Guide to Asthma

What Is Asthma?

Asthma is a long-term disease of the lungs. You might hear your doctor call it a chronic respiratory disease. It causes your airways to get inflamed and narrow and makes breathing difficult. Coughingwheezing, shortness of breath, and chest tightness are classic asthma symptoms. Severe asthma can make it hard to talk or be active. Some people refer to asthma as "bronchial asthma."

Asthma is a serious -- even dangerous -- disease that affects about 25 million Americans and causes nearly 2 million emergency room visits every year. With proper treatment, you can live well. Without it, you might have to make frequent visits to the emergency room and even stay at the hospital, which can affect your home life and ability to work.

How Is Asthma Classified?

Doctors rank the severity of asthma by its symptoms:

  1. Mild intermittent asthma. Mild symptoms less than twice a week. Nighttime symptoms less than twice a month. Few asthma attacks.
  2. Mild persistent asthma. Symptoms three to six times a week. Nighttime symptoms three to four times a month. Asthma attacks might affect activities.
  3. Moderate persistent asthma. Symptoms three to six times a week. Nighttime symptoms three to four times a month. Asthma attacks might affect activities.
  4. Severe persistent asthma. You have ongoing symptoms both day and night. They’re so frequent that you have to limit your activities.

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Types of Asthma

There are several:

  • Adult-onset asthma. Asthma can affect you at any age, although it's more common in people under age 40. More than 20 million adult Americans, or 8.3% of the adult population, has it. You’re more likely to get it if you have a family history of asthma, allergies, or eczema.
  • Status asthmaticus. These prolonged asthma attacks don’t respond to treatment with bronchodilators and are a medical emergency. They need immediate treatment.
  • Asthma in children. Symptoms can vary from episode to episode in the same child. Symptoms of asthma to look for include:
    • Frequent coughing spells, which may happen during play, at nighttime, or while laughing. It's important to know that coughing may be the only symptom.
    • Less energy during play, or pausing to catch breath during play
    • Rapid or shallow breathing
    • Complaint of chest tightness or chest "hurting"
    • Whistling sound when breathing in or out. This sound is called wheezing.
    • Seesaw motions in the chest from labored breathing. These motions are called retractions.
    • Shortness of breath, loss of breath
    • Tightened neck and chest muscles
    • Weakness or tiredness
  • Exercise-induced bronchoconstriction. You might hear this called exercise-induced asthma. It happens during physical activity when you breathe in air that’s drier that what’s in your body and your airways narrow. It can affect people who don’t have asthma, too. You’ll notice symptoms within a few minutes after you start to exercise, and they might last for 10 to 15 minutes after you stop.
  • Allergic asthma. Things that trigger allergies, like dust, pollen and pet dander, can also cause asthma attacks.
  • Nonallergic asthma. This type flares in extreme weather. It could be the heat of summer or the cold of winter. It could also show up when you’re stressed or have a cold.
  • Occupational asthma. This usually affects people who work around chemical fumes, dust, or other irritating things in the air.
  • Eosinophilic asthma. This severe, chronic form is marked by high levels of white blood cells called eosinophils. This type usually affects adults between 35 and 50.
  • Nocturnal asthma. When you have this, your asthma symptoms get worse at night.
  • Aspirin-induced asthma. When you have this, you’ll have asthma symptoms when you take aspirin, along with a runny nose, sneezing, sinus pressure, and a cough.
  • Cough-variant asthma. Unlike other types, the only symptom of this kind of asthma is a chronic cough.

Symptoms of Asthma

There are three major features of asthma:

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1. Airway obstruction. When you breathe normally, the bands of muscle that surround your airways are relaxed and air moves freely. But when you have asthma, those bands of muscle tighten. Air can’t move freely. When there’s less air in your lungs, you feel short of breath. The air moving out through your tightened airways causes wheezing.

2.  Inflammation . People with asthma have red and swollen bronchial tubes. This inflammation can damage the lungs. Treating this inflammation is key to managing asthma in the long run.

3. Airway irritability. People with asthma have sensitive airways that tend to overreact and narrow due to even the slightest triggers.

