http://homepages.ed.ac.

uk/jjarvis/research/asthma/defining_
asthma.html
What Is Asthma?
Asthma is a disease which can affect people of all ages. It is a disease which is defined not by a
specific cause but instead by its symptoms. A clearcut definition of asthma is notoriously hard to
find. Even the best definitions will have qualifying statements added to them. The definition
given by the late Professor Flenley, former Professor of Respiratory Medicine, The University of
Edinburgh was:
"Bronchial asthma is characterised by episodic acute limitation of airflow,
reversing either spontaneously or in response to treatment."
Unavoidably, what one doctor may diagnose as asthma another may not. In truth, definitions will
vary depending on which level they wish to describe asthma, be it the observed symptoms in a
patient or the histopathology observed from a microscope slide. What really matters is that when
considering the disease caused asthma, one should consider that it may be more than just one
disease.

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What are the symptoms of asthma?

The common symptoms of asthma are quite well known. In addition to the wheeze and general
breathing difficulty, coughing, runny eyes and nose, chest tightnesss and sneezing may also
occur. These symptoms are usually in response to a 'trigger'. A trigger is any particle which,
although innocuous to normal individuals, is capable of initiating an asthmatic response in
asthmatic patients. Often symptoms which are similar to those seen in asthmatic subjects also
occur in non-asthmatics. There are however differences in both duration and frequency of
symptoms seen with asthma from those seen with, for example, chronic bronchitis.

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What causes asthma.

Asthma is commonly attributed to exposure to environmental agents. These agents vary
immensely but they include the faecal detritus of the house dust mite, animal dander, pollen and
certain chemicals.

When discussing possible causes of asthma is important to distinguish what is meant by 'cause'.
Many people believe that the increase in asthma seen over the past few decades in the United
Kingdom is due to increased pollution. Unfortunately the available data do not support this
theory - pollution levels in the UK have actually fallen steadily over the last 40 years! The
pollution may on bad days affect asthma sufferers more than the general population but there is
little to suggest that pollution actually causes an increase in the number of people who are
asthmatic

A distinction is needed to describe agents that actually cause asthma from those that merely
make pre-existing asthma periodically worse. Agents that can actually cause asthma are known
as sensitising agents. Agents that might trigger an asthma attack in an asthmatic subject are
called triggering agents.

It should be noted that sensitising agents will not necessarily cause asthma in everyone. Not
everyone who is exposed to house dust mites develops asthma. It seems that some people are
more susceptible to such agents than others. Why is not fully known. Various theories abound but
it is at least in part a result of genetic predisposition.

Triggers elicit asthmatic attacks in asthmatic subjects by irritating the already inflamed and
hyperreactive airways. Indeed triggers such as cold air or methacholine (a signalling chemical
naturally present in the body) are used by doctors to measure the degree of reactivity of patients
lungs. Characteristically, the lungs of asthmatic subjects react to far lower amounts of trigger
than the lungs of healthy control subjects.

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The pathophysiology of asthma?

Asthma is now most commonly described amongst experts as an inflammatory response disease.
It has been suggested that the two main causes of breathlessness - airway wall inflammation and
airway wall constriction - are both due to the release inflammatory response chemical signals.

To understand the pathophysiology of asthma a little backround airway anatomy is required. We

breath through our noses and mouths. To reach the lungs both these inlets converge on the
trachea (the windpipe) below which an upside down tree like structure occurs. Two main
branches (bronchi) split, one to each lung. Gradually more and branches and twigs (the
bronchioles) split off to eventually end in the alveoli. Like the leaves of a tree, the alveoli are
effectively cul-de-sacs. It is in the alveoli that fresh oxygenated air enters the bloodstream and
stale (carbon dioxide-loaded) air comes out again.

Asthma effects only the bronchi and bronchioles, not the alveoli. The bronchi and bronchioles
are tubes through which air must pass to reach the alveoli, and thus be absorbed into the blood.
In asthma these tubes become partly or completely blocked. This results in difficulty or
impossibility to breath.
The airway tubes are lined with a layer of cells known a the epithelial layer. Normally this layer
is involved in 'brushing' mucous up the airways by means of hair-like cilia. The cilia act like a
conveyor sending the mucous up the airways until finally it can be swallowed. This mucous
conveyor carries any foreign particles out of the lung. When it stops or is damaged mucous can
build up and block the lungs.

The epithelial layer of cells in asthmatic subjects is often inflamed and damaged. A damaged or
scarred epithelial layer can allow foreign particles to penetrate the lung lining more easily. In
response to foreign particles the cells release signalling chemicals which can make the damage
worse.

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The immuno-biochemistry of asthma

Sensitising agents (or allergen as they are sometimes called) are specific. Where asthma is due to
an allergy, the resulting response to the specific allergen is far, far greater in the asthmatic subject
than the normal subject. In other words, tiny amounts of allergen can cause an asthmatic
response.

Allergens act by being inappropriately recognised by the body's defensive immune system.
Special chemicals called antibodies recognise the allergen and initialise a cellular response. Cells
release signalling chemicals which 'warn' other cells with the result that they to release signalling
chemicals. These chemicals produce a number of effects. One such chemical, histamine, can
cause the muscle encircling the airways to contract, thereby narrowing the diameter of the
airways.

The level of antibodies throughout the body is normally tightly controlled. The levels rise during
infections as antibodies seek out bacteria or viruses so that special killer cells can deal with them.
In asthmatic subjects there is often an increase in the levels of certain antibodies even in the
absence of infection.

Since the epithelial layers that line the lung are often damaged in asthmatics, foreign particles
can more readily penetrate the lung lining. This, coupled with the increased numbers of
antibodies, results in an immune allergic response. When antibodies find a specific foreign
particle, the antibodies signal to special cells known as mast cells. Mast cells in turn release more
signalling chemicals. The resulting signal cascade sparks of an asthmatic response, firstly by
causing the airway smooth muscle to contract and secondly to produce further inflammation and
damage.

Top
The treatment of asthma?

NOTE - For issues of personal health always consult with your own GP / physician.

There is a large number of treatments available for asthma. Whilst environmental (and therefore
allergen) control measures are often to be encouraged, there remains a need to treat the
underlying inflammation characteristic of an asthmatic's airways. Pharmacological intervention
in asthma is either preventative or curative. The former tends to target the underlying chronic
inflammation of the airway walls in a bid to reduce the hyperreactivity. The latter approach to
treatment is used in the acute phase of the disease in which an asthmatic attack is actually
present. Some common classes of drug for asthma treatment are listed below. The information
for each drug type gets more detailed as the definition progresses so just read up to where you
feel comfortable!

Beta-2 Agonists
E.g. Salbutamol, salmeterol, terbutaline, rimeterol, fenoterol, pirbuterol, reprotelol. Most
commonly administered using measured dose inhalation via an 'inhaler'. Beta-2 agonists
are an acute phase treatment, producing a dilation of the airway walls, thus decreasing the
airways resistance enough to make breathing easier. Salbutamol has a duration of effect
of just a few hours. Salmeterol is a longer acting Beta-2 agonist. This class of drugs
works by activating Beta-2 Adrenergic receptors on the encircling smooth muscle of the
airway walls. Activation of these G-protein coupled receptors causes an increase the
amount of intracellular cyclic-AMP. This cAMP causes relaxation in the smooth muscle
cells which encircle the bronchi and bronchioles.
Xanthine drugs
E.g. theophylline, theobromine, caffeine, aminophylline, proxifylline, enprofylline.
Theophylline is commonly found in tea, caffeine in coffee and theobromine in chocolate.
There method of action is unclear. It could be that they act as phosphodiesterase
inhibitors, thus preventing the breakdown of cAMP, though the concentrations used
therapeutically do not seem high enough. Another theory is that they may affect cyclic-
GMP phosphodiesterase. Alkylxanthines have been shown to both inhibit and potentiate
certain adenosine responses at micromolar concentrations so the true mechanism could be
quite complicated. Methyl xanthines apparently cause the release of catecholamines,
which include adrenalin.
Corticosteroids
E.g. beclomethasone, betamethasone and budesonide. These drugs have an anti-
inflammatory effect. They are used prophylactically. They seem to be the category of
choice for tackling the underlying inflammation which is believed to play such a key role
in asthma.
Sodium Cromoglycate
Also called Intal, disodium cromoglycate or cromolyn sodium in the U.S.A.. The first
choice anti-inflammatory for children. Curiously this drug was shown to be effective in
 people without prior testing in animals. The mechanism by which sodium cromoglycate
works is unclear but a decrease in bronchial hyperreactivity is seen with prolonged use.

