Asthma Classification and external resources
ICD-10	J45.
ICD-9	493
OMIM	600807
DiseasesDB	1006
MedlinePlus	000141
eMedicine	med/177  emerg/43
MeSH	C08.127.108

Asthma is a chronic condition involving the respiratory system in which the airways occasionally constrict, become inflamed, and are lined with excessive amounts of mucus, often in response to one or more triggers. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings J00-J99 - Diseases of the respiratory system (J00-J06 Acute upper respiratory infections ( Acute Nasopharyngitis ( Common cold) The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Mendelian Inheritance in Man project is a Database that catalogues all the known Diseases with a genetic component, and—when possible—links them The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books In Medicine, a chronic disease is a Disease that is long-lasting or recurrent In living organisms a respiratory system functions to allow Gas exchange. lung is the essential Respiration organ in air-breathing Animals including most Tetrapods a few Fish and a few Snails The most primitive Inflammation ( Latin, inflamatio, to set on fire is the complex biological response of vascular tissues to harmful stimuli such as Pathogens In vertebrates mucus is a slippery secretion produced by and covering Mucous membranes It is a viscous Colloid containing Antiseptic enzymes (such as ^[1] These episodes may be triggered by such things as exposure to an environmental stimulant such as an allergen, environmental tobacco smoke, cold or warm air, perfume, pet dander, moist air, exercise or exertion, or emotional stress. An allergen is a nonparasitic Antigen capable of stimulating a Type-I hypersensitivity reaction in atopic individuals In children, the most common triggers are viral illnesses such as those that cause the common cold. Acute viral nasopharyngitis or acute coryza, usually known as the common cold, is a highly contagious viral Infectious disease of the ^[2] This airway narrowing causes symptoms such as wheezing, shortness of breath, chest tightness, and coughing. A symptom' (from Greek σύμπτωμα, "accident misfortune that which befalls" from συμπίπτω, "I befall" from A wheeze is a continuous coarse whistling sound produced in the respiratory Airways during breathing Dyspnea or dyspnoea (pronounced disp-nee-ah, IPA /dɪsp'niə/ from Latin dyspnoea, from Greek dyspnoia from In Medicine, a cough ( Latin: tussis) is a sudden and often repetitively occurring defence Reflex which helps to clear the large breathing passages The airway constriction responds to bronchodilators. A bronchodilator is a substance that dilates the bronchi and Bronchioles decreasing airway resistance and thereby facilitating airflow Between episodes, most patients feel well but can have mild symptoms and they may remain short of breath after exercise for longer periods of time than the unaffected individual. The symptoms of asthma, which can range from mild to life threatening, can usually be controlled with a combination of drugs and environmental changes. Medication, also referred to as medicine, can be loosely defined as any substance intended for use in the diagnosis cure mitigation treatment or prevention of disease

Public attention in the developed world has recently focused on asthma because of its rapidly increasing prevalence, affecting up to one in four urban children. The term developed country, or advanced country, is used to categorize countries with developed Economies in which the tertiary and quaternary sectors In Epidemiology, the prevalence of a Disease in a Statistical population is defined as the total number of cases of the disease in the population at a given ^[3]

Contents 1 Signs and symptoms 2 Cause 2.1 Environmental 2.2 Genetic 2.3 Gene-environment Interactions 3 Pathophysiology 3.1 Bronchoconstriction 3.2 Bronchial inflammation 3.3 Stimuli 3.4 Pathogenesis 3.5 Asthma and sleep apnea 3.6 Asthma and gastro-esophageal reflux disease 4 Diagnosis 4.1 Differential diagnosis 5 Prevention 5.1 Trigger avoidance 5.2 Air Filters 6 Treatment 6.1 Medical 6.2 Pharmaceutical 6.3 Long-acting β2-agonists 6.4 Emergency 6.5 Non-medical treatments 6.6 Treatment controversies 7 Prognosis 8 Epidemiology 8.1 Population disparities 8.2 Socioeconomic factors 8.3 Asthma and athletics 9 History 10 See also 11 References 12 External links

