Bronchial asthma is a chronic inflammatory airways disorder. Chronic inflammation leads to bronchi hyperresponsiveness (their increased sensitivity to different environmental influences), manifested in their spasm.
As a result, due to excess mucus production, inflammatory edema and spasm bronchial wall thickens, its lumen narrows. Through such bronchoconstriction there is not sufficient gaseous exchange with environment, which can lead to recurring asthma attacks, sibilant rales, dyspnea and coughing, particularly at night and / or early in the morning.
Attacks disappear on their own or under drugs influence.
- Paroxysmal non-productive cough, often early in the morning or at night, which may be accompanied by sibilant rales in chest. After attack there is possible to observe small amount of viscous yellow sputum discharge.
- Dyspnea with a primary difficulties with exhaling.
- Feeling shortness of breath.
- Feeling chest congestion.
- Sibilant in chest.
- Suffocation attacks.
These symptoms often appear at night, early in the morning and in contact with different provoking factors:
- allergens: some foods (e. g. citrus fruits, chocolate, milk, nuts, etc.), medicines (e. g., antibiotics), domestic and library dust, pollen, animal hair;
- cold air inhalation;
- contact with household chemicals products (detergents, powders, perfumes);
- physical activity (e. g., running);
- acute respiratory viral infections (colds), etc.
During asthma attack a person tries to take a sitting posture, with emphasis on arm on table or chair seat (it makes breathing easier).
Types of bronchial asthma:
- mainly allergic – associated with occurrence of specified allergens, such as certain foods (citrus, chocolate, milk, nuts, etc.), domestic and library dust, pollen, animal hair. As a part of allergic asthma form there distinguished the so-called atopic bronchial asthma: as a rule, it occurs in early childhood and has a tendency to increased sensitivity to domestic factors (for example, cleaning products, detergents, etc.);
- non-allergic – related to non-allergic factors (e. g. hormonal changes at women during menstrual cycle). This form also includes the so-called idiosyncratic (or aspirin-induced) asthma manifesting in intolerance to aspirin, non-steroidal anti-inflammatory drugs and all yellow drugs, asthma symptoms (asthma attacks, dry cough, shortness of breath with difficulties with exhaling) and polyps formation (benign soft tissue ecphyma protruding mucosa) in nasal cavity;
- mixed – combines features of two above-mentioned forms;
- there distinguish separately cough asthma, which manifests only in coughing attacks, without shortness of breath and suffocation.
According to severity degree there are the following disease types.
- Mild intermittent bronchialasthma:
- occasional asthma attacks (shortness of breath and cough attacks) – less than once a week;
- no asthma attacks at night;
- normal lung function according to spirometry indicators (respiratory function study method): FEV1 (forced expiratory volume during first second) more than 80%;
- normal lung function according to peakflowmetry indicators (respiratory function study method for self-control at home using a special device – a peakflowmeter): PEF spread (peak expiratory flow rate – parameter, evaluating state of respiratory function) between morning and evening indicators is at least 20%.
- Mild persistent bronchialasthma:
- asthma attacks appear not less than once a week (but not more than once a day);
- possible asthma attacks at night;
- normal lung function according to spirometry indicators (respiratory function study method): FEV1 is greater than 80%;
- minor violations of respiratory function according to peakflowmetry indicators: PEF spread between morning and evening indicators is from 20% to 30%.
- Moderately severe persistent bronchialasthma:
- asthma attacks appear more than once a week;
- exacerbations violate physical activity (increased attacks in the afternoon or at night);
- nocturnal asthma symptoms appear more than once a week;
- moderate disorders of lung function according to spirometry indicators (respiratory function study method): FEV1 is 60-80%;
- PEF spread between morning and evening indicators is over 30%.
- Severe persistent bronchialasthma:
- persistent asthma attacks during the day;
- physical activity is very limited;
- frequent nocturnal asthma attacks;
- significant violations of lung function according to spirometry indicators (respiratory function study method): FEV1 is less that 60%;
- PEF spread between morning and evening indicators is over 30%.
In terms of disease control (according to severity of asthma manifestations) there are distinguished the following asthma types.
- no daytime symptoms or less than twice a week;
- no nocturnal symptoms;
- no limitation of physical activity;
- no need for bronchodilators (medications for quick attack relief) or need for them arises less than twice a week;
- no exacerbations during year;
- normal respiratory function indicators.
- Partially controlled (not fully controlled) – in case of any of the following signs:
- daytime symptoms appear more than twice a week;
- there are night symptoms;
- there is limitation of physical activity;
- need for bronchodilators (medications for quick attack relief) arises more than twice a week;
- there are exacerbations during year;
- reduced respiratory function indicators.
