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Asthma is an airway disorder that causes respiratory hypersensitivity

,
infammation, and intermittent obstruction. Asthma commonly causes
constriction of the smooth muscles in the airway, wheezing, and dyspnea.
Asthma is a chronic infammatory disorder of the airways in which many cells
and cellular elements play a role, in particular, mast cells, eosinophils, T
lymphocytes, macrophages, neutrophils, and epithelial cells. In susceptible
individuals, this infammation causes recurrent episodes of wheezing,
breathlessness, chest tightness and coughing, particularly at night or in the early
morning. These episodes are usually associated with widespread but variable
airfow obstruction that is often reversible either spontaneously or with
treatment. The infammation also causes an associated increase in the existing
bronchial responsiveness to a variety of stimuli. Reversibility of airfow limitation
may be incomplete in some patients with asthma.
Asthma is a common chronic disorder of the airways that is complex and
characterized by variable and recurring symptoms, airfow obstruction, bronchial
hyperresponsiveness, and an underlying infammation. The interaction of these
features of asthma determines the clinical manifestations and severity of asthma
and the response to treatment.
xercise!induced asthma "IA#, or exercise!induced bronchospasm "I$#, is an
asthma variant de%ned as a condition in which exercise or vigorous physical
activity triggers acute bronchospasm in persons with heightened airway
reactivity. It is observed primarily in persons who have asthma "exercise!induced
bronchospasm in asthmatic persons# but can also be found in patients with
normal resting spirometry %ndings with atopy, allergic rhinitis, or cystic %brosis
and even in healthy persons, many of whom are elite athletes "exercise!induced
bronchospasm in athletes#. xercise!induced bronchospasm is often a neglected
diagnosis, and the underlying asthma may be silent in as many as &'( of
patients, except during exercise
Pathophysiology
The pathophysiology of asthma is complex and involves the following components:
• Airway inflammation
• Intermittent airflow obstruction
• Bronchial hyperresponsiveness
The mechanism of inflammation in asthma may be acute, subacute, or chronic, and the
presence of airway edema and mucus secretion also contributes to airflow obstruction and
bronchial reactivity. Varying degrees of mononuclear cell and eosinophil infiltration, mucus
hypersecretion, desuamation of the epithelium, smooth muscle hyperplasia, and airway
remodeling are present
!ome of the principal cells identified in airway inflammation include mast cells, eosinophils,
epithelial cells, macrophages, and activated T lymphocytes. T lymphocytes play an important
role in the regulation of airway inflammation through the release of numerous cyto"ines.
#ther constituent airway cells, such as fibroblasts, endothelial cells, and epithelial cells,
contribute to the chronicity of the disease. #ther factors, such as adhesion molecules $eg,
selectins, integrins%, are critical in directing the inflammatory changes in the airway. &inally,
cell'derived mediators influence smooth muscle tone and produce structural changes and
remodeling of the airway.
(),(*
The presence of airway hyperresponsiveness or bronchial hyperreactivity in asthma is an
exaggerated response to numerous exogenous and endogenous stimuli. The mechanisms
involved include direct stimulation of airway smooth muscle and indirect stimulation by
pharmacologically active substances from mediator'secreting cells such as mast cells or
nonmyelinated sensory neurons. The degree of airway hyperresponsiveness generally
correlates with the clinical severity of asthma.
Airflow obstruction can be caused by a variety of changes, including acute
bronchoconstriction, airway edema, chronic mucous plug formation, and airway remodeling.
Acute bronchoconstriction is the conseuence of immunoglobulin +,dependent mediator
release upon exposure to aeroallergens and is the primary component of the early asthmatic
response. Airway edema occurs *'-. hours following an allergen challenge and is referred to
as the late asthmatic response. /hronic mucous plug formation consists of an exudate of
serum proteins and cell debris that may ta"e wee"s to resolve. Airway remodeling is
associated with structural changes due to long'standing inflammation and may profoundly
affect the extent of reversibility of airway obstruction
The pathogenesis of exercise!induced bronchospasm is controversial. The
disease may be mediated by water loss from the airway, heat loss from the
airway, or a combination of both. The upper airway is designed to )eep inspired
air at *''( humidity and body temperature at +,-. "/0.1-2#. The nose is unable
to condition the increased amount of air re3uired for exercise, particularly in
athletes who breathe through their mouths. The abnormal heat and water fuxes
in the bronchial tree result in bronchoconstriction, occurring within minutes of
completing exercise. Results from bronchoalveolar lavage studies have not
demonstrated an increase in infammatory mediators. These patients generally
develop a refractory period, during which a second exercise challenge does not
cause a signi%cant degree of bronchoconstriction.
Clinical
History
A detailed assessment of the medical history should address $(% whether symptoms are
attributable to asthma, $-% whether findings support the li"elihood of asthma $eg, family
history%, $0% asthma severity, and $.% the identification of possible precipitating factors.