Signs and symptoms

In some individuals asthma is characterized by chronic respiratory impairment. In others it is an intermittent illness marked by episodic symptoms that may result from a number of triggering events, including upper respiratory infection, stress, airborne allergens, air pollutants (such as smoke or traffic fumes), or exercise. Some or all of the following symptoms may be present in those with asthma: dyspnea, wheezing, stridor, coughing, an inability for physical exertion. Dyspnea or dyspnoea (pronounced disp-nee-ah, IPA /dɪsp'niə/ from Latin dyspnoea, from Greek dyspnoia from Stridor is a high pitched sound resulting from turbulent air flow in the upper airway Some asthmatics who have severe shortness of breath and tightening of the lungs never wheeze or have stridor and their symptoms may be confused with a COPD-type disease. Chronic obstructive pulmonary disease ( COPD) is a Disease of the lungs in which the Airways become narrowed

An acute exacerbation of asthma is commonly referred to as an asthma attack. The clinical hallmarks of an attack are shortness of breath (dyspnea) and either wheezing or stridor. Dyspnea or dyspnoea (pronounced disp-nee-ah, IPA /dɪsp'niə/ from Latin dyspnoea, from Greek dyspnoia from A wheeze is a continuous coarse whistling sound produced in the respiratory Airways during breathing Stridor is a high pitched sound resulting from turbulent air flow in the upper airway ^[4] Although the former is "often regarded as the sine qua non of asthma",^[4] some patients present primarily with coughing, and in the late stages of an attack, air motion may be so impaired that no wheezing may be heard. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Please do NOT add the Battlestar Galactica episode In Medicine, a cough ( Latin: tussis) is a sudden and often repetitively occurring defence Reflex which helps to clear the large breathing passages When present the cough may sometimes produce clear sputum. Sputum is matter that is Expectorated from the respiratory tract such as Mucus or Phlegm, mixed with Saliva, which can then be spat The onset may be sudden, with a sense of constriction in the chest, breathing becomes difficult, and wheezing occurs (primarily upon expiration, but can be in both respiratory phases). In Animal physiology, respiration is the transport of Oxygen from the outside air to the cells within tissues and the transport of Carbon dioxide

Signs of an asthmatic episode include wheezing, prolonged expiration, a rapid heart rate (tachycardia), rhonchous lung sounds (audible through a stethoscope), the presence of a paradoxical pulse (a pulse that is weaker during inhalation and stronger during exhalation), and over-inflation of the chest. A Sign is an indication of some fact or quality and a medical sign is an objective indication of some medical fact or quality that is detected by a Physician Rhonchi is the "coarse rattling sound somewhat like snoring usually caused by secretion in bronchial airways" The stethoscope (from Greek στηθοσκόπιο, of στήθος stéthos - chest and σκοπή skopé - examination) is an acoustic In Medicine, a pulsus paradoxus (PP also paradoxic pulse and paradoxical pulse, is an exaggeration of the normal variation in the pulse during the inspiratory During a serious asthma attack, the accessory muscles of respiration (sternocleidomastoid and scalene muscles of the neck) may be used, shown as in-drawing of tissues between the ribs and above the sternum and clavicles. Muscle (from Latin musculus, diminutive of mus "mouse" is contractile tissue of the body and is derived from the Tissue is a cellular organizational level intermediate between cells and a complete organism The sternum (from Greek στέρνον sternon, "chest" or breastbone) is a long flat Bone located in the center of the thorax (chest

During very severe attacks, an asthma sufferer can turn blue from lack of oxygen, and can experience chest pain or even loss of consciousness. Cyanosis is a blue coloration of the Skin and mucous membranes due to the presence of deoxygenated Hemoglobin in Blood vessels near the skin surface In Medicine, chest pain is a Symptom of a number of serious conditions and is generally considered a Medical emergency. Consciousness has been defined loosely as a constellation of attributes of Mind such as Subjectivity, Self-awareness, Sentience, and the Just before loss of consciousness, there is a chance that the patient will feel numbness in the limbs and palms may start to sweat. The person's feet may become icy cold. Severe asthma attacks, which may not be responsive to standard treatments (status asthmaticus), are life-threatening and may lead to respiratory arrest and death. Status asthmaticus is an acute exacerbation of Asthma that does not respond to standard treatments of Bronchodilators and Corticosteroids Symptoms Despite the severity of symptoms during an asthmatic episode, between attacks an asthmatic may show few or even no signs of the disease. ^[5]

Cause

Asthma is caused by a complex interaction of genetic and environmental factors that researchers do not fully understand yet. ^[6] These factors can also influence how severe a person’s asthma is and how well they respond to medication. ^[7] As with other complex diseases, many genetic and environmental factors have been suggested as causes of asthma, but not all of them have been replicated. In addition, as researchers detangle the complex causes of asthma, it is becoming more evident that certain environmental and genetic factors may only affect asthma when combined.

