Asthma

Name	Asthma
Caption	Peak flow meters are used to measure one's peak expiratory flow rate
Diseasesdb	1006
Icd10
Icd9
Omim	600807
Medlineplus	000141
Emedicinesubj	article
Emedicinetopic	806890
Meshid	D001249

Asthma (from the Greek άσθμα, ásthma, "panting") is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Treatment of acute symptoms is usually with an inhaled short-acting beta-2 agonist (such as salbutamol).

Its diagnosis is usually made based on the pattern of symptoms and/or response to therapy over time. The prevalence of asthma has increased significantly since the 1970s. As of 2010, 300 million people were affected worldwide. In 2009 asthma caused 250,000 deaths globally. ! scope="col" style="width:7em;" | Symptom frequency ! scope="col" style="width:7em;" | Nighttime symptoms ! scope="col" style="width:6em;" | %FEV₁ of predicted ! scope="col" style="width:6em;" | FEV₁ Variability ! scope="col" style="width:10em;" | Use of short-acting beta₂ agonist for symptom control (not for prevention of EIB) |- ! scope="row" | Intermittent | ≤2 per week | ≤2 per month | ≥80% | <20% | ≤2 days per week |- ! scope="row" | Mild persistent | >2 per weekbut not daily | 3-4 per month | ≥80% | 20–30% | >2 days/weekbut not daily |- ! scope="row" | Moderate persistent | Daily | >1 per week but not nightly | 60–80% | >30% | Daily |- ! scope="row" | Severe persistent | Throughout the day | Frequent (often 7x/week) | <60% | >30% | Several times per day |}

Asthma is clinically classified according to the frequency of symptoms, forced expiratory volume in 1 second (FEV₁), and peak expiratory flow rate. Moderate is defined as between 80 and 200 L/min or 25% and 50% of the predicted best while severe is defined as ≤ 80 L/min or ≤25% of the predicted best.

Status asthmaticus

Status asthmaticus is an acute exacerbation of asthma that does not respond to standard treatments of bronchodilators and steroids. Nonselective beta blockers (such as Timolol) have caused fatal status asthmaticus.

Exercise induced

A diagnosis of asthma is common among top athletes. One survey of participants in the 1996 Summer Olympic Games, in Atlanta, Georgia, U.S., showed that 15% had been diagnosed with asthma, and that 10% were on asthma medication.

There appears to be a relatively high incidence of asthma in sports such as cycling, mountain biking, and long-distance running, and a relatively lower incidence in weightlifting and diving. It is unclear how much of these disparities are from the effects of training in the sport.

Exercise induced asthma can be treated with the use of a short-acting beta2 agonist. In one study monitoring workplace asthma by occupation, the highest percentage of cases occurred among operators, fabricators, and laborers (32.9%), followed by managerial and professional specialists (20.2%), and in technical, sales, and administrative support jobs (19.2%). Most cases were associated with the manufacturing (41.4%) and services (34.2%) industries.

Signs and symptoms

Common symptoms of asthma include wheezing, shortness of breath, chest tightness and coughing. Symptoms are often worse at night or in the early morning, or in response to exercise or cold air.

Sleep Disorders

Due to altered anatomy of the respiratory tract: increased upper airway adipose deposition, altered pharynx skeletal morphology, and extension of the pharyngeal airway; leading to upper airway collapse.

Cause

Asthma is caused by environmental and genetic factors. These factors influence how severe asthma is and how well it responds to medication. The interaction is complex and not fully understood.

Studying the prevalence of asthma and related diseases such as eczema and hay fever have yielded important clues about some key risk factors. The strongest risk factor for developing asthma is a history of atopic disease; In children between the ages of 3-14, a positive skin test for allergies and an increase in immunoglobulin E increases the chance of having asthma. In adults, the more allergens one reacts positively to in a skin test, the higher the odds of having asthma.

Because much allergic asthma is associated with sensitivity to indoor allergens and because Western styles of housing favor greater exposure to indoor allergens, much attention has focused on increased exposure to these allergens in infancy and early childhood as a primary cause of the rise in asthma. Primary prevention studies aimed at the aggressive reduction of airborne allergens in a home with infants have shown mixed findings. Strict reduction of dust mite allergens, for example, reduces the risk of allergic sensitization to dust mites, and modestly reduces the risk of developing asthma up until the age of 8 years old. However, studies also showed that the effects of exposure to cat and dog allergens worked in the converse fashion; exposure during the first year of life was found to reduce the risk of allergic sensitization and of developing asthma later in life.