Asthma Causes and Triggers

When you have asthma, your airways react to many different things in the environment called asthma triggers. Contact with these triggers cause asthma symptoms to start or worsen. Common asthma triggers include:

  • Infections like sinusitiscolds, and flu
  • Allergens such as pollens, mold, pet dander, and dust mites
  • Irritants like strong odors from perfumes or cleaning solutions
  • Air pollution
  • Tobacco smoke
  • Exercise 
  • Cold air or changes to the weather, such as changes in temperature or humidity
  • Strong emotions such as anxiety, laughter, crying, or stress
  • Medications such as aspirin

What Is an Asthma Attack?

An asthma attack is a sudden worsening of symptoms. With an asthma attack, your airways tighten, swell up, or fill with mucus. Common symptoms include:

  • Coughing, especially at night
  • Wheezing
  • Shortness of breath or trouble breathing
  • Chest tightness, pain, or pressure

Not every person with asthma has the same symptoms of an asthma attack. You may not have all of them, or you may have different ones at different times. They may be subtle, like having less energy. They may also vary from mild to severe between one asthma attack and the next.

Diagnosis of Asthma

If you think you have asthma, see your doctor. They’ll refer you to an asthma specialist, also known as a pulmonologist, who can examine you and run tests for asthma to see if you have it.

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The doctor will start with a physical exam, then ask about your symptoms and medical history.

You’ll get lung tests to see how well your lungs work:

  • Spirometry. This simple breathing test measures how much air you blow out and how fast.
  • Peak flow. Peak flow tests measure how well your lungs push out air. Although they’re less accurate than spirometry, they can be a good way to test your lungs at home -- even before you feel any symptoms. You use a small device called a peak flow meter for the test. It can help you figure out what makes your asthma worse, whether your treatment is working, and when you need emergency care.
  • Methacholine challenge. This test is more commonly used for adults than children. You might get it if your symptoms and spirometry test don’t clearly show a diagnosis of asthma. When you have asthma and inhale methacholine, your airways narrow. During this test, you inhale increasing amounts of methacholine mist before and after spirometry. If your lung function drops by at least 20%, you have asthma. The doctor will give you medicine at the end of the test to reverse the effects of the methacholine.
  • Exhaled nitric oxide test. You’ll breathe into a tube connected to a machine that measures the amount of nitric oxide in your breath. Your body makes this gas normally, but levels could be high if your airways are inflamed.

Other tests you might get include:

  • Chest X-ray. While a chest X-ray isn’t an asthma test, your doctor can use it to make sure nothing else is causing your symptoms. An X-ray is an image of the inside of your body created by using low doses of radiation.
  • Computerized tomography (CT). This test takes a series of X-rays and puts them together to create a cross-sectional view of your insides. A scan of your lungs and sinuses can identify any structural problems or diseases (like an infection) that can cause breathing problems or make them worse.
  • Allergy tests. These can be blood or skin tests. They can help figure out if you’re allergic to pets, dust, mold, and pollen. Once you know your allergy triggers, you can get treatment to prevent them -- and asthma attacks.
  • Sputum eosinophils. This test looks for high levels of white blood cells (eosinophils) in the mix of saliva and mucus (sputum) that comes out when you cough.

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Asthma Treatment

There are many asthma treatments available to relieve your symptoms. Your doctor will work with you to create an asthma action plan that will outline your treatment and medications. They might include:

