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technology 25 Nov 2019

Asthma

By Dr. Walter Odongo, Pharmacist
Member, Pharmaceutical Society of Kenya (MPSK)

Asthma is a condition in which your airways narrow and swell and may produce extra mucus. This can make breathing difficult and trigger coughing, a whistling sound (wheezing) when you breathe out and shortness of breath. For some people, asthma is a minor nuisance. For others, it can be a major problem that interferes with daily activities and may lead to a life-threatening asthma attack. Asthma can’t be cured, but its symptoms can be controlled. Because asthma often changes over time, it’s important that you work with your doctor to track your signs and symptoms and adjust your treatment as needed.

Symptoms

Asthma symptoms vary from person to person. You may have infrequent asthma attacks, have symptoms only at certain times — such as when exercising — or have symptoms all the time. Asthma signs and symptoms include:

• Shortness of breath.

• Chest tightness or pain.

• Wheezing when exhaling, which is a common sign of asthma in children.

• Trouble sleeping caused by shortness of breath, coughing or wheezing.

• Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or the flu.

Signs that your asthma is probably worsening include:

• Asthma signs and symptoms that are more frequent and bothersome.

• Increasing difficulty breathing, as measured with a device used to check how well your lungs are working.(peak flow meter)

• The need to use a quick-relief inhaler more often.

The type of asthma that you have can determine which symptoms you experience. Not everyone with asthma will experience these particular symptoms. If you think the symptoms you’re experiencing could be a sign of a condition such as asthma, make an appointment to see your doctor. The first indication that you have asthma may not be an actual asthma attack.

Causes

It isn’t clear why some people get asthma and others don’t, but it’s probably due to a combination of environmental and inherited (genetic) factors.

Asthma triggers

Asthma triggers. photo/courtesy

Exposure to various irritants and substances that trigger allergies (allergens) can trigger signs and symptoms of asthma. Asthma triggers are different from person to person and can include:

• Airborne allergens, such as pollen, dust mites, mold spores, pet dander or particles of cockroach waste.

• Respiratory infections, such as the common cold.

• Physical activity.

• Cold air.

• Air pollutants and irritants, such as smoke.

• Certain medications, including beta blockers, aspirin, and nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve).

• Strong emotions and stress.

• Sulfites and preservatives added to some types of foods and beverages, including shrimp, dried fruit, processed potatoes, beer and wine.

• Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat.

Types of Asthma

There are many different types of asthma. The most common type is bronchial asthma, which affects the bronchi in the lungs. Additional forms of asthma include childhood asthma and adult-onset asthma. In adult-onset asthma, symptoms don’t appear until at least age 20.Other specific types of asthma are described below.

(a) Allergic asthma (extrinsic asthma)

>Allergens trigger this common type of asthma. These might include: pet dander from animals like cats and dogs, food, mold, pollen, dust

>Allergic asthma is often seasonal because it often goes hand-in-hand with seasonal allergies.

(b) Nonallergic asthma (intrinsic asthma)

>Irritants in the air not related to allergies trigger this type of asthma. These irritants might include: burning wood, cigarette smoke, cold air, air pollution, viral illnesses, air fresheners, household cleaning products, perfumes.

(c) Occupational asthma

>Occupational asthma is a type of asthma induced by triggers in the workplace. These include: Dust, dyes, gases and fumes, industrial chemicals, animal proteins, rubber latex

>These irritants can exist in a wide range of industries, including: Farming, textiles, woodworking, manufacturing

(d) Exercise-induced bronchoconstriction (EIB)

>Exercise-induced bronchoconstriction (EIB) usually affects people within a few minutes of starting exercise and up to 10–15 minutes after physical activity.

>This condition was previously known as exercise-induced asthma (EIA).

>Up to 90 percent of people with asthma also experience EIB, but not everyone with EIB will have other types of asthma.

(e) Aspirin-induced asthma

>Aspirin-induced asthma (AIA), also called aspirin-exacerbated respiratory disease (AERD), is usually severe.

>It’s triggered by taking aspirin or another NSAID (nonsteroidal anti-inflammatory drug), such as naproxen (Aleve) or ibuprofen (Advil).The symptoms may begin within minutes or hours. These patients also typically have nasal polyps.

>About 9 percent of people with asthma have AIA. It usually develops suddenly in adults between the ages of 20 and 50.