The inconsistency of this data has inspired research into other facets of Western society and their impact upon the prevalence of asthma. One subject that appears to show a strong correlation is the development of asthma and obesity. In the United Kingdom and United States, the rise in asthma prevalence has echoed an almost epidemic rise in the prevalence of obesity. In Taiwan, symptoms of allergies and airway hyper-reactivity increased in correlation with each 20% increase in body-mass index. Several factors associated with obesity may play a role in the pathogenesis of asthma, including decreased respiratory function due to a buildup of adipose tissue (fat) and the fact that adipose tissue leads to a pro-inflammatory state, which has been associated with non-eosinophilic asthma.

Asthma has been associated with Churg–Strauss syndrome, and individuals with immunologically mediated urticaria may also experience systemic symptoms with generalized urticaria, rhino-conjunctivitis, orolaryngeal and gastrointestinal symptoms, asthma, and, at worst, anaphylaxis. Additionally, adult-onset asthma has been associated with periocular xanthogranulomas.

Environmental

Many environmental risk factors have been associated with asthma development and morbidity in children.

General

Recent studies show a relationship between exposure to air pollutants (e.g. from traffic) and childhood asthma. This research finds that both the occurrence of the disease and exacerbation of childhood asthma are affected by outdoor air pollutants. High levels of endotoxin exposure may contribute to asthma risk.

Viral respiratory infections are not only one of the leading triggers of an exacerbation but may increase one's risk of developing asthma especially in young children.

Respiratory infections such as rhinovirus, Chlamydia pneumoniae and Bordetella pertussis are correlated with asthma exacerbations.

Psychological stress has long been suspected of being an asthma trigger, but only in recent decades has convincing scientific evidence substantiated this hypothesis. Rather than stress directly causing the asthma symptoms, it is thought that stress modulates the immune system to increase the magnitude of the airway inflammatory response to allergens and irritants.

Beta blocker medications such as metoprolol may trigger asthma in those who are susceptible.

Tobacco

Maternal tobacco smoking during pregnancy and after delivery is associated with a greater risk of asthma-like symptoms, wheezing, and respiratory infections during childhood. Low air quality, from traffic pollution or high ozone levels, has been repeatedly associated with increased asthma morbidity and has a suggested association with asthma development that needs further research.

Hygiene Hypothesis

Antibiotic use early in life has been linked to development of asthma in several examples; it is thought that antibiotics make children who are predisposed to atopic immune responses susceptible to development of asthma because they modify gut flora, and thus the immune system (as described by the hygiene hypothesis). The hygiene hypothesis (see below) is a hypothesis about the cause of asthma and other allergic disease, and is supported by epidemiologic data for asthma. All of these things may negatively affect exposure to beneficial bacteria and other immune system modulators that are important during development, and thus may cause an increased risk for asthma and allergy.

Caesarean sections have been associated with asthma, possibly because of modifications to the immune system (as described by the hygiene hypothesis).

Volatile Organic Compounds

Observational studies have found that indoor exposure to volatile organic compounds (VOCs) may be one of the triggers of asthma, however experimental studies have not confirmed these observations. Even VOC exposure at low levels has been associated with an increase in the risk of pediatric asthma. Because there are so many VOCs in the air, measuring total VOC concentrations in the indoor environment may not represent the exposure of individual compounds. Exposure to VOCs is associated with an increase in the IL-4 producing Th2 cells and a reduction in IFN-γ producing Th1 cells. Thus the mechanism of action of VOC exposure may be allergic sensitization mediated by a Th2 cell phenotype. Different individual variations in discomfort, from no response to excessive response, were seen in one of the studies. These variations may be due to the development of tolerance during exposure. Another study has concluded that formaldehyde may cause asthma-like symptoms. Low VOC emitting materials should be used while doing repairs or renovations which decreases the symptoms related to asthma caused by VOCs and formaldehyde. In another study "the indoor concentration of aliphatic compounds (C8-C11), butanols, and 2,2,4-trimethyl 1,3-pentanediol diisobutyrate (TXIB) was significantly elevated in newly painted dwellings. The total indoor VOC was about 100 micrograms/m3 higher in dwellings painted in the last year". The author concluded that some VOCs may cause inflammatory reactions in the airways and may be the reason for asthmatic symptoms.

