Asthma is a commonly missed or misdiagnosed disease
It is estimated that there are more than 300 million people with asthma in the world. In Kuwait, the prevalence is about 10%. The incidence, the emergency room and hospital visits, morbidity, mortality and the cost of care are on the increase.
Asthma is a disease of the small airways in the lung. The airways become smaller as they progress through the lungs, like branches of a tree. The symptoms of asthma are produced as a result of narrowing of the small air ways and inflammation in them leading to decrease in air flow. These can be varied and include repeated attacks of breathlessness, wheezing, chest tightness, and coughing. This inflammation may be present even when the person does not have any symptoms.
The diagram on the left shows the condition when the airways are normal sized and air flows easily in and out. The diagram on the right shows an attack, during which muscles of the air passages constrict. Mucus clogs the airways, making them narrower and reduces the amount of air moving in and out of the lungs. The person can have one or more of the symptoms of coughing, chest tightness, wheezing and breathing difficulty.
Risk Factors for Development of Asthma
These include genetic and environmental factors.
Atopy is a genetic factor in which the body produces immunoglobulin E after exposure to allergens. A person with high levels of IgE in the blood has more chance to develop asthma. If a person has a parent with asthma, he or she is three to six times more likely to develop asthma.
Exposure to house dust mite and cockroach, respiratory syncytial virus (RSV) infections and tobacco smoke in the environment are believed to cause asthma in children. Exposures to cat, dog,cockroach, domestic birds and house dust mite allergen, tobacco smoke, nitrous oxides ,fungi or molds, formaldehyde, fragrances, rhinoviruses, and several respiratory infectious agents are reasons for exacerbations and worsening of the disease.
Diagnosis of Asthma
Asthma is a commonly missed or misdiagnosed problem as the symptoms can vary. It can be difficult to differentiate it from other respiratory illnesses especially in young children, the elderly, smokers, people with seasonal allergies, those exposed to chemical fumes and people with recurrent acute respiratory infections.
ï¿½ Do you have a troublesome cough, particularly at night?
ï¿½ Are you awakened by coughing or breathing difficulty?
ï¿½ Do you cough or wheeze after physical activity?
ï¿½ Do you have breathing problems during a particular season?
ï¿½ Do you cough, wheeze, or develop chest tightness after exposure to allergens?
ï¿½ Do colds last more than 10 days and do you develop chest symptoms after a cold?
If you have one or more of the above symptoms, asthma is a possibility. In the absence of specific symptoms, some physical findings still increase the possibility asthma. These include:
ï¿½ A wheezing sound in the lungs
ï¿½ Chest deformity or expansion of the chest area especially in children
ï¿½ Nasal swelling , increased secretions or polyps
ï¿½ Indications of an allergic skin condition
Lung function tests are important to make an accurate diagnosis of asthma and to assess the extent of airflow reduction.
The computerized test shown (spirometry) measures the maximum amount of air forcibly exhaled from the lungs after the patient has taken a deep breath. Airflow is related to the size of the air ways which become narrow due to asthma. Airflow can be measured before and after the patient uses a fast-acting bronchodilator (medicine that makes the passage wider) to determine the medicationï¿½s effect on reversing airflow obstruction. In asthma there should be a significant increase in airflow after using the bronchodilator. The test also helps the doctor to prescribe the optimum medicines and also to assess the progress through a repeat examination.
Reducing Exposure to House Dust Mites. These microscopic organisms live in soft furnishings like pillows, mattresses, carpets, and drapes. They produce particles that cause allergic reactions when inhaled. Decreasing the number of dust mites to which people with asthma are exposed may help control their asthma. One way of reducing exposure is by using mattress and pillow case covers (encasements) which may be plastic or vinyl and covered with cotton, nylon, or knit fabric. They provide a barrier between the dust mites and the person with asthma. Any linen like sheet placed over the encasements should be washed weekly in hot water.
Down-filled pillows, quilts, or comforters should not be used. Down filling consists of tiny feathers that contain large numbers of dust mites. If a child with asthma wants to play or sleep with a stuffed toy, wash the toy frequently in hot water, or put it in the freezer for a few hours every 2 weeks. Freezing cold kills dust mites as effectively as hot water. The hot water should be about 60 degrees Celsius to kill the mites.