- Uncontrolled – manifests in presence of three or more signs of partly controlled asthma.
- Recrudescence is a sharp deterioration in disease course, increased symptoms.
The disease is based on bronchi hyperresponsiveness (i. e., inadequately strong reaction, expressed in lumen narrowing, excessive mucus production and swelling) to various stimuli action.
Factors relevant to asthma development are divided into the following groups.
- Factors contributing to disease development (internal factors):
- genetic predisposition – presence of bronchial asthma or any forms of allergy among close relatives;
- obesity – predisposes to asthma development due to diaphragm elevation and lack of lung ventilation;
- sex – disease often develops in childhood at boys, which can be explained by anatomical features of bronchial tree structure (narrower bronchial lumen), in middle age it is more common at women.
- Factors that provoke symptoms (external factors):
- allergens – trigger allergic reaction on bronchial tree level: domestic and library dust;
- food (usually citrus fruits, nuts, chocolate, fish, milk);
- animal hair, feathers;
- drugs (e. g., aspirin, certain antibiotics).
Often asthmatic patients reveal allergy to several different allergens.
- Triggers – factors that cause bronchial spasm:
- tobacco smoke;
- physical activity (e. g., running);
- contact with household chemicals (detergents, powders, perfumes);
- impact of factors that pollute environment (for example, exhaust gases in urban areas);
- climatic factors (dry climate, cold air);
- acute respiratory viral infections (ARVI).
- Complaints and medical history analysis:
- presence of asthma attacks (or suffocation), provoked by exposure to allergens (food and non-food). Attacks disappear after using bronchodilators;
- presence of asthma attacks at night;
- frequency of daytime and night-time attacks (this factor is determined by disease severity and treatment process);
- presence of asthma at relatives;
- seasonality of the disease (for example, spring and summer is the time of plants blossom).
- General examination:
- there may be allergic skin rash (bumps, redness), which indicates tendency to allergic reactions;
- lungs auscultation (presence of wheezing, hard breathing, at fully controlled asthma there may be no wheezing);
- during asthma attack: loud, sometimes audible without stethoscope wheezing in bronchi, stridulous breathing, prolonged expiration. Anxiety, fear, face blanching are possible.
- Allergic tests: drop of extracts of different allergen are applied on skin, and skin reaction to them is estimated (redness presence indicates allergy).
- Blood tests: possible signs of allergic reactions (increase in number of eosinophils).
- Determination of IgE immunoglobulin (antibodies) in blood: generally antibodies level (specific proteins of immune system, the main function of which is recognition of foreign agent and its further liquidation) in blood is increased. IgE is responsible for allergic reactions implementation.
- Sputum analysis: at complete disease control there may be no changes, during exacerbations phase special elements are detected in sputum, that are visible under a microscope, consisting of mucus and eosinophils degradation products (red blood cells, causing allergic reactions); increased eosinophils contents in sputum.
- Chest X-ray examination: usually does not detect changes, it is carried out to exclude other diseases (e. g., tuberculosis (infectious disease, often developing at lower immunity and affecting lungs)).
- Peakflowmetry: method to measure peak expiratory flow rate (PEF) – expiratory flow rate during first second (at bronchial asthma it is reduced). For this a patient is offered after a deep breath to exhale with force in a special tube of the device (peakflowmeter), expiratory flow rate is calculated automatically. This method is well suited for self-monitoring respiratory function at home.
- Spirometry (spirography): method for determining lungs volume, as well as expiratory flow rate. This method is based on forced exhalation into a tube which forms part of the device. At asthma expiratory flow during first second is primarily reduced, it indicates presence of airflow obstruction (bronchoconstriction). It is the primary method of assessing respiratory function state.
- Test with bronchodilator – spirometry examination before and after drug, dilating bronchi, inhalation. It is used to assess bronchoconstriction reversibility. At bronchial asthma bronchial conductivity improves and spirometric indicators are increasing.
- Provocative (bronchoconstricting) test – used to provoke asthma symptoms, if at the time of examination respiratory function is not impaired. It is based on performing spirometry after methacholine and histamine inhalation (substances narrowing bronchi in case of hyperreactivity) at 3, 6, 9 and 12 minutes. At bronchial asthma lung function indicators are decreased.
- Body plethysmography – a method of respiratory function assessment, which allows to specify all lung volume and capacity, including those that are not defined by spirography.
