Asthma is a disorder characterized by two predominant features. The first is a spasm of the bronchial tubes entering the lungs due to muscle tissue that normally surrounds these structures. The second feature seen in asthma is inflammation in the bronchial tubes, leading to swelling (edema) in the walls of the tubes, plus a marked increase in the production of mucus. The combination of these abnormalities leads to a bronchial tube that is decreased in diameter as well as plugged with thick secretions. It is important to note that each patient usually has a mixture of the two processes, although one feature may predominate. As a general rule, spasm occurs rapidly, and is more easily reversed. On the other hand, symptoms of asthma that have been present for greater than one day probably have a significant inflammatory component, and reversal may take days or weeks to obtain.
Where does asthma come from? No one really knows. There is an inherited tendency in many families to develop asthma, although this is seen only 50% of the time. Probably 5-10% of children will experience asthma. Fortunately, in 50% of these, their symptoms will disappear by puberty. Unfortunately, 1/3 of those children who initially improve will have recurrence of their asthma in adulthood, usually to remain this time. Although most patients seek a single environmental cause, this is rarely the case. Nonetheless, there are well documented causes of asthma, usually occurring after long term exposure at the work place. Such causative agents include wheat flour ("baker's asthma"), solvents in paints, exposure to wood dusts, and the list goes on. Interestingly, even though a few asthmatics owe the development of their disease to a specific agent, once asthma develops, increased airway sensitivity occurs to a multitude of substances, including smoke from cigarettes and fireplaces, air pollution, hairsprays, perfumes, chemical solvents, dust, and many other sources. Allergies to animals (especially cat), pollens, molds, house dust mites, and cockroach droppings are often inciting causes in some people, especially children. Asthma is also associated with other physical problems such as sinusitis and gastric reflux (heartburn), which can often contribute to nightly attacks of wheezing. Certain medications, especially aspirin and other medicines for arthritis can aggravate symptoms in about 15% of asthmatics. These medicines should be avoided.
The treatment of asthma varies depending on the severity of the disease and the physical needs of the patient. In mild asthma, where medications are only taken as needed, long term survival is basically unchanged by daily therapy. However, in more severe asthma, the heart is forced to work especially hard to push blood through the lungs. This strain is not sensed by the body until significant damage occurs. In such cases, your doctor would be adamant in recommending daily treatment. One drawback in the treatment of asthma is that in 15% of all asthmatics (especially children), the symptoms of asthma are not recognized until significant airway obstruction occurs, leading to emergency room visits at the last minute. In these patients, a peak flow meter can be used to allow the patient or parent to recognize symptoms much earlier in an attack. This simple device costs approximately $25, is easy to use, and offers a safety margin in treating more serious asthma patients. Various medications may be used with success. Inhaled therapy works as well as oral products, without most deleterious side effects. Also, some medications are specifically designed to reduce the bronchial spasm, while others reduce inflammation. For specific allergies, "shot therapy" may be helpful, particularly in children. Controversial forms of therapy may be appropriate in more severe forms of asthma. Your doctor will discuss the reason that a specific medicine is chosen for you or your child.
Final Note: Effective asthma therapy requires frequent evaluation by your doctor to avoid unnecessary illness and hospitalizations. The treatment of asthma is a cooperative effort, in which treatment is based on the patient's needs (a different regime is prescribed for the couch potato and the mountain climber, even though they have the same degree of asthma). Understanding a disease process can also result in a reduction in fear of the disease, better compliance with medications, and a personal confidence which may reduce the severity of an attack.
What to do in an Asthma Attack
Very few times exist in which a patient develops an acute asthma attack without warning sings that can be picked up hours or even days prior to the attack. Be on the allergy for an increased cough, fatigue, or worsening episodes of shortness of breath with exertion, since these are the most frequent warning signs indicating that increased usage of certain inhaled medications may be indicated. If a worsening asthma pattern is detected, the following may be helpful:
The patient should remain at rest, and not perform physical labor. If a child, he/she should be brought inside to play. Remain calm especially with children, since anxiety is contagious and can perpetuate the worsening of asthma in most children and susceptible adult patients.
Remove possible inciting causes: smoke from fireplaces, cigarettes, other fumes and vapors. This may include animals that trigger asthma. Start on a regular use of certain inhaled medications (Alupent, Atrovent, Brethair, Maxair, Proventil, and Ventolin) using them regularly every 4-6 hours, usually for 3-4 days until the episode is improved. If the attack is more troublesome, you can maximize your treatment by altering the method of delivery of these medications by:
Take a single spray from your inhaler, wait five (5) minutes and take a second inhalation. For most children and adults, 1-2 additional puffs (3-4 puffs total) can be taken, waiting five (5) minutes after the last inhalation of the above listed medicines before taking any other prescribed inhalers. It is imperative to note that only the above listed inhalers give immediate relief during an acute attack. No change in frequency is needed for any other inhaler unless specifically indicated.
Other medications may be recommended during acute episodes. These would be discussed separately.
When to go to the Emergency Room
Seek immediate attention if a patient has such a severe episode that inhaled treatment is impossible due inability to inhale normally.
If the specifically listed medications above don’t easily control asthma for at least four (4) hours, then seek additional care. Needing to use these inhalers more frequently than every four (4) hours is a warning flag that signifies a progressive worsening of asthma.
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