Asthma

geekymedics.com/asthma/

Dr Ria Smith

Introduction
Asthma is a common disease affecting 8 million people in the UK, characterised by
chronic inflammation of the airways. The hyper-responsive airways typical of asthma
cause symptoms such as shortness of breath, cough and wheeze in response to stimuli.1

On average, 3 people die from an acute asthma attack every day in the UK.2 This article
focuses on chronic asthma; for more information on the management of an asthma
attack, see the Geeky Medics guide to acute asthma management.

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Aetiology
Asthma is characterised by chronic inflammation of the airways. There are several
mechanisms which lead to airway inflammation, including:3

Inflammatory cell infiltration of airways

Smooth muscle hypertrophy
Thickening and disruption of the airway membrane

Acute exacerbations of chronic asthma are most frequently caused by respiratory

viruses. Other causes include bacterial infections, allergens, pollutants and occupational
exposure.3

Risk factors
Several risk factors which are likely to increase the development or persistence of asthma
have been identified.1

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Non-modifiable risk factors include:

Personal or family history of atopy

Male sex (asthma development) or female sex (persistence to adulthood)
Prematurity and low birth weight

Modifiable risk factors include:

Exposure to tobacco smoke, inhaled particulates and occupational dusts

Obesity
Social deprivation
Infections in infancy

Clinical features

History
A respiratory history should elicit the typical symptoms of asthma: wheeze, cough and
breathlessness. Symptoms are characteristically episodic and diurnal (worse at night
and early morning).

Other important areas to cover in the history include:

Triggers (pets, carpets, temperature)

Occupation (exposure to dusts, chemicals)
Frequency of exacerbations and previous hospital/intensive care admissions
Personal or family history of atopy
Best expected and recent peak expiratory flow rate (PEFR)
Adherence with treatment
Smoking (including passive smoking) history

A thorough systems review is important to rule out alternative causes for the
presentation.

Clinical examination
A respiratory examination may be normal between exacerbations. Typical clinical findings
in asthma may include:

Around the bedside: oxygen, inhaler and spacer, PEFR meter

Inspection: increased work of breathing, cyanosis, cough, audible wheeze
Peripheries: fine tremor (salbutamol use), tachycardia, oral candidiasis (steroid
inhaler use)
Chest: polyphonic expiratory wheeze

Differential diagnoses

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The main symptoms of asthma can be seen in many diseases. Important and common
differentials to consider include:

Respiratory: bronchiectasis, COPD, fibrosis, pulmonary embolism, infection

(pertussis and tuberculosis), lung cancer
Gastrointestinal: gastro-oesophageal reflux
Cardiac: heart failure
Other: chronic sinusitis, allergic rhinitis, foreign body inhalation, vocal cord
dysfunction

Investigations
A combination of history, examination and investigations can lead to a likely
diagnosis of asthma. There is no single test that can be used to make a definitive
diagnosis.

Bedside investigations
Alongside basic observations, PEFR is important for monitoring response to treatment
and can demonstrate diurnal variation when there is >20% variability in twice daily
readings.1 Predicted PEFR can be calculated from age, sex and height.

Laboratory investigations

Basic blood tests include WCC and CRP to look for infection. More specialist tests
include eosinophil count and total IgE, IgE to aspergillus, as well as other allergens or
fungus.1

If the patient has a productive cough, a sputum sample should be sent for microscopy,
sensitivity and culture (MCS).

Imaging
A chest X-ray is usually normal, but may rarely show signs of hyperinflation or bronchial
wall thickening. A chest X-ray is also important to rule out infection, collapse or
pneumothorax.

Other
Spirometry with bronchodilator reversibility testing is important to support a
diagnosis of suspected asthma.

Spirometry in asthma
Spirometry findings suggestive of asthma include:

FEV1/FVC ratio <70% indicates airflow obstruction

Improvement of FEV1 by 12% AND 200ml with bronchodilators
Improvement of FEV1 by 400ml with bronchodilators

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Fractional exhaled nitric oxide (FeNO) testing measures the level of exhaled nitric
oxide. FeNO ≥40ppb in adults and ≥35ppb in children confirms eosinophilic inflammation,
but is only suggestive of asthma. Importantly, 1 in 5 people with a positive FeNO test do
not have asthma and conversely 1 in 5 people with a negative result have asthma.1

Direct bronchial challenge test (using histamine or methacholine) is carried out in

specialist centres when there is diagnostic uncertainty.

Skin prick testing can suggest atopy.

