What is asthma and how is it treated?

Asthma or bronchial asthma is a disease of the respiratory system with a chronic character. The manifestations of the disease include whistling sound when breathing, difficulty in breathing, suffocation attacks, coughing, and tightness in the chest. They occur due to the constriction of the bronchi lumen caused by the specific immunological (allergy) or non-specific mechanisms. The constriction is reversible partially, completely, spontaneously, or as a result of therapy.

The therapy of asthma is made with symptomatic medications aimed at the stopping of an acute attack and basis therapy medicines that affect the mechanism of the spasm occurrence, i.e. attacks-preventive measures.

Short information about asthma

When can you suspect that you have asthma?

The main symptoms of asthma are:

- Suffocation;
- Shortage of air;
- Wheezing, especially when exhaling deeply;
- Coughing commonly at night and/or early in the morning;
- The tightness of heaviness in the chest.

The manifestations can be from mild to severe and last from several hours to several days if the disease is not diagnosed and treated.

An asthma attack is when all signs of the disease develop very quickly.  For the first time, it can cause fear, uncertainty, and helplessness. There may be several reasons for starting an asthma attack: intensive physical exercise, various environmental factors, stress, or contact with allergens.

What causes asthma?

Asthma can be provoked by genetic (unchangeable) risk factors and environmental and lifestyle (changeable) factors. The disease that develops in adults is more frequent in women.

The disease can be provoked by these factors:

- Genetic predisposition (if a person has family members with the disease, or has allergic rhinitis or atopic dermatitis);
- Respiratory tract infections in a young age;
- Contact with allergens or household or industrial chemicals;
- Tobacco smoking;
- Obesity.

The risk is higher in individuals who have several factors for asthma onset and also live a sedentary lifestyle and do not exercise. Worth noting that to minimize the risk it is important to quit smoking tobacco in any forms, i.e. in hookah, electronic cigarettes, and so on.

From the mid-eighties of the twentieth century, there is a steady raise in asthma incidence all over the world. It is especially high in New Zeeland, United Kingdome, and Cuba. It is suggested that above the islands the concentration of allergens is higher due to the local flora and allergens brought by oceanic air currents.

In Europe, the disease incidence has grown fourfold from 1992 to 2002. The highest growth indicator was recorded in Italy. The statistics started to improve in the later years with the integration of prophylactic therapy and education of individuals with asthma on correct management of the disease.

How is asthma diagnosed?

If you notice or had in the past the episodes of breathing with whistle sound, especially in forced exhale, trouble inhaling, chest tightness or heaviness, cough attacks that occur at night or early in the morning, you should go to your physician. Tell your physician about these symptoms even if they have already disappeared. Also, you should inform your physician about the history of asthma in your family and your allergies if you have them. The healthcare specialist should know your medical history and then appoint tests that can confirm asthma.

Before going to a doctor, observe and record the following factors:

- Your breathing, i.e. episodes of wheezing, shortness of breath, and other symptoms, write down when they occur and how long they last;
- Whether there are activities that provoke suffocation attacks or shortness of breath;
- Whether you have breathing difficulty at work and feel better at home.

Write down all of your observations in detail and also inform your physician about any medicines or supplements you use/used when the manifestations occurred.

There is no one single way of diagnosing the disease and it cannot be established just based on the patient’s complaints.

The doctor should hear your respiratory ways. In the case of asthma, he or she hears wheezing of extended exhales. However, if no wheezing is heard, it doesn’t mean that a patient doesn’t have asthma.

If your physician thinks that you may have asthma, he or she will appoint spirometry, a pulmonary function test that measures lung function, namely the volume and/or airflow in inhalation and exhalation. If the test doesn’t show the signs of asthma but you still have the symptoms, your doctor should appoint a trial treatment or will be referred to a pulmonologist for a consultation.

How is spirometry done?

Spirometry is the test of the respiratory ways that doesn’t cause any discomfort or harm. In some cases, frequent and potent inhalation/exhalation can increase the pressure in the chest, stomach, and the eyes and cause discomfort. It also has certain contraindications that your doctor should inform you beforehand. Before the test you should follow the certain rules:

- If you use bronchodilators or inhalers, based on the lasting of their effect, your physician will advise you not to use it for 4-24 hours before the test;
- Do not do physical exercises;
- Do not smoke;
- Do not come to the examination with a full stomach, but two hours before the examination you can have a snack.

