ASTHMA Asthma is a disorder that causes the airways of the lungs to swell and narrow, leading to wheezing, shortness

of breath, chest tightness, and coughing. The word asthma originates from an ancient Greek word meaning panting. Essentially, asthma is an inflammatory lung condition that makes it difficultto breathe properly. When any person inhales, the air travels through the following structures: Air passes into the lungs and flows through progressively smaller airways called bronchi and then bronchioles. The lungs contain millions of these airways. All bronchioles lead to alveoli, which are microscopic sacs where oxygen and carbon dioxide are exchanged.

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The major features of the lungs include the bronchi, the bronchioles, and the alveoli. The alveoli are the microscopic blood vessel-lined sacks in which oxygen and carbon dioxide gas are exchanged. Asthma is a chronic condition in which these airways undergo changes when stimulated by allergens or other environmental triggers. Such changes appear to be two specific responses: The hyperreactive response (also called hyperresponsiveness) The inflammatory response These actions in the airway cause coughing, wheezing, and shortness of breath (dyspnea), the classic symptoms of asthma.

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Inflammation or excess mucus secretion can further decrease the amount of air flow. the airways relax and open to rid the lungs of the irritant. making breathing difficult. the immune system delivers white blood cells and other immune factors to the airways. their airways do not relax and narrow. When people with asthma try to take those same deep breaths. during an asthma attack the airways narrow. and a phlegmproducing cough. but a special hyperreactive response occurs in people with asthma: When people without asthma breathe in and out deeply.HYPERREACTIVE RESPONSE In the hyperreactive response. INFLAMMATORY RESPONSE The hyperreactive stage is followed by the inflammatory response. Smooth muscles in the airways of people with asthma may have a defect. which generally contributes to asthma in the following way: In response to allergens or other environmental triggers. an inability to exhale properly. These so-called inflammatory factors cause the airways to swell. smooth muscles in the airways of the lungs constrict and narrow excessively in response to inhaled allergens or other irritants. smooth muscles located in the bronchioles of the lung constrict and decrease the flow of air in the airways. and to produce a thick sticky mucus. to fill with fluid. And. Everyone's airways respond by constricting when exposed to allergens or irritants. . causing patients to pant for breath.      During an asthma attack. perhaps a deficiency in a critical chemical that prevents the muscles from relaxing. This combination results in wheezing. breathlessness.

Cockroach dust is a major asthma trigger and may reduce lung function even in people without a history of asthma. When an asthma attack occurs. asthma symptoms can be triggered by breathing in allergy-causing substances (called allergens or triggers). from plants. In sensitive people. which can even be carried on clothing. the muscles surrounding the airways become tight and the lining of the air passages swells.) In people with allergies. which are coated with enzymes that contain a powerful allergen. In both children and adults with existing allergic asthma an upper respiratory tract infection often worsens an attack. THE ALLERGIC RESPONSE (ALLERGENS) Nearly half of adults with asthma have an allergy-related condition. the allergic response usually does not play a strong causal role. indoor chemicals. Asthma tends to run in families. dogs usually cause fewer problems. Symptoms Asthma symptoms vary in severity from occasional mild bouts of breathlessness to daily wheezing that lasts even when a patient takes large doses of medication.Inflammation appears to be present in the lungs of all patients with asthma. INFECTIONS Respiratory viral and bacterial infections play a role in some cases of adult-onset asthma. the immune system overreacts to exposure to allergens. These are the primary allergens in the home. Animal dander. Alternative Names Bronchial asthma Causes Asthma is caused by inflammation in the airways. People with asthma who already have pets and are not allergic to them probably have a low risk for developing such allergies later on. ENVIRONMENTAL FACTORS (IRRITANTS) An asthma attack can also be induced or aggravated by direct irritants to the lungs. specifically mite feces. Important irritants involved in asthma include cigarette smoke. Cats harbor significant allergens. and air pollution. and plays a key role in all forms of the disease. This reduces the amount of air that can pass by. in most cases developed first in childhood. Allergic asthma is triggered by inhaling certain substances (allergens) such as: Dust mites. Pollen. After exposure to asthma triggers. even those with mild cases. Asthma is most likely caused by a combination of genetic (inherited) factors and environmental triggers (such as allergens and infections). so children whose parents have asthma are more likely to develop it themselves. Molds. The exact cause of asthma is unknown. (In patients who first develop asthma during adulthood. Cockroaches. symptoms       . which.