The hygiene hypothesis is a theory about the cause of asthma and other allergic disease, and is supported by epidemiologic data for asthma. In Medicine, the hygiene Hypothesis states that a lack of early childhood exposure to infectious agents Symbiotic microorganisms (e For example, asthma prevalence has been increasing in developed countries along with increased use of antibiotics, c-sections, and cleaning products. ^[8][9][10] All of these things may negatively affect exposure to beneficial bacteria and other immune system modulators that are important during development, and thus may cause increased risk for asthma and allergy.

Environmental

Many environmental risk factors have been associated with asthma, but a few stand out as well-replicated or that have a meta-analysis of several studies to support their direct association:

• Poor air quality, from traffic pollution or high ozone levels, has been repeatedly associated with increased asthma morbidity and has a suggested association with asthma development that needs further research. A risk factor is a variable associated with an increased risk of Disease or Infection. In Statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses The Air Quality Index ( AQI) is a standardized indicator of the Air Quality in a given location OZONE is an object oriented Operating system written in the C programming language. In Medicine, Epidemiology and Actuarial science, the term morbidity can refer to the state of poor health (from Latin ^[11][12]
• Environmental tobacco smoke, especially maternal cigarette smoking, is associated with high risk of asthma prevalence and asthma morbidity, wheeze, and respiratory infections. ^[11]
• Viral respiratory infections at an early age, along with siblings and day care exposure, may be protective against asthma, although there have been controversial results, and this protection may depend on genetic context. ^[11][13][14]
• Antibiotic use early in life has been linked to development of asthma in several examples; it is thought that antibiotics make one susceptible to development of asthma because they modify gut flora, and thus the immune system (as described by the hygiene hypothesis). In modern usage an antibiotic is a Chemotherapeutic agent with activity against Microorganisms such as Bacteria, fungi or Protozoa The gut flora are the Microorganisms that normally live in the Digestive tract and can perform a number of useful functions for their hosts ^[8]
• Caesarean sections have been associated with asthma when compared with vaginal birth; a meta-analysis found a 20% increase in asthma prevalence in children delivered by Caesarean section compared to those who were not. A Caesarean section (or Cesarean section in American English) also known as C-section, is a form of Childbirth in which a surgical It was proposed that this is due to modified bacterial exposure during Caesarean section compared with vaginal birth, which modifies the immune system (as described by the hygiene hypothesis). ^[9]
• Psychological stress on the part of a child's caregiver has been associated with asthma, and is an area of active research. Stress can modify behaviors that affect asthma, like smoking, but research suggests that stress has other effects as well. There is growing evidence that stress may influence asthma and other diseases by influencing the immune system. ^[11]

Genetic

Over 100 genes have been associated with asthma in at least one genetic association study. History See also History of genetics The existence of genes was first suggested by Gregor Mendel (1822-1884 who in the 1860s studied inheritance Studies concerning genetic association aim to test whether single-locus alleles or genotype frequencies (or more generally multilocus Haplotype frequencies are different between ^[15] However, as with all association studies, replication is important before genetic variation (such as a single nucleotide polymorphism, or SNP) in a certain gene is thought to influence asthma. A single nucleotide polymorphism ( SNP, pronounced snip) is a DNA sequence variation occurring when a single Nucleotide - A, T Through the end of 2005, 25 genes had been associated with asthma in six or more separate populations:^[15]

