Asthma

<h2 style="text-align: justify;"><span style="color: #333333; font-family: arial, helvetica, sans-serif;"><strong>Asthma</strong></span></h2> <p dir="ltr" style="text-align: justify;"><span style="color: #333333; font-size: medium; font-family: arial, helvetica, sans-serif;">Asthma is a disease commonly called as a wheezing problem. It is a chronic inflammatory disorder of the airway characterised by hyper-responsiveness and obstruction of the airway in response to various stimuli. That is, our airway tries to wash away a small piece of dust by creating a huge flood in our lungs. And that like any other floods is a disaster to our body.</span></p> <h3 dir="ltr" style="text-align: justify;"><span style="color: #333333; font-family: arial, helvetica, sans-serif;"><strong>Causes</strong></span></h3> <p style="text-align: justify;"><span style="color: #333333; font-size: medium; font-family: arial, helvetica, sans-serif;">A combination of genetic and environmental factors make the airway respond to the following triggers.</span></p> <h3 style="text-align: justify;"><span style="color: #333333; font-family: arial, helvetica, sans-serif;"><strong>The Common Triggers:</strong></span></h3> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; color: #333333; font-size: medium;">Airborne particles, such as pollen, dust, spores, pet dander or excreta of cockroach</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Respiratory infections, such as the common cold</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Physical activity (exercise-induced asthma)</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Cold air</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Air pollutants and irritants, such as smoke</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Certain medications, including beta-blockers, aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve)</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Strong emotions and stress</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Sulphites and preservatives in some food items (especially packed stuff)</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Even daily household dust like chilli powder in the kitchen or dust from a long standing bookshelf can trigger an episode of asthma</span></p> </li> </ul> <h3 style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Pathophysiology:</strong></span></h3> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Acute and chronic inflammatory response–</strong> the immune system immediately deports all its soldiers in the form of cells, enzymes, and fluids. All the mediators reach the site of inflammation. </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Bronchial smooth muscle contraction-</strong> one of the primary immune response is to constrict the bronchial tree to try to avoid further entry of the dust particles. But in case of asthma, it is an exaggerated response to a trivial particle or sometimes nothing at all.</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Epithelial damage–</strong> the inflammatory reaction results in damaging the epithelium of the bronchial tree and the alveolar epithelium. The epithelium is the group of cells lining the walls of these structures.</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Airway remodeling–</strong> these changes happening multiple times results in a long term remodeling of the airway resulting in reduced airway diameter.</span></p> </li> </ul> <h3 dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Signs and Symptoms:</strong></span></h3> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">A cough which is worse at night or early morning </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Wheezing </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Shortness of breath</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Chest tightness </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Nocturnal awakening </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Symptoms are episodic and seasonal </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Triggers of asthma as mentioned before aggravate or start the episode of symptoms </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Another history of Gastroesophageal reflux disease, sinusitis, rhinitis, postnasal drip, aspirin sensitivity, family history of atopy or prior asthma treatment </span></p> </li> </ul> <p style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">On examination, the doctor would be able to identify the wheezing and prolonged expiratory phase. Signs of atopy, tachypnoea or accessory muscle use may be appreciated. </span></p> <h3 style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Diagnosis of Asthma:</strong></span></h3> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Complete Blood Count may reveal Eosinophilia</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Serum IgE levels may be elevated </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Allergy skin testing and allergen-specific IgE</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Chest Radiography </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Pulmonary Function Tests showing reduced forced expiratory volume and peak expiratory flow rate</span></p> </li> </ul> <h3 style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Asthma Phenotypes- Latest Update</strong></span></h3> <p style="text-align: justify;"><span style="color: #333333; font-size: medium; font-family: arial, helvetica, sans-serif;"><strong></strong><strong>1.</strong> <strong>Allergic Asthma-</strong> Presents during childhood itself. Patient has other associated symptoms of allergy like eczema, allergic rhinitis, allergy to food items etc. The sputum examination in these patients would show increased number of eosinophils (a type of white blood cell involved in allergic conditions).</span></p> <p style="text-align: justify;"><span style="color: #333333; font-size: medium; font-family: arial, helvetica, sans-serif;"><strong>2. Nonallergic asthma-</strong> These patients will not have any allergic symptoms and their blood picture will not show any allergic parameters.</span></p> <p style="text-align: justify;"><span style="color: #333333; font-size: medium; font-family: arial, helvetica, sans-serif;"><strong>3. Late onset asthma-</strong> This is usually non-allergic in nature and common among adult females.</span></p> <p style="text-align: justify;"><span style="color: #333333; font-size: medium; font-family: arial, helvetica, sans-serif;"><strong>4. Asthma with fixed airflow limitation-</strong> When a long standing asthma patient develops airflow limitation evident by lung function tests due to airway remodeling, it is described under this phenotype.