Some patients are not even aware that they are experiencing shortness of breath. It is very difficult to predict when an attack will become very serious. since they are less conscious of symptoms. (The inflammation itself must still be treated. the severity of this symptom does not always reflect the degree to which lung function is impaired. After an initial acute attack. and. Initial chest tightness without any other symptoms may be an early indicator of a serious attack. The flesh around the ribs of the chest appears to be sucked in. These patients are at particular risk for very serious and even life-threatening asthma attacks. work. Some patients find this cough even more distressing than wheezing or sleep disturbances.       The classic symptoms of an asthma attack include: Wheezing when breathing out is nearly always present during an attack. Shortness of breath is a major source of distress in patients with asthma. Shortness of breath (dyspnea). Usually the attack begins with wheezing and rapid breathing. Coughing. appropriate management of asthma involves much more: Identifying and avoiding allergens and other asthma triggers Following appropriate drug treatments Home monitoring performed by either patient or family Good communication between the doctor and patient Needed psychosocial support Treatment of asthma in all environments (school. however. the first symptom of asthma is a nonproductive cough.) SYMPTOMS OF A LIFE-THREATENING ATTACK     The following signs and symptoms may indicate a life-threatening situation: As the chest labors to bring enough air into the lungs. stringy mucus. Chest tightness or pain. Treatment GENERAL APPROACH FOR TREATING AND MANAGING ASTHMA While medications play an essential role in the management of asthma. Lacking enough oxygen.rarely develop abruptly but progress over a period of hours or days. inflammation lasts for days to weeks. all breathing muscles become visibly active. Rapid heart rate Sweating The end of an attack is often marked by a cough that produces thick. the airways have become seriously obstructed by the time the patient calls the doctor. breathing often becomes shallow. However. exercise)       . The patient may begin to lose consciousness. Occasionally. often without symptoms. because it usually causes relapse. as it becomes more severe. the skin becomes bluish. In some people. Asthma often progresses very slowly to a serious condition or may develop to a fatal or near-fatal attack within a few minutes.

school. ranging from none to two or more in the last 6 months TREATING SYMPTOMS VERSUS CONTROLLING THE DISEASE Patients can greatly reduce the frequency and severity of asthma attacks by understanding the difference between coping with asthma attacks and controlling the disease over time. For adults and children over age 5 with moderate-to-severe persistent asthma. Beta2-agonists and anticholinergics do not have any effect on the disease process itself. Medications and dosages are increased when needed. These drugs are usually short-acting betaadrenergic agonists (beta2-agonists). Patients can greatly reduce the frequency and severity of asthma attacks by understanding the difference between coping with asthma attacks and controlling the disease over time.   Medications for asthma fall into two categories: Rescue (Quick-Relief) Medication. Simply coping with asthma symptoms without also controlling the damaging inflammatory response is a common and serious error. Based on severity of patients' asthma and their age.       These are the signs of well-controlled asthma: Asthma symptoms occur twice a week or less Rescue bronchodilator medication is used twice a week or less Symptoms do not cause nighttime or early morning awakening Symptoms do not limit work. The overuse of bronchodilators can have serious consequences. not using steroids can lead to permanent lung damage. Other drugs used in special cases include corticosteroids taken by mouth and anticholinergic drugs. They are only useful for treating symptoms. or exercise activities Peak flow meter readings are normal or the patient’s personal best Both the doctor and the patient consider the asthma to be well controlled STEPS FOR TREATING ASTHMA A stepwise approach is recommended for treating asthma. there are . ranging from fewer than 2 days per week to throughout the day Nighttime awakenings. ranging from none to nightly Short-acting beta2-agonist use for symptom control. Long-Term Control (Maintenance) Medication. Moderate Persistent. ranging from none to extremely limited Lung function as measured by FEV1 and FEV1/FVC. and decreased when possible. Medications that open the airways (bronchodilators. These components are: Symptom frequency. many patients do not understand the difference between medications that provide rapid short-term relief and those that are used for long-term symptom control. measured with pulmonary function testing at the doctor's office Number of exacerbations (sudden worsening) requiring oral corticosteroids. Mild Persistent. Unfortunately. Six specific components of severity are used to classify patients. ranging from 2 or fewer days per week to several times per day Interference with normal activity. doctors recommend inhaled corticosteroids sometimes with long-acting beta2-agonists. Many patients with moderate or severe asthma overuse their short-term medications and underuse their corticosteroid medications. and Severe Persistent.      The severity of asthma is classified into four groups: Intermittent. or inhalers) are used to quickly relieve any moderate or severe asthma attack.

