What Is Asthma?

Asthma is a chronic disease of the airways. It makes breathing difficult. There is inflammation of the air passages that result in a temporary narrowing of the airways leading to wheezing, shortness of breath, chest tightness and coughing. It is a Reversible Obstructive Airway Disease (ROAD) because the obstruction of the lungs is reversible, either spontaneously or with medication. It is also referred to as bronchial asthma. It is one of the most common chronic diseases in the world. The word asthma is derived from a Greek word which means breathlessness or panting.

What happens in our body during an asthma attack?

The air we breathe reaches the lung through the windpipe (trachea), which divides into two large tubes (bronchi). Each bronchi further divides into many little tubes (bronchioles). Bronchioles eventually lead to tiny air sacs (alveoli), where oxygen from the air is exchanged with carbon dioxide from the bloodstream

There are three features of asthma:

Airway obstruction. During breathing, muscle surrounding the airways is relaxed and air moves freely. But in asthma, allergy-causing substances make the muscle surrounding the airways tighten and air cannot move freely. This causes a person to feel short of breath and breathing becomes laboured. The air moving through the tightened airways causes a whistling sound known as wheezing.

Inflammation. The inflammation occurs in response to an allergen or irritant and results from the action of chemical mediators (histamine, leukotriene, etc.). People with asthma have red and swollen bronchial tubes. The inflamed tissues produce an excess amount of “sticky” mucus into the tubes. Irritation of the airways by excessive mucus may also initiate coughing.

Airway irritability. The airways of people with asthma are extremely sensitive to even the slightest triggers such as pollen, animal dander, dust or fumes.

What are the triggers that cause Asthma?

Asthma is caused due to inflammation in the airways. During an 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.

Asthma triggers can be broadly categorized into:

1. SPECIFIC(Allergens and Irritants): In sensitive people, asthma symptoms is triggered by breathing in allergy-causing substances like:

• Airborne irritants: Any substances 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 asthma attack are common cold, flu, bronchitis and sinus infections. They are a common cause of asthma especially in children.
• Food 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 Sulfite additives like sodium bisulfite, potassium bisulfite, sodium metabisulfite, potassium metabisulfite and sodium sulfite can also trigger asthma.
• 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 you smoke with asthma. Babies whose mothers smoked during pregnancy have worse lung function and increased risk of wheezing.
• Heart burn: Severe heartburn, known as gastroesophageal reflux disease (GERD) and asthma often go hand-in-hand. The stomach acids reflux into the esophagus because the valve between the esophagus and stomach does not function properly. If the acid reaches into the 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.
• Hormonal: In many women with asthma, the rise in progesterone and sharp decline in oestrogen just before menstruation increases the risk for asthma attacks by triggering bronchoconstriction. In case of men, low testosterone levels cause asthma because testosterone reduces the conversion of DHEAS (dehydroepiandrosterone sulfate) to DHEA. Decreased DHEA is believed to be the source of asthma.
• Alcohol: alcohol can cause asthma to worsen. One possible reason could be that alcohol causes various degrees of acid reflux. Another reason is sensitivity to sulfites used mostly in wines and beers that can increase symptoms in people with asthma.

2. NON-SPECIFIC: Emotional Stress: extreme emotions such as anxiety, anger and fear induce stress which in turn changes heart-rate and breathing patterns. There is rapid, shallow breathing causing constriction of airways and this consequently leads to an asthmatic attack.

• Exercise-induced – asthma triggered by exercise or physical exertion.
• Extreme weather - Hot and humid weather or extremely cold weather causes asthma symptoms to flare-up.
• Genetic predisposition – family history of allergies. Genetic tendency for asthma leads to susceptibility to be affected by external or internal trigger factors.

What are the symptoms of Asthma?

Most people with asthma have attacks separated by symptom-free periods. You may not have any asthma attack symptoms for weeks to months. Symptoms 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.
  • begins suddenly
  • comes in episodes with symptom-free periods in between
  • worse at night or early in the morning
  • may subside on its own
  • gets worse when you breath in cold air
  • gets worse with exercise and heartburn
  • gets better with drugs that open the airways

If you or anyone you know experiences the symptoms below, it is an emergency and time to call a 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
• Other symptoms that may occur are abnormal breathing pattern, stopped breathing and chest pain

What happens during severe asthma attack? What is Status Asthmaticus?

A severe, potentially fatal attack of asthma is called status asthmaticus. An acute asthma attack is potentially life-threatening because it may continue despite the use of your usual asthma medications (inhaled bronchodilators). The symptoms may include:

• persistent shortness of breath and inability to speak in full sentences
• breathlessness even while lying down
• chest tightness and bluish tint to lips
• feeling of agitation, confusion or unable to concentrate
• signs of respiratory system failure
• Very severe asthma attacks affects airways so much that the lack of air in your lungs does not cause a wheezing sound or coughing. Causes of status asthmaticus are unknown.  The patient may have a history of infrequent health care resulting in poor treatment of asthma and a history of intubation or hospitalization for asthma. Patients with poor mental health or psychosocial disorders are at a higher risk for a life-threatening asthma attack.