Top

Further reading
1. Respiratory Medicine. Flenley, D.C. 2nd Edition 1990 Bailliere Tindall, London.
2. Chapter 17 of Pharmacology by Rang, H.P. and Dale, M.M.. 2nd Edition 1991 Churchill
Livingstone, Edinburgh.

The University Of Edinburgh

Last edited

Work funded by
http://en.wikipedia.org/wiki/Asthma

Asthma
From Wikipedia, the free encyclopedia

For other uses, see Asthma (disambiguation).

Asthma
Classification and external resources

Peak flow meters are used to measure the peak expiratory

flow rate, important in both monitoring and diagnosing
asthma.[1]

ICD-10 J45

ICD-9 493

OMIM 600807

DiseasesDB 1006

MedlinePlus 000141

eMedicine article/806890

MeSH D001249

Asthma (from the Greek , sthma, "panting") is a common chronic inflammatory disease
of the airways characterized by variable and recurring symptoms, reversible airflow obstruction
and bronchospasm.[2] Common symptoms include wheezing, coughing, chest tightness, and
shortness of breath.[3]
Asthma is thought to be caused by a combination of genetic and environmental factors.[4] Its
diagnosis is usually based on the pattern of symptoms, response to therapy over time and
spirometry.[5] It is clinically classified according to the frequency of symptoms, forced expiratory
volume in one second (FEV1), and peak expiratory flow rate.[6] Asthma may also be classified as
atopic (extrinsic) or non-atopic (intrinsic)[7] where atopy refers to a predisposition toward
developing type 1 hypersensitivity reactions.[8]

Treatment of acute symptoms is usually with an inhaled short-acting beta-2 agonist (such as
salbutamol) and oral corticosteroids.[9] In very severe cases, intravenous corticosteroids,
magnesium sulfate, and hospitalization may be required.[10] Symptoms can be prevented by
avoiding triggers, such as allergens[11] and irritants, and by the use of inhaled corticosteroids.[12]
Long-acting beta agonists (LABA) or leukotriene antagonists may be used in addition to inhaled
corticosteroids if asthma symptoms remain uncontrolled.[13] The occurrence of asthma has
increased significantly since the 1970s. In 2011, 235300 million people globally have been
diagnosed with asthma,[14][15] and it caused 250,000 deaths.[15]

Signs and symptoms

Wheezing

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The sound of wheezing as heard with a stethoscope.

Problems playing this file? See media help.

Asthma is characterized by recurrent episodes of wheezing, shortness of breath, chest tightness,

and coughing.[16] Sputum may be produced from the lung by coughing but is often hard to bring
up.[17] During recovery from an attack it may appear pus like due to high levels of white blood
cells called eosinophils.[18] Symptoms are usually worse at night and in the early morning or in
response to exercise or cold air.[19] Some people with asthma rarely experience symptoms,
usually in response to triggers, whereas others may have marked and persistent symptoms.[20]
Associated conditions

A number of other health conditions occur more frequently in those with asthma, including
gastro-esophageal reflux disease (GERD), rhinosinusitis, and obstructive sleep apnea.[21]
Psychological disorders are also more common,[22] with anxiety disorders occurring in between
1652% and mood disorders in 1441%.[23] However, it is not known if asthma causes
psychological problems or if psychological problems lead to asthma.[24]

Causes
Asthma is caused by a combination of complex and incompletely understood environmental and
genetic interactions.[4][25] These factors influence both its severity and its responsiveness to
treatment.[26] It is believed that the recent increased rates of asthma are due to changing
epigenetics (heritable factors other than those related to the DNA sequence) and a changing
living environment.[27]

Environmental

Many environmental factors have been associated with asthma's development and exacerbation
including allergens, air pollution, and other environmental chemicals.[28] Smoking during
pregnancy and after delivery is associated with a greater risk of asthma-like symptoms.[29] Low
air quality from factors such as traffic pollution or high ozone levels,[30] has been associated with
both asthma development and increased asthma severity.[31] Exposure to indoor volatile organic
compounds may be a trigger for asthma; formaldehyde exposure, for example, has a positive
association.[32] Also, phthalates in PVC are associated with asthma in children and adults.[33][34]

Asthma is associated with exposure to indoor allergens.[35] Common indoor allergens include:
dust mites, cockroaches, animal dander, and mold.[36][37] Efforts to decrease dust mites have been
found to be ineffective.[38] Certain viral respiratory infections, such as respiratory syncytial virus
and rhinovirus,[39] may increase the risk of developing asthma when acquired as young children.
[40]
Certain other infections, however, may decrease the risk.[39]

Hygiene hypothesis

The hygiene hypothesis attempts to explain the increased rates of asthma worldwide as a direct
and unintended result of reduced exposure, during childhood, to non-pathogenic bacteria and
viruses.[41][42] It has been proposed that the reduced exposure to bacteria and viruses is due, in
part, to increased cleanliness and decreased family size in modern societies.[43] Exposure to
bacterial endotoxin in early childhood may prevent the development of asthma, but exposure at
an older age may provoke bronchoconstriction.[44] Evidence supporting the hygiene hypothesis
includes lower rates of asthma on farms and in households with pets.[43]

Use of antibiotics in early life has been linked to the development of asthma.[45] Also, delivery
via caesarean section is associated with an increased risk (estimated at 2080%) of asthmathis
increased risk is attributed to the lack of healthy bacterial colonization that the newborn would
have acquired from passage through the birth canal.[46][47] There is a link between asthma and the
degree of affluence.[48]

Genetic
CD14-endotoxin interaction based on CD14 SNP C-159T [49]

Endotoxin levels CC genotype TT genotype

High exposure Low risk High risk

Low exposure High risk Low risk

Family history is a risk factor for asthma, with many different genes being implicated.[50] If one
identical twin is affected, the probability of the other having the disease is approximately 25%.[50]
By the end of 2005, 25 genes had been associated with asthma in six or more separate
populations, including GSTM1, IL10, CTLA-4, SPINK5, LTC4S, IL4R and ADAM33, among
others.[51] Many of these genes are related to the immune system or modulating inflammation.
Even among this list of genes supported by highly replicated studies, results have not been
consistent among all populations tested.[51] In 2006 over 100 genes were associated with asthma
in one genetic association study alone;[51] more continue to be found.[52]

Some genetic variants may only cause asthma when they are combined with specific
environmental exposures.[4] An example is a specific single nucleotide polymorphism in the
CD14 region and exposure to endotoxin (a bacterial product). Endotoxin exposure can come
from several environmental sources including tobacco smoke, dogs, and farms. Risk for asthma,
then, is determined by both a person's genetics and the level of endotoxin exposure.[49]

