Mesothelioma Info

Asthma is a chronic respiratory disease that causes difficulty breathing. Asthma is caused by inflamed and constricted airways brought on by an allergic reaction or an environmental trigger. It is potentially life-threatening, but is controllable. Asthma often begins in childhood, even as early as infancy; however, it can occur at any age, even among elderly individuals.


In asthma, the airways become narrowed, thereby trapping air and causing the lungs to become overinflated. The narrowing can occur in varying degrees over a short period of time, causing mild to severe breathing difficulty during an attack.


Asthma affects more than 15 million people in the U.S., where the disease is responsible for more than 5,000 deaths each year. It is the most common chronic disease of childhood. While asthma can be very disruptive, frustrating, and expensive, if properly controlled, the likelihood of danger and discomfort decreases significantly.


Asthma attacks can begin suddenly, or they can take days to develop. An asthma attack occurs when the airways undergo changes due to respiratory infection, allergies, irritants, and other environmental triggers.
The inflammation of asthma causes recurrent episodes of wheezing, breathlessness, tightening of the chest, and coughing. The episodes often occur at night or in the early morning hours.


Asthma is thought to have two primary stages: hyper-reactivity and the inflammatory response. The first stage, hyper-reactivity (also referred to as hyper-responsiveness), occurs when the smooth muscles in the airways constrict and narrow when exposed to inhaled allergens or other irritants. The airways of someone with asthma do not relax, making breathing difficult. The second stage is the inflammatory response. This reaction causes the airways to swell, fill with fluid, and produce thick, sticky mucus. You then experience wheezing and breathlessness, have difficulty exhaling, and have a cough that produces phlegm.


Asthma attacks can be mild or severe. If you are having a mild to moderate attack, you may experience a tight sensation in the chest, wheezing, coughing, and difficulty sleeping. After you take asthma medication, the airways usually open up within a few minutes and the symptoms diminish.
If you are having a severe asthma attack, you will become increasingly breathless, and your neck muscles may become tight. The lack of oxygen will cause your skin to turn bluish, and the skin between your ribs will appear to be sucked in. You may even lose consciousness. Both asthma medication and emergency medical assistance are essential during a severe attack.


Figure 1. Anatomy of the lungs and inflamed airways

Causes

An asthma attack is usually triggered by something that bothers the lungs. The exact causes of asthma are complex and varied, and it is often difficult to determine precisely what initiates an attack. Genetic susceptibility and environmental triggers are among the factors believed to cause asthma. Intense exercise, especially when performed in cold air, may induce asthma. Asthma usually is worse at night when the airways are cooler, mucus does not clear as effectively, and the metabolism of medications can become altered.



Sleep apnea may also be related to the incidence of asthma attacks. Sleep apnea is a disorder that occurs when the body “forgets” to breathe. Breathing ceases for a few seconds (sometimes as much as two minutes, or more) during sleep, but not as a result from an obstruction in the airways. The muscles that control breathing simply don't function correctly.
Viral infections can be potent triggers. Viral respiratory infections, including the common cold and influenza, can be triggers for a severe asthmatic attack. Viral infections may be the main factor that causes chronic asthma.
The common cold (rhinovirus) is one of the most common infectious agents associated with asthma attacks, and it can provoke and intensify asthma attacks.


Allergens can initiate or perpetuate asthma. Airborne pollens, molds, dust, animal dander, and cockroach allergen can trigger asthmatic attacks. The dust mite, a component of house dust, is one of the key causes of asthma symptoms. Dust mites are invisible to the naked eye, and live in bedding, fabric, and carpet. Tobacco and wood smoke, perfume, paint, hair spray, or any other fumes can play a role in triggering asthma attacks. Food allergens or additives also are believed to trigger asthma.


There is an association between gastroesophageal reflux disease (GERD) and asthma. Gastroesophageal reflux disease (GERD) causes heartburn when acid from the stomach creeps into the esophagus. The condition is common in many patients with asthma. Some researchers believe that GERD may cause asthma when the acid spill reaches the throat. The irritation this acid causes to the trachea (the tube which brings air in and out of the body) is believed to trigger spasms and narrowing of the airways in the lungs.


