Understanding Asthma: A Comprehensive Information Guide

Asthma is a chronic lung condition that inflames and narrows the airways, causing breathing problems for the millions of people who suffer from the disease. The exact cause of asthma is unknown, and the severity of symptoms can vary dramatically from one person to the next. It is a complex disease that is not limited to any one set of symptoms, or that affects everyone in the same way. During an asthma attack, the lining of the airways becomes swollen, and the muscles surrounding the airways contract, which further narrows the airway. As a result, inflammation increases, and there is a buildup of mucus, all of which make breathing that much more difficult. Although there is no cure for asthma, with proper treatment most people with asthma can lead normal lives. On this site you will find a variety of information designed to help you better understand and manage asthma to achieve optimal health. The airways of the lungs are the means by which air is transported to and from the blood. In an asthma sufferer, the airways are more "twitchy" than normal, for a variety of reasons. When the airways come into contact with something that "annoys" them (a trigger), such as cold air or exercise, the muscles around the walls of the airways contract and the airways narrow. This makes it harder for air to get in/out of the lungs, and results in symptoms such as coughing, wheezing, shortness of breath and chest tightness. At the same time, the lining of the airways becomes inflamed and swollen, and produces a stickier than normal mucus, adding to the obstruction. It is the bronchial inflammation that makes the airways hypersensitive, or more likely to overreact to triggers. These ongoing changes in the airways cause increased difficulty in breathing, and can result in an asthma attack. It is important to realize that airways narrowing and inflammation occur on an ongoing basis, not just during an attack, which is why people still need to take asthma medication when they feel fine. This inflammation can cause damage to the airways, and alter lung function in the long term if not treated.

What is Asthma?

Asthma is a chronic (long-term) lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing (a whistling sound when you breathe), chest tightness, shortness of breath, and coughing. The coughing often occurs at night or early in the morning. Asthma affects people of all ages, but it most often starts in childhood. In the United States, more than 22 million people are known to have asthma. This includes nearly 6 million children.

People with asthma have inflamed airways which are super sensitive. The airways are the tubes that carry air in and out of your lungs. When the airways come into contact with something that irritates them, making asthma worse, the muscles around the walls of the airways tighten so the airways become narrower. The lining of the airways swell and they produce sticky mucus. These reactions cause the airways to become narrower and irritated, that's why it becomes harder for air to get in and out of the lungs.

Common Symptoms

Asthma symptoms often result in feelings of breathlessness, chest tightness, and wheezing, although in reality, asthma is defined by excessive narrowing of the airways. And despite what many people will have you believe, asthma is more than a "dusty" or "exercise disorder" - it is a chronic condition that is currently in the process of being understood. Given this, common symptoms of asthma are non-specific and vary quite a bit between individuals and over time. Symptoms above and beyond chronic and recurrent airflow limitation may include a widely variable mix of the following: cough, especially at night, chest tightness, wheezing, sputum production, and increased work or effort to breathe. Asthma has been definitively diagnosed when the above symptoms are present and are either partially or fully reversible with treatments designed to manipulate airway function. It is important to note that the presence of these symptoms can be indicative of other conditions including COPD or congestive heart failure amongst others. Finally, it is often wise for an individual with asthma to identify specific triggers of their symptoms and monitor their asthma control over time. This can be done with a simple tool known as "peak flow" which measures how forcefully one can exhale.

Causes and Triggers

All asthma sufferers have sensitive airways, which can be further irritated or 'twitchy', due to the way muscles within the airway react to different changes. When the airway reacts in this way, it becomes narrow, swollen, and produces more mucus. Step by step, these events cause the airway to become more and more narrowed, making it difficult to breathe. This is due to muscle cells in the airways at times producing too much of a tough protein, causing the airway muscles to contract, the basis of asthma symptoms. The changeability of the airway, known as airway hyperresponsiveness, means the airways overreact to things they are allergic to or irritants, causing further narrowing. Cells in the airways might also make more mucus than usual in response to continued exposure to an allergen or irritant. This then causes ongoing (chronic) inflammation and structural changes in the airways.

