Asthma

Pantea Andreea,gr.17
Definition

Asthma is a chronic (long-lasting) inIlammatory disease oI the airways. In those susceptible to
asthma, this inIlammation causes the airways to spasm and swell periodically so that the airways
narrow. The individual then must wheeze or gasp Ior air. Obstruction to air Ilow either resolves
spontaneously or responds to a wide range oI treatments, but continuing inIlammation makes the
airways hyper-responsive to stimuli such as cold air, exercise, dust mites, pollutants in the air,
and even stress and anxiety.
Description

According to the American Lung Association, as oI 2007, about 34.1 million Americans,
including 9 million children, had been diagnosed with asthma during their liIetime. This number
appears to be both increasing, especially among children under age 6, while at the same time the
disease is becoming more severe. Asthma is estimated to cause between 3,500 and 5,000 deaths
annually in the United States. Asthma is closely linked to allergies; about 75 oI people with
asthma also have allergies.
The changes that take place in the lungs oI people with asthma makes the airways (the "breathing
tubes," or bronchi and the smaller bronchioles) hyper-reactive to many diIIerent types oI stimuli
that do not aIIect healthy lungs. In an asthma attack, the muscle tissue in the walls oI bronchi go
into spasm, and the cells lining the airways swell and secrete mucus into the airways. Both these
actions cause the bronchi to become narrowed (bronchoconstriction). As a result, an asthmatic
person has to make a much greater eIIort to breathe in air and to expel it.
Cells in the bronchial walls, called mast cells, release certain substances that cause the bronchial
muscle to contract and stimulate mucus Iormation. These substances, which include histamine
and a group oI chemicals called leukotrienes, also bring white blood cells into the area, which is
a key part oI the inIlammatory response. Many individuals with asthma are prone to react to such
"Ioreign" substances as pollen, house dust mites, or animal dander; these substances are called
allergens. On the other hand, asthma aIIects many individuals who are not allergic in this way.
About two-thirds oI all cases oI asthma are diagnosed in people under age 18, but asthma also
may Iirst appear during adult years. While the symptoms may be similar, certain important
aspects oI asthma diIIer in children and adults.

Causes and symptoms
In most cases, asthma is caused by inhaling an allergen that sets oII the chain oI biochemical and
tissue changes leading to airway inIlammation, bronchoconstriction, and wheezing. Avoiding or
at least minimizing exposure to asthma triggers is the most eIIective way oI treating asthma, so it
is helpIul to identiIy which speciIic allergen or irritant is causing symptoms in a particular
individual. Once asthma is present, symptoms may be triggered or aggravated iI the individual
also has rhinitis (inIlammation oI the lining oI the nose) or sinusitis (sinus inIlammation). When
stomach acid passes back up the esophagus (acid reIlux), this also may worsen asthma
symptoms. A viral inIection oI the respiratory tract (e.g., a cold) also may trigger or worsen an
asthmatic reaction. Aspirin, NSAIDs, and beta-blocker drugs also may worsen the symptoms oI
asthma.
The most common inhaled allergens that trigger asthma attacks are:
O animal dander
O mites in house dust
O Iungi (molds) that grow indoors
O cockroach allergens
O pollen
O chemicals, Iumes, or airborne industrial pollutants
O smoke

Inhaling tobacco smoke, either by smoking or being around people who are smoking, can irritate
the airways and trigger an asthmatic attack. Air pollutants such as wood smoke can have a
similar eIIect. In addition, three Iactors that regularly produce attacks in certain asthmatic
individuals, and may sometimes be the sole cause oI symptoms are:
O inhaling cold air (cold-induced asthma)
O exercise-induced asthma
O stress or a high level oI anxiety

Wheezing is oIten obvious, but mild asthma attacks may be conIirmed only when the
physician listens to the individual's chest with a stethoscope. Besides wheezing and being
short oI breath, the individual may cough and/or may report a Ieeling oI "tightness" in the
chest. Wheezing is oIten loudest when the individual breathes out (exhales) in an attempt
to expel air through the narrowed airways. Some people with asthma are Iree oI
symptoms most oI the time but occasionally may have episodes oI shortness oI breath.
Others spend much oI their time wheezing or have Irequent bouts oI shortness oI breath
until properly treated. Crying or laughing may bring on an attack. Severe episodes oIten
develop when the individual has a viral respiratory tract inIection or is exposed to a
heavy load oI an allergen or irritant (e.g., breathing in smoke Irom a campIire). Asthma
attacks may last only a Iew minutes or can continue Ior hours or even days (a condition
called status asthmaticus).
Being short oI breath may cause an individual to become visibly anxious, sit upright, lean
Iorward, and use the muscles oI the neck and chest wall to help move air in and out oI the
lungs. The individual may be able to say only a Iew words at a time beIore stopping to
take a breath. ConIusion and a bluish tint to the skin are clues that the oxygen supply is
seriously low and that emergency treatment is needed. In a severe attack that lasts Ior an
extended period, some oI the air sacs in the lung may rupture so that air collects within
the chest. This makes it even harder Ior the lungs to exchange enough air.
Diagnosis