Gastroesophageal reflux often is made worse with the use of oral theophyline, a commonly used bronchodilator medicine that helps stop asthma attacks. Reflux can be made worse because the bronchodilator medicine relaxes the gastroesophageal sphincter, thus allowing even more highly acidic digestive fluids to leak out of the stomach.


Hormones may be involved in asthma. Some patients whose bodies produce too much thyroid hormone (hyperthyroidism) have persistent asthma. In asthmatic women, asthma frequently gets worse before menstrual periods.
There is a close association between sinusitis and asthma. Sinusitis is an inflammation or infection of the air pockets on either side of and behind the nose. A reflex from the inflamed sinuses can trigger an asthma attack.
Symptoms

Typical asthma symptoms include coughing, shortness of breath, a wheezing sound during breathing, and a tight feeling or pain in the chest. If you have asthma, you are likely to experience at least one or more of these symptoms, which may become worse at night.


In severe cases, asthma attacks can be life-threatening. Your breathing may become shallow as your chest works to exhale sufficient air from the lungs. Without adequate oxygen, your skin will turn a bluish color, and the skin around your rib cage will look sucked in. If untreated, you may start to lose consciousness.


Asthma symptoms vary in severity. The symptoms can range from an occasional mild attack of breathlessness to persistent wheezing that does not improve with medication. Asthma symptoms can be seasonal, or can be present year-round. They can come on sporadically, or can be continuous.


Asthma-like wheezing can occur as a result of other serious conditions. Serious lung conditions such as croup, Kartagener's syndrome, and cystic fibrosis; or an obstruction in the trachea, could cause wheezing. Chronic bronchitis and emphysema, the diseases that so often plague smokers, are also associated with wheezing, as is cardiac failure or vocal cord dysfunction. Speak to your doctor about any breathing difficulties you are having, as there are many possible reasons for why you are having trouble.
Risk Factors

Young children are more likely to develop asthma. Asthma often starts during childhood. A child who develops asthma is genetically inclined to have a hypersensitive reaction to environmental allergens (atopy). Individuals with atopy produce antibodies that are directed toward commonly found allergens such as dust mites, pollen, animal proteins, and mold.


Infants and young children who experience wheezing along with viral respiratory infections or allergies, or who have a family history of allergies are likely to have a type of asthma that will continue through childhood.
Adult-onset asthma may have a variety of causes. Asthma can develop at any age, although it most often starts during childhood and adolescence. Adults who develop asthma frequently may have coexisting sinusitis, nasal polyps, and sensitivity to aspirin or similar nonsteroidal anti-inflammatory medications.


Occupational exposure to workplace materials, such as animal products, biological enzymes, plastic resin, wood dusts, and metals may trigger asthma attacks. Individuals exposed to certain irritating materials in occupational settings may experience airway inflammation, bronchial hyper-responsiveness, and clinical signs of asthma.


While identifying and removing the trigger can reduce asthma symptoms, some individuals continue to suffer from persistent asthma even after they are no longer exposed to the chemical or allergen that is making them sick. Other individuals who develop occupational asthma remain permanently impaired after leaving the job site.


Asthma frequently runs in families. If both parents have asthma, the probability that their child will have asthma is greater, although not all children will necessarily experience the same degree of severity. In pairs of identical twins, one may have asthma but the other may not, suggesting that inherited genetic factors do not fully account for the development of asthma.
Diagnosis

Your doctor will ask questions to determine the nature and severity of your symptoms, and your risk factors. Your doctor will ask questions about your pattern of symptoms and any family history of asthma or allergies that can support the likelihood that you have asthma. Your doctor will also ask about the frequency and severity of your symptoms, about medications that you take, and about whether or not you are exposed to the kinds of triggers that are known to cause asthma in others, such as viral respiratory infections and allergens or irritants.


Your doctor will perform a physical examination focusing on the upper respiratory tract, chest, and skin. Your doctor will look for hyperexpansion of the thorax (particularly in children), hunched-looking shoulders, and chest deformity, as these are physical findings that suggest asthma. Wheezing sounds during normal breathing or a prolonged phase of forced exhalation also may suggest asthma.