Asthma Medications

The other type of quick-relief asthma medication is oral corticosteroids. These are systemic steroids that are absorbed from the gastrointestinal tract and work throughout the body. They are "quick-relief" when used to treat acute asthma attacks, though the real purpose is to use them to prevent the need for their use by achieving better asthma control. This is done by suppressing inflammation throughout the airways. Not everyone with asthma needs to use corticosteroids. They have potentially severe side effects if used long-term and are mainly used for patients with moderate to severe persistent asthma. They are not a replacement for inhaled corticosteroids.

The medication primarily used in treating asthma is the β2-agonist. The drug in this class is a selective beta-adrenergic agonist that relaxes the smooth muscle in the airways and allows increased airflow. They are called "short-acting" β2-agonists (SABA) because the effects are acute and they are metabolized in a few hours. Tablets and liquids are available, but the most effective way to take it is with an inhaler. Albuterol and terbutaline are short-acting β2-agonists and are sometimes used to prevent exercise-induced asthma.

Quick-relief medications are asthma medications that are taken at the first sign of an asthma attack, in order to stop the symptoms. Sometimes they are taken in combination with allergy medications to reduce the allergic response that may be contributing to the asthma symptoms. There are two types of quick-relief asthma medications.

Quick-Relief Medications

Quick-relief medicines for fast asthma symptom relief - these are taken when asthma symptoms begin to worsen or to 'abort' an asthma attack. Quick-relief medicines do not take the place of asthma preventer medicines.

Short-acting B2 agonists - B2 agonists are effective bronchodilators on airway smooth muscle, they act quickly to relieve asthma symptoms. These are the most effective medicines for mild, moderate and severe asthma and are the preferred treatment for acute asthma symptoms. They are usually best given by a puffer. B2 agonist inhalers are classified as those "needing B2 agonist reliever" and nebulisers can also be used. 3-4 puffs of the inhaled "needing reliever" B2 agonist over 20 mins is as effective as giving salbutamol via a nebuliser. Generally, four separate doses of salbutamol given via a metered dose inhaler and spacer (or more doses of the inhaled "needing B2 agonist reliever" B2 agonist) is as effective as continuous nebulised salbutamol. Oral or intravenous B2 agonists are not usually necessary. B2 agonists are effective when used in combination with ipratropium bromide which is a medication that has a different mechanism but also cause bronchodilation. This may provide an effective treatment without the need for a course of oral corticosteroids.

Long-Term Control Medications

In a setting where eliminated contact with triggers doesn't work as expected, then long-term drugs are in clinical practice. These types of asthmatic medications are used to control asthma symptoms by dampening airway inflammation and/or by affecting other cellular responses implicated in asthma. These types of medications need to be taken on a regular basis usually to attain the best control of asthma. It has been shown that these drugs are very effective in the long term by using them for a few months or a year. After that, when symptoms decrease or vanish, these drugs can gradually be tapered off with regular follow-ups. These types of medications include the following. Inhaled corticosteroids (ICS) are the most potent anti-inflammatory medication and the first line of treatment for persistent asthma. They are also used for preventing asthma in those with a history of severe attacks or in those with a high risk of asthma. By taking ICS medication in relieving doses, it can reverse an acute asthma exacerbation. The dose and type of device vary depending on the brand. It is very important to rinse the mouth after taking ICS to avoid hoarseness and the development of oral thrush. Oral corticosteroids may be given for a short period in severe acute asthma, but the long-term use of oral corticosteroids for chronic asthma is not recommended due to the high risk of side effects. Thus, the inhaled route of corticosteroid with a spacer is the modality.