Asthma symptoms may include the following4

.ough, worse particularly at night
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6heezing

7hortness of breath

.hest tightness

7putum production

8ecreased exercise tolerance

Asthma symptom patterns can vary as follows4

9erennial versus seasonal

.ontinual versus episodic

8uration, severity, and fre3uency

8iurnal variations "nocturnal and early!morning awa)enings#

9recipitating or aggravating factors for asthma, also discussed in .auses,
may include the following4

nvironmental allergen exposure "dust mites, pet dander, pollens#

:ccupation

;edications

xercise

<iral upper respiratory tract infections

7trong emotional expression

;enstrual cycles

Airborne dusts or chemicals

Asthma development variables include the following4

Age at onset

=istory of in>ury early in life due to infection or passive smo)e
exposure

9rogress of disease

.urrent response to asthma management

.omorbid conditions "sinusitis, rhinitis, gastroesophageal refux#

2amily history may reveal the following conditions4

Asthma

Allergy

7inusitis

Rhinitis

czema

7ocial history may reveal the following conditions4

=ome characteristics

7mo)ing

6or)place or school characteristics

ducational level

mployment

7ocial support

8etermine the pro%le of a typical asthma exacerbation.

The impact asthma has on the patient and family may have involved the
following4

mergency department visits, hospitalizations, I.? admissions,
intubations

;issed days from wor) or school or activity limitation

Assess the patient@s disease perception based on the following elements4

Anowledge of asthma and treatment

?se of medications

.oping mechanisms

2amily support

conomic resources
The clinical history findings for exercise'induced bronchospasm are typical of asthma but are
only associated with exercise. Typical symptoms include cough, whee1ing, shortness of
breath, and chest pain or tightness. !ome individuals also may report sore throat or 2I upset.
• Asthma symptoms are usually associated with exercise but may be related
to exposure to cold air or other triggers, such as seasonal allergens,
pollutants "eg, sulfur, nitrous oxide, ozone#, or upper respiratory tract
infections.
• Initially, airway dilation is noted during exercise. If exercise continues
beyond approximately *' minutes, bronchoconstriction supervenes,
resulting in asthma symptoms. If the exercise period is shorter, symptoms
may develop up to &!*' minutes after completion of exercise. A higher
intensity level of exercise results in a more intense attac). Running
produces more symptoms than wal)ing.
• 9atients may note asthma symptoms are related to seasonal changes or
the ambient temperature and humidity in the environment in which a
patient exercises. .old, dry air generally provo)es more obstruction than
warm, humid air. .onse3uently, many athletes have good exercise
tolerance in sports such as swimming. Athletes who are more physically %t
may not notice the typical asthma symptoms and may only report a
reduced or more limited level of endurance.
• 7everal modi%ers in the history should prompt an evaluation for causes
other than exercise!induced bronchospasm. 6hile patients may report
typical obstructive symptoms, a history of a cho)ing sensation with
exercise, inspiratory wheezing, or stridor should prompt an evaluation for
evidence of vocal cord dysfunction.
Physical
• Beneral asthma physical %ndings
o vidence of respiratory distress manifests as increased respiratory
rate, increased heart rate, diaphoresis, and use of accessory
muscles of respiration.
o ;ar)ed weight loss or severe wasting may indicate severe
emphysema.
• 9ulsus paradoxus4 This is an exaggerated fall in systolic blood pressure
during inspiration and may occur during an acute asthma exacerbation.
• 8epressed sensorium4 This %nding suggests a more severe asthma
exacerbation with impending respiratory failure.
• .hest examination
o nd!expiratory wheezing or a prolonged expiratory phase is found
most commonly, although inspiratory wheezing can be heard.
o 8iminished breath sounds and chest hyperinfation "especially in
children# may be observed during acute asthma exacerbations.
o The presence of inspiratory wheezing or stridor may prompt an
evaluation for an upper airway obstruction such as vocal cord
dysfunction, vocal cord paralysis, thyroid enlargement, or a soft
tissue mass "eg, malignant tumor#.
• ?pper airway
o Coo) for evidence of erythematous or boggy turbinates or the
presence of polyps from sinusitis, allergic rhinitis, or upper
respiratory tract infection.
o Any type of nasal obstruction may result in worsening of asthma or
symptoms of exercise!induced bronchospasm.
• 7)in4 :bserve for the presence of atopic dermatitis, eczema, or other
manifestations of allergic s)in conditions.
Causes
• 2actors that can contribute to asthma or airway hyperreactivity may
include any of the following4
o nvironmental allergens4 =ouse dust mites, animal allergens
"especially cat and dog#, coc)roach allergens, and fungi are most
commonly reported.
o <iral respiratory tract infections
o xerciseD hyperventilation
o Bastroesophageal refux disease
o .hronic sinusitis or rhinitis
o Aspirin or nonsteroidal anti!infammatory drug "E7AI8#
hypersensitivity, sul%te sensitivity
o ?se of beta!adrenergic receptor bloc)ers "including ophthalmic
preparations#
o :besity4 $ased on a prospective cohort study of 01,''' patients,
those with an elevated body mass index are more li)ely to have
asthma.
o nvironmental pollutants, tobacco smo)e
o :ccupational exposure
o Irritants "eg, household sprays, paint fumes#
o <arious high and low molecular weight compounds4 A variety of high
and low molecular weight compounds are associated with the
development of occupational asthma, such as insects, plants, latex,
gums, diisocyanates, anhydrides, wood dust, and fuxes.
o motional factors or stress
o 9erinatal factors4 9rematurity and increased maternal age increase
the ris) for asthmaD breastfeeding has not been de%nitely shown to
be protective. $oth maternal smo)ing and prenatal exposure to
tobacco smo)e also increase the ris) of developing asthma.
• 2actors that contribute to exercise!induced bronchospasm symptoms "in
both people with asthma and athletes# include the following4
o xposure to cold or dry air
o nvironmental pollutants "eg, sulfur, ozone#
o level of bronchial hyperreactivity
o .hronicity of asthma and symptomatic control
o 8uration and intensity of exercise
o Allergen exposure in atopic individuals
o .oexisting respiratory infection
Diferential Diagnoses
Airway 2oreign $ody =eart 2ailure
Allergic and nvironmental
Asthma
9ulmonary mbolism
Alpha*!Antitrypsin 8e%ciency 9ulmonary osinophilia
Aspergillosis 7arcoidosis
$ronchiectasis 7inusitis, .hronic
$ronchiolitis Tracheomalacia
.hronic :bstructive 9ulmonary
8isease
?pper Respiratory Tract
Infection
.hurg!7trauss 7yndrome <ocal .ord 8ysfunction
.ystic 2ibrosis
2oreign $ody Aspiration
Bastroesophageal Refux
8isease
Other Problems to Be Considered
Aspirin or 3!AI4 hypersensitivity
#ccupational asthma
5eactive airways dysfunction syndrome
Tracheal and bronchial tumors
#ther causes of upper airway obstruction
Workup
Laboratory Studies