Your doctor will also look for signs of an allergic reaction, such as increased nasal secretion, mucosal swelling, nasal polyps, or allergic skin conditions.
Lung function tests are usually performed to confirm asthma and to determine its severity. Spirometry is a lung test doctors use to establish whether you have airflow obstruction, and whether it is reversible. Very precise measurements of inhaled and exhaled air are measured when you blow into a device called a spirometer. Spirometry is done periodically to assess obstruction and airway function.


When asthma is suspected, but previous spirometry measurements were normal or almost normal, doctors can use other methods to diagnose or rule out asthma. These include provoking the bronchial tubes (bronchoprovocation) with methacholine, histamine, or exercise followed by spirometry.


You can perform tests yourself in your own home to monitor your progress. Peak flow meters also are helpful for measuring airflow obstruction. A peak flow meter can help to discover if there is airway narrowing hours, and perhaps even days before asthma symptoms appear. Peak flow meters are inexpensive, simple, and portable tests that you can use to monitor yourself between doctor visits.



By keeping records of the measurements, you and your doctor can learn if the particular treatment plan you are using is working well, what makes the asthma worse, and when to add or drop medications. You obtain the measurements by blowing into a tube and reading the corresponding number. Peak flow numbers are color-coded into zones of red (danger), yellow (warning), and green (good), and show you how well your asthma is being controlled.


Figure 2. Peak flow meter
A peak flow meter is a device that measures how well air moves out of your lungs. The peak flow meter can be used to find out if there is airway narrowing hours, even days, before you have any symptoms of asthma. By taking medicine before symptoms develop, you may be able to stop the attack from becoming serious. Children younger than three are usually not good candidates for peak flow devices, but anyone older should consider using one.


How to use a peak flow meter:

• Place the indicator at the base of the numbered scale
• Stand up
• Take a deep breath
• Place the meter in your mouth and close your lips around the mouthpiece
• Do no put your tongue inside the hole
• Blow out as HARD and FAST as you can
• Write the number down that you get
• Repeat these steps two more times
• Write down the highest of the three numbers achieved

FIND YOUR PERSONAL BEST PEAK FLOW NUMBER
Your personal best number is the highest peak flow number you can achieve over a two-week period when your asthma is under good control, meaning you feel fine and do not have asthma symptoms.


Take peak flow readings twice a day for two weeks, in the morning when you wake up and about 10 to 12 hours later. If you take inhaled beta2-agonist medication, take your readings before and after you inhale it.
Keep a diary of your readings.


Once you know your personal best number, your health care professional will assign a zoning system to your range of numbers that will tell you what to do. The zoning system is set up like a traffic light:
Green Zone: (80% to 100% of your personal best number) means that everything is going great. No asthma symptoms are present and you may take your medications as usual.


Yellow Zone: (50% to 80% of your personal best number) means be cautious. You may be having an episode of asthma that requires an increase or a change in your medications. Your asthma may not be under control. Inform your doctor.


Red Zone: (below 50% of your personal best number) signals a medical alert. You must take an inhaled beta2-agonist right away and call your doctor immediately. You need medical attention as soon as possible.
Your doctor will help you create a plan of what to do when your peak flow readings change and how to react in the case of an emergency.
Prevention and Screening

Know what triggers your asthma. You can help to prevent asthma attacks by avoiding things known to make your asthma worse. Discuss asthma triggers with your doctor and take steps to avoid them. Specific triggers may vary from individual to individual.


Avoid cigarette smoke. Smoking cigarettes will make asthma symptoms worse, and secondhand smoke may spur an asthma attack. Your doctor can suggest ways to help you stop smoking. Ask family members to stop smoking as well. Do not permit anyone to smoke in your home or around you. Protect children by making sure no one smokes at a children's day care center.


Reduce your exposure to dust mites. Frequent vacuuming is beneficial, but will not completely remove house dust mites from carpeting or upholstered furniture. When vacuuming, use a dust mask, a double-layered or microfilter vacuum cleaner bag, or a vacuum cleaner with a high efficiency air filtration filter, known as a HEPA filter. Even better, find someone else to do the vacuuming and stay out of the rooms while they are being cleaned.