(f) Nocturnal asthma

>In this type of asthma, symptoms worsen at night. Triggers that are thought to bring on symptoms at night include: Heartburn, pet dander, dust mites. The body’s natural sleep cycle may also trigger nocturnal asthma.

(g) Cough-variant asthma (CVA)

>Cough-variant asthma (CVA) doesn’t have classic asthma symptoms of wheezing and shortness of breath. It’s characterized by a persistent, dry cough.

>If it’s not treated, CVA can lead to full-blown asthma flares that include the other more common symptoms. Risk factors.

A number of factors are thought to increase your chances of developing asthma. They include:

• Having a blood relative with asthma, such as a parent or sibling

• Having another allergic condition, such as atopic dermatitis — which causes red, itchy skin — or hay fever — which causes a runny nose, congestion and itchy eyes

• Being overweight.

• Being a smoker.

• Exposure to second-hand smoke.

• Exposure to exhaust fumes or other types of pollution.

• Exposure to occupational triggers, such as chemicals used in farming, hairdressing and manufacturing.

ALSO READ: Bad breath (Halitosis)

Photo/courtesy

Complications

Asthma complications include:

• Signs and symptoms that interfere with sleep, work and other activities.

• Sick days from work or school during asthma flare-ups.

• A permanent narrowing of the tubes that carry air to and from your lungs (bronchial tubes), which affects how well you can breathe.

• Emergency room visits and hospitalizations for severe asthma attacks.

• Side effects from long-term use of some medications used to stabilize severe asthma.

Proper treatment makes a big difference in preventing both short-term and long-term complications caused by asthma.

Prevention

While there’s no way to prevent asthma, you and your doctor can design a step-by-step plan for living with your condition and preventing asthma attacks.• Follow your asthma action plan. With your doctor and health care team, write a detailed plan for taking medications and managing an asthma attack. Then be sure to follow your plan.

Asthma is an ongoing condition that needs regular monitoring and treatment. Taking control of your treatment can make you feel more in control of your life.

• Get vaccinated for influenza and pneumonia. Staying current with vaccinations can prevent flu and pneumonia from triggering asthma flare-ups.

• Identify and avoid asthma triggers. A number of outdoor allergens and irritants — ranging from pollen and mold to cold air and air pollution — can trigger asthma attacks. Find out what causes or worsens your asthma, and take steps to avoid those triggers.

• Monitor your breathing. You may learn to recognize warning signs of an impending attack, such as slight coughing, wheezing or shortness of breath. But because your lung function may decrease before you notice any signs or symptoms, regularly measure and record your peak airflow with a home peak flow meter. A peak flow meter measures how hard you can breathe out. Your doctor can show you how to monitor your peak flow at home.

• Identify and treat attacks early. If you act quickly, you’re less likely to have a severe attack. You also won’t need as much medication to control your symptoms .When your peak flow measurements decrease and alert you to an oncoming attack, take your medication as instructed. Also, immediately stop any activity that may have triggered the attack. If your symptoms don’t improve, get medical help as directed in your action plan.

• Take your medication as prescribed. Don’t change your medications without first talking to your doctor, even if your asthma seems to be improving. It’s a good idea to bring your medications with you to each doctor visit. Your doctor can make sure you’re using your medications correctly and taking the right dose.

• Pay attention to increasing quick-relief inhaler use. If you find yourself relying on your quick-relief inhaler, such as albuterol, your asthma isn’t under control. See your doctor about adjusting your treatment.

Diagnosis

>>Physical exam. Your doctor will perform a physical exam to rule out other possible conditions, such as a respiratory infection or chronic obstructive pulmonary disease (COPD). Your doctor will also ask you questions about your signs and symptoms and about any other health problems.

>>Tests to measure lung function. You may be given lung function tests to determine how much air moves in and out as you breathe. These tests may include:

• Spirometry. This test estimates the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath and how fast you can breathe out.

• Peak flow. A peak flow meter is a simple device that measures how hard you can breathe out. Lower than usual peak flow readings are a sign that your lungs may not be working as well and that your asthma may be getting worse. Your doctor will give you instructions on how to track and deal with low peak flow readings.

.Lung function tests often are done before and after taking a medication to open your airways called a bronchodilator (brong-koh-DIE-lay-tur), such as albuterol. If your lung function improves with use of a bronchodilator, it’s likely you have asthma.>>Additional testsOther tests to diagnose asthma include:

• Methacholine challenge. Methacholine is a known asthma trigger. When inhaled, it will cause your airways to narrow slightly. If you react to the methacholine, you likely have asthma. This test may be used even if your initial lung function test is normal.