What are the types of Asthma

1. Asthma due to allergies: Allergic asthma is the most common type of asthma. Allergic rhinitis (hay fever) is inflammation of the inner lining of the nose due to increased sensitivity (allergy) to a substance. Your body’s immune cells release histamines along with other chemicals leading to allergy symptoms. Most of the times asthma symptoms are triggered by allergic rhinitis. The muscles around your airways tighten (an effect called bronchospasm). The airways themselves become inflamed and flooded with thick mucus.

2. Exercise-Induced Asthma: Exercise-induced asthma is a type of asthma triggered by vigorous or prolonged exercise or physical exertion. Narrowing of airway begins five to 20 minutes after exercise begins, making it difficult to catch your breath.

Normally, the air we take in is first warmed and moistened by the nasal passages. But during exercise people tend to breathe through their mouths thus inhaling colder and drier air. In exercise-induced asthma, the muscle bands around the airways are sensitive to these changes in temperature and humidity. They react by contracting, which narrows the airway. This results in symptoms of exercised-induced asthma.

3. Cough-Variant Asthma: Severe coughing with asthma is the predominant symptom in this type of asthma. Asthma triggers for cough-variant asthma are usually postnasal drip, chronic rhinitis, sinusitis or heartburn (gastroesophageal reflux disease GERD). It is vastly underdiagnosed and undertreated.

4. Occupational Asthma: Substances found in the workplace cause the airways of the lungs to swell and narrow, leading to asthma attacks. The patient develops symptoms of asthma as the result of an irritant, not an allergic reaction. The most common triggers are wood dust, grain dust, animal dander, fungi or chemicals like ammonia. Workers at higher risk are bakers, detergent manufacturers, drug manufacturers, millers, those working with animals and in textile industry, etc.

5. Nocturnal (Night time) Asthma: Chances of having symptoms are much higher during sleep because asthma is influenced by the sleep-wake cycle (circadian rhythms). It can ruin sleep regardless of the time of day. Reasons may be due to any of these:

• Increased exposure to allergens at night
• Cooling of the airways
• Reclining position – causes accumulation of secretions in the airways, increased blood volume in the lungs, decreased lung volumes, and increased airway resistance
• Sleeping itself causes changes in airway function.
• Hormones – follow a circadian (day-night) pattern. epinephrine maintains the relaxation and prevents the constriction of the bronchial muscles of the airways. It prevents the secretion of the chemical histamine which is responsible for the inflammation of the airways. Very early in the morning, the epinephrine levels are the lowest while that of histamine are highest.

When should I call my doctor for Asthma?

Call your doctor if:

• your attack requires more medication than recommended
• the symptoms get worse even with treatment
• you have shortness of breath

You may need emergency treatment if the following symptoms occur:

• Drowsiness or confusion
• Severe shortness of breath even at rest
• Chest pain
• Bluish colour of the lips and face
• Rapid pulse
• Breathing difficulty
• Severe anxiety

Diagnosis and Treatment of Asthma

Self care and Prevention of Asthma

“National asthma guidelines have advised avoidance of environmental tobacco smoke (ETS-passive smoking) for patients with asthma for decades, but it is unclear to what degree these recommendations are being followed…” said Lara J. Akinbami, medical officer, National Centre for Health Statistics, Centres for Disease Control and Prevention, who led the study.

Researchers undertook this investigation after co-author Brian Kit conducted a study showing that 53 percent of children with asthma were exposed to smoke from cigarettes, cigars or pipes from 2005 to 2010, according to a National Centre statement. Investigators analysed data from the 2003-2010 National Health and Nutrition Examination Survey (NHANES) for 972 children aged six to 19 years who had been diagnosed with asthma and had reported having asthma at the time of the survey. These findings were presented at the Paediatric Academic Societies (PAS) annual meeting in Boston, US.

Source: IANS

“About 85 to 90 per cent of children suffer relapse because they never adhere to instructions. Correct treatment and lifestyle modifications are enough to manage and even treat asthma. But, public have stigmatised inhalers and they do not follow instructions of the physicians properly,” senior paediatrician P. Sudershan Reddy, said on the eve of World Asthma Day.

The most common symptoms that occur during asthma attack among children include tightness in chest, shortness of breath recurring cough and wheezing. Because of narrow opening of the airway, children do have trouble breathing and this causes wheezing.