Caboratory assessments and studies are not routinely indicated for
asthma, but they may be used to exclude other diagnoses.

$lood eosinophilia greater than F( or +''!F''GHC supports the diagnosis
of asthma, but an absence of this %nding is not exclusionary. osinophil
counts greater than 0( may be observed in patients with concomitant
atopic dermatitis. This %nding should prompt an evaluation for
allergic bronchopulmonary aspergillosis, .hurg!7trauss syndrome,
or eosinophilic pneumonia.

Total serum immunoglobulin levels greater than *'' I? are fre3uently
observed in patients experiencing allergic reactions, but this %nding is not
speci%c for asthma and may be observed in patients with other conditions
"eg, allergic bronchopulmonary aspergillosis, .hurg!7trauss syndrome#. A
normal total serum immunoglobulin level does not exclude the diagnosis
of asthma. levated serum Ig levels are re3uired for chronic asthma
patients to be treated with omalizumab "Iolair#.

In assessing asthma control, the $ritish Thoracic 7ociety recommends
using sputum eosinophilia determinations to guide therapy. An
improvement in asthma control, a decrease in hospitalizations, and a
decrease in exacerbations were noted in those patients in whom sputum!
guided therapy was used.
5+
A controlled prospective study has shown that
ad>usting inhaled corticosteroid "I.7# treatment to control sputum
eosinophiliaJas opposed to controlling symptoms, short!acting beta!
agonist "7A$A# use, nocturnal awa)enings, and pulmonary functionJ
signi%cantly reduced both the rate of asthma exacerbations and the
cumulative dose of inhaled corticosteroids.
5F