- Arterial blood gases examination: bronchial asthma, depending on its severity may decrease oxygen concentration and increase carbon dioxide concentration in blood.
- Determination of nitric oxide in exhaled air (a method suitable for primary asthma diagnosis when patient is not taking medications).
- It is also possible to consult a pulmonologist.
- Allergens elimination (avoiding contacts): eliminate foods to which a person has allergy (citrus fruits, chocolate, dairy products, etc.), as well as contact with possible non-food allergens (pollen, drugs, animal hair).
- Do not bring pets, if a person suffers from multiple allergies (e. g. food, medicines). Perform daily wet cleaning in residential area.
- If possible, change place of residence (environment). Marine climate with moderate humidity will positively affect health condition.
- Adequate physical activity:
- walking in a moderate pace;
- breathing exercises (according to various methods: inflating balloons, blowing air through a straw, diaphragmatic breathing), which is aimed at training respiratory muscles.
- Visiting «Asthma School», where doctors in understandable to patient form talk about disease features, give advice on treatment, physical activity, introduced spectrum of drug, and special features of their reception, teach rules of inhalers use.
Drug therapy – all drugs for bronchial asthma treatment can be divided into 3 groups.
- «Emergency» preparations – means for quick bronchi expansion. Used to eliminateasthma attack:
- short-acting beta2-agonists;
- short-acting M-anticholinergic drugs;
- short-acting theophyllins (have a weak effect and severe adverse effects, therefore, are now being used less and less);
- glucocorticosteroid hormones intravenously or orally in pills (used for prolonged asthma attack, not amenable to above mentioned drugs action).
- The basic drugs to relieveasthma attack are short-acting beta2-agonists, short-acting M-anticholinergics and combinations of them.
- They are available as aerosol inhalers.
- These means should always be within reach for patient with asthma (on bedside table, in a purse, etc.).
- These drugs quickly relieve asthma attack by eliminating bronchospasm and reduce bronchi swelling.
- They only eliminate symptoms but do not treat the disease itself.
- Therefore their use as sole drug is only possible at mild asthma.
- In more severe cases, they should complement basic anti-inflammatory drugs and used «on demand», that is only for relieving attack.
- They can be used not more than 6 – 8 times a day, in more often sensitivity to them is reduced, which can lead to asthmatic status (asthma complication as a severe prolonged attack).
- Basic (anti-inflammatory) drugs – the main drugs for asthma treatment.
- Glucocorticosteroid hormone pills (at exacerbations) in inhaled form.
- Inhaled corticosteroids are the main forms of drugs for bronchial asthma treatment, since they are able to suppress inflammation in bronchial tree.
- Many patients are afraid to take hormones, as there is an opinion of large number of side effects.
- Serious side effects (diabetes, high arterial blood pressure, osteoporosis (reduction of bone mass and impaired bone structure, which leads to bone fragility and increased risk of fracture)) may be caused by hormones introduced into the body in the form of pills or injections.
- Inhaled hormones in average doses are deprived of these side effects, because they operate at application site – bronchial tree.
- Since inflammation at bronchial asthma is chronic, these drugs require long-term, continuous use.
- To estimate full effect of these drugs is possible only after 3 months of use.
- Refusal to receive them can transfer disease to more severe course.
- Side effects of inhaled hormones can include hoarseness and oral candidiasis (a fungal disease characterized by white fur on tongue, oral mucosa), which is easily prevented by rinsing mouth after each inhalation.
- Leukotriene system inhibitors (leukotriene antagonists) – one of basic types of drugs that suppress inflammation in bronchial tree. However, overall effect is much smaller than that of inhaled glucocorticoids. It can be used as an addition to inhaled hormones. Has a good effect at aspirin-induced asthma.
- Cromones (mast cell stabilizers) – one of basic types of drugs that suppress inflammation in bronchial tree. However, overall effect is much smaller than that of inhaled glucocorticoids. They are used mainly at mild asthma.
- IgE inhibitors (antibodies) – appointed only at exacerbation of allergic asthma and high IgE levels in blood in case of hormone replacement therapy ineffectiveness.
- Glucocorticosteroid hormone pills (at exacerbations) in inhaled form.
- Control drugs – allow long maintaining bronchi in open state:
- long-acting beta2-agonists (effect is provided for 12 or 24 hours) – basic products of the group. Used as supplements to basic medicines;
- long-acting theophyllines – may be combined with long-acting beta2-agonists if it is difficult to deal with night symptoms. Currently do not have independent application.
