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Asthma

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Dr Sameer Advani
Pulmonologist

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Asthma is a lung disorder that affects your airways and causes difficulty in breathing. It is triggered by inflammation of the air passages. The inflammation causes the air passages to become narrow. The narrowness is indicated by the noisy and whistling breathing, shortness of breath, chest tightness and coughing. 

There can be several triggers or factors that can aggravate the symptoms of asthma. Common factors include dust, mites, pollen, smoke, pollution, weather change, cold & cough and respiratory infections. Asthma can be broadly classified into two categories – specific and non-specific. Specific asthma hits you when you breathe in allergens or irritants, while non-specific asthma is caused by exercise, weather conditions or genetic predisposition. The exact cause of asthma is not known, but it is seen in families with a history of the condition. Asthma cannot be cured, but it can be managed well with several treatment options to relieve the symptoms and prevent severe attacks.  

The following are the types, causes, symptoms of and treatment for asthma:

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Types

There are two types of asthma, based on the nature of the trigger behind it: Extrinsic asthma and intrinsic asthma.


  • Extrinsic asthma: It is an immune response to an external allergen such as pollen, animal dander, dust, etc.

  • Intrinsic asthma: It occurs when you inhale certain chemical agents such as cigarette smoke, paint vapours, etc. In some cases, it may also be worsened by a chest infection, stress, and even loud bouts of laughter. Some drugs like aspirin and other NSAIDs are also known to cause asthma attacks.

Symptoms

Most people with asthma experience symptoms intermittently. The time gap between asthma flare-ups could be weeks or months. The symptoms generally worsen in the night or early in the morning. Other factors that can worsen asthma manifestations are breathing in cold air, strenuous physical exercise and heartburn. The tell-tale signs of this condition include:


  • Cough with or without sputum (phlegm) production

  • Chest tightness: Pulling in of the skin between the ribs when breathing

  • Breathlessness

  • Wheezing: A musical, whistling or hissing sound with breathing.


Apart from these, there are other manifestations of this condition which demand immediate addressal by the doctor

  • Bluish colour of the lips and face

  • Decreased level of alertness, such as severe drowsiness or confusion

  • Rapid pulse

  • Severe anxiety due to shortness of breath

  • Sweating

Causes And Risk Factors

Causes

During an episode of asthma attack, the muscles surrounding the airways become tight, and the lining of the air passages become swollen. This reduces the amount of air that can pass by. Though doctors haven’t been able to identify a specific cause behind asthma, specific triggers  have been spotted. Asthma triggers can be broadly categorized into Specific and Non-Specific Triggers:


  • Specific Triggers: The specific triggers include allergens, irritants, conditions like heartburn and more.



  • Airborne irritants: Any substance you breathe in can become an allergen. These might include traffic fumes, animal dander (from dogs and cats), house dust mites, pollen, mold, industrial fumes (especially those containing sulphur dioxide), household chemicals (air fresheners and aerosols), perfumed cosmetics, scented flowers, etc.

  • Respiratory infections: Viral or bacterial respiratory infections that trigger an asthma attack are common cold, flu, bronchitis and sinus infections. These infections adversely affect asthma patients, especially children. 

  • Certain foods and food additives: Some of the most common foods associated with allergic symptoms are eggs, cow’s milk, peanuts, soy, wheat, fish, shrimp, etc. Food preservatives, especially sulphite additives, can also be potential triggers behind an asthma flare-up. They include sodium bisulphite, potassium bisulphite, sodium metabisulphite, potassium metabisulfite and sodium sulphite.

  • Tobacco smoke: Cigarette smoke contains different chemicals and gases that can irritate the lungs. Smoking increases your chance of getting asthma. Symptoms such as coughing and wheezing become worse when an asthma patient smokes. New-borns can have poor lung function and an increased risk of wheezing if their mothers smoke during pregnancy.