in their ability to deliver medication. can help patients make sure they are getting the right amount of medication. environmental control measures.specific recommendations regarding whether to use long-term control medications and which ones to use. Doctors may always adjust these recommendations based on a specific patient. Patients should track their medicine and throw the device away when the last dose has been administered. In choosing therapy. In a hospital setting. Avoiding or managing environmental triggers is always important. Factors that may contribute to this include parental history of asthma. Patient education. and known sensitivity to different allergens or foods. for the drugs to be effective and safe. . doctors must also consider the risk an individual patient has for more severe exacerbations. however. and the patient carefully trained in their use. and management of any other conditions are also included. They vary. A spacer. The two basic inhaler devices are the metered-dose inhaler (MDI) and dry powder inhalers (DPIs). Long-acting beta2-agonists and leukotriene antagonists are additional therapies usually used in addition to inhaled corticosteroids. A nebulizer is a device that administers the drug in a fine spray that the patient breathes in. or when a patient cannot use an inhaler.6 weeks to assess response. Others may exhale too forcefully before inhalation.   Key points regarding recommendations for adults include: Inhaled corticosteroids are the preferred long-term control therapy. or even inside them. Some patients hold the MDI too close to their mouths. MDI-delivered drugs must be used regularly as prescribed. which is short tube attached to the mouthpiece. a nebulizer may be used. The standard device for administering any asthma medication is the metereddose inhaler (MDI). This device allows precise doses to be delivered directly to the lungs. DEVICES USED FOR ADMINISTERING INHALED DRUGS Most asthma drugs are taken with inhalers. Often MDIs continue to deliver propellant after the drug has been used up. Metered-Dose Inhaler. Patients should be reevaluated within 2 . atopic dermatitis.

Doctors recommend that patients with even mild asthma monitor their own conditions. generally. MONITORING People who self-manage their asthma with peak air flow measurements and adjust their medications as needed have fewer hospitalizations and unplanned doctors visits. Dry-powder may cause tooth erosion. have a better quality of life than those who rely only on the occasional doctor or emergency room visit to control symptoms. monitoring involves the following steps: A peak flow meter is the standard monitoring device for measuring peak expiratory flow rate (PEFR).  In general. so they should not be stored in humid places (bathroom cabinets) or locations subject to high temperatures (glove compartments during summer months. Some patients find that they are easier to manage than MDIs. Dry powder inhalers (DPIs) deliver a powdered form of beta2-agonists or corticosteroids directly into the lungs. . and children are advised to rinse their mouths out right after using a DPI and to brush twice a day with a fluoride toothpaste.Dry Powder Inhalers. and. Humidity or extreme temperatures can affect the performance of these inhalers.