Medical conditions

A triad of atopic eczema, allergic rhinitis and asthma is called atopy.[53] The strongest risk factor
for developing asthma is a history of atopic disease;[40] with asthma occurring at a much greater
rate in those who have either eczema or hay fever.[54] Asthma has been associated with Churg
Strauss syndrome, an autoimmune disease and vasculitis. Individuals with certain types of
urticaria may also experience symptoms of asthma.[53]

There is a correlation between obesity and the risk of asthma with both having increased in
recent years.[55][56] Several factors may be at play including decreased respiratory function due to
a buildup of fat and the fact that adipose tissue leads to a pro-inflammatory state.[57]

Beta blocker medications such as propranolol can trigger asthma in those who are susceptible.[58]
Cardioselective beta-blockers, however, appear safe in those with mild or moderate disease.[59]
Other medications that can cause problems are ASA, NSAIDs, and angiotensin-converting
enzyme inhibitors.[60]
Exacerbation

Some individuals will have stable asthma for weeks or months and then suddenly develop an
episode of acute asthma. Different individuals react differently to various factors.[61] Most
individuals can develop severe exacerbation from a number of triggering agents.[61]

Home factors that can lead to exacerbation of asthma include dust, animal dander (especially cat
and dog hair), cockroach allergens and mold.[61] Perfumes are a common cause of acute attacks in
women and children. Both viral and bacterial infections of the upper respiratory tract can worsen
the disease.[61] Psychological stress may worsen symptomsit is thought that stress alters the
immune system and thus increases the airway inflammatory response to allergens and irritants.[31]
[62]

Pathophysiology
Main article: Pathophysiology of asthma

Figure A shows the location of the lungs and airways in the body. Figure B shows a cross-section of a
normal airway. Figure C shows a cross-section of an airway during asthma symptoms.

Obstruction of the lumen of a bronchiole by mucoid exudate, goblet cell metaplasia, and epithelial
basement membrane thickening in a person with asthma.
Asthma is the result of chronic inflammation of the airways which subsequently results in
increased contractability of the surrounding smooth muscles. This among other factors leads to
bouts of narrowing of the airway and the classic symptoms of wheezing. The narrowing is
typically reversible with or without treatment. Occasionally the airways themselves change.[16]
Typical changes in the airways include an increase in eosinophils and thickening of the lamina
reticularis. Chronically the airways' smooth muscle may increase in size along with an increase
in the numbers of mucous glands. Other cell types involved include: T lymphocytes,
macrophages, and neutrophils. There may also be involvement of other components of the
immune system including: cytokines, chemokines, histamine, and leukotrienes among others.[39]

Diagnosis
While asthma is a well recognized condition, there is not one universal agreed upon definition.[39]
It is defined by the Global Initiative for Asthma as "a chronic inflammatory disorder of the
airways in which many cells and cellular elements play a role. The chronic inflammation is
associated with airway hyper-responsiveness that leads to recurrent episodes of wheezing,
breathlessness, chest tightness and coughing particularly at night or in the early morning. These
episodes are usually associated with widespread but variable airflow obstruction within the lung
that is often reversible either spontaneously or with treatment".[16]

There is currently no precise test with the diagnosis typically based on the pattern of symptoms
and response to therapy over time.[5][39] A diagnosis of asthma should be suspected if there is a
history of: recurrent wheezing, coughing or difficulty breathing and these symptoms occur or
worsen due to exercise, viral infections, allergens or air pollution.[63] Spirometry is then used to
confirm the diagnosis.[63] In children under the age of six the diagnosis is more difficult as they
are too young for spirometry.[64]

Spirometry

Spirometry is recommended to aid in diagnosis and management.[65][66] It is the single best test for
asthma. If the FEV1 measured by this technique improves more than 12% following
administration of a bronchodilator such as salbutamol, this is supportive of the diagnosis.[67] It
however may be normal in those with a history of mild asthma, not currently acting up.[39] As
caffeine is a bronchodilator in people with asthma, the use of caffeine before a lung function test
may interfere with the results.[68] Single-breath diffusing capacity can help differentiate asthma
from COPD.[39] It is reasonable to perform spirometry every one or two years to follow how well
a person's asthma is controlled.[69]

Others

The methacholine challenge involves the inhalation of increasing concentrations of a substance

that causes airway narrowing in those predisposed. If negative it means that a person does not
have asthma; if positive, however, it is not specific for the disease.[39]
Other supportive evidence includes: a 20% difference in peak expiratory flow rate on at least
three days in a week for at least two weeks, a 20% improvement of peak flow following
treatment with either salbutamol, inhaled corticosteroids or prednisone, or a 20% decrease in
peak flow following exposure to a trigger.[70] Testing peak expiratory flow is more variable than
spirometry, however, and thus not recommended for routine diagnosis. It may be useful for daily
self-monitoring in those with moderate to severe disease and for checking the effectiveness of
new medications. It may also be helpful in guiding treatment in those with acute exacerbations.
[71]

Classification
Clinical classification ( 12 years old)[6]

Symptom Night time %FEV1 of FEV1

Severity SABA use
frequency symptoms predicted Variability

Intermittent 2/week 2/month 80% <20% 2 days/week

Mild persistent >2/week 34/month 80% 2030% >2 days/week

Moderate persistent Daily >1/week 6080% >30% daily

Severe persistent Continuously Frequent (7/week) <60% >30% twice/day

Asthma is clinically classified according to the frequency of symptoms, forced expiratory

volume in one second (FEV1), and peak expiratory flow rate.[6] Asthma may also be classified as
atopic (extrinsic) or non-atopic (intrinsic), based on whether symptoms are precipitated by
allergens (atopic) or not (non-atopic).[7] While asthma is classified based on severity, at the
moment there is no clear method for classifying different subgroups of asthma beyond this
system.[72] Finding ways to identify subgroups that respond well to different types of treatments
is a current critical goal of asthma research.[72]

Although asthma is a chronic obstructive condition, it is not considered as a part of chronic

obstructive pulmonary disease as this term refers specifically to combinations of disease that are
irreversible such as bronchiectasis, chronic bronchitis, and emphysema.[73] Unlike these diseases,
the airway obstruction in asthma is usually reversible; however, if left untreated, the chronic
inflammation from asthma can lead the lungs to become irreversibly obstructed due to airway
remodeling.[74] In contrast to emphysema, asthma affects the bronchi, not the alveoli.[75]

Asthma exacerbation
Severity of an acute exacerbation[76]

Near-fatal High PaCO2 and/or requiring mechanical ventilation

 Clinical signs Measurements

Altered level of consciousness Peak flow < 33%

Exhaustion Oxygen saturation < 92%

Arrhythmia PaO2 < 8 kPa

Life threatening
(any one of) Low blood pressure "Normal" PaCO2

Cyanosis

Silent chest

Poor respiratory effort

Peak flow 3350%

Acute severe
Respiratory rate 25 breaths per minute
(any one of)
Heart rate 110 beats per minute

Unable to complete sentences in one breath

Worsening symptoms

Moderate Peak flow 5080% best or predicted

No features of acute severe asthma

An acute asthma exacerbation is commonly referred to as an asthma attack. The classic

symptoms are shortness of breath, wheezing, and chest tightness.[39] While these are the primary
symptoms of asthma,[77] some people present primarily with coughing, and in severe cases, air
motion may be significantly impaired such that no wheezing is heard.[76]

Signs which occur during an asthma attack include the use of accessory muscles of respiration
(sternocleidomastoid and scalene muscles of the neck), there may be a paradoxical pulse (a pulse
that is weaker during inhalation and stronger during exhalation), and over-inflation of the chest.
[78]
A blue color of the skin and nails may occur from lack of oxygen.[79]