Apart Irom listening to the individual's chest, the examiner should look Ior maximum chest
expansion while taking in air. Hunched shoulders and contracted neck muscles are other signs oI
narrowed airways. Nasal polyps or increased amounts oI nasal secretions oIten are noted in
asthmatic individuals. Skin changes, such as atopic dermatitis or eczema, are indications that the
individual is likely to allergies.
The physician will ask about a Iamily history oI asthma or allergies. A diagnosis oI asthma may
be strongly suggested when typical signs and symptoms are present. A test called spirometry
measures how rapidly air is exhaled and how much air is retained in the lungs. Repeating the test
aIter the individual inhales a bronchodilator drug that widens the airways will show whether the
airway narrowing is reversible, which is a very typical Iinding in asthma. OIten individuals use a
related instrument, called a peak Ilow meter, to keep track oI asthma severity when at home.
It oIten is diIIicult to determine what is triggering asthma attacks. Allergy skin testing may be
used, although an allergic skin response does not always mean that the allergen being tested is
causing the asthma. The body's immune system produces speciIic antibody to Iight oII each
allergen. Measuring the amount oI a speciIic antibody in the blood may indicate how sensitive
the individual is to a particular allergen. II the diagnosis is still in doubt, the individual can inhale
a suspect allergen while using a spirometer to detect airway narrowing. Spirometry also can be
repeated aIter a bout oI exercise when exercise-induced asthma is suspected. A chest x ray may
be done to help rule out other lung disorders.
%reatment

The goals oI asthma treatment are to prevent troublesome symptoms, maintain lung Iunction as
close to normal as possible, and allow individuals to pursue their normal activities including
those requiring exertion. Individuals should periodically be examined and have their lung
Iunction measured by spirometry to make sure that treatment goals are being met. The best drug
therapy is that which controls asthmatic symptoms while causing Iew or no side eIIects. Many
people with asthma are treated with a combination oI long-acting drugs taken on a regular basis
to help prevent asthma attacks and short-acting (quick relieI) drugs given by inhaler to reduce the
immediate symptoms oI an attack.
Drugs
The choice oI initial drug treatment oIten depends on whether the asthma is classiIied as
intermittent, mildly persistent, moderately persistent, or severely persistent, the age oI the
individual, other medical conditions that may be present, and other drugs the patient may be
taking. It make take several attempts to Iind the best combination oI drugs to control the asthma.
Beta-receptor agonists (bronchodilators)

These drugs, which relax the airways, oIten are the best choice Ior relieving sudden attacks oI
asthma and Ior preventing attacks oI exercise-induced asthma. Some bronchodilators, such as
albuterol (Ventolin, Proventil) and levalbuterol (Xopenex), act mainly in lung cells and have
little eIIect on other organs. Bronchodilators occasionally may be taken orally (i.e., pills or
liquid), but normally they are administered through inhalers. The inhaled drugs go directly into
the lungs and cause Iewer side eIIects. These drugs generally start acting within minutes, but
their eIIects last only Iour to six hours.

eukotriene receptor antagonists
The leukotriene receptor antagonists such as montelukast (Singulair), zaIirlukast (Accolate), and
ZyIlo (zileuton) control inIlammation oI the airways by blocking the action oI leukotrienes,
which are chemicals involved in producing inIlammation. These drugs are tablets taken by
mouth on a regular basis to treat or prevent symptoms oI asthma and exercise-induced asthma.
Corticosteroids
These drugs, which resemble natural body hormones, block inIlammation and are oIten eIIective
in relieving symptoms oI chronic asthma and preventing asthma episodes, but they generally are
not used to treat asthma attacks once they have begun. Examples include Iluticasone (Flovent),
triamcinolone (Azmacort), and beclomethasone (Vanceril, Beclovent, QVAR) all oI which are
taken by inhalation. When corticosteroids are taken by inhalation over a long time, asthma
attacks become less Irequent as the airways become less sensitive to allergens. Prendisone
(Deltasone, Orasone, Meticorten) is given by mouth (i.e., pills) to speed recovery aIter treatment
oI initial symptoms oI an asthma attack and sometimes to treat chronic asthma.
Corticosteroids are strong drugs and usually can control even severe cases oI asthma over the
long term and maintain good lung Iunction. Corticosteroids may cause numerous side eIIects,
however, including bleeding Irom the stomach, loss oI calcium Irom bones, cataracts in the eye,
and a diabetes-like state.
Other drugs
Cromolyn (Intal) and nedocromil (Tilade) are anti-inIlammatory drugs that aIIect mast cells.
They may be used as initial treatment to prevent asthmatic attacks.
Managing asthmatic attacks
A severe asthma attack should be treated as quickly as possible; proIessional emergency medical
assistance may be needed, as an individual experiencing an acute attack may need to be given
extra oxygen. Rarely is it necessary to use a mechanical ventilator to help the individual breathe.
An inhaler, usually containing a beta-receptor agonist, is inhaled repeatedly or continuously. II
the individual does not respond promptly and completely, a corticosteroid may be given. A
course oI corticosteroid therapy, given aIter the attack is over, may make a recurrence less likely.
Many asthma experts recommend a device called a "spacer" to be used along with metered-dose
inhalers. The spacer is a tube or bellows-like device held in or around the mouth into which the
metered-dose inhaler is puIIed. This device enables more medication Irom a metered-dose
inhaler to reach the lungs.
Maintaining control