  • Heartburn: Severe heartburn, known as gastroesophageal reflux disease (GERD), and asthma often go hand-in-hand. Your stomach acids reflux into the oesophagus when the valve between this organ and the stomach does not function properly. If the acid reaches your airways, the irritation and inflammation can trigger an asthma attack.

  • Drugs: Certain prescription and over-the-counter drugs like aspirin and non-steroidal anti-inflammatory drugs (ibuprofen and beta-blockers) may trigger asthma attacks.

  • Alcohol: alcohol can cause asthma symptoms to worsen. One possible reason could be that alcohol causes acid reflux. Other potential factors could be the sulphites used in wines and beers.



  • Non-Specific Triggers: This category of triggers includes everything from emotional stress to genetic predisposition:



  • Emotional Stress: Extreme emotions such as anxiety, anger, and fear-induced stress change the heart rate and breathing patterns. Rapid, shallow breathing causes constriction of airways which consequently leads to an asthmatic attack.

  • Exercise: Asthma can be triggered by intense exercise sessions or physical exertion.

  • Extreme weather: Hot and humid weather or extremely cold weather causes asthma symptoms to flare up.

  • Genetic predisposition: Yes, if you have a family member with asthma or have a family history of allergies, you are more likely to be vulnerable to asthma attack triggers.


Risk Factors

  1. Family history: If a person’s mother or father had asthma, such person has three to six times greater chances of becoming an asthma patient than the person having healthy parents.

  2.  Persons having a history of viral respiratory infections during infancy and childhood become asthmatic as adults.  

  3. If a person has an allergic condition, such as atopic dermatitis (eczema) or allergic rhinitis (hay fever), chances of him/her contracting asthma increase.

Prevention

The best way to prevent the relapse of an asthma attack episode is to avoid the triggers. However, the triggers vary from person to person. Common triggers include air pollution, allergies, cold air, a cold or flu virus, smoke, fragrances, etc.  The following steps can help in avoiding the triggers:


  • Maintain an asthma diary: Identify your triggers and make a note of them in a diary.  Keep a tab on your symptoms and pen them down.  Discuss with your physician about all of these to chalk out a fool-proof plan for dealing with asthma.

  • Stay away from smoke: Smoke from tobacco, candles and fire aren’t good for asthma patients. Do not smoke or allow anyone to do so in your car or at home.

  • Maintain distance from sick people: Coming in close contact with someone suffering from cough and cold will increase your risk of an asthma attack. Stay away from them. Also, wash your hands well before eating and avoid touching your face as much as possible.

  • Get a flu shot: Immunise yourself against the flu virus because it can trigger an asthma attack. You need to take this shot every year. Getting a vaccine for pneumonia is highly recommended for asthma patients. This vaccine needs to be administered once every 5 to 10 years.

Diagnosis


  1. The diagnosis of asthma is based on a patient’s medical history, physical examination and laboratory test results. Your doctor will take a detailed medical history and ask you about your symptoms and allergy triggers. He may suggest one or more of the following tests to diagnose asthma, assess your breathing and monitor the effectiveness of asthma treatment:

    • Lung function tests: Most commonly advised lung function tests include:



    • Spirometry: This is a breathing test that tells your doctor how much and how fast you blow out air. The purpose is to measure airway obstruction.

    • Methacholine challenge: This is a confirmatory test for asthma, in case your spirometry doesn’t show clear results.

    • Peak flow: It measures your capacity to push air out of your lungs. It can be performed at home with a device called ‘peak flow meter’ to figure out how successful your treatment is, whether or not you need emergency treatment, etc.

    • Exhaled nitric oxide test: It measures the levels of nitric oxide in your breath. An increase in the volume of this gas indicates inflammation in the airways.



    • Chest X-ray: This is a first-level imaging test that your doctor may suggest to have a broad overview of your lungs.