In a mild exacerbation the peak expiratory flow rate (PEFR) is 200 L/min or 50% of the
predicted best.[80] 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.[80]
Acute severe asthma, previously known as status asthmaticus, is an acute exacerbation of asthma
that does not respond to standard treatments of bronchodilators and corticosteroids.[81] Half of
cases are due to infections with others caused by allergen, air pollution, or insufficient or
inappropriate medication use.[81]

Brittle asthma is a kind of asthma distinguishable by recurrent, severe attacks.[76] Type 1 brittle
asthma is a disease with wide peak flow variability, despite intense medication. Type 2 brittle
asthma is background well-controlled asthma with sudden severe exacerbations.[76]

Exercise-induced
Main article: Exercise-induced bronchoconstriction

Exercise can trigger bronchoconstriction in both people with and without asthma.[82] It occurs in
most people with asthma and up to 20% of people without asthma.[82] In athletes is diagnosed
more commonly in elite athletes, with rates varying from 3% for bobsled racers to 50% for
cycling and 60% for cross-country skiing.[82] While it may occur with any weather conditions it is
more common when it is dry and cold.[83] Inhaled beta2-agonists do not appear to improve
athletic performance among those without asthma[84] however oral doses may improve endurance
and strength.[85][86]

Occupational
Main article: Occupational asthma

Asthma as a result of (or worsened by) workplace exposures, is a commonly reported

occupational disease.[87] Many cases however are not reported or recognized as such.[88][89] It is
estimated that 525% of asthma cases in adults are workrelated. A few hundred different agents
have been implicated with the most common being: isocyanates, grain and wood dust,
colophony, soldering flux, latex, animals, and aldehydes. The employment associated with the
highest risk of problems include: those who spray paint, bakers and those who process food,
nurses, chemical workers, those who work with animals, welders, hairdressers and timber
workers.[87]

Differential diagnosis

Many other conditions can cause symptoms similar to those of asthma. In children, other upper
airway diseases such as allergic rhinitis and sinusitis should be considered as well as other causes
of airway obstruction including: foreign body aspiration, tracheal stenosis or
laryngotracheomalacia, vascular rings, enlarged lymph nodes or neck masses. In adults, COPD,
congestive heart failure, airway masses, as well as drug-induced coughing due to ACE inhibitors
should be considered. In both populations vocal cord dysfunction may present similarly.[90]

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.[91] It closely
resembles asthma in symptoms, is correlated with more exposure to cigarette smoke, an older
age, less symptom reversibility after bronchodilator administration, and decreased likelihood of
family history of atopy.[92][93]

Prevention
The evidence for the effectiveness of measures to prevent the development of asthma is weak.[94]
Some show promise including: limiting smoke exposure both in utero and after delivery,
breastfeeding, and increased exposure to daycare or large families but none are well supported
enough to be recommended for this indication.[94] Early pet exposure may be useful.[95] Results
from exposure to pets at other times are inconclusive[96] and it is only recommended that pets be
removed from the home if a person has allergic symptoms to said pet.[97] Dietary restrictions
during pregnancy or when breast feeding have not been found to be effective and thus are not
recommended.[97] Reducing or eliminating compounds known to sensitive people from the work
place may be effective.[87] It is not clear if annual influenza vaccinations effects the risk of
exacerbations.[98] Immunization; however, is recommended by the World Health Organization.[99]

Management
While there is no cure for asthma, symptoms can typically be improved.[100] A specific,
customized plan for proactively monitoring and managing symptoms should be created. This
plan should include the reduction of exposure to allergens, testing to assess the severity of
symptoms, and the usage of medications. The treatment plan should be written down and advise
adjustments to treatment according to changes in symptoms.[101]

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, the use of
medication is recommended. Pharmaceutical drugs are selected based on, among other things,
the severity of illness and the frequency of symptoms. Specific medications for asthma are
broadly classified into fast-acting and long-acting categories.[102][103]

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 corticosteroids or alternatively, an oral leukotriene antagonist
or a mast cell stabilizer is recommended. For those who have daily attacks, a higher dose of
inhaled corticosteroids is used. In a moderate or severe exacerbation, oral corticosteroids are
added to these treatments.[9]

Lifestyle modification

Avoidance of triggers is a key component of improving control and preventing attacks. The most
common triggers include allergens, smoke (tobacco and other), air pollution, non selective beta-
blockers, and sulfite-containing foods.[104][105] Cigarette smoking and second-hand smoke (passive
smoke) may reduce the effectiveness of medications such as corticosteroids.[106] Dust mite control
measures, including air filtration, chemicals to kill mites, vacuuming, mattress covers and others
methods had no effect on asthma symptoms.[38] Overall exercise, however is beneficial in people
with stable asthma.[107]

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.[102]

Fastacting

Salbutamol 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.[9] They are recommended before exercise in those
with exercise induced symptoms.[108]
Anticholinergic medications, such as ipratropium bromide, provide additional benefit when used
in combination with SABA in those with moderate or severe symptoms. [9] Anticholinergic
bronchodilators can also be used if a person cannot tolerate a SABA. [73]

Older, less selective adrenergic agonists, such as inhaled epinephrine, have similar efficacy to
SABAs.[109] They are however not recommended due to concerns regarding excessive cardiac
stimulation.[110]

Longterm control
Fluticasone propionate metered dose inhaler commonly used for long-term control.

Corticosteroids are generally considered the most effective treatment available for long-term
control.[102] Inhaled forms such as beclomethasone are usually used except in the case of severe
persistent disease, in which oral corticosteroids may be needed. [102] It is usually recommended
that inhaled formulations be used once or twice daily, depending on the severity of symptoms.
[111]

Long-acting beta-adrenoceptor agonists (LABA) such as salmeterol and formoterol can improve
asthma control, at least in adults, when given in combination with inhaled corticosteroids. [112] In
children this benefit is uncertain.[112][113] When used without steroids they increase the risk of
severe side-effects[114] and even with corticosteroids they may slightly increase the risk. [115][116]

Leukotriene antagonists (such as montelukast and zafirlukast) may be used in addition to inhaled
corticosteroids, typically also in conjunction with LABA. [102] Evidence is insufficient to support use
in acute exacerbations.[117][118] In children they appear to be of little benefit when added to
inhaled steroids.[119] In those under five years of age, they were the preferred add-on therapy
after inhaled corticosteroids by the British Thoracic Society in 2009. [120]

Mast cell stabilizers (such as cromolyn sodium) are another non-preferred alternative to
corticosteroids.[102]

Delivery methods

Medications are typically provided as metered-dose inhalers (MDIs) in combination with an

asthma spacer or as a dry powder inhaler. The spacer is a plastic cylinder that mixes the
medication with air, making it easier to receive a full dose of the drug. A nebulizer may also be
used. Nebulizers and spacers are equally effective in those with mild to moderate symptoms.
However insufficient evidence is available to determine whether a difference exists in those with
severe disease.[121]

Adverse effects

Long-term use of inhaled corticosteroids at conventional doses carries a minor risk of adverse
effects.[122] Risks include the development of cataracts and a mild regression in stature.[122][123]

Others

When asthma is unresponsive to usual medications, other options are available for both
emergency management and prevention of flareups. For emergency management other options
include:

Oxygen to alleviate hypoxia if saturations fall below 92%.[124]

Magnesium sulfate intravenous treatment has been shown to provide a bronchodilating effect
when used in addition to other treatment in severe acute asthma attacks. [10][125]

Heliox, a mixture of helium and oxygen, may also be considered in severe unresponsive cases. [10]

Intravenous salbutamol is not supported by available evidence and is thus used only in extreme
cases.[124]

Methylxanthines (such as theophylline) were once widely used, but do not add significantly to
the effects of inhaled beta-agonists. [124] Their use in acute exacerbations is controversial. [126]