Many of these genes are related to the immune system or to modulating inflammation. Glutathione S-transferase Mu 1 (gene name GSTM1) is a human Glutathione S-transferase. Interleukin -10 (IL-10 or IL10 also known as human cytokine synthesis inhibitory factor (CSIF is an anti- Inflammatory Cytokine. CTLA4 ( C ytotoxic T - L ymphocyte A ntigen 4) is a CD28-family receptor expressed on mainly CD4+ T cells. Serine peptidase inhibitor Kazal type 5, also known as SPINK5, is a human Gene. Lymphotoxin alpha (TNF superfamily member 1, also known as LTA, is a human Gene. Nucleotide-binding oligomerization domain containing 1, also known as NOD1, is a human Gene. Glutathione S-transferase pi, also known as GSTP1, is a human Gene. STAT6 is a human Gene. The Protein encoded by this gene is a member of the STAT family of Transcription factors In response to cytokines Nitric oxide synthase 1 (neuronal, also known as NOS1, is a human Gene. CCL5 (earlier called RANTES) is an 8kDa Protein classified as a chemotactic Cytokine or Chemokine. The thromboxane receptor is a protein on the surface of cells in the Endothelium of blood vessels and in the Placenta which interacts with the Transforming growth factor beta 1, also known as TGFB1, is a Interleukin-4, abbreviated IL-4, is a Cytokine that induces differentiation of naive helper T cells ( Th0 cells to Th2 cells Upon activation by Interleukin 13 ( IL-13) is a Cytokine secreted by many cell types but especially T helper type 2 (Th2 cells that is an important mediator of allergic Cluster of differentiation 14 also known as CD14 is a human Gene. The beta-2 adrenergic receptor (β2 adrenoreceptor also known as ADRB2, is an Beta-adrenergic receptor, and also denotes the human Gene encoding Major histocompatibility complex class II DR beta 1, also known as HLA-DRB1, is a human Gene. Major histocompatibility complex class II DQ beta 1, also known as HLA-DQB1, is a human Gene and also denotes the genetic locus which contains this gene Tumor necrosis factors (or the TNF-family) refers to a group of Cytokines family that can cause Apoptosis. Interleukin 4 receptor is a Type I cytokine receptor. IL4R is its human Gene. ADAM metallopeptidase domain 33, also known as ADAM33, is a human Gene. However, even among this list of highly replicated genes associated with asthma, the results have not been consistent among all of the populations that have been tested. ^[15] This indicates that these genes are not associated with asthma under every condition, and that researchers need to do further investigation to figure out the complex interactions that cause asthma.

Gene-environment Interactions

Research suggests that some genetic variants may only cause asthma when they are combined with specific environmental exposures, and otherwise may not be risk factors for asthma. ^[6]

The CD14 SNP C-159T and endotoxin exposure are a well-replicated example of a gene-environment interaction that is associated with asthma. Endotoxins (not to be confused with Enterotoxin) are potentially toxic, natural compounds found inside Pathogens such as Bacteria. Endotoxin exposure varies from person to person and can come from several environmental sources, including environmental tobacco smoke, dogs, and farms. Researchers have found that risk for asthma changes based on a person’s genotype at CD14 C-159T and level of endotoxin exposure. The genotype is the genetic constitution of a cell an organism or an individual (i ^[16]

CD14-endotoxin interaction based on CD14 SNP C-159T^[16]

Endotoxin levels	CC genotype	TT genotype
High exposure	Low risk	High risk
Low exposure	High risk	Low risk

Pathophysiology

Bronchoconstriction

During an asthma episode, inflamed airways react to environmental triggers such as smoke, dust, or pollen. The bronchioles or bronchioli are the first Airway branches that no longer contain Cartilage. The airways narrow and produce excess mucus, making it difficult to breathe. In vertebrates mucus is a slippery secretion produced by and covering Mucous membranes It is a viscous Colloid containing Antiseptic enzymes (such as In essence, asthma is the result of an immune response in the bronchial airways. An immune system is a collection of mechanisms within an Organism that protects against Disease by identifying and killing Pathogens and Tumor The bronchioles or bronchioli are the first Airway branches that no longer contain Cartilage. ^[17]

The airways of asthmatics are "hypersensitive" to certain triggers, also known as stimuli (see below). Hypersensitivity (also called hypersensitivity reaction refers to undesirable (damaging discomfort-producing and sometimes fatal reactions produced by the normal immune system In response to exposure to these triggers, the bronchi (large airways) contract into spasm (an "asthma attack"). A bronchus (plural bronchi, adjective bronchial) is a caliber of airway in the Respiratory tract that conducts air into the Lungs No Gas A spasm is a sudden involuntary contraction of a Muscle, a group of muscles or a hollow organ, or a similarly sudden Contraction of an Orifice Inflammation soon follows, leading to a further narrowing of the airways and excessive mucus production, which leads to coughing and other breathing difficulties. Inflammation ( Latin, inflamatio, to set on fire is the complex biological response of vascular tissues to harmful stimuli such as Pathogens In vertebrates mucus is a slippery secretion produced by and covering Mucous membranes It is a viscous Colloid containing Antiseptic enzymes (such as

The normal calibre of the bronchus is maintained by a balanced functioning of these systems, which both operate reflexively. The parasympathetic reflex loop consists of afferent nerve endings which originate under the inner lining of the bronchus. Whenever these afferent nerve endings are stimulated (for example, by dust, cold air or fumes) impulses travel to the brain-stem vagal centre, then down the vagal afferent pathway to again reach the bronchus. Acetylcholine is released from the afferent nerve endings. This acetylcholine results in the excessive formation of cyclic Guanine Mono phosphate (GMP). This initiates bronchoconstriction.