Non-Medical Treatments

Allergy management involves avoiding those things that set off allergies and asthma. More than 50 percent of Americans with asthma have allergies; in fact, the two conditions often go hand in hand. Allergic reactions are one of the most common triggers of asthma symptoms. Common allergens are animal proteins, dust mites, cockroaches, molds, pollens, and certain foods. If a person knows what they are allergic to, the best strategy is to avoid or eliminate the allergen from their environment. This is especially important in the bedroom, since so much time is spent there. Measures include using allergen-proof mattress and pillow covers, and using washable curtains and blinds. Carpets, if at all possible, should be removed and if not, use a vacuum cleaner with a microfilter bag, which traps small particles, and vacuum at least once a week. Other measures include keeping windows closed during high pollen seasons, using air conditioning if possible, and not allowing smoking in the home. Removing an animal from the house is often a tough decision, but is an important step in the allergy control process. If elimination measures are not possible or if the allergen is still causing problems, one can try allergy medications to desensitize them to the allergen and decrease the allergic symptoms. In severe cases allergy shots may be appropriate. This form of treatment involves receiving injections over a period of three to five years and can lead to a significant decrease in allergic symptoms but is not effective for everyone.

Allergy Management

Attempt to identify and reduce contact with allergens to which you are sensitive. Many people are allergic to house dust mites, animal dander, cockroaches, pollens, molds, and certain foods. An allergist can determine your specific allergies through allergy testing. Once the specific allergens have been identified, measure the levels of allergens in various locations in your home and work to reduce their presence. For example, encase bedding and pillows with mite-proof covers and remove stuffed animals and other dust collectors.

Unfortunately, it is impossible to completely avoid the substances to which you are allergic. However, managing allergy can significantly improve asthma control. The following are steps recommended in the NAEPP guidelines for allergen avoidance. It is important that patients use this information in the context of their specific allergic profile as identified by the allergist.

Breathing Techniques

Pursed lip breathing is a simple way to help get air out of your lungs, making it easier to breathe in. Breathe out (exhale) slowly through your mouth with pursed (sticking out) lips. This should slow down your exhalation, making it last 2-3 times as long as you would normally do. It can also help to make your breathing more regular and to stop your chest from feeling tight. Practice this exercise when you are feeling well, and then use it when you are active or when you have to breathe out against resistance, for instance when you are using an inhaler or walking into a cold wind.

Breathing techniques are an important way to control breathlessness. When we are breathless, we all use our breathing muscles in the wrong way, especially if we are very tight and wheezy. For instance, we may use neck, shoulder, and chest muscles to help us breathe in when these should be relaxed and we should be using our diaphragm to make breathing easier. Or we may trap air in our lungs, making them overinflated and breathless. This is called hyperinflation. We often do this because it feels like we are trying to get more air in, but it makes us more breathless. The following techniques can help you to breathe in a more relaxed and efficient way and can help you to get rid of trapped air from your lungs.

Environmental Control

School may be a special problem for asthmatic children and adolescents. It is estimated that one out of every six children in the United States has a special healthcare need, including asthma. In the school environment, poor indoor air quality, as well as the presence of cockroaches or rodents, can both serve as powerful triggers for asthma symptoms. A recent study conducted by the New York City Board of Education found that reducing airborne cockroach allergens in the school environment resulted in fewer missed school days among students with moderate to severe asthma. In the workplace, the Americans with Disabilities Act requires employers to provide reasonable accommodations to qualified employees with asthma that may enable these individuals to work in an environment free from asthma triggers.

Professional home assessment is one way to create an asthma-safe home. One such program is offered by the American Lung Association (ALA). The ALA's "Healthy House" program offers assistance in selecting and working with professional home inspectors to identify asthma triggers and develop a plan to remove them. ALA literature states, "The goal of the program is to improve the health and quality of life for people who have asthma or other lung diseases." (For more information, visit the ALA website at [Link] The American Lung Association can also provide printed information on indoor air quality and recommends other services and products that they have found to be beneficial for people with asthma.

Environmental control is an important aspect of asthma management. Simple changes in the home, school, or workplace can remove asthma triggers and help individuals avoid the onset of asthma symptoms. However, successful environmental control depends on recognizing the specific triggers.