The dissociative anesthetic ketamine is theoretically useful if intubation and mechanical

ventilation is needed in people who are approaching respiratory arrest; however, there is no
evidence from clinical trials to support this. [127]

For those with severe persistent asthma not controlled by inhaled corticosteroids and LABAs,
bronchial thermoplasty may be an option.[128] It involves the delivery of controlled thermal
energy to the airway wall during a series of bronchoscopies.[128][129] While it may increase
exacerbation frequency in the first few months it appears to decrease the subsequent rate. Effects
beyond one year are unknown.[130] Evidence suggests that sublingual immunotherapy in those
with both allergic rhinitis and asthma improve outcomes.[131]

Alternative medicine

Many people with asthma, like those with other chronic disorders, use alternative treatments;
surveys show that roughly 50% use some form of unconventional therapy.[132][133] There is little
data to support the effectiveness of most of these therapies. Evidence is insufficient to support
the usage of Vitamin C.[134] There is tentative support for its use in exercise induced
brochospasm.[135] Acupuncture is not recommended for the treatment as there is insufficient
evidence to support its use.[136][137] Air ionisers show no evidence that they improve asthma
symptoms or benefit lung function; this applied equally to positive and negative ion generators.
[138]
"Manual therapies", including osteopathic, chiropractic, physiotherapeutic and respiratory
therapeutic maneuvers, have insufficient evidence to support their use in treating asthma.[139] The
Buteyko breathing technique for controlling hyperventilation may result in a reduction in
medications use however does not have any effect on lung function.[103] Thus an expert panel felt
that evidence was insufficient to support its use.[136]

Prognosis

Disability-adjusted life year for asthma per 100,000 inhabitants in 2004.[140]

no data 350400

<100 400450

100150 450500

150200 500550

200250 550600

250300 >600

300350

The prognosis for asthma is generally good, especially for children with mild disease.[141]
Mortality has decreased over the last few decades due to better recognition and improvement in
care.[142] Globally it causes moderate or severe disability in 19.4 million people as of 2004
(16 million of which are in low and middle income countries).[143] Of asthma diagnosed during
childhood, half of cases will no longer carry the diagnosis after a decade.[50] Airway remodeling
is observed, but it is unknown whether these represent harmful or beneficial changes.[144] Early
treatment with corticosteroids seems to prevent or ameliorates a decline in lung function.[145]

Epidemiology
Main article: Epidemiology of asthma
Rates of asthma in different countries of the world as of 2004.

no data 6-7%

<1% 7-8%

1-2% 8-10%

2-3% 10-12.5%

3-4% 12.515%

4-5% >15%

5-6%

As of 2011, 235330 million people worldwide are affected by asthma,[14][15][146] and

approximately 250,000-345,000 people die per year from the disease.[16][147] Rates vary between
countries with prevalences between 1 and 18%.[16] It is more common in developed than
developing countries.[16] One thus sees lower rates in Asia, Eastern Europe and Africa.[39] Within
developed countries it is more common in those who are economically disadvantaged while in
contrast in developing countries it is more common in the affluent.[16] The reason for these
differences is not well known.[16] Low and middle income countries make up more than 80% of
the mortality.[148]

While asthma is twice as common in boys as girls,[16] severe asthma occurs at equal rates.[149] In
contrast adult women have a higher rate of asthma than men[16] and it is more common in the
young than the old.[39]

Global rates of asthma have increased significantly between the 1960s and 2008[150][151] with it
being recognized as a major public health problem since the 1970s.[39] Rates of asthma have
plateaued in the developed world since the mid-1990s with recent increases primarily in the
developing world.[152] Asthma affects approximately 7% of the population of the United States[114]
and 5% of people in the United Kingdom.[153] Canada, Australia and New Zealand have rates of
about 1415%.[154]

History
1907 advertisement for Grimault's Indian Cigarettes, emphasising their alleged efficacy for the relief of
asthma and other respiratory conditions

Asthma was recognized in Ancient Egypt and was treated by drinking an incense mixture known
as kyphi.[155] It was officially named as a specific respiratory problem by Hippocrates circa 450
BC, with the Greek word for "panting" forming the basis of our modern name.[39] In 200 BC it
was believed to be at least partly related to the emotions.[23]

In 1873, one of the first papers in modern medicine on the subject tried to explain the
pathophysiology of the disease while one in 1872, concluded that asthma can be cured by
rubbing the chest with chloroform liniment.[156][157] Medical treatment in 1880, included the use of
intravenous doses of a drug called pilocarpin.[158] In 1886, F.H. Bosworth theorized a connection
between asthma and hay fever.[159] Epinephrine was first referred to in the treatment of asthma in
1905.[160] Oral corticosteroids began to be used for this condition in the 1950s while inhaled
corticosteroids and selective short acting beta agonist came into wide use in the 1960s.[161][162]

A notable and well-documented case in the 19th century was that of young Theodore Roosevelt
(1857-1919). At that time there was no effective treatment. Roosevelt's youth was in large part
shaped by his poor health partly related to his asthma. He experienced recurring nighttime
asthma attacks that caused the experience of being smothered to death, terrifying the boy and his
parents.[163]

During the 1930s1950s, asthma was known as one of the "holy seven" psychosomatic illnesses.
Its cause was considered to be psychological, with treatment often based on psychoanalysis and
other talking cures.[164] As these psychoanalysts interpreted the asthmatic wheeze as the
suppressed cry of the child for its mother, they considered the treatment of depression to be
especially important for individuals with asthma.[164]

http://www.who.int/respiratory/asthma/definition/en/

Chronic respiratory diseases

Chronic respiratory diseases
Global Alliance Against Respiratory Diseases (GARD)

Chronic obstructive pulmonary disease (COPD)

Asthma

Other chronic respiratory diseases

Publications

Asthma: Definition
Asthma attacks all age groups but often starts in childhood. It is a disease characterized by
recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from
person to person. In an individual, they may occur from hour to hour and day to day.

This condition is due to inflammation of the air passages in the lungs and affects the sensitivity
of the nerve endings in the airways so they become easily irritated. In an attack, the lining of the
passages swell causing the airways to narrow and reducing the flow of air in and out of the lungs.

http://www.asthma.ca/adults/about/whatIsAsthma.php

What Is Asthma?

Have you, or someone you know, been diagnosed with asthma? If so, you probably have lots of
questions.

You may wonder, for example, just what asthma is. The medical definition of asthma is simple,
but the condition itself is quite complex.

Doctors define asthma as a "chronic inflammatory disease of the airway" that causes the
following symptoms:
 Shortness of breath
Tightness in the chest
Coughing
Wheezing

Asthma has no set pattern. Its symptoms:

Can be mild, moderate or severe

Can vary from person to person
Can flare up from time to time and then not appear for long periods
Can vary from one episode to the next

The cause of asthma is not known, and currently there is no cure. However, there are many
things you can do so you can live symptom-free.

Breathing: Normal Airway Versus Asthma Airway

In someone with normal lung function, air is inhaled through the nose and mouth. It passes
through the trachea (also called the windpipe) before moving into the bronchi (large airways),
which are branching tubes leading away from the trachea. The bronchi branch into smaller and
smaller tubes, ending in many small sacs called alveoli. It's in the alveoli that oxygen, which the
body needs, is passed to the blood, while carbon dioxide, which the body doesn't, is removed
from it.

People with asthma often have trouble breathing when they're in the presence of what are called
"triggers." When someone with asthma has asthma symptoms, it means that the flow of air is
obstructed as it passes in and out of the lungs. This happens because of one or both of the
following:

The lining of the airways becomes inflamed (irritated, reddened and swollen), and may
produce more mucous. The more inflammation the more sensitive the airway becomes,
and the more symptoms.
 The muscles that surround the airways become sensitive and start to twitch and tighten,
causing the airways to narrow. This usually occurs if the inflammation is not treated.