Bronchial inflammation

The mechanisms behind allergic asthma—i. e. , asthma resulting from an immune response to inhaled allergens—are the best understood of the causal factors. An immune system is a collection of mechanisms within an Organism that protects against Disease by identifying and killing Pathogens and Tumor An allergen is a nonparasitic Antigen capable of stimulating a Type-I hypersensitivity reaction in atopic individuals In both asthmatics and non-asthmatics, inhaled allergens that find their way to the inner airways are ingested by a type of cell known as antigen presenting cells, or APCs. The bronchioles or bronchioli are the first Airway branches that no longer contain Cartilage. Phagocytosis is the cellular process of engulfing solid particles by the Cell membrane to form an internal Phagosome, or "food vacuole See also Antigen presentation An antigen-presenting cell ( APC) or accessory cell is a cell that displays foreign Antigen complexed APCs then "present" pieces of the allergen to other immune system cells. An immune system is a collection of mechanisms within an Organism that protects against Disease by identifying and killing Pathogens and Tumor In most people, these other immune cells (T_H0 cells) "check" and usually ignore the allergen molecules. T helper cells (also known as effector T cells or Th cells) are a sub-group of Lymphocytes (a type of White blood cell or In asthmatics, however, these cells transform into a different type of cell (T_H2), for reasons that are not well understood. The resultant T_H2 cells activate an important arm of the immune system, known as the humoral immune system. The Humoral Immune Response (HIR is the aspect of immunity that is mediated by secreted Antibodies (as opposed to Cell-mediated immunity which involves The humoral immune system produces antibodies against the inhaled allergen. Antibodies (also known as immunoglobulins, abbreviated Ig) are Gamma globulin Proteins that are found in Blood or other Bodily Later, when an asthmatic inhales the same allergen, these antibodies "recognize" it and activate a humoral response. The Humoral Immune Response (HIR is the aspect of immunity that is mediated by secreted Antibodies (as opposed to Cell-mediated immunity which involves Inflammation results: chemicals are produced that cause the airways to constrict and release more mucus, and the cell-mediated arm of the immune system is activated. Inflammation ( Latin, inflamatio, to set on fire is the complex biological response of vascular tissues to harmful stimuli such as Pathogens The inflammatory response is responsible for the clinical manifestations of an asthma attack. The following section describes this complex series of events in more detail.