Eair et al studied the capability of mepolizumab to allow prednisone
sparing in those rare individuals who have sputum eosinophilia and airway
symptoms despite continued prednisone treatment. The agent reduced
blood and sputum eosinophils and permitted prednisone sparing.
5&
Imaging Studies
• In most patients with asthma, chest radiography %ndings are normal or
may indicate hyperinfation. 2indings may help rule out other pulmonary
diseases such as allergic bronchopulmonary aspergillosis or sarcoidosis,
which can manifest with symptoms of reactive airway disease. .hest
radiography should be considered in all patients being evaluated for
asthma to exclude other diagnoses.
• 7inus .T scanning may be useful to help exclude acute or chronic sinusitis
as a contributing factor. In patients with chronic sinus symptoms, .T
scanning of the sinuses can also help rule out chronic sinus disease.
Other Tests
• Allergy s)in testing is a useful ad>unct in individuals with atopy. Results
help guide indoor allergen mitigation or help diagnose allergic rhinitis
symptoms. The allergens that most commonly cause asthma are
aeroallergens such as house dust mites, animal danders, pollens, and
mold spores. Two methods are available to test for allergic sensitivity to
speci%c allergens in the environment4 allergy s)in tests and blood
radioallergosorbent tests "RA7T#. Allergy immunotherapy may be
bene%cial in controlling allergic rhinitis and asthma symptoms for some
patients.
• In patients with asthma and symptoms of gastroesophageal refux disease
"BR8#, 5F!hour p= monitoring can help determine if BR8 is a
contributing factor.
Procedures
• 9ulmonary function testing "spirometry#
o
7pirometry assessments should be obtained as the primary test to
establish the asthma diagnosis. 7pirometry should be performed
prior to initiating treatment in order to establish the presence and
determine the severity of baseline airway obstruction.
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:ptimally,
the initial spirometry should also include measurements before and
after inhalation of a short!acting bronchodilator in all patients in
whom the diagnosis of asthma is considered. 7pirometry measures
the forced vital capacity "2<.#, the maximal amount of air expired
from the point of maximal inhalation, and the 2<
*
. A reduced ratio
of 2<
*
to 2<., when compared with predicted values, demonstrates
the presence of airway obstruction. Reversibility is demonstrated by
an increase of *5( and 5'' mC after the administration of a short!
acting bronchodilator.
o
The assessment and diagnosis of asthma cannot be based on
spirometry %ndings alone because many other diseases are
associated with obstructive spirometry indices.
o
As a preliminary assessment for exercise!induced asthma "IA#, or
exercise!induced bronchospasm "I$#, perform spirometry in all
patients with exercise symptoms to determine if any baseline
abnormalities "ie, the presence of obstructive or restrictive indices#
are present.
• ;ethacholine! or histamine!challenge testing
o
$ronchoprovocation testing with either methacholine or histamine is
useful when spirometry %ndings are normal or near normal,
especially in patients with intermittent or exercise!induced asthma
symptoms. $ronchoprovocation testing helps determine if airway
hyperreactivity is present, and a negative test result usually
excludes the diagnosis of asthma.
o
Trained individuals should perform this asthma testing in an
appropriate facility and in accordance with the guidelines of the
American Thoracic 7ociety published in *///.
5,
;ethacholine is
administered in incremental doses up to a maximum dose of *1
mgGmC, and a 5'( decrease in 2<
*
, up to the F mgGmC level, is
considered a positive test result for the presence of bronchial
hyperresponsiveness. The presence of airfow obstruction with an
2<
*
less than 1&!,'( at baseline is generally an indication to avoid
performing the test.
• xercise testing
o
xercise spirometry is the standard method for assessing patients
with exercise!induced bronchospasm. Testing involves 1!*' minutes
of strenuous exertion at 0&!/'( of predicted maximal heart rate
and measurement of postexercise spirometry for *&!+' minutes.
The de%ned cutoK for a positive test result is a *&( decrease in
2<
*
after exercise.
o
xercise testing may be accomplished in + diKerent ways, using
cycle ergometry, a standard treadmill test, or free running exercise.
This method of testing is limited because laboratory conditions may
not sub>ect the patient to the usual conditions that trigger exercise!
induced bronchospasm symptoms, and results have a lower
sensitivity for asthma compared with other methods.
• ucapnic hyperventilation
o
ucapnic hyperventilation with either cold or dry air is an alternate
method of bronchoprovocation testing.
o
It has been used to evaluate patients for exercise!induced asthma
and has been shown to produce results similar to those of
methacholine!challenge asthma testing.
• 9ea)!fow monitoring
o
9ea)!fow monitoring is designed for ongoing monitoring of patients
with asthma because the test is simple to perform and the results
are a 3uantitative and reproducible measure of airfow obstruction.
o
It can be used for short!term monitoring, exacerbation
management, and daily long!term monitoring. 9ea)!fow monitoring
should not be used as a substitute for spirometry to establish the
initial diagnosis of asthma.
o
Results can be used to determine the severity of an exacerbation
and to help guide therapeutic decisions as part of an asthma action
plan.
• Buidelines for the use of pea)!fow meters for asthma
o
Advise the patient to use the pea)!fow meter upon awa)ening in
the morning before using a bronchodilator.
o
Instruct the patient on how to establish a personal best pea)
expiratory fow "92# rate.
o