Both of these factors cause the airways to narrow, making it difficult for air to pass in and out of
them.

The airways of someone with asthma are inflamed, to some degree, all the time. The more
inflamed the airway the more sensitive the airway becomes. This leads to an increase in
breathing difficulty.

Asthma Can Affect Anyone

Asthma is a chronic condition, meaning it needs to be monitored and controlled over a lifetime.

Anyone can get asthma, although it's usually first diagnosed in young people. Currently, about
three million Canadians have asthma.

Living with Asthma

Most people with asthma can live full, active lives. The trick is learning how to keep the asthma
symptom-free. If you have asthma, you can control it:

By avoiding your asthma triggers

By taking your medication
Through education from your healthcare team
By following an asthma action plan
http://www.mayoclinic.org/diseases-
conditions/asthma/basics/definition/con-20026992
Definition
By Mayo Clinic Staff

Appointments & care

At Mayo Clinic, we take the time to listen, to find answers and to provide you the best care.

Learn more. Request an appointment.

Multimedia

Asthma attack

Asthma is a condition in which your airways narrow and swell and produce extra mucus. This
can make breathing difficult and trigger coughing, wheezing and shortness of breath.

For some people, asthma is a minor nuisance. For others, it can be a major problem that
interferes with daily activities and may lead to a life-threatening asthma attack.

Asthma can't be cured, but its symptoms can be controlled. Because asthma often changes over
time, it's important that you work with your doctor to track your signs and symptoms and adjust
treatment as needed.

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Symptoms
By Mayo Clinic Staff
Multimedia

Asthma attack

Asthma symptoms range from minor to severe and vary from person to person. You may have
infrequent asthma attacks, have symptoms only at certain times such as when exercising or
have symptoms all the time.

Asthma signs and symptoms include:

Shortness of breath
Chest tightness or pain

Trouble sleeping caused by shortness of breath, coughing or wheezing

A whistling or wheezing sound when exhaling (wheezing is a common sign of asthma in children)

Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or the flu

Signs that your asthma is probably worsening include:

Asthma signs and symptoms that are more frequent and bothersome
Increasing difficulty breathing (measurable with a peak flow meter, a device used to check how
well your lungs are working)

The need to use a quick-relief inhaler more often

For some people, asthma symptoms flare up in certain situations:

Exercise-induced asthma, which may be worse when the air is cold and dry
Occupational asthma, triggered by workplace irritants such as chemical fumes, gases or dust

Allergy-induced asthma, triggered by particular allergens, such as pet dander, cockroaches or

pollen
When to see a doctor

Seek emergency treatment

Severe asthma attacks can be life-threatening. Work with your doctor ahead of time to determine
what to do when your signs and symptoms worsen and when you need emergency treatment.
Signs of an asthma emergency include:

Rapid worsening of shortness of breath or wheezing

No improvement even after using a quick-relief inhaler, such as albuterol

Shortness of breath when you are doing minimal physical activity

Contact your doctor

See your doctor:

If you think you have asthma. If you have frequent coughing or wheezing that lasts more than a
few days or any other signs or symptoms of asthma, see your doctor. Treating asthma early may
prevent long-term lung damage and help keep the condition from worsening over time.
To monitor your asthma after diagnosis. If you know you have asthma, work with your doctor to
keep it under control. Good long-term control helps you feel better on a daily basis and can
prevent a life-threatening asthma attack.

If your asthma symptoms get worse. Contact your doctor right away if your medication doesn't
seem to ease your symptoms or if you need to use your quick-relief inhaler more often. Don't try
to solve the problem by taking more medication without consulting your doctor. Overusing
asthma medication can cause side effects and may make your asthma worse.

To review your treatment. Asthma often changes over time. Meet with your doctor on a regular
basis to discuss your symptoms and make any needed treatment adjustments.

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Causes
By Mayo Clinic Staff

It isn't clear why some people get asthma and others don't, but it's probably due to a combination
of environmental and genetic (inherited) factors.
Asthma triggers

Exposure to various substances that trigger allergies (allergens) and irritants can trigger signs and
symptoms of asthma. Asthma triggers are different from person to person and can include:

Airborne allergens, such as pollen, animal dander, mold, cockroaches and dust mites
Respiratory infections, such as the common cold

Physical activity (exercise-induced asthma)

Cold air

Air pollutants and irritants, such as smoke

Certain medications, including beta blockers, aspirin, ibuprofen (Advil, Motrin IB, others) and
naproxen (Aleve)

Strong emotions and stress

Sulfites and preservatives added to some types of foods and beverages, including shrimp, dried
fruit, processed potatoes, beer and wine

Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your
throat

Menstrual cycle in some women

Risk factors
By Mayo Clinic Staff

A number of factors are thought to increase your chances of developing asthma. These include:

Having a blood relative (such as a parent or sibling) with asthma

Having another allergic condition, such as atopic dermatitis or allergic rhinitis (hay fever)
Being overweight
Being a smoker
Exposure to secondhand smoke
Having a mother who smoked while pregnant
Exposure to exhaust fumes or other types of pollution
Exposure to occupational triggers, such as chemicals used in farming, hairdressing and
manufacturing
Exposure to allergens, exposure to certain germs or parasites, and having some types of bacterial
or viral infections also may be risk factors. However, more research is needed to determine what
role they may play in developing asthma.

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Complications
By Mayo Clinic Staff

Asthma complications include:

Symptoms that interfere with sleep, work or recreational activities

Sick days from work or school during asthma flare-ups
Permanent narrowing of the bronchial tubes (airway remodeling) that affects how well
you can breathe
Emergency room visits and hospitalizations for severe asthma attacks
Side effects from long-term use of some medications used to stabilize severe asthma

Proper treatment makes a big difference in preventing both short-term and long-term
complications caused by asthma.

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Preparing for your appointment

By Mayo Clinic Staff

You're likely to start by seeing your family doctor or a general practitioner. However, when you
call to set up an appointment, you may be referred to an allergist or a pulmonologist.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good
idea to be well prepared. Here's some information to help you get ready for your appointment, as
well as what to expect from your doctor.

What you can do

These steps can help you make the most of your appointment:

Write down any symptoms you're having, including any that may seem unrelated to the reason
for which you scheduled the appointment.
 Note when your symptoms bother you most for example, if your symptoms tend to get
worse at certain times of the day, during certain seasons, or when you're exposed to cold air,
pollen or other triggers.

Write down key personal information, including any major stresses or recent life changes.

Make a list of all medications, vitamins and supplements that you're taking.

Take a family member or friend along, if possible. Sometimes it can be difficult to recall all the
information provided to you during an appointment. Someone who accompanies you may
remember something that you missed or forgot.

Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the
most of your time together. List your questions from most important to least important in case
time runs out. For asthma, some basic questions to ask your doctor include:

Is asthma the most likely cause of my breathing problems?

Other than the most likely cause, what are other possible causes for my symptoms?

What kinds of tests do I need?

Is my condition likely temporary or chronic?

What's the best treatment?

What are the alternatives to the primary approach that you're suggesting?

I have these other health conditions. How can I best manage them together?

Are there any restrictions that I need to follow?

Should I see a specialist?

Is there a generic alternative to the medicine you're prescribing me?

Are there any brochures or other printed material that I can take home with me? What websites
do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask
questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve
time to go over any points you want to spend more time on. Your doctor may ask:

What exactly are your symptoms?

When did you first notice your symptoms?
 How severe are your symptoms?

Do you have breathing problems most of the time or only at certain times or in certain
situations?

Do you have allergies, such as atopic dermatitis or hay fever?

What, if anything, seems to improve your symptoms?

Do allergies or asthma run in your family?