Pthalates

There is a significant association between asthma-like symptoms (wheezing) among preschool children and the concentration of DEHP (pthalates) in indoor environment. DEHP (di-ethylhexyl phthalate) is a plasticizer that is commonly used in building material. The hydrolysis product of DEHP (di-ethylhexyl phthalate) is MEHP (Mono-ethylhexyl phthalate) which mimics the prostaglandins and thromboxanes in the airway leading to symptoms related to asthma. Another mechanism that has been studied regarding phthalates causation of asthma is that high phthalates level can "modulate the murine immune response to a coallergen". Asthma can develop in the adults who come in contact with heated PVC fumes. Two main type of phthalates, namely n-butyl benzyl phthalate (BBzP) and di(2-ethylhexyl) phthalate (DEHP), have been associated between the concentration of polyvinyl chloride (PVC) used as flooring and the dust concentrations. Water leakage were associated more with BBzP, and buildings construction were associated with high concentrations of DEHP. Asthma has been shown to have a relationship with plaster wall materials and wall-to wall carpeting. The onset of asthma was also related to the floor–leveling plaster at home. Therefore, it is important to understand the health aspect of these materials in the indoor surfaces.

Genetic

Over 100 genes have been associated with asthma in at least one genetic association study. However, such studies must be repeated to ensure the findings are not due to chance. Through the end of 2005, 25 genes had been associated with asthma in six or more separate populations:

Gene–environment interactions

{| class="wikitable" style = "float: right; margin-left:15px; text-align:center" |+ CD14-endotoxin interaction based on CD14 SNP C-159T

Exacerbation

Some individuals will have stable asthma for weeks or months and then suddenly develop an episode of acute asthma. Different asthmatic individuals react differently to various factors. However, most individuals can develop severe exacerbation of asthma from several triggering agents.

Home factors that can lead to exacerbation include dust, house mites, animal dander (especially cat and dog hair), cockroach allergens and molds at any given home. Children living in less hygienic environments (East Germany vs. West Germany, families with many children, day care environments) tend to have lower incidences of asthma and allergic diseases. This seems to run counter to the logic that viruses are often causative agents in exacerbation of asthma. Additionally, other studies have shown that viral infections of the lower airway may in some cases induce asthma, as a history of bronchiolitis or croup in early childhood is a predictor of asthma risk in later life. Studies which show that upper respiratory tract infections are protective against asthma risk also tend to show that lower respiratory tract infections conversely tend to increase the risk of asthma.

Socioeconomic factors

The incidence of asthma is highest among low-income populations worldwide. Asthma deaths are most common in low and middle income countries, and in the Western world, it is found in those low-income neighborhoods whose populations consist of large percentages of ethnic minorities. Additionally, asthma has been strongly associated with the presence of cockroaches in living quarters; these insects are more likely to be found in those same neighborhoods.

Most likely due to income and geography, the incidence of and treatment quality for asthma varies among different racial groups.

Diagnosis

{| border="1" cellpadding="5" cellspacing="0" align="center" class="wikitable" style="float: right; margin-left:15px" |+ Severity of acute asthma exacerbations

The British Thoracic Society determines a diagnosis of asthma using a ‘response to therapy’ approach. If the patient responds to treatment, then this is considered to be a confirmation of the diagnosis of asthma. The response measured is the reversibility of airway obstruction after treatment. Airflow in the airways is measured with a peak flow meter or spirometer, and the following diagnostic criteria are used by the British Thoracic Society:

≥20% difference on at least three days in a week for at least two weeks;

≥20% improvement of peak flow following treatment, for example:

*10 minutes of inhaled β-agonist (e.g., salbutamol);

*six weeks of inhaled corticosteroid (e.g., beclometasone);

*14 days of 30 mg prednisolone.

≥20% decrease in peak flow following exposure to a trigger (e.g., exercise).

