Symptoms of asthma develop as a result of the narrowing and inflammation of the airways. Wheezing is a characteristic symptom of asthma, along with shortness of breath. Chest pain or tightness can accompany an asthma attack.
Asthma Related Symptoms and Signs
Asthma results from complex interactions between an individual’s inherited genetic makeup and interactions with the environment. The factors that cause a genetically predisposed individual to become asthmatic are poorly understood. The following are risk factors for asthma:
Asthma may not be the same in different affected individuals. Asthma specialists currently use a variety of clinical data to categorize a patient’s asthma. This data includes the age of asthma onset, the presence or absence of environmental allergies, the presence or absence of elevated blood or sputum levels of eosinophils (a type of white blood cell), lung function testing (spirometry and fractional excretion of nitric oxide), obesity, and cigarette smoke exposure.
Types: T2 high or non T2 (T2 low)
Your doctor may refer to asthma as being “allergic” or “eosinophilic.” One or both of these characteristics make up a “T2 high” phenotype of asthma, which is the term for the type of immune inflammation associated with asthma. The allergic type typically develops in childhood and is related to environmental allergies, which approximately 70%-80% of children with asthma have. Naturally, there is a family history of allergies. Additionally, other allergic conditions, such as food allergies or eczema, are often also present. Allergic asthma often goes into remission in early adulthood. However, in many cases, asthma reappears later. Sometimes allergic asthma can appear with elevated blood or sputum eosinophils. Asthma that develops in adulthood may be associated with sputum or blood eosinophils but without environmental allergies. Sometimes patients in this category also have nasal polyps, which are eosinophil-rich growths in the nasal lining.
Non-T2 asthma, or T2 low asthma, comprises a smaller yet challenging to treat a proportion of asthma that is not associated with allergies or eosinophils. This type of asthma is sometimes called “neutrophilic asthma” and may be related to obesity.
The classic signs and symptoms of asthma are shortness of breath, cough (often worse at night), and wheezing (high-pitched whistling sound produced by turbulent airflow through narrow airways, typically with exhalation). Many patients also report chest tightness. It is important to note that these symptoms are episodic. Individuals with asthma can go long periods without any symptoms.
Common triggers for asthmatic symptoms include exposure to allergens (pets, dust mites, cockroaches, molds, and pollens), exercise, and viral infections. Other triggers include strong emotion, odor exposure, and temperature extremes. Tobacco use or exposure to secondhand smoke complicates asthma management.
Many of the symptoms and signs of asthma are nonspecific and can be seen in other conditions. Symptoms that might suggest conditions other than asthma include new symptom onset in older age, the presence of associated symptoms (such as chest discomfort, lightheadedness, palpitations, and fatigue), and lack of response to appropriate medications for asthma.
The physical exam in asthma is often completely normal. Occasionally, wheezing is present. In an asthma exacerbation, the respiratory rate increases, the heart rate increases, and the work of respiration increases. Individuals often require accessory muscles to breathe, and breath sounds can be diminished. It is important to note that the blood oxygen level typically remains relatively normal, even amid a significant asthma exacerbation. A low blood oxygen level is, therefore, concerning for impending respiratory failure.
The diagnosis of asthma begins with a detailed history and physical examination. Primary-care providers are familiar with an asthma diagnosis, but specialists such as allergists or pulmonologists may be involved. A typical history is an individual with a family history of allergic conditions or a personal account of allergic rhinitis who experiences coughing, wheezing, and difficulty breathing, especially with exercise, viral infections, or during the night. In addition to a typical history, improvement with a trial of appropriate medications is very suggestive of asthma.
In addition to the history and exam, the following are diagnostic procedures that can help with the diagnosis of asthma:
The treatment goals for asthma are to:
Inhaled corticosteroids (ICS) are the most effective anti-inflammatory agents available for the chronic treatment of asthma. They are first-line therapy per most asthma guidelines. It is well recognized that ICS are effective in decreasing the risk of asthma exacerbations. Furthermore, combining a long-acting bronchodilator (LABA) and an ICS has a significant additional beneficial effect on improving asthma control. Short-acting rescue inhalers are the standard of care for breakthrough symptoms.
The most commonly used asthma medications include the following:
There is often concern about the potential long-term side effects of inhaled corticosteroids. Numerous studies have repeatedly shown that even long-term use of inhaled corticosteroids has very few if any sustained, clinically significant side effects, including changes in bone health, growth, or weight. However, the goal always remains to treat all individuals with the least amount of medication that is effective. Patients with asthma should be routinely reassessed for any appropriate changes to their medical regimen.
Asthma medications can be administered via inhalers, either with or without a spacer or nebulized solution. It is important to note that if an individual has proper technique with an inhaler, the amount of medication deposited in the lungs is no different from using a nebulized solution. When prescribing asthma medications, it is essential to provide the appropriate teaching on proper delivery techniques.
Smoking cessation and or minimizing exposure to secondhand smoke is critical when treating asthma. Treating concurrent conditions such as allergic rhinitis and gastroesophageal reflux disease (GERD) may also improve asthma control. Vaccinations such as the annual influenza vaccination and pneumonia vaccination are also indicated.
Although most individuals with asthma are treated as outpatients, the treatment of severe exacerbations can require management in the emergency department or hospital. These individuals typically require supplemental oxygen, early administration of systemic steroids, and frequent or even continuous administration of bronchodilators via a nebulized solution. Individuals at high risk for poor asthma outcomes are referred to a specialist (pulmonologist or allergist).
The following factors should prompt consideration or referral:
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