• Imaging tests. A chest X-ray can help identify any structural abnormalities or diseases (such as infection) that can cause or aggravate breathing problems.

• Allergy testing. Allergy tests can be performed by a skin test or blood test. They tell you if you’re allergic to pets, dust, mold or pollen. If allergy triggers are identified, your doctor may recommend allergy shots.

• Nitric oxide test. This test measures the amount of the gas nitric oxide in your breath. When your airways are inflamed — a sign of asthma — you may have higher than normal nitric oxide levels. This test isn’t widely available.

• Sputum eosinophils. This test looks for certain white blood cells (eosinophils) in the mixture of saliva and mucus (sputum) you discharge during coughing. Eosinophils are present when symptoms develop and become visible when stained with a rose-colored dye.

• Provocative testing for exercise and cold-induced asthma. In these tests, your doctor measures your airway obstruction before and after you perform vigorous physical activity or take several breaths of cold air.

Classifications

>To classify your asthma severity, your doctor will consider how often you have signs and symptoms and how severe they are. Your doctor will also consider the results of your physical exam and diagnostic tests.

>Determining your asthma severity helps your doctor choose the best treatment. Asthma severity often changes over time, requiring treatment adjustments. Asthma classifications include:

• Intermittent. Most people have this type of asthma, which doesn’t interfere with daily activities. Symptoms are mild, lasting fewer than two days per week or two nights per month.

• Mild persistent. The symptoms occur more than twice a week — but not daily — and up to four nights per month.• Moderate persistent. The symptoms occur daily and at least one night every week, but not nightly. They may limit some daily activities.

• Severe persistent. The symptoms occur several times every day and most nights. Daily activities are extremely limited.

Treatment

Prevention and long-term control are key to stopping asthma attacks before they start. Treatment usually involves learning to recognize your triggers, taking steps to avoid triggers and tracking your breathing to make sure your medications are keeping symptoms under control. In case of an asthma flare-up, you may need to use a quick-relief inhaler.

Medications

The right medications for you depend on a number of things — your age, symptoms, asthma triggers and what works best to keep your asthma under control. Preventive, long-term control medications reduce the swelling (inflammation) in your airways that leads to symptoms. Quick-relief inhalers (bronchodilators) quickly open swollen airways that are limiting breathing. In some cases, allergy medications are necessary.

Photo/courtesy

(a) Long-term asthma control medications, generally taken daily, are the cornerstone of asthma treatment. These medications keep asthma under control on a day-to-day basis and make it less likely you’ll have an asthma attack. Types of long-term control medications include:

• Inhaled corticosteroids. These medications include fluticasone propionate (Flovent HFA, Flovent Diskus, Xhance), budesonide (Pulmicort Flexhaler, Pulmicort Respules, Rhinocort), ciclesonide (Alvesco), beclomethasone (Qvar Redihaler), mometasone (Asmanex HFA, Asmanex Twisthaler) and fluticasone furoate (Arnuity Ellipta).You may need to use these medications for several days to weeks before they reach their maximum benefit. Unlike oral corticosteroids, inhaled corticosteroids have a relatively low risk of serious side effects.

• Leukotriene modifiers. These oral medications — including montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo) — help relieve asthma symptoms.Montelukast has been linked to psychological reactions, such as agitation, aggression, hallucinations, depression and suicidal thinking. Seek medical advice right away if you experience any of these reactions.

• Combination inhalers. These medications — such as fluticasone-salmeterol (Advair HFA, Airduo Digihaler, others), budesonide-formoterol (Symbicort), formoterol-mometasone (Dulera) and fluticasone furoate-vilanterol (Breo Ellipta) — contain a long-acting beta agonist along with a corticosteroid.

• Theophylline. Theophylline (Theo-24, Elixophyllin, Theochron) is a daily pill that helps keep the airways open by relaxing the muscles around the airways. It’s not used as often as other asthma medications and requires regular blood tests.

(b) Quick-relief (rescue) medications are used as needed for rapid, short-term symptom relief during an asthma attack. They may also be used before exercise if your doctor recommends it. Types of quick-relief medications include:

• Short-acting beta agonists. These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others) and levalbuterol (Xopenex, Xopenex HFA).Short-acting beta agonists can be taken using a portable, hand-held inhaler or a nebulizer, a machine that converts asthma medications to a fine mist. They’re inhaled through a face mask or mouthpiece.