Spirometry implies the test during which you need to do a series of regular inhales and exhales, then deep inhales and forced exhales in a special mouthpiece while your nose is closed with a special nose clip. The cycles of different breathing are made several times (at least three times and usually not more than eight times). If lung function is impaired, quick-acting bronchodilators are used, and then in 15 minutes, the test is repeated.

How is asthma treated?

For the therapy of asthma different approaches are used. It is important to know that there is no single best treatment method suitable for everyone as the severity and individual features vary.

The aim of the therapy is the achievement and support of sufficient control over the manifestation and ensuring of the improved quality of life. This result is preferably obtained with the lowest dosage of the medication(s) which ensures fewer adverse reactions.

The disease is well controlled if:

- The manifestations are lacking during daytime or are short-lived and not more frequent than twice a week;
- During the night the manifestations do not occur or if they do than not more frequent than twice a month;
- The disease doesn’t’ restrain physical activity;
- A patient doesn’t need the short-acting inhalers for acute attacks or uses them less than twice a week;
-  Lung function indications are in the norm limits (at least 80% the same as five years ago);
- There are no severe flare-ups or if they occur than less than once a year.

Drug therapy of asthma

The drug therapy of the disease is divided into basis treatment aimed at the management of the manifestations occurrence and quick stopping of suffocation attack.

For mild episodic asthma, the therapy of attacks with quick-acting beta-2 agonists is advised. For chronically manifesting asthma, doctors prescribe permanent basic therapy and additional short-acting inhalers for acute episodes.

The basis treatment usually starts with glucocorticoids for inhalation or hormonal treatment. These medicines have an anti-inflammatory effect; they decrease swelling and irritation in the walls of the lower respiratory tract thus improving breathing function.

The basis treatment is started with the smallest dosages of the first-line medications. They are the ones that have fewest adverse reactions and do not cause resistance to other treatment methods. If the initial dosage is insufficiently effective, it is raised according to the physician’s recommendations. Only if they are ineffective, the physician can prescribe the second-choice medications. If the chosen therapy ensures the control of asthma for at least three consecutive months, the dosage can be lowered to the initial one. It is substantial to go to a physician regularly to ensure timely adjustment of the therapy in accordance with the dynamics of the disease.

If a single medication isn’t sufficient for the control of asthma manifestations, other or additional drug can be prescribed. In most cases, it is long-acting beta-2 agonists. It can come in a separate inhaler or two substances can be combined in a single inhaler which is more convenient.

Beta-2 agonists are bronchodilators, i.e. they dilate the bronchi, which facilitate breathing. The medicines that relax bronchi help preventing wheezing and shortness of breath. They do not help with acute attacks.

There is also a group of less frequently used medicines that are used in the form of oral pills.

If after a month of basis treatment use the desired effect wasn’t achieved, the doctor must assess the correctness of inhaler use technique and whether the individual observes the therapeutic plan and required lifestyle changes of not. If needed, the treatment is adjusted. For instance, the dosages and the frequency of use of the used medication can be altered, or the medications are replaced. If the improvement isn’t achieved even in the use of the raised dosages of two medicines, a consultation of a pulmonologist is needed.

Treatment of attacks. The use of bronchodilators effectively relieves already existing symptoms but these medicines do not help to prevent exacerbations.

Short-acting Beta-2 agonists such as Proventil (Albuterol), also called quick-acting bronchodilators, help relieve acute asthma episodes. They relax the muscles in the respiratory ways, open them, and facilitate breathing. Their action is short-lived and sometimes in severe symptoms repeated use is required. When these medicines are prescribed, ask your doctor how many maximum dosages can be used in a day without harm to your health.

In case of asthma exacerbation, oral glucocorticoids are used. The scheme of use is prescribed by the doctor individually. Besides the pills, the basis therapy treatment must be continued as before.

