Diagnosis of Asthma

The purpose of diagnostic investigation is to first rule out other conditions and secondly to assess the severity of the asthma. A thorough case history allows the doctor to identify the characteristic signs and symptoms of asthma, assess the severity and monitor the success of the treatment in the future. It is accompanied by a thorough examination of the respiratory system and identification of other clinical features that may or may not be related to asthma.

There are four broad categories for the classification of asthma :

• Mild intermittent asthma where the symptoms such as wheezing, breathlessness and/or coughing are mild and present at most 2 days in a week and not more than 2 nights in a month.
• Mild persistent asthma where the symptoms occur more than twice in a week but is limited to at most one episode in a day.
• Moderate persistent asthma where the symptoms occur only once a day and more than one night in a week.
• Severe persistent asthma where the symptoms continue throughout the day on most days of the week and often arises at night as well.

Specialized investigation will more accurately measure the functioning of the respiratory system and this is known as pulmonary function tests, or simply lung function tests. Spirometry and peak flow are the two most widely used methods to assess the respiratory function. With spirometry, the volume of air can be measured which correlates with the degree of narrowing of the airway. A peak flow meter measures the force of expiration. Both tests are difficult to perform on younger children as it requires patient cooperation. Other tests like a metacholine challenge and nitric oxide test will also confirm the diagnosis of asthma. Allergen testing may be useful for patients with allergic asthma as it helps to identify trigger factors.

Treatment of Asthma

Asthma treatment depends on a number of factors like the severity of the condition or whether it is allergic asthma or non-allergic asthma. The medication can be divided into acute treatment and chronic/long term treatment. The aim of asthma management is to prevent acute attacks or at least minimize the frequency of these attacks while easing, or if possible even resolving, the symptoms. However, the symptoms will often return should the medication be discontinued and therefore it is imperative that asthmatic patients adhere to the treatment protocol laid out by the doctor.

Both acute and chronic medication may be inhaled or ingested (orally) although some acute medication can be administered intravenously. The range of medication may have one or more of the following effects :

• Reduce airway inflammation – corticosteroids, beta agonists (adrenergic)
• Open the airways (bronchodilation) – beta agonists, theophylline, anticholinergic

For allergic asthma, a combination of drugs along with antihistamines and decongestants may be used to reduce the allergic response, reduce airways inflammation and open the airways.

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Simple Explanation of Asthma

Asthma is the chronic inflammation of the bronchi and bronchioles due to an increased hypersensitivity of the walls of the airways. When the walls of the bronchi and bronchioles are inflamed, it swells, secretes more mucus and the muscles in the wall may constrict. All of these effects serves to narrow the lumen of the airway and therefore restrict airflow.

In asthma, the reason for this narrowing is that the walls of the airway are extremely sensitive (hypersensitivity) and react to various stimuli (hyper-responsive) that may not affect other individuals. This is referred to as allergic asthma. It is associated with atopy, a constitutional allergic state, which also gives rise to other allergic conditions like atopic dermatitis and allergic rhinitis. These three conditions – atopic dermatitis, asthma and allergic rhinitis – are referred to as the allergic triad.

However, sometimes asthma is not related to allergies and may be termed non-allergic asthma. This is more frequently seen in the workplace (occupational asthma). There is usually underlying airway disease that causes narrowing and obstruction. Asthma may also be associated with certain drugs, like aspirin, and physical activity despite the absence of allergies. It is more likely for these types of asthma to be seen in a person with a history of childhood asthma.

Causes of Asthma

As discussed above, asthma is due to a hyper-reactive airway that is triggered by the inhalation of allergens. This commonly includes :

• House dust mite (HDM)
• Pollen
• Animal dander (particularly from pets)
• Cockroaches
• Fungi and molds

Organic and non-organic dusts, fumes from gases, smoke, certain drugs and exercise may all exacerbate existing asthma and long term exposure may even lead to the development of asthma.

Signs and Symptoms

Asthma is sometimes commonly referred to as wheezing. However, the term wheeze describes the abnormal breathing sound characteristic of asthma. It typically sounds as a whistling or rattling noise that is associated with the labored breathing. Other signs and symptoms includes shortness of breath, tightness of the chest and coughing. Patients often report the symptoms worsening with cold weather, exercise, exposure to cigarette smoke, dust and other allergens, as well as with a common cold or flu.

Asthmatics may be asymptomatic (have no symptoms) between attacks and acute episodes can very severe and even require hospitalization. It is possible, however, for an asthmatic patient to experience ongoing symptoms for weeks and months with no easing of symptoms for even short periods. Some forms of asthma like cough-variant asthma may not present with the typical signs and symptoms apart from coughing. At other times, some patients may only experience symptoms at night when asleep – nocturnal asthma. It is therefore not uncommon for asthma to be initially mistaken for chest infections and other respiratory illnesses.

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There are lots of asthma triggers which come under the category of allergens and irritants which are usually found in the stuff and floors of home like carpets, rugs, curtains etc. Most common triggers include dust mites, mold, pet dander, rodents, pollen, tobacco smoke, sharp smells of perfumes etc. So it is must to make house an asthma healthy zone to avoid its symptoms. Merck launched a “Build Smart, Breathe Easier” campaign to educate people about the magnitude of “asthma-healthy home”.