- Inhaled medicines specifics:
- proper inhalers use – often lack of effect of prescription drugs appears because of incorrect inhalation technique. Ask your doctor to explain to you how to use appointed inhaler. The drug should enter straight bronchial tree, otherwise treatment effect is significantly reduced up to complete absence;
- spacer may help to facilitate inhalation – a special device for inhaler that contributes to large aerosol particles settling (annoying pharyngeal mucosa) and helps smaller particles to penetrate bronchial tree. Spacer promotes more complete drug delivery to bronchi, preventing dispersion in ambient air;
- the best drugs delivery to bronchial tree during exacerbation is possible by using nebulizer – device that splits drug molecule to smallest particles penetrating the smallest bronchi;
- basic therapy preparations must be used within 15 minutes after «first aid» drugs inhalation, as bronchi expand and allow hormone drugs to penetrate deeper into bronchial tree.
Additional methods of treatment
- allergen immunotherapy: during remission phase there may by conducted hyposensitization (reducing sensitivity to allergens) therapy: injection of small allergens doses contributes to body «addiction» to these substances, which subsequently reduces allergic reactions severity;
- spa treatment: marine climate, salt rooms.
First aid for asthma attack
- calm and seat the patient;
- provide fresh air: open the window, release neck to free breathing;
- to inhale 1 – 2 doses of bronchodilator inhaler;
- with no effect after 5 – 10 minutes repeat inhalation of bronchodilator.
Asthma Complications and Consequences
- Respiratory insufficiency: lack of oxygen in the body.
- Status asthmaticus – the most serious complication, manifested in long protracted asthma attack. If left untreated, can be fatal.
- Pneumothorax – accumulation of air in pleural cavity (cavity formed by pleura – outer lung coat) due to lung areas rupture.
- Pulmonary heart disease: failure of the right heart ventricle to perform its function. Accompanied by severe dyspnea, edema.
- Pulmonary emphysema: alveoli expansion (air passages bubbles, in which gas exchange is performed), destruction of membranes between them with excess air retention in lungs. As a rule, appears at long-term disease course and absence of treatment.
- Proper nutrition and healthy lifestyle during pregnancy: smoking and alcohol cessation, limited medication intake, walking outdoors.
- If expectant mother has multiple allergies (e. g. food, medicines), during pregnancy she should avoid contacts with any allergens (both known and potential: for example, citrus, chocolate, milk, nuts, animal hair, house dust, pollen).
- Limiting allergenic foods: chocolate, citrus fruits, nuts, etc.
- Hypoallergenic lifestyle: limiting allergens presence at home:
- pillows with synthetic filling (not feather);
- exclusion of main items, which collect dust (carpets, wool and pile fabric, feather pillows, stuffed animals);
- limited cosmetics use (e. g. mascara, lipsticks, shadows);
- using hygienic products (soap, shampoo, etc.) without cosmetic perfumes (without added flavors);
- closed bookshelves with glass doors (books accumulate dust);
- no pets (e. g., cats, dogs, hamsters, fish);
- daily wet cleaning (preferably in moist gauze bandage);
- changing bed clothes once a week. In winter, dry it in cold, in summer – in the sun;
- limited access to the street during plants blossom period on dry windy day, because at this time concentration of dust in the air is the highest;
- limited trips to the village;
- changing clothes, taking shower, rinsing the throat during plants blossom period after walking outside.
- Adequate physical activity (aimed at training respiratory muscles): walking at a moderate pace, swimming, breathing exercises (according to various methods: inflating balloons, blowing air through a straw, diaphragmatic breathing).
- Always have medication to relieve asthma attacks at hand.
- No self-medication at asthma and other related diseases, since drugs can provoke allergic reaction (especially antibiotics), some drugs used to reduce high blood pressure, may provoke bronchospasm and induce asthma attacks.
- Continuous intake of drugs prescribed. Bronchial asthma is characterized by chronic inflammation, so you can not limit yourself only with preparations for bronchi expansion (except for mild bronchial asthma), you must use permanent anti-inflammatory drugs.
- Proper inhalers use – often lack of effect of prescription drugs appears because of incorrect inhalation technique. Ask your doctor to explain to you how to use appointed inhaler. The drug should enter straight bronchial tree, otherwise treatment effect is significantly reduced up to complete absence.
- Self-monitoring of disease using peakflowmeter (a device that allows monitoring respiratory function at home). After a deep breath to exhale with force in a special tube of the device, expiratory flow rate (PEF – peak expiratory flow) is calculated automatically. Normally, spread between morning and evening PEF should not exceed 20%. It is recommended to keep peakflowmetry diaries.