It is important to use the meter at the same times each day and to stand or sit in the same position to keep an accurate record. Immunotherapy ("allergy shots") may help reduce asthma symptoms. Immunotherapy poses some risk for severe allergic reactions. Treatment of allergies and sinusitis can help control asthma. After about 2 months. TREATING SEASONAL ALLERGIES AND SINUSITIS Patients with asthma and chronic allergic rhinitis may need to take medications daily. For mild-to-moderate asthma. The NAEPP notes that while it is not clear if oral corticosteroids are safe for pregnant women. exposure to any allergens or triggers. Patients with severe seasonal allergies may need to start medications a few weeks before the pollen season. Patients whose persistent asthma does not respond to standard dosages of inhaled corticosteroids may need a higher dosage or the addition of a long-acting beta-agonist to their drug regimen. a single determination each morning usually suffices. patients and doctors can use the recorded data for administering medications effectively and to recognize problems before they become serious. especially for children with poorly controlled asthma. The overall goal should be to achieve less than a 20% (and ideally only 10%) variation in readings between evening and morning rates. PREVENTING AND TREATING RESPIRATORY INFECTIONS . however. They may also help prevent the development of asthma in children with allergies. The guidelines recommend that pregnant women with asthma have albuterol available at all times. For severe asthma. Other Treatments IMMUNIZATIONS Patients with asthma should receive the flu vaccine annually. and to continue medicine until the season is over. uncontrolled asthma poses an even greater risk for a woman and her fetus. TREATMENT OF ASTHMA DURING PREGNANCY Guidelines from the National Asthma Education and Prevention Program (NAEPP) emphasize that most asthma medications are safe for pregnant women. oral corticosteroids may be necessary. They should also record attacks. Patients should keep an ongoing record of their peak flow readings to help them detect worsening of their condition. but patients should check with their doctors. Inhaled corticosteroids should be used for persistent asthma. and the use of asthma medications. in patients with known allergies. and they should receive the vaccination against pneumococcal pneumonia at least once.     Patients with severe asthma should take PEFR readings two or three times a day. and medications taken.

In one study. massage therapy. Some patients report benefits from many stress reduction techniques. urine injections. homeopathic remedies. hypnosis. adolescents. evidence does not support any value from most alternative therapies.      MANAGING HORMONAL-RELATED ASTHMA Women who suspect that menstrual-related changes may influence asthma severity should keep a diary of their menstrual dates and times of asthma attacks. There have been very few well-conducted studies supporting their use. People with asthma should try to minimize their risk for respiratory tract infections. and meditation practices. nearly half of asthma or allergy sufferers resorted to alternative treatments. To date. including the common cold. Be sure to talk to your doctor before taking these medicines. however. such as acupuncture. TREATING GASTROESOPHAGEAL REFLUX DISEASE (GERD) Patients with obvious symptoms of reflux may consider the following lifestyle changes: Avoiding heavy meals and meals with fried food Avoiding caffeine Avoiding eating or drinking at least 3 hours before bedtime Elevating the head of the bed by 6 inches Taking medications treating gastroesophageal reflux. Washing hands is a very simple but effective preventive measure. however. OTHER TREATMENTS Children. Sometimes. and most herbal remedies. including high-dose vitamins. .Respiratory infections. adjusting medications in anticipation of menstruation may help prevent attacks. breathing relaxation techniques. and adults with asthma are widely using alternative therapies. Relaxation and Stress-Reduction Techniques. can act with allergies to worsen asthma.