Prior to initiating the therapy of asthma, the physician must evaluate the severity of the disease. It is crucial for the correct dosage and frequency of use of the medicines. Then your doctor or a nurse should ensure that you know how to use the prescribed inhaler properly. There are different types of inhalers so it is important to learn how to use your first inhaler and every new inhaler if you change them.

Non-drug treatment of asthma

For the therapy of asthma, besides medication treatment, it is important to implement certain lifestyle changes. You need to try to avoid irritants of the respiratory tract such as smoke and allergens. Tobacco smoking is one of the major risks for the development of asthma. Quitting smoking substantially improves a patient’s condition with asthma and health in general.

Another important factor is physical activity. Lack of physical activity plays an important role in the development of asthma. Adequate physical exercising is highly recommended in asthma. Regular physical exercises promote better oxygen absorption and can improve quality of life and control asthma.

Control of asthma dynamics

It is important to control the dynamics of the disease on your own daily. One of the methods is the use of the device test called PEF (peak expiratory flow) meter. It is a device that helps to assess the maximum expiratory flow, evaluate the movement of air in the airways and the strength of the muscles that provide this action.

PEF meter does not replace spirometry. It is a small device that can be used for regular testing of the lung condition and in case of any deviations you should go to a doctor and do spirometry.

Prevention of asthma attacks/exacerbations

Below you can find the list of the major triggers the exposure to which should be avoided as they can provoke an acute asthma attack.

- Cold air. It irritates the airways and can trigger an acute suffocation attack. When you are outdoors in winter, cover your nose and mouth with a scarf.
- Physical exercises. Although you should not avoid physical exercises if you are diagnosed with the disease, you need to discuss with your doctor what exercises are preferable for you. Before a workout, don’t forget to warm up and do a cool down afterward. Avoid working out outdoors when it’s cold or during the high pollen season. Also, you should temporarily refrain from exercising while your asthma is not under control.
- Infectious diseases. Lung diseases such as bronchitis and pneumonia are very dangerous for people with asthma because of the increased amount f mucus forming in the lungs and breathing impairment associated with it. Consult your doctor on how to avoid getting infected, for instance, the possibility of getting a flu vaccine every year.
- Pollen. It is the main allergen that causes allergic reactions and flare-ups of asthma. During high pollen season, avoid spending much time outdoors, keep your windows closed or install filters, wash your hands and face once you get home and do a wet cleaning every day.
- Excess weight. The disease is most widespread among people with excess weight both in kids and adults.
- Tobacco smoking and passive smoking. Adults who smoke or are exposed to tobacco smoke are 40-60% more likely to develop asthma than non-smokers not exposed to smoke. Children are also at higher risk of developing the disease when they are exposed to cigarette smoke. For people with diagnosed asthma, smoking is contraindicated. Also, you should avoid being around smokers and in premises where others smoke.
- Mold fungi. Mold usually occurs in moist premises. Fungal spores act as allergens so it is important to keep your house mold-free.
- Cockroaches and their secretions can cause allergic reactions in many people. Cockroaches are attracted to leftovers, trash, and dry foods. Do not keep trash open.
- Dandruff of pets. Dandruff is secreted by most domestic animals - dogs, cats, birds, and rodents. If you have been diagnosed with asthma, it is not recommended to have pets. If you already have a pet, then make sure they are kept out of the bedroom. Pet must be washed regularly.

Treatment of other diseases in asthma

You should inform your physician about all other diseases and conditions you have as they can influence the treatment of asthma.
In the case of cardiovascular diseases, certain medications for their treatment are unsuitable for patients with asthma. You should inform your doctor about all drugs that you use including painkillers. In some rare cases, patients have an allergy to aspirin. In such cases, as a painkiller, only paracetamol (acetaminophen) should be used.

Where to buy medicines for asthma?

To save on the therapy considering that asthma is in most cases a life-long condition, you can buy asthma medicines online. Online pharmacies offer generic versions of the most effective medicines that cost several times cheaper than their branded counterparts. But make sure you get precise instructions from your doctor on the active substance name and the dosages so that you could purchase the right medications.

Post by: Kylie Richardson, General Practitioner, Rotterdam, Netherlands