“Due to initial cost factors, a majority of parents discontinue inhalers and try to adopt tablets. However, we have seen that in the long run, children develop complications after using tablets. It is always advisable to use inhalers,” says senior chest physician, Government General and Chest Diseases Hospital, Erragadda, K. Subhakar.

Docs are also afraid that the asthma cases are also on the rise. Allaying fears of addiction to steroids in inhalers, Dr Sudershan Reddy said that they are very useful because they provide targeted medication. “There are no side effects and adverse reactions from inhalers. There should be no inhibitions to use inhalers. Physicians, however, must make sure that they spend a lot of time with parents and explain them properly about the finer aspects of asthma,” Dr. Reddy added.

Physicians point out that 60 per cent of asthma cases among children is treatable. “If children take medications properly, then the condition is treatable. There are children who have allergic asthma and they have to continue medication for longer time,” Dr. Subhakar said.

Asthma: All you need to know

Diagnosis and treatment

Self-care and prevention

There are few strategies to follow:

   1.  Limit your exposure to allergens. The following measures would lessen asthma attacks

• Avoid pets with fur or feathers in the house or keep them outdoors
• Use an air conditioner with a clean air filter
• Keep humidity of the house low
• When pollen counts are high, stay indoors as far as possible
• Dust mites live in fabrics and carpets. Cover bedding and pillows using allergen proof covers. Change bed sheets and pillow covers regularly. Wash the bed and pillow covers in hot water. Replace carpeted floor with hardwood floors or tile.
• Avoid stuffed animals, or only buy washable ones
• Avoid foam rubber bedding with synthetic materials
• Keep your kitchen and bathroom clean. Keep them dry to prevent mold and cockroaches.
• Avoid air pollution, industrial dusts and other irritating fumes as much as possible.
• Eliminate tobacco smoke from the home

2.      Take regular medications. The control medications should be taken every day to maintain the airways. They prevent an attack of asthma. They maintain the normal diameter of the airways and control airway inflammation. Quit smoking. It can undo the effect of any medicine you are taking.

3.      Monitor Lung Function regularly. Lung function usually decreases a couple of days prior to an asthma attack. A peak flow meter is a simple device to your lung function. It measures how quickly you can move air out of your lungs. It helps you see if an attack is coming and when medication is needed or other action needs to be taken. Peak flow values of 50% – 80% of your best results are a sign of a moderate asthma attack. Values below 50% are a sign of a severe attack. 

What should I do when I have an Asthma attack?

During an acute attack of Asthma:

• Take a puff from the inhaler. Always keep your inhaler with you.
• Open the windows of the room if you are in a warm and humid room.
• Loosen any tight clothing. Sit-up.
• If you do not feel any improvement, continue to take one puff of inhaler every minute for 3 to 5 minutes or until your symptoms improve
• If all the above steps fail, contact your doctor.

   

What are my chances of recovering completely from Asthma?

There is no cure for asthma. Symptoms sometimes improve over time. With proper self-management and prompt medical treatment, most people with asthma can lead normal lives

What happens if I do not take my Asthma medications? What are the complications of Asthma?

1. Decreased quality of life – decreased ability to exercise and take part in other activities, fatigue, underperformance or absence from work, psychological problems including stress, anxiety and depression.

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

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

4. Status asthmaticus (severe asthma attacks that do not respond to treatment).

What are the tests available for Asthma? How can Asthma be diagnosed?

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

• Blood and Sputum analysis – show an increase in the number of eosinophils. The level of a certain antibodies can be elevated.
• Chest X-ray – may show abnormality in the airway.
• Arterial blood gas analysis – shows decreased oxygen concentration in blood.
• Lung function testing () – The two most common pulmonary function tests for asthma are spirometry and methacholine challenge tests
• Spirometry - helpful in judging severity of airway obstruction. It measures how much air you can breathe in and out and how fast you can blow air out. Some of the common values looked at are:

a.   Forced Vital Capacity or FVC – total volume of air one can exhale after maximum breathing in

b.   Forced Expiratory Volume in One Second, or FEV1- measures the volume of air one can exhale in the first second.

• Methacholine challenge test – commonly used in adults. Performed when your symptoms and spirometry do not convincingly diagnose asthma. Methacholine is an agent that, when inhaled, causes the airways to spasm (contract involuntarily) and narrow if asthma is present
• Allergy test- to identify any allergies that trigger asthma symptoms. Skin tests and blood tests help in detecting allergens.

   

How can my Asthma be treated? What is the treatment for Status Asthmaticus?