Encase your bed mattress and pillows in special allergen-impermeable dust-proof covers. If you don't use dust-proof covers on your pillows, wash your pillows weekly in water hotter than 130°F (54.4°C). Sheets and blankets also should be washed weekly in hot water. Avoid resting on fabric-covered furniture. Having hardwood floors rather than wall-to-wall carpeting may help prevent dust from accumulating. Because high indoor humidity promotes dust mites, try to decrease indoor humidity to less than 50% by using a dehumidifier or a central air-conditioning system. Remove any carpets that are placed on concrete, as mold could grow there easily.
Protect yourself from animal dander.



If you own pets, you can take steps to minimize your exposure to animal dander. If you have a yard or patio, keep furred or feathered pets outside, weather permitting. If animals must live inside, keep them outside the bedroom and make sure the door is closed at all times. Keep pets out of rooms with carpets and fabric-covered furniture. Cover the air vents in the bedroom with a filter.


Take necessary measures to prevent cockroaches. Many people with asthma are allergic to dried droppings and remains of cockroaches. Poison bait or traps can help control the pests. Food and garbage should not be left exposed, but kept in closed containers. Vigorous and frequent extermination procedures are required to remove cockroaches. If pesticide spray is used, be sure to stay out of the room until the odor is gone.
Avoid exposure to pollen and outdoor mold. To avoid exposure to pollens from trees, grass, or weeds, and from outdoor molds, try to keep your windows closed during the season when pollen or mold spore counts are high. During allergy season, remain indoors with the windows closed; especially during the morning when pollen and mold spore counts are at their highest.


Reduce moisture to help eliminate indoor mold. Reduce indoor humidity to less than 50% by using air conditioners or dehumidifiers. Fix all leaks and eliminate any other water sources that are associated with mold growth. Clean moldy surfaces with a product that contains bleach.


Reduce exposure to other irritants. Try to avoid using wood-burning stoves, fireplaces, and kerosene heaters. Stay away from other irritants, such as perfumes, talcum powder, hair spray, paints, or any other substance that emits noxious fumes.


Get a yearly influenza (flu) shot to protect yourself against influenza.
Treatment

Urgent Care

Seek emergency medical help if you have a severe asthma attack. Once an asthma attack begins, it can progress very quickly or very slowly. What may appear to be a mild attack at first may very rapidly warrant a trip to the hospital. Urgent care at the hospital for severe asthma may involve administration of beta2-agonists. If you do not respond to other medications, you may be given a corticosteroid. Most patients are given oxygen therapy.
Self Care

Learn how to monitor your symptoms. Learn to recognize your symptom patterns to determine whether your asthma is under control. This can be achieved by using a daily diary and a periodic self-assessment form.
The daily diary should include symptoms and/or peak flow, medication use, and restricted activity. You can monitor all of these factors at home. The diary is especially helpful if you are trying new treatments in an effort to control asthma, and if you need help identifying allergens and irritants that provoke your asthma.


The periodic self-assessment sheet, which is filled out at during office visits, is designed to pinpoint your perception of asthma control, how well you are able to self-manage the condition, and overall satisfaction with treatment.
Table 1. Example of a Patient Diary

Symptoms and ActivitiesMedications TakenPeak FlowCommentsDateWheezeCoughActivitySleepInhaled SteroidsOral SteroidsCromolynAMPM Wheeze: None = 0, Some = 1, Medium = 2, Severe = 3Cough: None = 0, Occasional = 1, Frequent = 2, Continuous = 3Activity: Normal = 0, Can run short distance or climb 3 flights of stairs = 1, Can Walk Only = 2, Missed school/work, or stayed indoors = 3Sleep: Fine = 0, Slept well, slight wheeze or cough = 1, Awake 2 or 3 times, wheeze and cough = 2, Bad night, awake most of time = 3Expert Panel for the National Institutes of Health, National Asthma Education of Prevention Program: Guidelines for the Diagnosis of Asthma. 1997 July; 97-4051:36.
Table 2. Sample Patient Self-Assessment Sheet

