Asthma

Today asthma is viewed as a chronic (long-lasting) inflammatory disease of the airways. In those susceptible to asthma, this inflammation causes the airways to narrow periodically. This, in turn, produces wheezing and breathlessness, sometimes to the point where the patient gasps for air. Obstruction to air flow either stops spontaneously or responds to a wide range of treatments, but continuing inflammation makes the airways hyper-responsive to stimuli such as cold air, exercise, dust mites, pollutants in the air, and even stress and anxiety.

Description

About 10 million Americans have asthma, and the number seems to be increasing. Between 1982-92, the rate actually rose by 42%. Not only is asthma becoming more frequent, but it also is a more severe disease than before, despite modern drug treatments. In the same 10-year period, the death rate from asthma in the United States increased by 35%.

The changes that take place in the lungs of asthmatic persons makes the airways (the "breathing tubes," or bronchi and the smaller bronchioles) hyper-reactive to many different types of stimuli that don't affect healthy lungs. In an asthma attack, the muscle tissue in the walls of bronchi go into spasm, and the cells lining the airways swell and secrete mucus into the air spaces. Both these actions cause the bronchi to become narrowed (bronchoconstriction). As a result, an asthmatic person has to make a much greater effort to breathe in air and to expel it.

Cells in the bronchial walls, called mast cells, release certain substances that cause the bronchial muscle to contract and stimulate mucus formation. These substances, which include histamine and a group of chemicals called leukotrienes, also bring white blood cells into the area, which is a key part of the inflammatory response. Many patients with asthma are prone to react to such "foreign" substances as pollen, house dust mites, or animal dander; these are called allergens. On the other hand, asthma affects many patients who are not "allergic" in this way.

Asthma usually begins in childhood or adolescence, but it also may first appear during adult years. While the symptoms may be similar, certain important aspects of asthma are different in children and adults.

Child-onset asthma

When asthma does begin in childhood, it often does so in a child who is likely, for genetic reasons, to become sensitized to common "allergens" in the environment (atopic person). When these children are exposed to house-dust mites, animal proteins, fungi, or other potential allergens, they produce a type of antibody that is intended to engulf and destroy the foreign materials. This has the effect of making the airway cells sensitive to particular materials. Further exposure can lead rapidly to an asthmatic response. This condition of atopy is present in at least one-third and as many as half of the general population. When an infant or young child wheezes during viral infections, the presence of allergy (in the child itself or a close relative) is a clue that asthma may well continue throughout childhood.

Adult-onset asthma

Allergenic materials may also play a role when adults become asthmatic. Asthma can actually start at any age and in a wide variety of situations. Many adults who are not allergic do have such conditions as sinusitis or nasal polyps, or they may be sensitive to aspirin and related drugs. Another major source of adult asthma is exposure at work to animal products, certain forms of plastic, wood dust, or metals.

Causes and symptoms

In most cases, asthma is caused by inhaling an allergen that sets off the chain of biochemical and tissue changes leading to airway inflammation, bronchoconstriction, and wheezing. Because avoiding (or at least minimizing) exposure is the most effective way of treating asthma, it is vital to identify which allergen or irritant is causing symptoms in a particular patient. Once asthma is present, symptoms can be set off or made worse if the patient also has rhinitis (inflammation of the lining of the nose) or sinusitis. When, for some reason, stomach acid passes back up the esophagus (acid reflux), this can also make asthma worse. A viral infection of the respiratory tract can also inflame an asthmatic reaction. Aspirin and a type of drug called beta-blockers, often used to treat high blood pressure, can also worsen the symptoms of asthma.

The most important inhaled allergens giving rise to attacks of asthma are:

• animal dander
• mites in house dust
• fungi (molds) that grow indoors
• cockroach allergens
• pollen
• occupational exposure to chemicals, fumes, or particles of industrial materials in the air

Inhaling tobacco smoke, either by smoking or being near people who are smoking, can irritate the airways and trigger an asthmatic attack. Air pollutants can have a similar effect. In addition, there are three important factors that regularly produce attacks in certain asthmatic patients, and they may sometimes be the sole cause of symptoms. They are:

• inhaling cold air (cold-induced asthma)
• exercise-induced asthma (in certain children, asthma is caused simply by exercising)
• stress or a high level of anxiety

Wheezing is often very obvious, but mild asthmatic attacks may be confirmed when the physician listens to the patient's chest with a stethoscope. Besides wheezing and being short of breath, the patient may cough and may report a feeling of "tightness" in the chest. Children may have itching on their back or neck at the start of an attack. Wheezing is often loudest when the patient breathes out, in an attempt to expel used air through the narrowed airways. Some asthmatics are free of symptoms most of the time but may occasionally be short of breath for a brief time. Others spend much of their days (and nights) coughing and wheezing, until properly treated. Crying or even laughing may bring on an attack. Severe episodes are often seen when the patient gets a viral respiratory tract infection or is exposed to a heavy load of an allergen or irritant. Asthmatic attacks may last only a few minutes or can go on for hours or even days (a condition called status asthmaticus).