Stimuli

• Allergens from nature, typically inhaled, which include waste from common household pests, such as the house dust mite and cockroach, grass pollen, mould spores, and pet epithelial cells;
• Indoor air pollution from volatile organic compounds, including perfumes and perfumed products. An allergen is a nonparasitic Antigen capable of stimulating a Type-I hypersensitivity reaction in atopic individuals The house dust mite (sometimes abbreviated by Allergists to HDM) is a cosmopolitan guest in Human habitation Cockroaches (or simply "roaches" are Insects of the order Blattaria. Pollen is a fine to coarse powder consisting of microgametophytes ( pollen grains) which produce the male Gametes (sperm cells of WikipediaManual_of_Style#National_varieties_of_English --> Molds (or In biology and medicine epithelium is a tissue composed of cells that line the cavities and surfaces of structures throughout the body Pollution is the introduction of contaminants into an environment that causes instability disorder harm or discomfort to the physical systems or living organisms they are in This article describes a highly specialized aspect of its subject in the "Terminology and legal definitions" section Examples include soap, dishwashing liquid, laundry detergent, fabric softener, paper tissues, paper towels, toilet paper, shampoo, hairspray, hair gel, cosmetics, facial cream, sun cream, deodorant, cologne, shaving cream, aftershave lotion, air freshener and candles, and products such as oil-based paint.
• Medications, including aspirin,^[18] β-adrenergic antagonists (beta blockers), and penicillin. Medication, also referred to as medicine, can be loosely defined as any substance intended for use in the diagnosis cure mitigation treatment or prevention of disease Aspirin, or acetylsalicylic acid (ASA (əˌsɛtɨlsælɨˌsɪlɨk ˈæsɨd is a Salicylate drug, often used as an Analgesic to relieve Beta blockers (sometimes written as β-blocker) are a class of drugs used for various indications but particularly for the management of Cardiac arrhythmias Penicillin (sometimes abbreviated PCN or pen) is a group of Beta-lactam antibiotics used in the treatment of Bacterial Infections
• Food allergies such as milk, peanuts, and eggs. A food allergy is an adverse immune response to a food protein Milk is an opaque white liquid produced by the Mammary glands of female Mammals (including Monotremes. The peanut, or Groundnut ( Arachis hypogaea) is a species in the Legume family Fabaceae native to South America, Mexico An egg is a round or oval body laid by the female of many animals consisting of an Ovum surrounded by layers of Membranes and an outer casing which acts to nourish However, asthma is rarely the only symptom, and not all people with food or other allergies have asthma.
• Use of fossil fuel related allergenic air pollution, such as ozone, smog, summer smog, nitrogen dioxide, and sulfur dioxide, which is thought to be one of the major reasons for the high prevalence of asthma in urban areas. Fossil fuels or mineral fuels are fossil source Fuels that is Hydrocarbons found within the top layer of the Earth’s crust. An allergen is a nonparasitic Antigen capable of stimulating a Type-I hypersensitivity reaction in atopic individuals Pollution is the introduction of contaminants into an environment that causes instability disorder harm or discomfort to the physical systems or living organisms they are in OZONE is an object oriented Operating system written in the C programming language. Smog is a kind of Air pollution; the word "smog" is a Portmanteau of Smoke and Fog. Summer smog, which is common in major cities such as New York and Los Angeles, is Pollutants mainly Ozone, which collect in large cities Nitrogen dioxide is the Chemical compound with the formula N[[Oxygen O]]2
• Various industrial compounds and other chemicals, notably sulfites; chlorinated swimming pools generate chloramines—monochloramine (NH₂Cl), dichloramine (NHCl₂) and trichloramine (NCl₃)—in the air around them, which are known to induce asthma. Sulfites (also sulphites) are compounds that contain the sulfite Ion S[[oxygen O]]32− Chlorine (ˈklɔriːn from the Greek word 'χλωρóς' ( khlôros, meaning 'pale green' is the Chemical element with Atomic number 17 and Chloramine (monochloramine is a Chemical compound with the formula NH2Cl ^[19]
• Early childhood infections, especially viral respiratory infections. An infection is the detrimental Colonization of a host Organism by a foreign Species. A virus (from the Latin virus meaning Toxin or Poison) is a sub-microscopic infectious agent that is unable Upper respiratory tract infections, ( URTI or URI) are the illnesses caused by an acute Infection which involves the upper Respiratory tract: However, persons of any age can have asthma triggered by colds and other respiratory infections even though their normal stimuli might be from another category (e. Acute viral nasopharyngitis or acute coryza, usually known as the common cold, is a highly contagious viral Infectious disease of the g. pollen) and absent at the time of infection. In many cases, significant asthma may not even occur until the respiratory infection is in its waning stage, and the person is seemingly improving. Eighty percent of asthma attacks in adults and 60% in children are caused by respiratory viruses.
• Exercise or intense use of respiratory system. The effects of which differ somewhat from those of the other triggers, since they are brief. It is known that exercising regularly actually helps to cure asthma.
• Hormonal changes in adolescent girls and adult women associated with their menstrual cycle can lead to a worsening of asthma. Hormones (from Greek ὁρμή - "impetus" are chemicals released by cells that affect cells in other parts of the body The menstrual cycle is a recurring cycle of physiologic changes that occurs in reproductive-age Females Overt menstruation (where there is blood flow from the Some women also experience a worsening of their asthma during pregnancy whereas others find no significant changes, and in other women their asthma improves during their pregnancy. Pregnancy ( Latin graviditas) is the carrying of one or more offspring known as a Fetus or Embryo, inside the Uterus of a Female
• Emotional stress which is poorly understood as a trigger. Emotional stress can affect breathing temporarily, however unlike something such as heart problems, it is unclear if it has any long-term effect.
• Cold weather can make it harder for asthmatics to breathe. ^[20] Whether high altitude helps or worsens asthma is debatable and may vary from person to person. ^[21]