In contrast, the US National Asthma Education and Prevention Program (NAEPP) uses a ‘symptom patterns’ approach. Their guidelines for the diagnosis and management of asthma state that a diagnosis of asthma begins by assessing if any of the following list of indicators is present. While the indicators are not sufficient to support a diagnosis of asthma, the presence of multiple key indicators increases the probability of a diagnosis of asthma. The NAEPP guidelines do not recommend testing peak expiratory flow as a regular screening method because it is more variable than spirometry. However, testing peak flow at rest (or baseline) and after exercise can be helpful, especially in young patients who may experience only exercise-induced asthma. It may also be useful for daily self-monitoring and for checking the effects of new medications.

Differential diagnosis

Differential diagnoses include:

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease can coexist with asthma and can occur as a complication of chronic asthma. After the age of 65 most people with obstructive airway disease will have asthma and COPD. In this setting, COPD can be differentiated by increased airway neutrophils, abnormally increased wall thickness, and increased smooth muscle in the bronchi. However, this level of investigation is not performed due to COPD and asthma sharing similar principles of management: corticosteroids, long acting beta agonists, and smoking cessation. It closely resembles asthma in symptoms, is correlated with more exposure to cigarette smoke, an older age, less symptom reversibility after bronchodilator administration (as measured by spirometry), and decreased likelihood of family history of atopy.

Others

The term "atopy" was coined to describe this triad of atopic eczema, allergic rhinitis and asthma.

The most effective treatment for asthma is identifying triggers, such as cigarette smoke, pets, or aspirin, and eliminating exposure to them. If trigger avoidance is insufficient, medical treatment is recommended. Medical treatments used depends on the severity of illness and the frequency of symptoms. Specific medications for asthma are broadly classified into fast-acting and long-acting categories.

Bronchodilators are recommended for short-term relief of symptoms. In those with occasional attacks, no other medication is needed. If mild persistent disease is present (more than two attacks a week), low-dose inhaled glucocorticoids or alternatively, an oral leukotriene antagonist or a mast cell stabilizer is recommended. For those who suffer daily attacks, a higher dose of inhaled glucocorticoid is used. In a severe asthma exacerbation, oral glucocorticoids are added to these treatments.

Medications

Medications used to treat asthma are divided into two general classes: quick-relief medications used to treat acute symptoms; and long-term control medications used to prevent further exacerbation.

;Fast acting metered dose inhaler commonly used to treat asthma attacks.]] Short acting beta₂-adrenoceptor agonists (SABA), such as salbutamol (albuterol USAN) are the first line treatment for asthma symptoms. They are however not recommended due to concerns regarding excessive cardiac stimulation.

;Long term control metered dose inhaler commonly used for long term control.]] Glucocorticoids are the most effective treatment available for long term control. In December 2008, members of the FDA's drug-safety office recommended withdrawing approval for these medications in children. Discussion is ongoing about their use in adults. Leukotriene antagonists ( such as zafirlukast) are an alternative to inhaled glucocorticoids, but are not preferred. They may also be used in addition to inhaled glucocorticoids but in this role are second line to LABA.

;Safety and adverse effects Long-term use of glucocorticoids carries a significant potential for adverse effects. The incidence of cataracts is increased in people undergoing treatment for asthma with corticosteroids, due to altered regulation of lens epithelial cells. The incidence of osteoporosis is also increased, due to changes inbone remodeling.

Other

When an asthma attack is unresponsive to usual medications, other options are available for emergency management. Oxygen is used to alleviate hypoxia if saturations fall below 92%. Magnesium sulfate intravenous treatment has been shown to provide a bronchodilating effect when used in addition to other treatment in severe acute asthma attacks. There is little data to support the effectiveness of most of these therapies. Evidence is insufficient to support the usage of Vitamin C. Acupuncture is not recommended for the treatment as there is insufficient evidence to support its use. Air ionisers show no evidence that they improve asthma symptoms or benefit lung function; this applied equally to positive and negative ion generators.