</span></p> <p style="text-align: justify;"><span style="color: #333333; font-size: medium; font-family: arial, helvetica, sans-serif;"><strong>5. Asthma with obesity-</strong> In these patients, there are prominent airway symptoms despite inadequate inflammatory response.</span></p> <h3 dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Management of Asthma:</strong></span></h3> <p dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">The goals of therapy are</span></p> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">to relieve the symptoms </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">to reduce the limitation of physical activity </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">to optimize the lung function </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">to minimize the acute exacerbations and emergency visits</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">to individualize the medicines and reduce the side effects</span></p> </li> </ul> <h3 style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Stepwise Management Of Asthma:</strong></span></h3> <p dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Depending upon the severity, the patients are graded treatment is started. Then, patients are reassessed after 2-3 weeks and the grade of treatment is either stepped up or stepped down according to the necessity.</span></p> <p dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Step 1-</strong> Intermittent Asthma</span></p> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Only rescue therapy using salbutamol puffs</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">If puffs have to be used for more than twice in the same week, move to step 2</span></p> </li> </ul> <p dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Step 2-</strong> Mild Persistent Asthma</span></p> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Low dose inhaled steroid plus long acting beta agonists</span></p> </li> </ul> <p dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Step 3-</strong> Moderate Persistent Asthma</span></p> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Moderate dose inhaled steroids plus long acting beta agonists or Moderate dose inhaled steroids plus leukotriene inhibitors </span></p> </li> </ul> <p dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Step 4-</strong> Severe Persistent Asthma </span></p> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">High dose inhaled steroids plus long acting beta two agonists plus ORAL Steroids.</span></p> </li> </ul> <h3 dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Common Medications:</strong></span></h3> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Beta-agonists- salbutamol, formoterol, bambuterol</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Bronchodilators- Deri Phyl ENE</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Inhaled corticosteroids - betamethasone</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Leukotriene modulators – montelukast, zafirlukast</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Monoclonal anti-IgE antibody – infliximab, adalimumab</span></p> </li> </ul> <h3 dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Side Effects of The Drugs:</strong></span></h3> <p dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Beta agonists cause tremors, palpitations, sudden hypokalemia resulting in major cardiac involvements and even death if not monitored. So, report to the doctor in case of such symptoms. Either changing the drug or decreasing dosage is the suggested alternative.</span></p> <p dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Steroids cause oral or submucosal candidiasis. Maintain good oral hygiene and gargle using salt water daily to prevent local infection. sodium and water retention, steroid induced psychosis, developing diabetes and hypertension, in the long run, are some of the many side effects of steroids.</span></p> <h3 dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Complications:</strong></span></h3> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">During pregnancy, the severity changes and hence medication has to be tailored</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">For occupational asthma, detailed history of occupational exposure has to be obtained </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Acute exacerbation of asthma is an acute emergency condition</span></p> </li> </ul> <h3 style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Myths And Facts</strong></span></h3> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Myth:</strong> Any wheeze is asthma.</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Fact:</strong> all that has wheeze is not asthma. There are a various differential diagnosis to be considered.</span></p> </li> </ul> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Myth:</strong> Asthma patients almost always die of respiratory distress</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Fact:</strong> Asthma is a very treatable condition and the percentage of deaths is relatively less</span></p> </li> </ul> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Myth:</strong> Taking metered dose inhalers can cause severe unwanted complications </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Fact:</strong> Metered dose inhalers are a very effective way in the treatment of asthma</span></p> </li> </ul> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Myth:</strong> Asthma patients should never exercise </span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;"><strong>Fact:</strong> Exercise induced asthma is a possibility but exercises are not always contraindicated in asthma</span></p> </li> </ul> <h3 dir="ltr" style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Differential Diagnosis:</strong></span></h3> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Upper airway obstruction by tumour, epiglottitis/ vocal cord dysfunction, obstructive sleep apnoea etc.</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Lower airway diseases like allergic bronchopulmonary aspergillosis, alpha1 antitrypsin deficiency, COPD, bronchiectasis, cystic fibrosis</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Localized airway obstruction by foreign body</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Other diseases like cardiac failure, hypersensitivity reactions etc.</span></p> </li> </ul> <h3 style="text-align: justify;"><span style="font-family: arial, helvetica, sans-serif; color: #333333;"><strong>Prevention:</strong></span></h3> <ul style="text-align: justify;"> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Identify the triggers and avoid exposure to them</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Use the regular medications appropriately to avoid exacerbations</span></p> </li> <li dir="ltr"> <p dir="ltr"><span style="font-family: arial, helvetica, sans-serif; font-size: medium; color: #333333;">Patient education </span></p> </li> </ul> <div></div>