Asthma is a complex disease characterised by chronic airway inflammation, airway hyper responsiveness and variable airflow obstruction that reverses either spontaneously or with treatment.
Hallmark Symptoms:
- Shortness of breath
- Wheezing
- Coughing
- Chest tightness
Symptoms are often worse at night or early morning. Asthma is a common condition throughout the world and over recent decades, its worldwide prevalence has increased.
Risk factors for developing Asthma:
A number of factors like atopy, air pollution ( indoor and outdoor), obesity, respiratory infections, occupational exposures, tobacco smoke, premature birth are implicated. Gastroesophageal reflux, changes in weather, exercise, stress can also precipitate Asthma. Some medications like Aspirin,non specific beta blockers, Non steroidal anti inflammatory drugs may precipitate asthma symptoms. Cough variant asthma has cough instead of wheezing as the primary symptom of bronchial or airway hyper reactivity.
Clinical findings:
GINA(Global Initiative for Asthma) guidelines classifies asthma as Mild, Moderate and Severe based on the symptoms frequency and severity. Pulmonary Function Testing or Spirometry is done before and after giving inhaler bronchodilator. Additional tests include a chest X Ray ( which are usually normal in Asthma cases), skin testing , total serum IgE and allergen specific IgE, Absolute Eosinophilic counts, to assess sensitivity to environmental allergens can identify atopy in patients with persistent asthma who may benefit with treatment directed to their allergic diathesis. Evaluations for para nasal sinuses and gastroesophageal reflux should be considered.
Management of chronic asthma with a goal of asthma control
Four components of Asthma care:
- Assessing and monitoring asthma severity and asthma control
- Education of the patient
- Control of environmental factors & conditions that affect asthma
- Medications
A patient is thought to have ‘well controlled’ asthma if they
- do not require their rescue medication more than twice a week
- do not have daytime symptoms more than twice a week
- do not have night time symptoms more than twice a month
- do not have any activity limitations as result of their asthma
2. Patient Education
Education of asthma patients includes teaching in self management measures, such as self Monitoring with peak flow meters, correct technique of inhalers, adherence to prescribed medications and avoidance of environmental factors like smoke and dust.
3. Control of environmental factors and comorbidities conditions that affect asthma
Patient should be advised to control exposure to asthma triggers like pollutants and irritants. Testing for aero allergen sensitivities, avoidance of tobacco smoke and possibly allergen specific immunotherapy.
Comorbid conditions should also be identified and managed like obesity, GERD, upper respiratory infections, obstructive sleep apnea (OSA), allergic bronchopulmonary aspergillosis.
Vaccinations – The GINA guidelines recommend the influenza vaccination for all asthma patients over six months old. Adult patients aged 19-64 with asthma should receive the 23-valentines pneumococcal vaccine (Pneumovax 23) and annual influenza vaccinations.
4. Medications
- Inhaled corticosteroids are the most effective treatment for most patients with bronchial asthma
- If inhaled corticosteroids alone are not adequate, the most effective strategy is adding in another inhaled medication called long-acting beta agonist
- In patients whose asthma has been well controlled for at least 3 months, a step down controller therapy is considered
- Patients with refractory asthma should be considered for an immunomodulator
- Allergen immunotherapy should be considered in patients with stable asthma that have significant allergic triggers
Acute Severe Asthma or asthma attack is an emergency condition managed by short acting beta agonists, oral or injectable steroids, anti-cholinergics like ipratropium. Intubation, Mechanical Ventilation and Oxygen is needed if the attack is life threatening. To summarise, Inhaler therapy is the mainstay of treatment and most effective way to control asthma. Inhaled steroid have much lesser side effects as they act locally and thereby safe. The technique of using inhaler correctly is of prime importance and must be emphasised in doctor patient interactions.