To make this campaign a great success, Merck joined with Habitat for Humanity, the Asthma and Allergy Foundation of America (AAFA) and HGTV personality and carpenter Carter Oosterhouse to construct four houses in order to help the people having low incomes.

Dr. Gokul Gopalan, regional director of Medical Affairs, Respiratory, Merck. “We are pleased to partner with these experts to build homes with asthma-healthy features and educate about the importance of a healthy indoor environment, coupled with proper asthma management, Build Smart, Breathe Easier reinforces Merck’s ongoing commitment to educate people about their asthma and provide appropriate treatment options to physicians and their patients.”

It is very important to create and maintain asthma healthy home, Carter Oosterhouse from HGTV said “A house built with materials that are easy to clean and less likely to contain irritants, such as hard-surface floors or non-toxic paint, may have a positive impact on a family, especially one dealing with asthma, I am excited to be a part of this program which will help build sustainable homes with asthma-friendly features in partnership with low income families and will also educate about simple ways to try to reduce and avoid common household asthma triggers.”

The study was conducted on four different places in the UK involved such patients whom corticosteroids requirements were quite high and having sensitivity to at least one of common fungi.

In the beginning 18 patients were randomly administered with itraconazole 200 mg twice in a day and 23 were assigned to placebo. The changes were brought in the parameter of Asthma Quality of Life Questionnaire (AQLQ) score, which is attained on a scale of 1 to 7, with 7 exhibits an excellent quality of life in asthmatic patients.

The previous baseline AQLQ score was 4.13. At 32 weeks, the researchers noted a considerably increase in AQLQ score in the group treated with itraconazole (5.36) in comparison with placebo group (4.18).

The author also noted that, itraconazole was also linked to significant reductions in IgE levels, which were maintained even after the  four months of discontinuation of the treatment.

However, AQLQ scores variation following the completion of trial, showing that “continuous antifungal treatment beyond 8 months is essential for the good health maintenance for fungi allergen asthmatic patients, and IgE levels is unnecessary to monitor for relapse,” the authors say.

Dr. Denning’s and his colleagues theorize that “antifungal agent diminished allergen exposure directly by eliminating viable filamentous fungi.”

They conclude, “The length of the antifungal effect on symptoms of asthma seen in this study is promising.”

A new study conducted by researchers at ‘Barts’ and ‘The London School of Medicine and Dentistry’ has found a key component of the body’s own responses to allergens. Allergens are the substances that cause the immunity system of the body to trigger a fight against the foreign bodies. These foreign bodies could be just dust, pollen, peanut, milk, penicillin etc. and since they are not recognized by our immune system, body reacts to them. The symptoms occur in the form of inflamed airway or runny nose or itching in the eyes or rashes on the skin. So this key component which triggers this fight can be targeted to reduce the allergic reactions.

In contrary to the all the major treatments for asthma and allergies which target on reducing symptoms , this new study targets the immune system of the body.

As most of the allergies are mere responses of our immune system to the foreign elements, they can be avoided if the immune system is slowed down. However this involves a risk. The person may be left prone to infection since there would be no immunity to fight. So this treatment could be administered only in the extreme cases. The conventional treatment would continue focusing on managing the symptoms of allergy.

This limitation has been ruled out by the BBSRC team led by Professor Bart Vanhaesebroeck who has proven in its study that the allergic reaction can be hampered before the occurrence of the symptoms without affecting the immune system of the body by aiming at “p110delta”.

“P110delta” is a molecule, belonging to the family of eight proteins called ‘PI3Ks’.  These proteins control various biological functions of the body. Their involvement in various diseases including cancer makes them an important target for further research and development in producing an effective drug to combat these ailments.

The researchers tried to go behind the specific diseases associated with the eight members of the ‘PI3Ks’ proteins so that specific drugs could be developed with reduced side effects. They brought in use various genetic techniques to determine this.

In the recent study, the research confirmed that ‘p110delta’ is found to be playing more important role in allergic reactions than ‘p110gamma’, another member of the ‘PI3K’ family. So now they can be targeted to develop ‘p110delta’ blockers. Soon their clinical use can be expected to enter in the human arena.

Dr Khaled Ali, the lead researcher informed that ‘p110delta’, identified in 1997 had many apprehensions associated with it. However, the recent work has shown its ability to control the body’s reaction to an allergen and thus prevent the symptoms to occur.

This study has already confirmed that ‘p110delta’ is the key player among the ‘PI3K’ molecules. So Professor Vanhaesebroeck is quite hopeful that a drug could be developed very soon to combat the problem of allergies and a therapy could be devised for not only controlling the symptoms which occur in the body but also would be able to target the real causes.

This study promises to get a revolutionary way to fight against the allergies which cause misery to millions of human beings.