However. Probiotics. Always check with your doctor before using any herbal remedies or dietary supplements. hypnosis and biofeedback are all alternative ways to control pain. There have been a number of reported cases of serious and even lethal side effects from herbal products. and therefore have the potential to produce side effects that may be harmful. Breathing Exercises. which are being studied for protection. Few rigorous studies have evaluated herbal remedies for asthma. Manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. slightly thicker than a human hair. Breathing exercises may help improve patients’ quality of life even if they do not have a major impact on medication reduction. Herbal Remedies. evidence to date does not support efficacy in preventing or treating asthma. Probiotics are beneficial microbes that some believe may help protect against allergies and asthma. Just like a drug. herbs and supplements can affect the body's chemistry. Acupuncture involves the insertion of tiny sterile needles. Probiotics can be obtained in active yogurt cultures and supplements. .Acupuncture. at specific points on the body.

nebulizer Nebulizer Inhaler Inhaler Inhaler Inhaler Inhaler Pill Pill Pill Pill Syrup Pill Pill Inhaler Quick-Relief (Rescue) Short-Acting Beta2Medications (control Agonists acute attacks) Levalbuterol Metaproterenol Pirbuterol Ipratropium/Albuterol Anticholinergics Ipratropium Tiotropium Systemic Corticosteroids Cortisone Dexamethasone Hydrocortisone Methylprednisolone Prednisolone Prednisone Triamcinolone Long-Term Relief (Controller) Medications (prevent attacks and control chronic symptoms) Inhaled Corticosteroids Beclomethasone Budesonide Pulmicort Inhaler. nebulizer Inhaler Inhaler Inhaler Inhaler Inhaler Budesonide/Formoterol Symbicort Ciclesonide Flunisolide Fluticasone Fluticasone/Salmeterol Alvesco AeroBid Flovent Advair .MEDICATIONS FOR TREATMENT AND PREVENTION OF ASTHMA MEDICATIONS FOR TREATMENT AND PREVENTION OF ASTHMA Medication Purpose Drug Class Generic Name Albuterol Brand Names Proventil. Prelone Various Aristocort QVAR Administration Inhaler. AccuNeb Xopenex Alupent MaxAir Combivent Atrovent Spiriva Cortone Decadron Cortef Medrol Orapred. Ventolin.

and Blood Institute. et al. J Allergy Clin Immunol. N Engl J Med. Rockville. American Lung Association Epidemiology & Statistics Unit Research and Program Services. Savilahti E. Asthma. Korpela R. Epub 2006 Oct 23. November 2007. Ducharme FM. syrup References  American Lung Association. Spooner CH. Bousquet J. 2008 Jul 1. MD. FDA Salmeterol advisory panel voted to ban Foradil and Serevent. Ann Intern Med. Poussa T. Nelson H. US Dept of Health and Human Services. National Heart. 2007.2002.  Bateman E.  National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Lung. and Blood Institute. Cochrane Database Syst Rev. Trends in asthma morbidity and mortality. Theo-24 Nebulizer Injectable Pill Pill Pill.Mometasone Triamcinolone Long-Acting Beta2Agonists Formoterol Asmanex Azmacort Foradil Serevent Inhaler Inhaler Inhaler Inhaler Note: In 2008. Sutton L. NIH publications 08-4051. Epub 2008 Jun 3. 2009 Mar 5. National Heart.   Fanta CH. Lung. Bretzlaff JA. 2003. placebo-controlled trial. double-blind. 2007 Jan.  Rowe BH.Rockville. Corticosteroids for preventing relapse following acute exacerbations of asthma. Probiotics and prebiotic galactooligosaccharides in the prevention of allergic diseases: a randomized. Kral K.  National Asthma Education and Prevention Program Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics -. Anti-inflammatories IgE-inhibitor Leukotriene Modifiers Cromolyn Omalizumab Montelukast Zafirlukast Methylxanthine Theophylline Intal Xolair Singulair Accolate Uniphyl. US Dept of Health and Human Services.149(1):33-42. Quibron. Yancey S.360(10):1002-14. Haahtela T. Meta-analysis: effects of adding salmeterol to inhaled corticosteroids on serious asthma-related events. MD.(3):CD000195.119(1):192-8. Ortega H. Bota GW. 2007 Jul 18. Kukkonen K. . NIH publications 02-5074. Juntunen-Backman K.