Being short of breath may cause a patient to become very anxious, sit upright, lean forward, and use the muscles of the neck and chest wall to help breathe. The patient may be able to say only a few words at a time before stopping to take a breath. Confusion and a bluish tint to the skin are clues that the oxygen supply is much too low, and that emergency treatment is needed. In a severe attack that lasts for some time, some of the air sacs in the lung may rupture so that air collects within the chest. This makes it even harder to breathe in enough air. Almost always, even patients with the most severe attacks will recover completely.

Diagnosis

Apart from listening to the patient's chest, the examiner should look for maximum chest expansion while taking in air. Hunched shoulders and contracting neck muscles are other signs of narrowed airways. Nasal polyps or increased amounts of nasal secretions are often noted in asthmatic patients. Skin changes, like atopic dermatitis or eczema, are a tipoff that the patient has allergic problems.

Inquiring about a family history of asthma or allergies can be a valuable indicator of asthma. The diagnosis may be strongly suggested when typical symptoms and signs are present. A test called spirometry measures how rapidly air is exhaled and how much is retained in the lungs. Repeating the test after the patient inhales a drug that widens the air passages (a bronchodilator) will show whether the airway narrowing is reversible, which is a very typical finding in asthma. Often patients use a related instrument, called a peak flow meter, to keep track of asthma severity when at home.

Often, it is difficult to determine what is triggering asthma attacks. Allergy skin testing may be used, although an allergic skin response does not always mean that the allergen being tested is causing the asthma. Also, the body's immune system produces antibody to fight off the allergen, and the amount of antibody can be measured by a blood test. This will show how sensitive the patient is to a particular allergen. If the diagnosis is still in doubt, the patient can inhale a suspect allergen while using a spirometer to detect airway narrowing. Spirometry can also be repeated after a bout of exercise if exercise-induced asthma is a possibility. A chest x ray will help rule out other disorders.

Treatment

Patients should be periodically examined and have their lung function measured by spirometry to make sure that treatment goals are being met. These goals are to prevent troublesome symptoms, to maintain lung function as close to normal as possible, and to allow patients to pursue their normal activities including those requiring exertion. The best drug therapy is that which controls asthmatic symptoms while causing few or no side-effects.

Drugs

METHYLXANTHINES. The chief methylxanthine drug is theophylline. It may exert some anti-inflammatory effect, and is especially helpful in controlling nighttime symptoms of asthma. When, for some reason, a patient cannot use an inhaler to maintain long-term control, sustained-release theophylline is a good alternative. The blood levels of the drug must be measured periodically, as too high a dose can cause an abnormal heart rhythm or convulsions.

BETA-RECEPTOR AGONISTS. These drugs, which are bronchodilators, are the best choice for relieving sudden attacks of asthma and for preventing attacks from being triggered by exercise. Some agonists, such as albuterol, act mainly in lung cells and have little effect on other organs, such as the heart. These drugs generally start acting within minutes, but their effects last only four to six hours (although longer-acting forms are being developed). They may be taken by mouth, inhaled, or injected.

STEROIDS. These drugs, which resemble natural body hormones, block inflammation and are extremely effective in relieving symptoms of asthma. When steroids are taken by inhalation for a long period, asthma

A comparison of normal bronchioles and those of an asthma sufferer. (Illustration by Hans & Cassady.)

attacks become less frequent as the airways become less sensitive to allergens. This is the strongest medicine for asthma, and can control even severe cases over the long term and maintain good lung function. Steroids can cause numerous side-effects, however, including bleeding from the stomach, loss of calcium from bones, cataracts in the eye, and a diabetes-like state. Patients using steroids for lengthy periods may also have problems with wound healing, may gain weight, and may suffer mental problems. In children, growth may be slowed. Besides being inhaled, steroids may be taken by mouth or injected, to rapidly control severe asthma.

LEUKOTRIENE MODIFIERS. Leukotriene modifiers are a new type of drug that can be used in place of steroids, for older children or adults who have a mild degree of asthma that persists. They work by counteracting leukotrienes, which are substances released by white blood cells in the lung that cause the air passages to constrict and promote mucus secretion.

OTHER DRUGS. Cromolyn and nedocromil are anti-inflammatory drugs that are often used as initial treatment to prevent asthmatic attacks over the long term in children. They can also prevent attacks when given before exercise or when exposure to an allergen cannot be avoided. These are safe drugs but are expensive, and must be taken regularly even if there are no symptoms. Anti-cholinergic drugs, such as atropine, are useful in controlling severe attacks when added to an inhaled beta-receptor agonist. They help widen the airways and suppress mucus production.

