010thanthoseinthehighestincomecommunities.[196]

History
AsthmawasrecognizedinAncientEgyptandwastreatedbydrinkinganincensemixtureknownaskyphi.[19]Itwas
officiallynamedasaspecificrespiratoryproblembyHippocratescirca450BC,withtheGreekwordfor"panting"forming
thebasisofourmodernname.[20]In200BCitwasbelievedtobeatleastpartlyrelatedtotheemotions.[28]
In1873,oneofthefirstpapersinmodernmedicineonthesubjecttriedtoexplainthepathophysiologyofthediseasewhile
onein1872,concludedthatasthmacanbecuredbyrubbingthechestwithchloroformliniment.[197][198]Medicaltreatment
in1880,includedtheuseofintravenousdosesofadrugcalledpilocarpin.[199]In1886,F.H.Bosworththeorizeda
connectionbetweenasthmaandhayfever.[200]Epinephrinewasfirstreferredtointhetreatmentofasthmain1905.[201]
Oralcorticosteroidsbegantobeusedforthisconditioninthe1950swhileinhaledcorticosteroidsandselectiveshortacting
betaagonistcameintowideuseinthe1960s.[202][203]
Anotableandwelldocumentedcaseinthe19thcenturywasthatofyoungTheodoreRoosevelt(18581919).Atthattime
therewasnoeffectivetreatment.Roosevelt'syouthwasinlargepartshapedbyhispoorhealthpartlyrelatedtohisasthma.
Heexperiencedrecurringnighttimeasthmaattacksthatcausedtheexperienceofbeingsmotheredtodeath,terrifyingthe
boyandhisparents.[204]

EbersPapyrusdetailingtreatmentof
asthma

Duringthe1930sto1950s,asthmawasknownasoneofthe"holyseven"psychosomaticillnesses.Itscausewas
consideredtobepsychological,withtreatmentoftenbasedonpsychoanalysisandothertalkingcures.[205]Asthese
psychoanalystsinterpretedtheasthmaticwheezeasthesuppressedcryofthechildforitsmother,theyconsideredthetreatmentofdepressiontobeespecially
importantforindividualswithasthma.[205]

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1907advertisementfor
Grimault'sIndianCigarettes,
emphasisingtheiralleged
efficacyforthereliefof
asthma

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