Asthma Action Plan

Asthma action plans are based on zones defined by symptoms or peak flow (a measurement of how well your lungs are working). The three zones are red, yellow, and green. The green zone is when your asthma is under good control. When you enter the yellow zone, your asthma is getting out of control. You may have more coughing, wheezing, and shortness of breath. You may also wake up at night or have trouble doing activities. The red zone is a serious sign of uncontrolled asthma. You may have severe coughing, wheezing, and shortness of breath. These symptoms may limit your activities and you may feel tired all the time. It might be hard to sleep or talk because of shortness of breath. An asthma attack is a sudden worsening of asthma symptoms from the yellow zone to the red zone or a change in symptoms that is severe. Knowing your zones will help you recognize and treat symptoms early and help prevent an asthma attack.

Your doctor may recommend that you and your family create a written asthma action plan. This plan will help you monitor your asthma and know what to do in case of an asthma attack. Your doctor will work with you to create a plan that's right for you. The plan will have information about your asthma medicines, your triggers, and when to call the doctor or go to the emergency room. It will also help you learn how to manage your asthma day to day. This plan will help you take control of your asthma so you can live an active, healthy life.

Creating an Action Plan

Creating an asthma action plan can help you feel more in control of your asthma. With your doctor's help, you can identify your asthma triggers and decide the best ways to avoid them. This will mean less asthma symptoms and less need for quick relief medicines and oral steroids. You also will decide what medicines to take to prevent symptoms and how to adjust your medicines if symptoms worsen. This can keep asthma symptoms from getting bad enough to need an emergency room visit or hospital stay. Having an asthma action plan also can help you feel more confident in managing your child's asthma.

An asthma action plan often uses a stoplight as a guide to help you recognize and respond to changes in your symptoms. When you are doing well, when your symptoms are getting worse, and when you are having a severe episode or an asthma attack. For example, when symptoms are in the yellow zone, this is a signal to add quick relief medicines and to cut back on activities. When symptoms are in the red zone, this is a signal to take quick relief medicines and to call the doctor if symptoms don't get better.

An asthma action plan (also known as a management plan) is a written plan that you create with your doctor to help control your asthma. The asthma action plan shows your daily treatment, such as what kind of medicines to take and when to take them. The plan also helps you deal with sudden increases in your asthma symptoms. Your doctor may give you a written asthma action plan or may fill one out with you.

Monitoring Symptoms

Monitoring symptoms helps you recognize symptoms early so you can take steps to prevent a serious asthma attack.

Steps for monitoring symptoms include:

• Learn which symptoms usually occur before an asthma attack.
• Check your asthma by doing spirometry or peak flow. You and your doctor can learn more about your asthma and how well it is controlled by doing these simple tests. You take blow into a tube-like device, which measures how well air is moving out of your lungs.
• Use a record or chart to keep track of your symptoms and peak flow or spirometry results. This will help you recognize the pattern of your asthma and show you how well you are meeting your treatment goals.
• Follow your asthma action plan. Step up your medicines as directed when asthma symptoms are increasing, and step them down when symptoms are lessening. This will help prevent asthma attacks.
• See your doctor if you are having to use your quick-relief medicines more and more, or if your asthma is keeping you from your usual activities.

Your asthma action plan can help you recognize symptoms or changes in your peak flow/symptoms that could indicate an asthma attack is starting. Following your plan will tell you what to do when you recognize these changes, and it may prevent an asthma attack.

Emergency Procedures

Most people with asthma will at some time have an asthma attack. An attack is when the symptoms of asthma start. They come on very quickly, over a few hours or so.

If you have an asthma attack:

• Take two puffs of your reliever inhaler (usually blue) every two to four hours.
• Sit upright in a chair and try to take slow steady breaths.
• If you do not start to feel better, get worse, or are having an attack and short of breath, follow the steps from your asthma action plan and you should call 111. If it's an emergency, call an ambulance and say it's an asthma attack.
• Keep taking the inhaler every two minutes until four lots of 10 puffs have been taken.

It is important to keep calm and reassure others around you. It can be disturbing to watch somebody have an asthma attack. A portable nebulizer can be used as an alternative to inhalers and spacers in a severe asthma attack.