  • Inhaled corticosteroids. These medications are used to treat asthma in the long term. That means you’ll take it every day to keep your asthma under control. They prevent and ease swelling inside your airways, and they may cut down mucus production. You’ll use a device called an inhaler to get the medicine into your lungs. Common inhaled corticosteroids include:
    • Beclomethesone (QVAR)
    • Budesonide (Pulmicort)
    • Fluticasone (Flovent)
  • Leukotriene modifiers. Another long-term asthma treatment, these medications block the action of leukotrienes, substances in your body that trigger an asthma attack. You take them as a pill once a day. Common leukotriene modifiers include:
    • Montelukast (Singulair)
    • Zafirlukast (Accolate)
  • Long-acting beta-agonists. These medications relax the muscle bands that surround your airways. You might hear them called bronchodilators. You’ll take these medications with an inhaler -- even when you have no symptoms. Frequently used long-acting beta agonists include:
    • Formoterol (Foradil)
    • Salmeterol (Serevent)
  • Combination inhaler. This device gives you an inhaled corticosteroid and a long-acting beta-agonist together to ease your asthma. Common ones include:
    • Budesonide and formoterol (Symbicort)
    • Fluticasone and salmeterol (Advair Diskus)
    • Fluticasone and vilanterol (Breo)
    • Mometasone and formoterol (Dulera)
  • Theophylline. It opens up your airways and eases tightness in your chest. You take this long-term medication by mouth, either by itself or with an inhaled corticosteroid.
  • Short-acting beta-agonists. These are known as rescue medicines or rescue inhalers. They loosen the bands of muscles around your airways and ease symptoms like wheezing, chest tightness, coughing, and shortness of breath. Examples include:
    • Albuterol (Accuneb, ProAir, Proventil, Ventolin)
    • Levalbuterol (Xopenex HFA)
  • Anticholinergics. These bronchodilators prevent the muscle bands around your airways from tightening. Common ones include:
    • Ipratropium (Atrovent)
    • Tiotropium bromide (Spiriva)

You can get ipratropium in an inhaler or as a solution for a nebulizer, a device that turns liquid medicine into a mist that you breathe in through a mouthpiece. Tiotropium bromide comes in a dry inhaler, which lets you breathe the medicine in as a dry powder.

  • Oral and intravenous corticosteroids. You’ll take these along with a rescue inhaler during an asthma attack. They ease swelling and inflammation in your airways. You’ll take oral steroids for short bursts between 5 days and 2 weeks. Frequently prescribed oral steroids include:
    • Methylprednisolone (Medrol)
    • Prednisolone (Orapred, Prelone, Pediapred)
    • Prednisone (Deltasone)

You’re more likely to get steroids injected directly into a vein if you wind up in the hospital for a bad asthma attack. This will get the medication into your system more quickly.

  • Biologics. If you have severe asthma that doesn’t respond to control medications, you might try a biologic:
    • Omalizumab (Xolair) treats asthma caused by allergens. You get it as an injection every 2 to 4 weeks.
    • Other biologics are designed to stop your immune cells from creating substances that cause inflammation. These drugs include:
      • Benralizumab (Fasenra)
      • Mepolizumab (Nucala)
      • Reslizumab (Cinqair)
WebMD Medical Reference Reviewed by Dan Brennan, MD on May 22, 2019

Sources

SOURCES: 

American Lung Association: "Asthma." 

Asthma and Allergy Foundation of America: "Asthma Overview," “Asthma Facts and Figures,” “Peak Flow Meters.”

CDC.

Murray, J. and Nadel, J. Textbook of Respiratory Medicine, Third edition, W.B. Saunders Company, 2000. 

Rose, B.D. (ed). UpToDate, Wellesley, MA, 2005.

National Heart, Lung, and Blood Institute: “Asthma,” “Asthma Info.”

Medscape: “Aspirin and Asthma,” “Asthma Guidelines.”

American College of Allergy, Asthma and Immunology: “Asthma Cough,” “Exercise-Induced Bronchoconstriction (EIB),” “Nonallergic Asthma,” “Occupational Asthma.”

American Partnership for Eosinophilic Disorders: “Eosinophilic Asthma.”

The Mount Sinai Journal of Medicine: “Nocturnal asthma: mechanisms and management.”

Mayo Clinic: “Albuterol (Inhalation Route),” “Asthma,” “Asthma medications: Know your options,” “Asthma: Steps in testing and diagnosis,” “CT scan,” Nitric oxide test for asthma,” “Nonallergic rhinitis.”

American Academy of Allergy, Asthma & Immunology: “Sinusitis.”

National Asthma Council Australia: “Asthma & Lung Function Tests.”

National Jewish Health: “Inhaled Steroids,” “Oral Steroids.”

Palo Alto Medical Foundation: “Anticholinergics,” “Dry Powder Medication,” “Inhaled Corticosteroids,” “Inhaled Medications for Asthma,” “Leukotriene Modifiers,” “Long-Acting Beta Agonists,” “Nebulizers,” “Oral Corticosteroids,” “Rescue Reliever Medications & Short-Acting Beta Agonists,” “Theophylline.”

Partners Healthcare: “Asthma & Steroids In Tablet Form.”

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