Inform the patient that a pea) fow of less than 0'( of the patient@s
personal best indicates a need for additional medication and a pea)
fow below &'( indicates severe exacerbation.
o
Advise the patient to use the same pea)!fow meter over time.
• xhaled nitric oxide
o
xhaled nitric oxide analysis has been shown to predict airway
infammation and asthma controlD however, it is technically more
complex and not routinely used in the monitoring of patients with
asthma.
o
A prospective, controlled study has shown that when inhaled
corticosteroid asthma treatment was ad>usted to control the fraction
of exhaled nitric oxide, as opposed to controlling the standard
indices of asthma, the cumulative dose of I.7 was reduced, with no
worsening of the fre3uency of asthma exacerbations.
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Treatment
Medical Care
• Achieve and maintain control of asthma symptoms
• 6aintain normal activity levels, including exercise
• 6aintain pulmonary function as close to normal as possible
• 7revent asthma exacerbations
• Avoid adverse effects from asthma medications
• 7revent asthma mortality
#verall management of asthma should incorporate the following . treatment components:
• #b8ective measures of lung function
• +nvironmental control measures and avoidance of ris" factors
• /omprehensive pharmacologic therapy
• 7atient education
The functions of asthma assessment and monitoring are closely lin)ed to the
concepts of severity, control, and responsiveness to treatment. 7everity is the
intrinsic intensity of the disease process. Asthma severity is measured most
easily and directly in a patient not receiving long!term!control therapy. Asthma
control is the degree to which the manifestations of asthma "symptoms,
functional impairments, and ris)s of untoward events# are minimized and the
goals of therapy are met. Asthma responsiveness is the ease with which asthma
control is achieved by therapy.
$oth asthma severity and asthma control include the domains of current
impairment and future ris). Impairment is the fre3uency and intensity of
symptoms and functional limitations the patient is experiencing or has recently
experienced as a result of asthma. Ris) is the li)elihood of either asthma
exacerbations, progressive decline in lung function "or, for children, reduced lung
growth#, or ris) of adverse eKects from medication
#n 9une -), -::;, The American Thoracic !ociety and the +uropean 5espiratory !ociety
8ointly released new official standards on asthma assessment and evaluation for clinical trials
and practice.
-;
Also see the 6edscape 6edical 3ews article, 3ew 2uidelines Issued for
Asthma Assessment.
Two additional asthma treatment strategies include management of exacerbations and regular
follow'up care. /lassify the severity of asthma before treatment, based on symptom
prevalence and measurement of lung function. /lassification of asthma severity and treatment
options are as follows:
• !tep ( ' Intermittent asthma
o Intermittent symptoms occurring less than once a wee"
o Brief exacerbations
o 3octurnal symptoms occurring less than twice a month
o Asymptomatic with normal lung function between exacerbations
o 3o daily medication needed
o &+V
(
or 7+& rate greater than <:=, with less than -:= variability
• !tep - ' 6ild persistent asthma
o !ymptoms occurring more than once a wee" but less than once a day
o +xacerbations affect activity and sleep
o 3octurnal symptoms occurring more than twice a month
o &+V
(
or 7+& rate greater than <:= predicted, with variability of -:'0:=
• !tep 0 ' 6oderate persistent asthma
o 4aily symptoms
o +xacerbations affect activity and sleep
o 3octurnal symptoms occurring more than once a wee"
o &+V
(
or 7+& rate *:'<:= of predicted, with variability greater than 0:=
• !tep . ' !evere persistent asthma
o /ontinuous symptoms
o &reuent exacerbations
o &reuent nocturnal asthma symptoms
o 7hysical activities limited by asthma symptoms
o &+V
(
or 7+& rate less than *:=, with variability greater than 0:=
3ote that the above guidelines apply to the general asthma population and may vary
depending on age, especially the pediatric population and the elderly population. !pecific
guidelines were published in -::0 on caring for asthmatic persons in the elderly population,
and they contain more specific information. !ee NAEPP Working Group Report:
Considerations for Diagnosing and Managing Asthma in the Elderly. N! Pu"li#ation No.
$%&'%%(.
Consultations
5efer any patient with moderate'to'severe persistent asthma that is difficult to control to a
pulmonologist or allergist to ensure proper stepwise asthma management, or refer for further
evaluation to help rule out other diagnoses such as vocal cord dysfunction. #ther criteria for
referral include the following:
• .onsideration for alternative diagnoses should be given in all patients, and
in particular in those older than +' years and younger than 5 years with
new symptoms suggestive of asthma.
• A signi%cant history of smo)ing greater than 5'!pac) years should ma)e
the diagnosis of chronic obstructive pulmonary disease ".:98# more li)ely
than asthma.
• An absence of airway obstruction on initial spirometry %ndings should
prompt consideration for alternative diagnoses and additional testing.
• Abnormalities found on chest radiography screening should prompt
referral to a specialist for further evaluation.
5efer patients to a pulmonologist for evaluation of symptoms consistent with exercise'
induced asthma $+IA%, or exercise'induced bronchospasm $+IB%. These patients should
undergo either exercise or bronchoprovocation testing to document evidence of airway
hyperreactivity and response to exercise.
5efer patients to an otolaryngologist for treatment of nasal obstruction from polyps, sinusitis,
or allergic rhinitis or for the diagnosis of upper airway disorders.