Do you have any chronic health problems?

Tests and diagnosis

By Mayo Clinic Staff

Appointments & care

At Mayo Clinic, we take the time to listen, to find answers and to provide you the best care.

Learn more. Request an appointment.

Physical exam

To rule out other possible conditions such as a respiratory infection or chronic obstructive
pulmonary disease (COPD) your doctor will do a physical exam and ask you questions about
your signs and symptoms and about any other health problems.

Tests to measure lung function

You may also be given lung (pulmonary) function tests to determine how much air moves in and
out as you breathe. These tests may include:

Spirometry. This test estimates the narrowing of your bronchial tubes by checking how much air
you can exhale after a deep breath and how fast you can breathe out.
Peak flow. A peak flow meter is a simple device that measures how hard you can breathe out.
Lower than usual peak flow readings are a sign your lungs may not be working as well and that
your asthma may be getting worse. Your doctor will give you instructions on how to track and
deal with low peak flow readings.

Lung function tests often are done before and after taking a bronchodilator (brong-koh-DIE-lay-
tur), such as albuterol, to open your airways. If your lung function improves with use of a
bronchodilator, it's likely you have asthma.
Additional tests

Other tests to diagnose asthma include:

Methacholine challenge. Methacholine is a known asthma trigger that, when inhaled, will cause
mild constriction of your airways. If you react to the methacholine, you likely have asthma. This
test may be used even if your initial lung function test is normal.
Nitric oxide test. This test, though not widely available, measures the amount of the gas, nitric
oxide, that you have in your breath. When your airways are inflamed a sign of asthma you
may have higher than normal nitric oxide levels.

Imaging tests. A chest X-ray and high-resolution computerized tomography (CT) scan of your
lungs and nose cavities (sinuses) can identify any structural abnormalities or diseases (such as
infection) that can cause or aggravate breathing problems.

Allergy testing. This can be performed by skin test or blood test. Allergy tests can identify allergy
to pets, dust, mold and pollen. If important allergy triggers are identified, this can lead to a
recommendation for allergen immunotherapy.

Sputum eosinophils. This test looks for certain white blood cells (eosinophils) in the mixture of
saliva and mucus (sputum) you discharge during coughing. Eosinophils are present when
symptoms develop and become visible when stained with a rose-colored dye (eosin).

Provocative testing for exercise and cold-induced asthma. In these tests, your doctor measures
your airway obstruction before and after you perform vigorous physical activity or take several
breaths of cold air.

How asthma is classified

To classify your asthma severity, your doctor considers your answers to questions about
symptoms (such as how often you have asthma attacks and how bad they are), along with the
results of your physical exam and diagnostic tests.

Determining your asthma severity helps your doctor choose the best treatment. Asthma severity
often changes over time, requiring treatment adjustments.

Asthma is classified into four general categories:

Asthma classification Signs and symptoms

Mild intermittent Mild symptoms up to two days a week and up to two nights a month

Mild persistent Symptoms more than twice a week, but no more than once in a single day

Moderate persistent Symptoms once a day and more than one night a week
Severe persistent Symptoms throughout the day on most days and frequently at night

Treatments and drugs

By Mayo Clinic Staff

Appointments & care

At Mayo Clinic, we take the time to listen, to find answers and to provide you the best care.

Learn more. Request an appointment.

Prevention and long-term control are key in stopping asthma attacks before they start. Treatment
usually involves learning to recognize your triggers, taking steps to avoid them and tracking your
breathing to make sure your daily asthma medications are keeping symptoms under control. In
case of an asthma flare-up, you may need to use a quick-relief inhaler, such as albuterol.

Medications

The right medications for you depend on a number of things, including your age, your
symptoms, your asthma triggers and what seems to work best to keep your asthma under control.

Preventive, long-term control medications reduce the inflammation in your airways that leads to
symptoms. Quick-relief inhalers (bronchodilators) quickly open swollen airways that are limiting
breathing. In some cases, allergy medications are necessary.

Long-term asthma control medications, generally taken daily, are the cornerstone of asthma
treatment. These medications keep asthma under control on a day-to-day basis and make it less
likely you'll have an asthma attack. Types of long-term control medications include:

Inhaled corticosteroids. These anti-inflammatory drugs include fluticasone (Flovent

HFA), budesonide (Pulmicort Flexhaler), flunisolide (Aerobid), ciclesonide (Alvesco),
beclomethasone (Qvar) and mometasone (Asmanex).

You may need to use these medications for several days to weeks before they reach their
maximum benefit. Unlike oral corticosteroids, these corticosteroid medications have a
relatively low risk of side effects and are generally safe for long-term use.

Leukotriene modifiers. These oral medications including montelukast (Singulair), zafirlukast

(Accolate) and zileuton (Zyflo) help relieve asthma symptoms for up to 24 hours. In rare cases,
these medications have been linked to psychological reactions, such as agitation, aggression,
 hallucinations, depression and suicidal thinking. Seek medical advice right away for any unusual
reaction.
Long-acting beta agonists. These inhaled medications, which include salmeterol (Serevent) and
formoterol (Foradil, Perforomist), open the airways. Some research shows that they may
increase the risk of a severe asthma attack, so take them only in combination with an inhaled
corticosteroid. And because these drugs can mask asthma deterioration, don't use them for an
acute asthma attack.

Combination inhalers. These medications such as fluticasone-salmeterol (Advair Diskus),

budesonide-formoterol (Symbicort) and mometasone-formoterol (Dulera) contain a long-
acting beta agonist along with a corticosteroid. Because these combination inhalers contain long-
acting beta agonists, they may increase your risk of having a severe asthma attack.

Theophylline. Theophylline (Theo-24, Elixophyllin, others) is a daily pill that helps keep the
airways open (bronchodilator) by relaxing the muscles around the airways. It's not used as often
now as in past years.

Quick-relief (rescue) medications are used as needed for rapid, short-term symptom relief
during an asthma attack or before exercise if your doctor recommends it. Types of quick-relief
medications include:

Short-acting beta agonists. These inhaled, quick-relief bronchodilators act within minutes to
rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin
HFA, others), levalbuterol (Xopenex) and pirbuterol (Maxair). Short-acting beta agonists can be
taken using a portable, hand-held inhaler or a nebulizer a machine that converts asthma
medications to a fine mist so that they can be inhaled through a face mask or a mouthpiece.
Ipratropium (Atrovent). Like other bronchodilators, ipratropium acts quickly to immediately
relax your airways, making it easier to breathe. Ipratropium is mostly used for emphysema and
chronic bronchitis, but it's sometimes used to treat asthma attacks.

Oral and intravenous corticosteroids. These medications which include prednisone and
methylprednisolone relieve airway inflammation caused by severe asthma. They can cause
serious side effects when used long term, so they're used only on a short-term basis to treat
severe asthma symptoms.

If you have an asthma flare-up, a quick-relief inhaler can ease your symptoms right away. But if
your long-term control medications are working properly, you shouldn't need to use your quick-
relief inhaler very often.

Keep a record of how many puffs you use each week. If you need to use your quick-relief inhaler
more often than your doctor recommends, see your doctor. You probably need to adjust your
long-term control medication.

Allergy medications may help if your asthma is triggered or worsened by allergies. These
include:
 Allergy shots (immunotherapy). Over time, allergy shots gradually reduce your immune system
reaction to specific allergens. You generally receive shots once a week for a few months, then
once a month for a period of three to five years.
Omalizumab (Xolair). This medication, given as an injection every two to four weeks, is
specifically for people who have allergies and severe asthma. It acts by altering the immune
system.

Allergy medications. These include oral and nasal spray antihistamines and decongestants as
well as corticosteroid and cromolyn nasal sprays.