NameDateHow many days in the past week have you had chest tightness, cough, shortness of breath, or wheezing (whistling in your chest)?01234567How many nights in the past week have you had chest tightness, cough, shortness of breath, or wheezing (whistling in your chest)?01234567Do you perform peak flow readings at home?YesNoIf yes, did you bring your peak flow chart?YesNoHow many days in the past week has asthma restricted your physical activity?01234567Have you had any asthma attacks since your last visit?YesNoHave you had any unscheduled visits to the doctor, including to the emergency department, since your last visit?YesNoHow many puffs of your short-acting inhaled beta2-agonist (quick relief medicine) do you use per day? How many of your short acting inhaled beta2-agonist inhalers did you go through over the past month? What questions or concerns would you like to discuss with the doctor? How well controlled is your asthma in your opinion? How satisfied are you with your asthma care? Expert Panel for the National Institutes of Health, National Asthma Education of Prevention Program: Guidelines for the Diagnosis of Asthma. 1997 July; 97-4051:36.
Know when to take prescribed medications and when to seek medical help. Be sure you understand your physician's instructions for performing self-monitoring, when to take medications, and when to call for medical assistance. Make certain you have and understand a written emergency management plan. Share this plan with members of your household so that they will know what to do in the event that you are unable to explain it yourself.
Drug Therapy

Your doctor is the best source of information on the drug treatment choices available to you.
Other Therapies

If your asthma is triggered by a specific allergen, such as dust, immunotherapy shots may help you develop an immunity against the substance that causes the attack. Immunotherapy is a preventive treatment for allergic reactions to substances such as grass pollens and house dust mites. This treatment involves injecting small doses of the substance to which you are allergic. The dosage increases over time. This causes the immune system to build a tolerance to the allergen, so that when you are exposed to it in the future, you are less sensitive.
Before starting treatment, you and your doctor will identify the factor that makes your asthma worse by discussing your case, and using skin or sometimes blood tests.


Once the allergen has been identified, an extract of it is injected into the skin of the arm. An injection may be given once a week (sometimes more often) for about 30 weeks, after which injections can be reduced to every two weeks. Eventually, injections can be given every four weeks. The duration of therapy may be three to five years, sometimes longer.
Alternative Medicine

Strengthening the immune system through proper diet and nutrition can help you resist asthma, according to natural health practitioners. This may be achieved in part by eliminating allergens in foods, resolving digestive problems, establishing the right balance of essential fatty acids, and supplying other nutrients. Good dietary management includes eating a balanced diet, avoiding artificial colorings, caffeine, alcohol, tobacco, sugar, and additives and preservatives.


You may want to take a multivitamin containing calcium if you are taking inhaled corticosteroids (ICCS), because they have a small potential to enhance osteoporosis.
Special Circumstances

Many people with asthma have a family history of rhinitis, sinusitis, eczema, or migraine headaches.


Uncontrolled asthma can lead to permanent lung damage. Although rare, in severe cases, an asthma attack can lead to lung failure. Once admitted to the emergency room, most people respond to treatment, but a few do not. Respiratory failure is a very serious condition, and can lead not only to lung damage, but damage to other organs as well.


Uncontrolled asthma is especially serious in pregnant women. If you are pregnant, uncontrolled asthma poses a threat to both you and your child. Pregnant women are at risk for potentially stronger asthma symptoms. Strong coughing, for example, could possibly initiate premature labor.
Although most asthma drugs are safe to take during pregnancy, the specific medications should be prescribed with care. Certain drugs are not recommended and some others should never be used if you are pregnant.
Prognosis

About half of all children with chronic asthma will experience few or no problems for some time after adolescence. There is no known way, however, to predict which children may outgrow asthma and which will not. Additionally, although asthma symptoms may stop for a period of time, this does not guarantee that asthma will not return later. Treatment should never be withheld in the expectation that asthma will go away on its own.
Asthma usually is a chronic condition, although in some cases it goes into long periods of remission. In patients with mild to moderate asthma, the condition can improve over time, and many adults eventually become free of symptoms.


Asthma can be controlled through the daily use of long-term drug treatments, lifestyle recommendations, and as needed, use of bronchodilators or quick-relief medications.
Follow-up

Patients with asthma should maintain regular follow-up visits with their physician. Uncontrolled asthma can be fatal. It is essential that you properly perform self-management by using peak flow meters and adjusting medications as required. You should keep a daily record of peak flow readings as well as asthma attacks, exposure to allergens or irritants, and other relevant factors to take with you to regularly scheduled physician visits.