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Asthma Answers and Questions

Essentials

Asthma is a common chronic disease worldwide and affects approximately 24 million persons in the United States. It is the most common chronic disease in childhood, affecting an estimated 7 million children. The pathophysiology of asthma is complex and involves airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness.
Essential update: Severe persistent asthma effectively treated with bronchial thermoplasty
Wechsler and colleagues examined the long-term safety and effectiveness of bronchial thermoplasty in 162 patients with severe persistent asthma from the Asthma Intervention Research 2 (AIR2) trial, which showed a 32% reduction in severe asthma exacerbations, an 84% reduction in respiratory symptom-related emergency department visits, a 73% reduction in hospitalizations for respiratory symptoms, and a 66% reduction in time lost from work/school/other daily activities because of asthma symptoms.
An average decrease of 44% in the proportion of patients experiencing severe exacerbations was maintained through 5 years of follow-up, and the reduction in respiratory symptom-related emergency department visits was 78%. The proportion of patients who experienced any respiratory adverse events, asthma adverse events, or hospitalizations for respiratory symptoms did not increase during follow-up. At 5 years, the average dose of inhaled corticosteroids was reduced by 18%; 12% of patients were completely weaned off long-acting beta2-agonists; and 7% of patients no longer required maintenance asthma medications.

Signs and symptoms

Signs and symptoms of asthma include the following:

• 

  Wheezing
• Coughing
• Shortness of breath
• Chest tightness/pain

Other nonspecific symptoms in infants or young children may be a history of recurrent bronchitis, bronchiolitis, or pneumonia; a persistent cough with colds; and/or recurrent croup or chest rattling.

Diagnosis

Updated guidelines from the National Asthma Education and Prevention Program highlight the importance of correctly diagnosing asthma.

• Episodic symptoms of airflow obstruction are present
• Airflow obstruction or symptoms are at least partially reversible
• Exclusion of alternative diagnoses

Spirometry with postbronchodilator response should be obtained as the primary test to establish the asthma diagnosis. Pulse oximetry measurement is desirable in all patients with acute asthma to exclude hypoxemia. The chest radiograph remains the initial imaging evaluation in most individuals with symptoms of asthma, but in most patients with asthma, chest radiography findings are normal or may indicate hyperinflation. Exercise spirometry is the standard method for assessing patients with exercise-induced bronchospasm.

Management

For all but the most severely affected patients, the ultimate goal is to prevent symptoms, minimize morbidity from acute episodes, and prevent functional and psychological morbidity to provide a healthy (or near healthy) lifestyle appropriate to the age of child.
Pharmacologic treatment
Pharmacologic management includes the use of relief and control agents. Control agents include inhaled corticosteroids, inhaled cromolyn (Intal) or nedocromil (Tilade), long-acting bronchodilators, theophylline (Theo-24, Theochron, Uniphyl), leukotriene modifiers, and anti-IgE antibodies. Relief medications include short-acting bronchodilators, systemic corticosteroids, and ipratropium (Atrovent).
The pharmacologic treatment of asthma is based on stepwise therapy. Asthma medications should be added or deleted as the frequency and severity of the patient's symptoms change.
Allergen avoidance
Environmental exposures and irritants can play a strong role in symptom exacerbations. The use of skin testing or in vitro testing to assess sensitivity to perennial indoor allergens is important. Once the offending allergens are identified, counsel patients on how to avoid them. Efforts should focus on the home, where specific triggers include dust mites, animals, cockroaches, mold, and pollen.

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