Diagnosis
Diagnosis of asthma starts with an initial detailed respiratory history and examination. If
there is a high probability of asthma based on this assessment, treatment should be
initiated and monitored with spirometry and symptom scores.1

If there is an intermediate probability of asthma, spirometry with bronchodilator

reversibility should be carried out. Other subsequent tests might include peak flow charts
and skin prick testing (1).

If there is a low probability of asthma, other causes should be investigated.1

Management
Asthma should be managed with a multidisciplinary approach, including the patient,
asthma nurse, GP, respiratory physician and respiratory physiotherapists where
appropriate.

General measures
A personalised asthma action plan should be completed. This can be completed with a
GP or asthma nurse and covers daily treatment, treatment escalation in an exacerbation
and when to seek help in an asthma attack.4 Patients should be encouraged to keep
PEFR diaries.

Asthma reviews should be carried out at least annually with a nurse or doctor. A review
should include symptoms and asthma control, smoking status, inhaler technique and
adherence, PEFR and vaccination status.5

Vaccinations should be kept up to date, and should include childhood, pneumococcal

and influenza vaccines.

Lifestyle measures should be considered in management of asthma. Smoking cessation

and weight loss should be encouraged, with help offered when appropriate. Asthma
triggers should be avoided when possible.

Medical treatment

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The aim of treatment is to control the disease. This is defined as:1

No daytime symptoms or night time waking due to asthma

No asthma attacks or need for rescue medications
No limitations on activity
Normal lung function
Minimal side effects

Inhalers are the mainstay of medical management in asthma however, other types of
treatment including oral leukotriene receptor antagonists (LTRA), theophylline or biologic
agents can be used with specialist input.

Treatment should be escalated in a step-wise approach, using the lowest possible

dose of inhaled steroid needed for optimum control. Treatment should be escalated
when symptoms are not adequately controlled.5,6

Management steps:

1. All those with symptomatic asthma should be given a short-acting beta-2 agonist
(SABA) for reliever therapy as required
2. Add low dose inhaled corticosteroid (ICS)
3. Add long-acting beta-2 agonist (LABA)
4. ICS dose increased or LTRA

Figure 1. The stepwise management of asthma

Complications
Respiratory complications of asthma include:1

Pneumonia
Collapse and pneumothorax
Respiratory failure
Status asthmaticus

Other important complications are an impaired quality of life in uncontrolled asthma,

side effects of steroid treatment and death.1

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Prognosis
Children with early-onset asthma and male children are more likely to grow out of their
asthma before adulthood.1

Key points
Asthma is a common disease, causing chronically inflamed and hyper-responsive
airways.
Risk factors can be non-modifiable (atopy, male) or modifiable (environmental
exposure, social deprivation).
A history should explore typical symptoms of asthma: wheeze, cough and
breathlessness. It should also include triggers, exacerbations, treatment adherence
and a systems review.
Clinical examination may be normal or may show signs of hypoxia and polyphonic
expiratory wheeze.
There is a wide differential however important alternatives to consider are
bronchiectasis, COPD, infection, reflux and heart failure.
There is no single test for asthma, although spirometry with reversibility testing,
PEFR, FeNO and blood tests can help make a diagnosis when asthma is
suspected.
Spirometry may be normal in asthma. FEV1/FVC ratio <70% indicates airflow
obstruction. Improvement of FEV1 by 12% and 200ml with bronchodilators suggests
reversible airway obstruction.
Asthma management is multidisciplinary and aims to control the disease by
minimising symptoms. A personalised asthma action plan and annual asthma
review should be completed in all asthma patients.
Alongside lifestyle measures, inhalers are the mainstay of treatment in asthma.
Treatment should be escalated in a step-wise approach.
Important complications in asthma are reduced quality of life, pneumonia,
pneumothorax, respiratory failure and death.

Reviewer

Dr Samantha Bosence

Respiratory Registrar

Editor

Dr Chris Jefferies

References

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1. NICE. Asthma. Published in 2021. Available from: [LINK].
2. Asthma UK. Facts and statistics. Published in 2017. Available from: [LINK].
3. Thorax. Asthma exacerbations – 2: Aetiology. Published in 2006. Available from:
[LINK].
4. Asthma UK. Your asthma action plan. Published in 2017. Available from: [LINK].
5. Patient Info. Management of adult asthma. Published in 2020. Available from:
[LINK].
6. British Thoracic Society. BTS/SIGN Guideline for the management of asthma.
Published in 2019. Available from: [LINK].

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