5efer patients to an allergist or immunologist for s"in testing to guide indoor allergen
mitigation efforts and consideration of immunotherapy to treat seasonal allergic rhinitis. The
use of immunotherapy for the treatment of asthma is controversial. !everal large, well'
conducted studies did not demonstrate any benefit, but a meta'analysis of ). randomi1ed
controlled trials confirmed efficacy in asthma.
00
The 3ational Asthma +ducation and
7revention 7rogram +xpert 7anel 5eport recommends that immunotherapy be considered if
the following criteria are fulfilled:
• A relationship is clear between symptoms and exposure to an unavoidable
allergen to which the patient is sensitive.
• 7ymptoms occur all year or during a ma>or portion of the year.
• 7ymptoms are diLcult to control with pharmacologic management
because the medication is ineKective, multiple medications are re3uired,
or the patient is not accepting of medication.
Diet
Information from prospective cohort studies and population'based studies in the past several
years suggests an association between asthma and obesity. 7atients with an elevated body
mass index have an increased ris" for developing asthma. A prospective cohort study of
<*,::: adults observed for ) years showed a linear relationship between body mass index and
the ris" of developing asthma.
0.
3o special diets are generally indicated. &ood allergy as a trigger for asthma is uncommon.
Avoidance of foods is recommended after a double'blind food challenge that yields positive
results. !ulfites have been implicated in some severe asthma exacerbations and should be
avoided in sensitive individuals.
Actiity
Activity is generally limited by patients> ability to exercise and their response to medications.
3o specific limitations are recommended for patients with asthma, although they should
avoid exposure to agents that may exacerbate their disease.
A significant number of patients with asthma also have exercise'induced bronchospasm, and
baseline control of their disease should be adeuate to prevent exertional symptoms. The
ability of patients with exercise'induced bronchospasm to exercise is based on the level of
exertion, degree of fitness, and environment in which they exercise.
6any patients have fewer problems when exercising indoors or in a warm, humid
environment than they do outdoors or in a cold, dry environment.
Medication
Asthma medications are generally divided into - categories, uic" relief $also called reliever
medications% and long'term control $also called controller medications%. ?uic" relief
medications are used to relieve acute asthma exacerbations and to prevent exercise'induced
asthma $+IA%, or exercise'induced bronchospasm $+IB% symptoms. These medications
include short'acting beta'agonists $!ABAs%, anticholinergics $used only for severe
exacerbations%, and systemic corticosteroids, which speed recovery from acute exacerbations.
@ong'term control medications include inhaled corticosteroids $I/!s%,
0),0*
cromolyn sodium,
nedocromil, long'acting beta'agonists $@ABAs%, combination inhaled corticosteroids and
long'acting beta'agonists, methylxanthines, and leu"otriene antagonists. Inhaled
corticosteroids are considered the primary drug of choice for control of chronic asthma. Ase
of these medications by the stepwise approach is outlined in 6edical /are.
The newest asthma medication is omali1umab $Bolair%, a recombinant 43A'derived
humani1ed immunoglobulin 2 monoclonal antibody that binds selectively to human
immunoglobulin + on the surface of mast cells and basophils. The drug reduces mediator
release, which promotes an allergic response. It is indicated for moderate'to'severe persistent
asthma in patients who react to perennial allergens, in whom symptoms are not controlled by
inhaled corticosteroids.
#ther medications that are rarely used to reduce oral systemic corticosteroid dependence
include cyclosporine, methotrexate, gold, intravenous immunoglobulin, dapsone,
troleandomycin, and hydroxychlorouine. Their use in patients with asthma is extremely
limited because of variable responses, adverse effects, and limited experience. #nly an
asthma specialist should administer these medications.
Beta!"adrenergic agonist agents
These agents relieve reversible bronchospasm by relaxing the smooth muscles of the bronchi.
Corticosteroids
These are highly potent agents that are the primary 4#/ for treatment of chronic asthma and
prevention of acute asthma exacerbations. 3umerous inhaled corticosteroids are used for
asthma and include beclomethasone $Beclovent, Vanceril%, budesonide $7ulmicort
Turbuhaler%, flunisolide $AeroBid%, fluticasone $&lovent%, and triamcinolone $A1macort%.
Leu#otriene receptor antagonists
These drugs are direct antagonists of mediators responsible for airway inflammation in
asthma. They are used for prophylaxis of exercise'induced bronchospasm and long'term
treatment of asthma as alternative to low doses of inhaled corticosteroids.
Mast cell stabili$ers
6ast cell stabili1ers prevent the release of mediators from mast cells that cause airway
inflammation and bronchospasm. They are indicated for maintenance therapy of mild'to'
moderate asthma or prophylaxis for exercise'induced bronchospasm.
%"Lipo&ygenase inhibitors
These asthma medications inhibit the formation of leu"otrienes. @eu"otrienes activate
receptors that may be responsible for events leading to the pathophysiology of asthma,
including airway edema, smooth muscle constriction, and altered cellular activity associated
with inflammatory reactions.
Monoclonal antibodies
These recombinant 43A'derived humani1ed immunoglobulin 2 monoclonal antibodies bind
selectively to human immunoglobulin + on the surface of mast cells and basophils. They
reduce mediator release, which promotes an allergic response. They are indicated for