Treatment

The aim of asthma treatment is symptom control and easing of airway inflammation. Treatment  of this condition rests on three pillars: Long-term asthma control medicines, quick-acting drugs and breathing workouts. Your treatment regimen has to be decided by your doctor. Do not indulge in self-medication as the consequences can be dangerous.


  • Long-term asthma control medicines: They don’t provide immediate relief to your symptoms. They work to reduce the severity and instances of an asthma attack. 



  • Steroids and Other Anti-Inflammatory Drugs: These are commonly used for most people with asthma, particularly the inhaled steroids. They prevent asthma attacks by reducing swelling and mucus production in the airways. For severe asthma (status asthmaticus), injections of drugs such as prednisone are often necessary. Prednisone is the most potent and effective anti-inflammatory asthma medication available.

  • Long-acting bronchodilators: They are often combined with inhaled steroids for long-term control of asthma symptoms. Long-acting bronchodilators are never used alone for long-term therapy.



  • Quick-relief drugs: These drugs are mainly used during an emergency caused by a severe flare-up. They are prescribed by a pulmonologist, and the patient is told how to use them in case the need arises. Short-acting bronchodilator inhalers are used to quickly relieve cough, wheezing, chest tightness, and shortness of breath caused by asthma. Bronchodilators relieve the symptoms of asthma by dilating or widen the bronchial tubes. They should not be used regularly. 

  • Breathing exercises: Your doctor will suggest breathing techniques to increase your lung capacity and ensure healthy inflow and outflow of air.

  • Tackling severe cases of asthma: During a severe asthma attack that does not respond to asthma drugs, a mechanical ventilator may be needed to assist the lungs and respiratory muscles. A facemask is applied, or a breathing tube is inserted in the nose or mouth for this asthma treatment. These breathing aids are temporary and removed once the attack has subsided, and the lungs have recovered sufficiently to resume the work of breathing on their own. A short hospital stay in an intensive care unit may be necessary with an acute attack. In case of a severe flare-up, continuous use of an asthma nebulizer and injections of drugs such as epinephrine and prednisone for asthma are often necessary. Other therapies may include anti-inflammatory drugs.

Lifestyle/management

A dietary regimen that includes the following is recommended by nutritionists:

Probiotics, ginger, Omega 3 fatty acids, low salt and magnesium-rich diet, rosemary leaves, and olive oil. Avoid Omega 6 foods, raw foods, dairy products and food additives.

Prognosis And Complications

Prognosis

Asthma is a chronic disease. The severity of attack varies from mild aggravations – which do not interfere with the patient’s active life – to grave exacerbations that may endanger the patient’s life.

The odds against complete remission of its symptoms are heavy. However, remission is possible in the case of relatively mild cases. In the case of smokers, there is a greater chance of permanent lung impairment. 

Complications




    • Decreased quality of life: It signifies the reduced ability to exercise and take part in other activities. The patient suffers from fatigue, underperformance or absence from work, psychological problems including stress, anxiety and depression.

    • Respiratory complications: Asthma can lead to a number of serious respiratory complications, like pneumonia (infection of the lungs), the collapse of a part or all of the lung and respiratory functions. In acute respiratory failure, the bronchial tubes are completely blocked. Oxygen level in the blood becomes dangerously low, or carbon dioxide level becomes alarmingly high. Such patients have to be immediately shifted on ventilators to avoid fatality.



  • Pregnancy issues: In pregnant women, asthma complications may include early labour, hypertension, gestational diabetes and haemorrhage. Asthma also puts the babies at risk of lower birth weight and breathing disorders.

References


  1.  Here's what Dr Navneet Sood, Consultant, Pulmonary & Critical Care Medicine, Jaypee Hospital, Noida, has to say about the types, causes, symptoms, and treatment of asthma.

  2.  American Lung Association https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/asthma-symptoms-causes-risk-factors/asthma-risk-factors#:~:text= The most common risk factors, industrial dusts in the workplace. ( Reviewed and approved by the American Lung Association Scientific and Medical Editorial Review Panel.)

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