Long-term asthma treatment is based on inhaling appropriate drugs using a special inhaler that
meters the dose. Individuals must be instructed in proper use oI an inhaler to be sure that it will
deliver the right amount oI drug. Once asthma has been controlled Ior several weeks or months, a
physician may recommend that the patient gradually cut down on drug treatment. The last drug
added usually is the Iirst to be reduced. Individuals should be seen by their physician every one
to six months, or as needed, depending on the Irequency oI asthma episodes.
School-age and older children may also be prescribed peak Ilow meters, simple devices which
measure how easy or diIIicult it is Ior a person to exhale. With home peak-Ilow monitoring, it is
possible Ior many children with asthma to discern at an early stage that a Ilare-up is just
beginning and adjust their medications appropriately.
Individuals with asthma do best when they have a written action plan to Iollow iI symptoms
suddenly become worse. This plan should address how to adjust their medication and when to
seek medical help. A 2004 report Iound that individuals with selI-management written action
plans had Iewer hospitalizations, Iewer emergency department visits, and improved lung
Iunction. They also had a 70 lower mortality rate.
ReIerral to an asthma specialist should be considered iI:
O a liIe-threatening asthma attack has occurred or iI asthma is severe and persistent

O treatment Ior three to six months has not met its goals

O some other condition, such as nasal polyps or chronic lung disease, is complicating
asthma treatment

O special tests, such as allergy skin testing or an allergen challenge, are needed

O intensive long-term corticosteroid therapy has been needed to control asthma.

$pecial populations
Infants and young children

It is especially important to closely watch the course oI asthma in young individuals. Treatment
is cut down when possible, and iI there is no clear improvement, treatment should be modiIied.
Asthmatic children oIten need medication at school to control acute symptoms or to prevent
exercise-induced attacks. Parents or guardians oI these children should consult the school district
on their drug policy in order to assure that a procedure is in place to permit their child to carry an
inhaler. The health care provider should write an asthma treatment plan Ior the child's school.
Proper management will usually allow a child to take part in play activities. Only as a last resort
should activities be limited.
%he elderly

Older persons oIten have other types oI lung disease, such as chronic bronchitis or emphysema.
These must be taken into account when treating asthma symptoms. Side eIIects Irom beta-
receptor agonist drugs (including a speeding heart and tremor) may be more common in older
individuals.
Prognosis

More than halI oI all asthma cases in children resolve by young adulthood, but chronic inIection,
pollution, cigarette smoke, and chronic allergen exposure are Iactors which make resolution less
likely. InIants and toddlers who have persistent wheezing even without viral inIections and those
who have a Iamily history oI allergies are most likely to continue to have asthma into the school-
age years.
Most individuals with asthma respond well once the proper drug or combination oI drugs is
Iound, and most asthmatics are able to lead relatively normal, active lives. A Iew individuals will
have progressively more trouble breathing and run a risk oI going into respiratory Iailure, Ior
which they must receive intensive treatment.
Prevention
Minimizing allergy episodes

Exposure to the common allergens and irritants that provoke asthmatic attacks oIten can be
reduced or avoided by implementing the Iollowing:
O II the individual is sensitive to a Iamily pet, remove the animal Irom the home. II this is
not acceptable, keep the pet out oI the bedroom (with the bedroom door closed), remove
carpeting, and keep the animal away upholstered Iurniture.

O To reduce exposure to dust mites, remove wall-to-wall carpeting, keep humidity low, and
use special covers Ior pillows and mattresses. Reduce the number oI stuIIed toys and
wash them weekly in hot water.

O II cockroach allergen is causing asthma attacks, killing the roaches using poison, traps, or
boric acid is preIerable to using sprayed pesticides. Avoid leaving Iood or garbage
exposed to discourage re-inIestation.

O eep indoor air clean by vacuuming carpets once or twice a week (with the asthmatic
individual absent). Avoid using humidiIiers and use air conditioning during warm
weather so that windows can be kept closed. Change heating and air conditioning Iilters
regularly. High-eIIiciency particulate air (HEPA) Iilters are available that are very
eIIective in removing allergens Irom household air.

O Avoid exposure to tobacco or wood smoke.

O Do not exercise outdoors when air pollution levels are high or when air is extremely cold.

O When asthma is related to exposure at work, take all precautions, including wearing a
mask and, iI necessary, arranging to work in a saIer area. Occupational saIety and health
(OSHA) regulations limit exposure to certain pollutants and potential allergens in the
workplace.