Fabric curtains should be replaced with shades or mini-blinds. Replace upholstered chairs with plastic or wood, and carpets with vinyl or wood floors with area rugs that can be shaken out frequently. Because dust mites need high humidity, keep the humidity levels below 50%.
Reducing Exposure to Tobacco Smoke: Parents of children with asthma should stop smoking. Until they can successfully quit, they should smoke only outdoors, not in the home or in the family car. They should not allow others to smoke in the home and should make sure the childï¿½s school is smoke-free.
Reducing Exposure to Cockroaches: Allergy to cockroaches is an important risk factor for worsening asthma. Food and water anywhere in the home will attract roaches, so immediately wash soiled dishes, throw away disposable food containers, and remove standing water from all rooms. Keep trash in closed containers, and keep food covered and put away. Discard grocery bags, newspapers, cardboard boxes etc. People tend to eat watching television. Cockroaches and cockroach remains are frequently found in living rooms, family rooms, and bedrooms.
Reducing Exposure to Pets: Animals shed fur and feathers; they leave saliva, urine, and feces. Cats and rodents cause more allergic reaction than dogs.
Avoiding other Asthma Triggers: Several allergens like molds and fungi, pollen of certain plants, industrial emissions and automobile exhaust fumes, some foods and food additives and drugs can trigger attacks. Even strenuous physical exercise; weather conditions like freezing temperatures, high humidity and thunderstorms can precipitate an attack. Strong emotional states, either positive or negative, can lead to hyperventilation and an asthma episode
Medications to Treat Asthma
Because everyoneï¿½s asthma is different, medications to treat it come in many forms: liquids, pills, powders, inhalors and injections. Treating asthma involves managing both the chronic inflammation and recurrent episodes of airflow limitation and narrowing of airways.
Two major categories of medications are:
Long term preventers.
Quick-relief medications are used to help counter the effects of an acute asthma episode. These are generally short-acting beta2-agonist bronchodilators delivered through an inhaler, nebulizer or dry powder inhalers. People should know how to use an inhaler correctly for the drug to reach the lungs and have a full effect.
Long term control medicines are taken daily over a long period of time. The most effective of these to reduce inflammation of the airways are corticosteroids, which are better used in inhaled form. Another important type of long term control medicine is long-acting beta2-agonists. Usually inhaled, but also available orally, this medicine relaxes the smooth muscles of the airways for long-term prevention of symptoms, especially at night.
The latest type of long-term control medication to treat asthma is leukotriene modifiers. Leukotriene modifiers may be considered as alternative therapy to low doses of inhaled corticosteriods for children with mild persistent asthma, but the position of leukotriene modifiers in therapy has not been fully established. Leukotriene modifiers improve symptoms and pulmonary function and reduce the need for quick-relief medications.
Managing Asthma: Asthma Management Goals
Asthma management is complex and the goals are to
ï¿½ Achieve and maintain control of symptoms
ï¿½ Prevent asthma exacerbation
ï¿½ Maintain pulmonary function as close to normal levels as possible
ï¿½ Avoid side effects from asthma medications
ï¿½ Prevent irreversible airway obstruction, and
ï¿½ Prevent death from asthma.
Awareness is important for the people with asthma and for their families and care givers. People with asthma should learn the correct way to inhale their medications and to monitor lung function with peak flow meters. They and their families should be able to recognize an emergency. Breathlessness at rest, having to lean forward, able to talk only in words and not sentences, restlessness and peak flow rate less than 60% of normal are indications of a severe attack, which if not treated adequately, can be life threatening.
Even though we do not have a cure for asthma at the present time, there are good ways to prevent and to treat effectively. With effective and adequate treatment most people with asthma can lead a normal life and participate in all activities they want to. Several athletes who have won Olympic medals have asthma and there are professional football players, basket ball players and successful people in all walks of life with asthma. So it is important to recognize asthma early, diagnose accurately, treat effectively and to follow up adequately to lead a normal life.