moderate'to'severe persistent asthma in patients who react to perennial allergens, in whom
symptoms are not controlled by inhaled corticosteroids.
Complications
The most common complications of asthma include pneumonia, pneumothorax or
pneumomediastinum, and respiratory failure reuiring intubation in severe exacerbations.
5is" factors for death from asthma include the following:
• 7revious severe asthma exacerbation $eg, intubation or I/A admission for asthma%
• Two or more hospitali1ations for asthma in the past year
• Three or more emergency department visits for asthma in the past year
• Cospitali1ation or emergency department visit for asthma in the past month
• Asing more than - canisters of short'acting beta'agonists per month
• 4ifficulty perceiving asthma symptoms or severity of exacerbations
• #ther ris" factors ' @ac" of a written asthma action plan, sensitivity to Alternaria
• !ocial history ' @ow socioeconomic status or inner'city residence, illicit drug use, or
ma8or psychosocial problems
• /omorbidities ' /ardiovascular disease, other chronic lung disease, chronic
psychiatric disease
/omplications associated with most medications used for asthma are relatively rare.
Cowever, in those patients who reuire long'term corticosteroid use, complications may
include osteoporosis, immunosuppression, cataracts, myopathy, weight gain, addisonian
crisis, thinning of s"in, easy bruising, avascular necrosis, diabetes, and psychiatric disorders.
A review by /ates et al addresses the possible lin" between beta-'agonists and increased
asthma mortality and whether daily long'acting beta-'agonist use alone or with inhaled
corticosteroids is safe. Adults and adolescents from (. studies $<:-< participants% and
children and adolescents from D studies $-D<< participants% were included in the review. The
authors concluded that the data were insufficient to warrant either $(% reassuring asthma
patients that inhaled corticosteroids with daily formoterol does not carry an increased ris" of
mortality when compared with inhaled corticosteroids alone or $-% concluding that evidence
of harm has been determined. &urther, /ates et al recommend that clinical decisions must
ta"e into account the potential benefits for the patient compared with the potential for harmful
events, including mortality.
.-
Prognosis
Approximately half the children diagnosed with asthma in childhood outgrow their disease by
late adolescence or early adulthood and reuire no further treatment. 7atients with poorly
controlled asthma develop long'term changes over time $ie, with airway remodeling%. This
can lead to chronic symptoms and a significant irreversible component to their disease. 6any
patients who develop asthma at an older age also tend to have chronic symptoms.
http:EEemedicine.medscape.comEarticleE-;*0:(
Asthma
?RC of this page4 http4GGwww.nlm.nih.govGmedlineplusGencyGarticleG'''*F*.htm
Asthma is an inflammatory disorder of the airways, which causes attac"s of whee1ing,
shortness of breath, chest tightness, and coughing.
Causes
Asthma is caused by inflammation in the airways. Fhen an asthma attac" occurs, the muscles
surrounding the airways become tight and the lining of the air passages swells. This reduces
the amount of air that can pass by.
In sensitive people, asthma symptoms can be triggered by breathing in allergy'causing
substances $called allergens or triggers%.
/ommon asthma triggers include:
• Animals "pet hair or dander#
• 8ust
• .hanges in weather "most often cold weather#
• .hemicals in the air or in food
• xercise
• ;old
• 9ollen
• Respiratory infections, such as the common cold
• 7trong emotions "stress#
• Tobacco smo)e
Aspirin and other nonsteroidal anti'inflammatory drugs $3!AI4s% provo"e asthma in some
patients.
6any people with asthma have a personal or family history of allergies, such as hay fever
$allergic rhinitis% or ec1ema. #thers have no history of allergies.
Symptoms
6ost people with asthma have attac"s separated by symptom'free periods. !ome people have
long'term shortness of breath with episodes of increased shortness of breath. +ither whee1ing
or a cough may be the main symptom.
Asthma attac"s can last for minutes to days, and can become dangerous if the airflow is
severely restricted.
!ymptoms include:
• .ough with or without sputum "phlegm# production
• 9ulling in of the s)in between the ribs when breathing "intercostal
retractions#
• 7hortness of breath that gets worse with exercise or activity
• 6heezing, which4
o .omes in episodes with symptom!free periods in between
o ;ay be worse at night or in early morning
o ;ay go away on its own
o Bets better when using drugs that open the airways
"bronchodilators#
o Bets worse when breathing in cold air
o Bets worse with exercise
o Bets worse with heartburn "refux#
o ?sually begins suddenly
+mergency symptoms:
• $luish color to the lips and face
• 8ecreased level of alertness, such as severe drowsiness or confusion,
during an asthma attac)
• xtreme diLculty breathing
• Rapid pulse
• 7evere anxiety due to shortness of breath
• 7weating
#ther symptoms that may occur with this disease:
• Abnormal breathing pattern !!breathing out ta)es more than twice as long
as breathing in
• $reathing temporarily stops
• .hest pain
• Easal faring
• Tightness in the chest
Exams and Tests
Allergy testing may be helpful to identify allergens in people with persistent asthma.
/ommon allergens include:
• .oc)roach allergens
• 8ust mites
• ;olds
• 9et dander
• 9ollens
/ommon respiratory irritants include:
• 2umes from burning wood or gas
• 9ollution
• Tobacco smo)e
The doctor will use a stethoscope to listen to the lungs. Asthma'related sounds may be heard.
Cowever, lung sounds are usually normal between asthma episodes.
Tests may include:
• Arterial blood gas
• $lood tests to measure eosinophil count "a type of white blood cell# and