Salpeter SR. 2006 Jun 20.While cough may accompany the usual symptoms associated with asthma. Vliagoftis H. you develop asthma symptoms following repeated exposures to allergens such as:      Second hand smoke Animal dander Dust Mites Cockroaches Mold Cough variant asthma. obstruction.360(18):1862-9.96(3):406-14. Kouranos VD. cough alone may be a precursor to or the sole symptom in this type of asthma. TENOR Study Group. Haselkorn T. Asthma in older adults: observations from the epidemiology and natural history of asthma: outcomes and treatment regimens (TENOR) study. Ann Intern Med. 2008 Dec. All of the following asthma classifications identify a type of asthma related to an underlying cause.144(12):904-12. When cough is the only asthma symptom. Slavin RG. Wenzel SE.In this type of asthma. Salpeter EE. exposure. Deniz Y. Ormiston TM. Buckley NS. Asthma classification is an important concept that allows doctors to place your asthma into specific categories. The main advantage in using an asthma classification is that it can help guide your doctor to design better treatment for you. and many ways you and your doctor may look at asthma classification. The exposure triggers symptoms from your immune system or through direct irritation of the airways. Dombrowski MP. TYPES OF ASTHMA There are several different asthma types. Occupational asthma. Schatz M. Ann Allergy Asthma Immunol. or specific symptom. or feel short of breath at work? Occupational asthma is a common respiratory condition that results from exposures in the workplace. Probiotics for the treatment of allergic rhinitis and asthma: systematic review of randomized controlled trials. Depending on the reason.  Allergic asthma. Clinical practice. and inflammation caused by exposure to certain substances in the workplace. your asthma type can be determined in any of the following ways:  The underlying cause of your asthma symptoms  The severity of symptoms  The way it's controlled Asthma Types Defined By Underlying Cause One of the ways to classify types of asthma is to look at the underlying cause. Lee JH. cough.   . Betsi GI. Ann Allergy Asthma Immunol. 2009 Apr 30. 2006 Mar. This type of asthma is characterized by airway irritation. Zheng B. Asthma in pregnancy. Falagas ME.N Engl J Med.101(6):570-9. this is known as cough variant asthma. Meta-analysis: effect of long-acting beta-agonists on severe asthma exacerbations and asthma-related deaths.Do you wheeze.

Medication induced asthma. in part. Very poorly controlled. Asthma Types Based On Method of Control Based on guidelines from NHLBI. you still experience bouts of severe or worsening asthma because of medication you take for another health condition. Lung. For some people. Not well controlled. wheezing and shortness of breath that disrupt sleep.Despite doing everything your doctor has recommended to control your asthma. You have symptoms and use your rescue inhaler two or fewer days per week. and Blood Institute. doctors suspect this type of asthma is akin to an allergic reaction. 2010. such as cough.  Intermittent  Mild Persistent  Moderate Persistent  Severe Persistent Your asthma treatment is.   Sources: National Heart. Nocturnal asthma. Exercise induced asthma. You rarely wake up at night due to your asthma and your peak flow (PEF) is greater than 80% of your best or predicted PEF. you are generally symptom-free and without impairment. the decline in lung function can be significantly more -. Accessed: May 20. the amount of air you breathe. PEF ranges from 60% to 80% and nighttime symptoms also occur more frequently.In this type of asthma.and this is all associated with increased symptoms. Asthma Types Defined By Severity   Your asthma severity can also be classified in one of the following categories based on several of your asthma symptoms.In this asthma classification you have daily symptoms and rescue inhaler use. Your PEF is less than 60% of predicted.This asthma classification is characterized by symptoms that occur several times per week and more frequent use of your rescue medication. While it’s not clearly understood how this happens. your ongoing asthma treatment and asthma classification can be looked at in terms of asthma control:  Well controlled-In this asthma classification. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma . decreases by at least 15% from bedtime to waking up in the morning. measured as your FEV1.This type of asthma occurs in 7% to 20% of the general population and is characterized by bronchoconstriction and asthma symptoms that develop during or following exercise. based on this asthma classification.