Dust mite control measures, including air filtration, chemicals to kill mites, vacuuming, mattress covers and others methods had no effect on asthma symptoms. However, a review of 30 studies found that "bedding encasement might be an effective asthma treatment under some conditions" (when the patient is highly allergic to dust mite and the intervention reduces the dust mite exposure level from high levels to low levels). Washing laundry/rugs in hot water was also found to improve control of allergens. The Buteyko breathing technique for controlling hyperventilation may result in a reduction in medications use however does not have any effect on lung function. Thus an expert panel felt that evidence was insufficient to support its use. Although conclusions from studies are mixed, most studies show that early treatment with glucocorticoids prevents or ameliorates decline in lung function as measured by several parameters. For those who continue to suffer from mild symptoms, corticosteroids can help most to live their lives with few disabilities. It is more likely to consider immediate medication of inhaled corticosteroids as soon as asthma attacks occur. According to studies conducted, patients with relatively mild asthma who have received inhaled corticosteroids within 12 months of their first asthma symptoms achieved good functional control of asthma after 10 years of individualized therapy as compared to patients who received this medication after 2 years (or more) from their first attacks. Though they (delayed) also had good functional control of asthma, they were observed to exhibit slightly less optimal disease control and more signs of airway inflammation.

Asthma mortality has decreased over the last few decades due to better recognition and improvement in care.

Epidemiology

for asthma per 100,000 inhabitants in 2004.]] of childhood asthma in the United States has increased since 1980, especially in younger children.]] As of 2009, 300 million people worldwide were affected by asthma leading to approximately 250,000 deaths per year.

It is estimated that asthma has a 7-10% prevalence worldwide., with as high as a 20 to 60-fold difference. Westernization however does not explain the entire difference in asthma prevalence between countries, and the disparities may also be affected by differences in genetic, social and environmental risk factors. while symptoms were most prevalent (as much as 20%) in the United Kingdom, Australia, New Zealand, and Republic of Ireland; they were lowest (as low as 2–3%) in Eastern Europe, Indonesia, Greece, Uzbekistan, India, and Ethiopia. or from a third-world country to Westernized one.

Asthma affects approximately 7% of the population of the United States It accounted for nearly 1/2 million hospitalizations Of all children, African Americans and Latinos who live in cities are more at risk for developing asthma. African American children in the U.S. are four times more likely to die of asthma and three times more likely to be hospitalized, compared to their white counterparts. In some Latino neighborhoods, as many as one in three children has been found to have asthma.

In England, an estimated 261,400 people were newly diagnosed with asthma in 2005; 5.7 million people had an asthma diagnosis and were prescribed 32.6 million asthma-related prescriptions.

The frequency of atopic dermatitis, asthma, urticaria and allergic contact dermatitis has been found to be lower in psoriatic patients. Some 9% of US children had asthma in 2001, compared with just 3.6% in 1980. The World Health Organization (WHO) reports that some 10% of the Swiss population suffers from asthma today, compared with just 2% some 25–30 years ago.

Variability

Asthma prevalence in the US is higher than in most other countries in the world, but varies drastically between diverse US populations. Mortality rates follow similar trends, and response to salbutamol is lower in Puerto Ricans than in African Americans or Mexicans. As with worldwide asthma disparities, differences in asthma prevalence, mortality, and drug response in the US may be explained by differences in genetic, social and environmental risk factors.

Asthma prevalence also differs between populations of the same ethnicity who are born and live in different places. US-born Mexican populations, for example, have higher asthma rates than non-US born Mexican populations that are living in the US.

There is no correlation between asthma and gender in children. More adult women are diagnosed with asthma than adult men, but this does not necessarily mean that more adult women have asthma.

History

Asthma was first recognized and named by Hippocrates circa 450 BC. During the 1930s–50s, asthma was considered as being one of the 'holy seven' psychosomatic illnesses. Its aetiology was considered to be psychological, with treatment often based on psychoanalysis and other 'talking cures'. among the first papers in modern medicine, is one that was published in 1873 and this paper tried to explain the pathophysiology of the disease. And one of the first papers discussing treatment of asthma was released in 1872, the author concluded in his paper that asthma can be cured by rubbing the chest with chloroform liniment. Among the first times researches referred to medical treatment was at the year 1880, where Dr. J. B. Berkart used IV method to administer doses of drug called Pilocarpin. In the year 1886, F.H. Bosworth FH suspected a connection between asthma and hay fever. Epinephrine was first referred to in the treatment of asthma in 1905, and for acute asthma in 1910.

Research

The University of Maryland School of Medicine announced in 2010 that bitter taste receptors had been discovered on smooth muscle in human lung bronchi. These smooth muscles control airway contraction and dilation — contrary to expectation, bitter substances such as quinine or chloroquine opened contracted airways, offering new insight into asthma.

References

;Bibliography

External links

Category:Chronic lower respiratory diseases