The aim of asthma treatment is to avoid the substances that trigger your symptoms and control airway inflammation. There are two basic kinds of medication for treating asthma:

1. CONTROL DRUGS – to prevent attacks. They control your symptoms. You must take them every day for them to work. They are administered orally or by inhalation. The most common and effective way to deliver asthma drugs to the lungs are asthma Inhalers. Metered-dose inhalers (MDI) and dry powder inhaler (Rotacaps) are the most widely used method. Have a warm drink or water after using MDI to get rid of unpleasant aftertaste of the medicine. Combination asthma inhalers contain two different medications: an inhaled steroid and a long-acting bronchodilator. They are popular due to their convenience. The medications last for at least 12 hours. If it is difficult to use small inhalers, your doctor may prescribe an asthma nebulizer, a breathing machine. The nebulizer changes asthma medications from a liquid to a mist which is more easily inhaled into the lungs. The asthma nebulizer with a mask is typically used for infants, small children and elderly adults.

•  Steroids and Other Anti-Inflammatory Drugs: the most important treatment for most people with asthma, particularly the inhaled steroids. They prevent asthma attacks by reducing swelling and mucus production in the airways which cause the airways to be less sensitive and less likely to react to asthma triggers. E.g. Asmanex, Alvesco, Qvar AeroBid, Flovent, Pulmicort. For severe asthma (status asthmaticus), injections of drugs such as epinephrine and prednisone are often necessary. . Prednisone is the most potent and effective anti-inflammatory asthma medication available.
• Long-acting bronchodilators – often combined with inhaled steroids for long-term control of asthma symptoms or when you have asthma symptoms daily despite treatment with a daily inhaled steroid alone. Long-acting bronchodilators are never used alone for long-term therapy.
• Other control drugs that may be used are Leukotriene inhibitors (such as Singulair and Accolate), Cromolyn sodium (Intal) or nedocromil sodium (Tilade), Omalizumab (Xolair), Aminophylline or theophylline (rarely used anymore).

2.      QUICK-RELIEF DRUGS – for use during attacks.

• Short-acting bronchodilator inhalers are used to quickly relieve the cough, wheeze, 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 daily in the treatment of asthma. The most commonly used short-acting bronchodilator is albuterol.

A severe asthma attack (status asthmaticus) may not respond quickly to routine treatment with asthma inhalers.

• Continuous use of an asthma nebulizer and injections of drugs such as epinephrine and prednisone for asthma are often necessary.
• Other therapies may include terbutaline injections, magnesium sulfate (induces smooth muscle relaxation of the airways) and leukotriene inhibitors, which are anti-inflammatory drugs.
• 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 are 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.

Please do note that all of the above mentioned drugs require a prescription from your asthma doctor.

What are the alternative treatments for Asthma?

HOMEOPATHY

Homeopathy aims at strengthening your immune system so that gradually you will need decreased asthma medication and eventually you may not need any. Some of the popular remedies are:

• Pulsetila: for spasmodic symptoms. Anxiety, sudden wheezing, difficulty breathing and a feeling of suffocation, which worsens if you move.
• Ipecanum: for chronic asthma. It is used if you are older and the attacks occur during midnight, when you are awakened with soreness and pain in the chest and heat in the head which improves with warmth. Especially useful if you are anaemic.
• Antimonium tartaricum: presence of fine rattling or crackling sounds in the chest. Difficulty breathing and feeling of suffocation. Suitable for young children and the elderly.
• Natrum mur: for general symptoms including a worsening of asthma on exposure to mold and dampness. Wheezing and breathing difficulties aggravated by exertion. Loose bowels after each attack.
• Spongia tosta: for a barking cough and little mucus during an asthma attack.
• Pulsatilla: if wheezing starts after eating rich food or you get too warm. Tightness in the chest which worsens during the evening and at night. Relieved by fresh, cool air. Coughing brings up yellow-coloured mucus.
• Carbo vegitable: helpful in a tense, constricted feeling in the lower part of the chest, with pressure in the stomach. Asthma attack brought about by gastric disturbances. Overindulgence in sweets, spicy food, stimulants and alcohol.

AYURVEDA

Some of the natural herbs used to cure asthma are Mullein, licorice, turmeric, thyme, black pepper, flax seed, antalkali ginger, clove, manna and myrrh. Massaging mustard oil with camphor over the chest loosens the mucus and helps in easy breathing during asthma attack. Inhaling steam with a few caraway seeds added to boiling water helps in dilation of bronchial passage. Honey is one of the most effective remedies used for treatment of asthma A few common medicines as suggested in Ayurveda are:

• A paste of Nagar and Bharangi in water
• Mixture of Shukti Bhasma, Trikuti Churna and Vasa Churna taken with honey
• Sitopaladi choorna
• Vasavleha
• Swaskuthar ras
• Panchakarma - before the onset of monsoon
• Rasayana Chikitsa – during asthma attacks
• Kantakari Avalehya (semi solid preparation)
• Vasa Avalehya (semi solid preparation)
• Shitopaladi churnam (powdered preparation)
• Kanakasava (the fermented preparation)
• Agatsyaharitaki

Self care and prevention of Asthma attacks