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This research was conducted in the leadership of Dr Antoine Magnan at the ‘University of Nantes’ in France. Dr Magnan and his colleague researchers explained that dry powder inhalers containing medication are common and very popular among the majority of the patients with asthma and chronic obstructive pulmonary disease. Researchers observed that, “The effectiveness in delivering drugs to the lungs depends on correctly performed inhalation maneuvers”.

Dr. Antoine Magnan and his team of researchers collected the results of almost 50 studies that were conducted previously by several researchers. These results were analyzed and reviewed. Evaluation of commonly adopted inhaling techniques applicable in patients with respiratory diseases enabled them to observe and highlight the most common errors made by patients when using these devices.

Findings of this evaluation show that almost 94% of the patients whose medical data and practices were studies were not using their inhalers correctly. This analysis depended on the type of inhaler and particular method of assessment.

According to the researchers, among the most common mistakes, not breathing out before using the inhaler, not holding the breath after inhalation, and failing in breathing deeply enough when inhaling the medication are the most common ones.
The study reveals that many participants demonstrated improper inhaler techniques and almost 25% of them never got any type of instructions for using the inhaler in right way.

Even the patients who received proper instructions about using the inhalers correctly did not have any idea about the quality and duration of their instructions. Doctors also did not care for conducting adequate reviews and follow up checks subsequent to the medications.

Researchers reported the results of their study in the journal “Respiratory Medicine” and explained that a large population of patients is committing errors in dealing with the dry powder inhalers and this may also increase the risks of insufficient drug delivery. Such a situation will, researchers say, adversely affect the drug efficiency and would possibly lead to” inadequate control of asthma and chronic obstructive pulmonary disease”.

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Dr Joachim Heinrich, at the ‘Institute of Epidemiology in Neuherberg, Germany’, and colleagues made an attempt to emphasize that even the international guidelines also advise that babies should not be given solid foods for up to 6 months after birth in order to reduce their risk of developing asthma and allergies. These research findings have been published in the January issue of the journal “Pediatrics”.

“Scientific evidence for this advice is scarce“, say the researchers. This new finding is based on the evidence of a study recently conducted that included analysis of data on 2,073 children who were monitored between a period of their birth and 6 years of age.
Parents of all these 2,073 children were asked to complete regular questionnaires on their children’s health and feeding habits. They were also asked to provide the information about the age at which they were given the solid food for the first time.

Researchers also conducted the blood tests and physical examination of all these children at the ages of 2 and 6 years with an objective to identify the chances of development of asthma and allergies.

Researchers, surprisingly, found no substantial evidence suggesting that delaying the introduction of solid foods for 4 to 6 months was in any way related with a reduced risk of asthma, hay fever, or sensitization against certain foods or even allergens in the air at the age of 6 years.

On the other hand, the researchers did observe some evidence that suggests about the delayed introduction of solid foods having a linkage with an increased risk of food allergies among the children.

This large population based study focusing on the asthma and allergic diseases could reveal no sustentative evidence for a “protective effect of a delayed introduction of solids past 4 or 6 months on asthma, allergic rhinitis, or food or inhalant sensitization against food or inhalant allergens at 6 years of age”, said Dr. Heinrich.

Researchers expressed that avoiding giving solid food to the babies for the initial four or six months or introducing the less diverse diet within a period of initial four months bears a significant statistical correlation and positive linkages with the food sensitization process in the babies. Researchers however, suggest being cautious when introducing such a diet to the babies.

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The study was published in the British Medical Journal’s Thorax and detailed the benefits for children whose mother’s stuck to a Mediterranean diet during their pregnancy. They discovered that women who ate primarily fresh fruit, nuts, grains and vegetables passed on benefits to their children that reduced the risk of asthma symptoms.

Six year olds whose mothers followed these diets were significantly less likely to display asthma symptoms. In addition, it appears that this diet also reduced the amount of children who suffered from allergies. 468 mothers and their children were examined during this study. They were tracked from the initial pregnancy up through six and half years after birth.

The study recommends that pregnant women eat vegetables at least eight times a week, preferably more. Fish is recommended at least three times a week. Legumes or nuts should be consumed at least once a week in order to gain the benefits from this special diet. Olive oil is also highly recommended as a replacement for other vegetable oils. It was found during the study that these amounts greatly reduced asthma symptoms in children.

However, once the child reaches the age of six, little benefit can be added to reduce asthma symptoms. This led researchers to the conclusion that the most vital timing is during pregnancy and possibly breast feeding. It is believed that the compounds in these foods are passed along to the unborn child, giving them extra protection against allergies and asthma.

Currently, allergies are the sixth most popular cause of chronic diseases in America. Over the past ten years, the incidence of childhood asthma and allergy problems has skyrocketed. This study suggests that this upsurge may be linked to poor diets that lack the necessary nutrients provided by a Mediterranean diet. To back up this theory, it has been proven that eating red meat more than three times a week can actually make asthma and allergy symptoms worse in some children.

Pregnant women looking to change their diets should first discuss their plans with their doctor. A well balanced diet is crucial during this time and any new foods should be examined to avoid potential allergic reactions, particularly with legumes and nuts.

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