Ig "a type of immune system protein called an immunoglobulin#
• .hest x!ray
• Cung function tests
• 9ea) fow measurements
Treatment
The goal of treatment is to avoid the substances that trigger your symptoms and control
airway inflammation. Gou and your doctor should wor" together as a team to develop and
carry out a plan for eliminating asthma triggers and monitoring symptoms.
There are two basic "inds of medication for treating asthma:
• .ontrol drugs to prevent attac)s
• Muic)!relief drugs for use during attac)s
/ontrol drugs for asthma control your symptoms if you don>t have mild asthma. Gou must
ta"e them every day for them to wor". Ta"e them even when you feel o"ay.
The most common control drugs are:
• Inhaled corticosteroids "such as Azmacort, <anceril, Aero$id, 2lovent#
prevent symptoms by helping to )eep your airways from swelling up.
• Cong!acting beta!agonist inhalers also help prevent asthma symptoms. 8o
not ta)e long!acting beta!agonist inhaler drugs alone. These drugs are
generally used together with an inhaled steroid drug. It may be easier to
use an inhaler that contains both drugs.
#ther control drugs that may be used are:
• Ceu)otriene inhibitors "such as 7ingulair and Accolate#
• :malizumab "Iolair#, which bloc)s a pathway that the immune system
uses to trigger asthma symptoms
• .romolyn sodium "Intal# or nedocromil sodium "Tilade#
• Aminophylline or theophylline "rarely used anymore#
Asthma uic"'relief drugs wor" fast to control asthma symptoms:
• Nou ta)e them when you are coughing, wheezing, having trouble
breathing, or having an asthma attac). They are also called OrescueO
drugs.
• They also can be used >ust before exercising to help prevent asthma
symptoms that are caused by exercise.
• Tell your doctor if you are using 3uic)!relief medicines twice a wee) or
more to control your asthma symptoms. Nour asthma may not be under
control, and your doctor may need to change your dose of daily control
drugs.
?uic"'relief drugs include:
• 7hort!acting bronchodilators "inhalers#, such as 9roventil, <entolin, and
Iopenex
• Nour doctor might prescribe oral steroids "corticosteroids# when you have
an asthma attac) that is not going away. These are medicines that you
ta)e by mouth as pills, capsules, or li3uid. 9lan ahead. ;a)e sure you do
not run out of these medications.
A severe asthma attac" reuires a chec"'up by a doctor. Gou may also need a hospital stay,
oxygen, and medications given through a vein $IV%.
Asthma action plans are written documents for anyone with asthma. An asthma action plan
should include:
• A plan for ta)ing asthma medications when your condition is stable
• A list of asthma triggers and how to avoid them
• =ow to recognize when your asthma is getting worse, and when to call
your doctor or nurse
A pea" flow meter is a simple device to measure how uic"ly you can move air out of your
lungs.
• It can help you see if an attac) is coming, sometimes even before any
symptoms appear. 9ea) fow measurements can help show when
medication is needed, or other action needs to be ta)en.
• 9ea) fow values of &'( ! 0'( of a speci%c person@s best results are a sign
of a moderate asthma attac), while values below &'( are a sign of a
severe attac).
Support Groups
Gou can often ease the stress caused by illness by 8oining a support group, where members
share common experiences and problems.
!ee: Asthma and allergy ' support group
Outlook !rognosis"
There is no cure for asthma, although symptoms sometimes improve over time. Fith proper
self management and medical treatment, most people with asthma can lead normal lives.
!ossi#le Complications
The complications of asthma can be severe. !ome include:
• 8eath
• 8ecreased ability to exercise and ta)e part in other activities
• Cac) of sleep due to nighttime symptoms
• 9ermanent changes in the function of the lungs
• 9ersistent cough
• Trouble breathing that re3uires breathing assistance "ventilator#
When to Contact a Medical !ro$essional
/all for an appointment with your health care provider if asthma symptoms develop.
/all your health care provider or go to the emergency room if:
• An asthma attac) re3uires more medication than recommended
• 7ymptoms get worse or do not improve with treatment
• Nou have shortness of breath while tal)ing
• Nour pea) fow measurement is &'( ! 0'( of your personal best
2o to the emergency room if:
• Nou develop drowsiness or confusion
• Nou have severe shortness of breath at rest
• Nour pea) fow measurement is less than &'( of your personal best
• Nou have severe chest pain
!re%ention
Gou can reduce asthma symptoms by avoiding "nown triggers and substances that irritate the
airways.
• .over bedding with Oallergy!proofO casings to reduce exposure to dust
mites.
• Remove carpets from bedrooms and vacuum regularly.
• ?se only unscented detergents and cleaning materials in the home.
• Aeep humidity levels low and %x lea)s to reduce the growth of organisms
such as mold.
• Aeep the house clean and )eep food in containers and out of bedrooms !!
this helps reduce the possibility of coc)roaches, which can trigger asthma
attac)s in some people.
• If a person is allergic to an animal that cannot be removed from the home,
the animal should be )ept out of the bedroom. 9lace %ltering material over
the heating outlets to trap animal dander.
• liminate tobacco smo)e from the home. This is the single most important
thing a family can do to help a child with asthma. 7mo)ing outside the
house is not enough. 2amily members and visitors who smo)e outside
carry smo)e residue inside on their clothes and hair !! this can trigger
asthma symptoms.
7ersons with asthma should also avoid air pollution, industrial dusts, and other irritating
fumes as much as possible.
Alternati%e &ames
Bronchial asthmaH +xercise'induced asthma
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'pdate Date( )*+,*-.+.