If a patient's asthma is caused by an allergen that cannot be avoided and it has been difficult to control symptoms by drugs, immunotherapy may be worth trying. Typically, increasing amounts of the allergen are injected over a period of three to five years, so that the body can build up an effective immune response. There is a risk that this treatment may itself cause the airways to become narrowed and bring on an asthmatic attack. Not all experts are enthusiastic about immunotherapy, although some studies have shown that it does reduce asthmatic symptoms caused by exposure to house-dust mites, ragweed pollen, and cats.

Managing asthmatic attacks

A severe asthma attack should be treated as quickly as possible. It is most important for a patient suffering an acute attack to be given extra oxygen. Rarely, it may be necessary to use a mechanical ventilator to help the patient breathe. A beta-receptor agonist is inhaled repeatedly or continuously. If the patient does not respond promptly and completely, a steroid is given. A course of steroid therapy, given after the attack is over, will make a recurrence less likely.

Maintaining control

Long-term asthma treatment is based on inhaling a beta-receptor agonist using a special inhaler that meters the dose. Patients must be instructed in proper use of an inhaler to be sure that it will deliver the right amount of drug. Once asthma has been controlled for several weeks or months, it is worth trying to cut down on drug treatment, but this must be done gradually. The last drug added should be the first to be reduced. Patients should be seen every one to six months, depending on the frequency of attacks.

Starting treatment at home, rather than in hospital, makes for minimal delay and helps the patient to gain a sense of control over the disease. All patients should be taught how to monitor their symptoms so that they will know when an attack is starting, and those with moderate or severe asthma should know how to use a flow meter. They should also have a written "action plan" to follow if symptoms suddenly become worse, including how to adjust their medication and when to seek medical help. If more intense treatment is necessary, it should be continued for several days. Over-the-counter "remedies" should be avoided. When deciding whether a patient should be hospitalized, the past history of acute attacks, severity of symptoms, current medication, and whether good support is available at home all must be taken into account.

Referral to an asthma specialist should be considered if:

• there has been a life-threatening asthma attack or severe, persistent asthma
• treatment for three to six months has not met its goals
• some other condition, such as nasal polyps or chronic lung disease, is complicating asthma
• special tests, such as allergy skin testing or an allergen challenge, are needed
• intensive steroid therapy has been necessary

Special populations

INFANTS AND YOUNG CHILDREN. It is especially important to closely watch the course of asthma in young patients. Treatment is cut down when possible and if there is no clear improvement, some other treatment should be tried. If a viral infection leads to severe asthmatic symptoms, steroids may help. The health care provider should write out an asthma treatment plan for the child's school. Asthmatic children often need medication at school to control acute symptoms or to prevent exercise-induced attacks. Proper management will usually allow a child to take part in play activities. Only as a last resort should activities be limited.

THE ELDERLY. Older persons often have other types of obstructive lung disease, such as chronic bronchitis or emphysema. This makes it important to know to what extent the symptoms are caused by asthma. Giving steroids for two to three weeks can help determine this. Side-effects from beta-receptor agonist drugs (including a speeding heart and tremor) may be more common in older patients. These patients may benefit from receiving an anti-cholinergic drug, along with the beta-receptor agonist. If theophylline is given, the dose should be limited, as older patients are less able to clear this drug from their blood. Steroids should be avoided, as they often make elderly patients confused and agitated. Steroids may also further weaken the bones.

Prognosis

Most patients with asthma respond well when the best drug or combination of drugs is found, and they are able to lead relatively normal lives. More than half of affected children stop having attacks by the time they reach 21 years of age. Many others have less frequent and less severe attacks as they grow older. Urgent measures to control asthma attacks and ongoing treatment to prevent attacks are equally important. A small minority of patients will have progressively more trouble breathing and they run a risk of going into respiratory failure and they must receive intensive treatment.

Prevention

Minimizing exposure to allergens

There are a number of ways to cut down exposure to the common allergens and irritants that provoke asthmatic attacks, or to avoid them altogether:

• If the patient is sensitive to a family pet, remove the animal or at least keep it out of the bedroom (with the bedroom door closed). Keep the pet away from carpets and upholstered furniture. Remove all feathers.
• To reduce exposure to house dust mites, remove wall-to-wall carpeting, keep the humidity down, and use special pillow and mattress covers. Cut down on stuffed toys, and wash them each week in hot water.
• If cockroach allergen is causing asthma attacks, kill the roaches (using poison, traps, or boric acid rather than chemicals). Take care not to leave food or garbage exposed.
• Keep indoor air clean by vacuuming carpets once or twice a week (with the patient absent), avoid using humidifiers, and do use air conditioning during warm weather (so that the windows can be closed).
• Avoid exposure to tobacco smoke.
• Do not exercise outside when air pollution levels are high.
• When asthma is related to exposure at work, take all precautions, including wearing a mask and, if necessary, arrange to work in a safer area.