• Anticholinergic agents. Like other bronchodilators, ipratropium (Atrovent HFA) and tiotropium (Spiriva, Spiriva Respimat) act quickly to immediately relax your airways, making it easier to breathe. They’re mostly used for emphysema and chronic bronchitis, but can be used to treat asthma.

• Oral and intravenous corticosteroids. These medications — which include prednisone (Prednisone Intensol, Rayos) and methylprednisolone (Medrol, Depo-Medrol, Solu-Medrol) — relieve airway inflammation caused by severe asthma. They can cause serious side effects when used long term, so these drugs are used only on a short-term basis to treat severe asthma symptoms. If you have an asthma flare-up, a quick-relief inhaler can ease your symptoms right away. But you shouldn’t need to use your quick-relief inhaler very often if your long-term control medications are working properly. Keep a record of how many puffs you use each week. If you need to use your quick-relief inhaler more often than your doctor recommends, see your doctor. You probably need to adjust your long-term control medication.

(c) Allergy medications may help if your asthma is triggered or worsened by allergies. These include:

• Allergy shots (immunotherapy). Over time, allergy shots gradually reduce your immune system reaction to specific allergens. You generally receive shots once a week for a few months, then once a month for a period of three to five years.

• Biologics. These medications — which include omalizumab (Xolair), mepolizumab (Nucala), dupilumab (Dupixent), reslizumab (Cinqair) and benralizumab (Fasenra) — are specifically for people who have severe asthma.

(d) Bronchial thermoplasty This treatment is used for severe asthma that doesn’t improve with inhaled corticosteroids or other long-term asthma medications. It isn’t widely available nor right for everyone. During bronchial thermoplasty, your doctor heats the insides of the airways in the lungs with an electrode. The heat reduces the smooth muscle inside the airways. This limits the ability of the airways to tighten, making breathing easier and possibly reducing asthma attacks. The therapy is generally done over three outpatient visits.

Lifestyle and home remedies

Photo/courtesy

Although many people with asthma rely on medications to prevent and relieve symptoms, you can do several things on your own to maintain your health and lessen the possibility of asthma attacks.

>Avoid your triggers. Taking steps to reduce your exposure to asthma triggers is a key part of asthma control. To reduce your exposure, you should:

• Use your air conditioner. Air conditioning reduces the amount of airborne pollen from trees, grasses and weeds that finds its way indoors. Air conditioning also lowers indoor humidity and can reduce your exposure to dust mites. If you don’t have air conditioning, try to keep your windows closed during pollen season.

• Decontaminate your decor. Minimize dust that may worsen night time symptoms by replacing certain items in your bedroom. For example, encase pillows, mattresses and box springs in dustproof covers. Avoid using down-filled pillows and blankets. Throughout the house, remove carpeting and install hardwood or linoleum flooring. Use washable curtains and blinds.

• Maintain optimal humidity. If you live in a damp climate, talk to your doctor about using a dehumidifier.

• Prevent mold spores. Clean damp areas in the bathroom, kitchen and around the house to keep mold spores from developing. Get rid of moldy leaves or damp firewood in the yard.

• Reduce pet dander. If you’re allergic to dander, avoid pets with fur or feathers. Having pets regularly bathed or groomed may also reduce the amount of dander in your surroundings.

• Clean regularly. Clean your home at least once a week. If you’re likely to stir up dust, wear a mask or have someone else do the cleaning. Wash your bedding regularly.

• Cover your nose and mouth if it’s cold out. If your asthma is worsened by cold or dry air, wearing a face mask can help.

>Stay healthy. Taking care of yourself can help keep your symptoms under control, including:

• Get regular exercise. Having asthma doesn’t mean you have to be less active. Treatment can prevent asthma attacks and control symptoms during activity.

>Regular exercise can strengthen your heart and lungs, which helps relieve asthma symptoms. If you exercise in cold temperatures, wear a face mask to warm the air you breathe.

• Maintain a healthy weight. Being overweight can worsen asthma symptoms, and it puts you at higher risk of other health problems.

• Control heartburn and gastroesophageal reflux disease (GERD). It’s possible that the acid reflux that causes heartburn may damage lung airways and worsen asthma symptoms. If you have frequent or constant heartburn, talk to your doctor about treatment options. You may need treatment for GERD before your asthma symptoms improve.

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