Asthma

Making a correct diagnosis is extremely important: if asthma is correctly diagnosed it can be treated appropriately.

The diagnosis of asthma involves all of the following:

1. A detailed history which would include:
   • family history of asthma, allergies, hay fever, eczema; children will have a greater chance of developing the above if there is a family history of allergies and asthma
   • child's medical history including:
     • when parents first noticed the child developed breathing problems; history of nasal stuffiness (rhinitis), itchy eyes (allergic conjunctivitis) and eczema, which are common accompaniments to asthma, and hives (urticaria).
     • history of recurrent and persistent cough following a cold, frequent colds, croup, seasonal changes (i.e. worse in the spring and fall), exercise limited by breathing problems, waking at night with symptoms.
     • school absences, emergency room visits (hospitalizations)
     • environmental history
2. Physical examination: i.e. listening to the lungs with a stethoscope; examination of nasal passages etc.
3. Chest x-ray may be done once to exclude the possibility of breathing problems being caused by something other than asthma.
4. Blood tests and sputum studies may be done.
5. Allergy prick skin testing: Skin tests can confirm the presence or absence of allergies; they must, however, be correlated to the history of symptoms.
6. Spirometry is a breathing test which measures the amount and rate at which air can pass through airways; if the airways are narrowed because of inflammation it will be more difficult for air to pass through the airways. This will result in changes in spirometry values. With children under the age of five years, generally this test is not indicated because there is a certain amount of effort and cooperation required. However, this is a very dependable method of making a diagnosis. Any difficult or troublesome asthma should be confirmed objectively by performing spirometry.
7. Challenge tests: Exercise challenge tests and methacholine inhalation tests are procedures used most frequently in clinical laboratories to evaluate airway responsiveness.
8. Differential diagnosis: Other possible causes of shortness of breath, wheeze, cough and chest tightness must be investigated in order to rule these out. i.e. such as heart disease, other lung conditions, gastroesophageal reflux.
9. A trial use of asthma medications: If asthma medications are taken and improvement in symptoms is seen this further supports the diagnosis of asthma.

Because of the variability of symptoms (meaning symptoms can become worse and improve over time) a diagnosis cannot always be made immediately.

Management

Patient Education

Patient education is an important area where asthma treatment can be improved. Asthma is common and controllable. Asthma is a disease that is variable, meaning that symptoms may get worse and may improve over time. Because of this variability it is often necessary to review and change the treatment. In order to enhance the patient-physician relationship, the patient must be familiar with the following:

The patient with this type of knowledge can communicate to the physician in order to work out an appropriate treatment plan. The goals of treatment should be understood and agreed upon by both the physician and the patient.

Long Term Asthma Management

Environmental Control

Environmental control should always be initiated along with taking the appropriate medications. If exposure to inducers are avoided, less medication is required.

It is not always easy to identify what inducer is making the asthma worse. It often means reviewing the history of symptoms carefully i.e. keeping track of the symptoms.

Controlling the inside and outside environment at home and in school, should be considered for those people who have identified allergies. For example:

• House dust mites: Dust mites are small parasites that live off the dead skin that we shed. Decrease exposure by enclosing mattress and box spring in plastic and washing all bed sheets and blankets in hot water once a week.
• Pets: If allergic to pets, animals should not be allowed in the house; this can include animals such as dogs, cats, gerbils and birds. People with identified animal allergies should not care for the pet.
• Smoke: No smoking in the home should be allowed at any time.
• Mold: Remove the mold wherever and whenever mold is found. Bleach can be used for this. The source of mold should be eliminated.
• High humidity: Increased moisture in the home can encourage mold growth and house dust mites, which require greater than 50% humidity to survive. Humidifiers, if not cleaned properly, can grow bacteria and produce a residue which some people find irritating to their lungs.
• Pollens: It may be necessary to avoid playing outside during times of high pollen counts. Pollen counts are usually greater in hot, dry and/or windy weather and usually between 4-10 AM. Camping and raking leaves will expose the person to pollens.

Medication Management

Medications: Anti-inflammatory

The successful approach to asthma management depends on using anti-inflammatory medications with bronchodilators as needed for immediate and occasional relief of symptioms.

The successful approach to asthma management, both in and out of hospital settings, is dependent upon the use of anti-inflammatory treatments with bronchodilators being prescribed for immediate and occasional relief of symptoms.

It has been shown that regular, frequent use of bronchodilator therapy may actually worsen the asthma. Again this stresses the need for adding anti-inflammatory medications if bronchodilator therapy is required often to control symptoms.

Anti-Inflammatory Medications (Preventers)

• prevent and reduce inflammation, swelling and mucus
• prevent symtpoms such as cough, wheeze and breathlessness
• need to be taken on a regular basis
• are slow acting (hours or weeks)

Types of Anti-Inflammatory Drugs

There are steroidal and non-steroidal anti-inflammatory drugs. The most common ones include:

Steroids

Non-Steroidal

Corticosteroid Inhalers

Corticosteroid drugs are the most effective preventer.

They work by reducing and preventing airway inflammation, swelling and mucus.

They must be used regularly and DO NOT have immediate effects. This means they have NO VALUE when an effect is needed in minutes.

A stepwise approach to treatment of asthma involves the introduction or change in anti-inflammatory medication.

Increased asthma symptoms indicate the need to increase the anti-inflammatory in order to achieve control. As control is achieved and the patient remains symptom free over a period of time (as specified by the physician), a decrease of medications can be initiated by the patient.

Side Effects of Corticosteroid Inhalers

Corticosteroid Tablets