Bronchial thermoplasty

This treatment which isn't widely available nor right for everyone is used for severe
asthma that doesn't improve with inhaled corticosteroids or other long-term asthma medications.

Generally, over the span of three outpatient visits, bronchial thermoplasty heats the insides of the
airways in the lungs with an electrode, reducing the smooth muscle inside the airways. This
limits the ability of the airways to tighten, making breathing easier and possibly reducing asthma
attacks.

Treat by severity for better control: A stepwise approach

Your treatment should be flexible and based on changes in your symptoms, which should be
assessed thoroughly each time you see your doctor. Then your doctor can adjust your treatment
accordingly. For example, if your asthma is well controlled, your doctor may prescribe less
medicine. If your asthma isn't well controlled or is getting worse, your doctor may increase your
medication and recommend more-frequent visits.

Asthma action plan

Work with your doctor to create an asthma action plan that outlines in writing when to take
certain medications or when to increase or decrease the dose of your medications based on your
symptoms. Also include a list of your triggers and the steps you need to take to avoid them.

Your doctor may also recommend tracking your asthma symptoms or using a peak flow meter on
a regular basis to monitor how well your treatment is controlling your asthma.

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Lifestyle and home remedies

By Mayo Clinic Staff
Although many people with asthma rely on medications to prevent and relieve symptoms, you
can do several things on your own to maintain your health and lessen the possibility of asthma
attacks.

Avoid your triggers

Taking steps to reduce your exposure to things that trigger asthma symptoms is a key part of
asthma control. It may help to:

Use your air conditioner. Air conditioning reduces the amount of airborne pollen from trees,
grasses and weeds that finds its way indoors. Air conditioning also lowers indoor humidity and
can reduce your exposure to dust mites. If you don't have air conditioning, try to keep your
windows closed during pollen season.
Decontaminate your decor. Minimize dust that may worsen nighttime symptoms by replacing
certain items in your bedroom. For example, encase pillows, mattresses and box springs in
dustproof covers. Remove carpeting and install hardwood or linoleum flooring. Use washable
curtains and blinds.

Maintain optimal humidity. If you live in a damp climate, talk to your doctor about using a
dehumidifier.

Prevent mold spores. Clean damp areas in the bath, kitchen and around the house to keep mold
spores from developing. Get rid of moldy leaves or damp firewood in the yard.

Reduce pet dander. If you're allergic to dander, avoid pets with fur or feathers. Having pets
regularly bathed or groomed also may reduce the amount of dander in your surroundings.

Clean regularly. Clean your home at least once a week. If you're likely to stir up dust, wear a
mask or have someone else do the cleaning.

Cover your nose and mouth if it's cold out. If your asthma is worsened by cold or dry air,
wearing a face mask can help.

Stay healthy

Taking care of yourself and treating other conditions linked to asthma will help keep your
symptoms under control. For example:

Get regular exercise. Having asthma doesn't mean you have to be less active. Treatment can
prevent asthma attacks and control symptoms during activity. Regular exercise can strengthen
your heart and lungs, which helps relieve asthma symptoms. If you exercise in cold
temperatures, wear a face mask to warm the air you breathe.
Maintain a healthy weight. Being overweight can worsen asthma symptoms, and it puts you at
higher risk of other health problems.

Eat fruits and vegetables. Eating plenty of fruits and vegetables may increase lung function and
reduce asthma symptoms. These foods are rich in protective nutrients (antioxidants) that boost
the immune system.
 Control heartburn and gastroesophageal reflux disease (GERD). It's possible that the acid reflux
that causes heartburn may damage lung airways and worsen asthma symptoms. If you have
frequent or constant heartburn, talk to your doctor about treatment options. You may need
treatment for GERD before your asthma symptoms improve.

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Alternative medicine
By Mayo Clinic Staff

Certain alternative treatments may help with asthma symptoms. However, keep in mind that
these treatments are not a replacement for medical treatment especially if you have severe
asthma. Talk to your doctor before taking any herbs or supplements, as some may interact with
medications you take.

While some alternative remedies are used for asthma, in most cases more research is needed to
see how well they work and to measure the extent of possible side effects. Alternative asthma
treatments include:

Breathing techniques. These exercises may reduce the amount of medication you need
to keep your asthma symptoms under control. Yoga classes increase fitness and reduce
stress, which may help with asthma as well.
Acupuncture. This technique involves placing very thin needles at strategic points on
your body. It's safe and generally painless.
Relaxation techniques. Techniques such as meditation, biofeedback, hypnosis and
progressive muscle relaxation may help with asthma by reducing tension and stress.
Herbal and natural remedies. A few herbal and natural remedies that may help improve
asthma symptoms include caffeine, magnesium and pycnogenol. Blends of different types
of herbs are commonly used in traditional Chinese, Indian and Japanese medicine.
However, more studies are needed to determine how well herbal remedies and
preparations work for asthma.
Omega-3 fatty acids. Found in fish, flaxseed and other foods, these healthy oils may
reduce the inflammation that leads to asthma symptoms.

Coping and support

By Mayo Clinic Staff

Asthma can be challenging and stressful. You may sometimes become frustrated, angry or
depressed because you need to cut back on your usual activities to avoid environmental triggers.
You may also feel limited or embarrassed by the symptoms of the disease and by complicated
management routines.

But asthma doesn't have to be a limiting condition. The best way to overcome anxiety and a
feeling of helplessness is to understand your condition and take control of your treatment. Here
are some suggestions that may help:

Pace yourself. Take breaks between tasks and avoid activities that make your symptoms
worse.
Make a daily to-do list. This may help you avoid feeling overwhelmed. Reward yourself
for accomplishing simple goals.
Talk to others with your condition. Chat rooms and message boards on the Internet or
support groups in your area can connect you with people facing similar challenges and let
you know you're not alone.
If your child has asthma, be encouraging. Focus attention on the things your child can
do, not on the things he or she can't. Involve teachers, school nurses, coaches, friends and
relatives in helping your child manage asthma.

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Prevention
By Mayo Clinic Staff

While there's no way to prevent asthma, by working together, you and your doctor can design a
step-by-step plan for living with your condition and preventing asthma attacks.

Follow your asthma action plan. With your doctor and health care team, write a detailed
plan for taking medications and managing an asthma attack. Then be sure to follow your
plan. Asthma is an ongoing condition that needs regular monitoring and treatment. Taking
control of your treatment can make you feel more in control of your life in general.
Get vaccinated for influenza and pneumonia. Staying current with vaccinations can
prevent flu and pneumonia from triggering asthma flare-ups.
Identify and avoid asthma triggers. A number of outdoor allergens and irritants
ranging from pollen and mold to cold air and air pollution can trigger asthma attacks.
Find out what causes or worsens your asthma, and take steps to avoid those triggers.
Monitor your breathing. You may learn to recognize warning signs of an impending
attack, such as slight coughing, wheezing or shortness of breath. But because your lung
function may decrease before you notice any signs or symptoms, regularly measure and
record your peak airflow with a home peak flow meter.
 Identify and treat attacks early. If you act quickly, you're less likely to have a severe
attack. You also won't need as much medication to control your symptoms.

When your peak flow measurements decrease and alert you to an oncoming attack, take
your medication as instructed and immediately stop any activity that may have triggered
the attack. If your symptoms don't improve, get medical help as directed in your action
plan.

Take your medication as prescribed. Just because your asthma seems to be improving,
don't change anything without first talking to your doctor. It's a good idea to bring your
medications with you to each doctor visit, so your doctor can double-check that you're
using your medications correctly and taking the right dose.
Pay attention to increasing quick-relief inhaler use. If you find yourself relying on
your quick-relief inhaler, such as albuterol, your asthma isn't under control. See your
doctor about adjusting your treatment.

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