Pathogenesis

The fundamental problem in asthma appears to be immunological: young children in the early stages of asthma show signs of excessive inflammation in their airways. Immunology is a broad branch of biomedical Science that covers the study of all aspects of the Immune system in all Organisms It deals with Epidemiological findings give clues as to the pathogenesis: the incidence of asthma seems to be increasing worldwide, and asthma is now very much more common in affluent countries. Epidemiology is the study of factors affecting the Health and Illness of populations and serves as the foundation and Logic of interventions made in the The term pathogenesis means step by step development of a disease due to a series of changes in the structure and /or function of a cell/tissue/organ being caused by a microbial, chemical or physical

In 1968 Andor Szentivanyi first described The Beta Adrenergic Theory of Asthma; in which blockage of the Beta-2 receptors of pulmonary smooth muscle cells causes asthma. ^[22] Szentivanyi's Beta Adrenergic Theory is a citation classic^[23] and has been cited more times than any other article in the history of the Journal of Allergy.

In 1995 Szentivanyi and colleagues demonstrated that IgE blocks beta-2 receptors. ^[24] Since overproduction of IgE is central to all atopic diseases, this was a watershed moment in the world of allergy. ^[25]

The Beta-Adrenergic Theory has been cited in the scholarship of such noted investigators as Richard F. Lockey (former President of the American Academy of Allergy, Asthma, and Immunology),^[26] Charles Reed (Chief of Allergy at Mayo Medical School),^[27] and Craig Venter (Human Genome Project). ^[28]

In 2006, Researchers at Harvard Medical School found evidence that asthma is caused by over-proliferation of a special type of natural "killer" cell. ^[29]

Asthma and sleep apnea

Main article: sleep apnea

It is recognized with increasing frequency, that patients who have both obstructive sleep apnea (OSA) and bronchial asthma, often improve tremendously when the sleep apnea is diagnosed and treated. Sleep apnea is a sleep disorder characterized by pauses in Breathing during Sleep. ^[30] CPAP is not effective in patients with nocturnal asthma only. ^[31]

Asthma and gastro-esophageal reflux disease

Main article: gastro-esophageal reflux disease

If gastro-esophageal reflux disease is present, the patient may have repetitive episodes of acid aspiration, which results in airway inflammation and "irritant-induced" asthma. Gastroesophageal reflux disease ( American English and Canadian English) or Gastro-oesophageal reflux disease ( British English, Hiberno-English GERD may be common in difficult-to-control asthma, but according to one study, treating it does not seem to affect the asthma. ^[32]

Diagnosis

Asthma is defined simply as reversible airway obstruction. Reversibility occurs either spontaneously or with treatment. The basic measurement is peak flow rates and the following diagnostic criteria are used by the British Thoracic Society:^[33]

• ≥20% difference on at least three days in a week for at least two weeks;
• ≥20% improvement of peak flow following treatment, for example:
  • 10 minutes of inhaled β-agonist (e. A peak flow meter is a small hand-held device used to manage Asthma by monitoring airflow through the bronchi and thus the degree of obstruction in the airways The British Thoracic Society (BTS is a specialist medical society in the United Kingdom in the field of respiratory medicine. g. , salbutamol);
  • six week of inhaled corticosteroid (e. Salbutamol ( INN) or albuterol ( USAN) is a short-acting β2-adrenergic receptor agonist used for the relief of Bronchospasm Corticosteroids are a class of Steroid hormones that are produced in the Adrenal cortex. g. , beclometasone);
  • 14 days of 30mg prednisolone. Beclometasone dipropionate ( INN modified or beclomethasone dipropionate ( USAN, former BAN) also referred to as beclometasone (INN Prednisolone is the active metabolite of Prednisone. Uses It is a Corticosteroid drug with predominantly Glucocorticoid and low Mineralocorticoid
• ≥20% decrease in peak flow following exposure to a trigger (e. g. , exercise).

In many cases, a physician can diagnose asthma on the basis of typical findings in a patient's clinical history and examination. Diagnosis is the identification by Process of elimination, of the nature of anything Asthma is strongly suspected if a patient suffers from eczema or other allergic conditions—suggesting a general atopic constitution—or has a family history of asthma. Eczema (from Greek έκζεμα) is a form of Dermatitis, or Inflammation of the Epidermis. Allergy is a disorder of the Immune system often also referred to as Atopy. Atopy (/ˈætəpi/ Greek ἀτοπία - placelessness or atopic syndrome is an allergic Hypersensitivity affecting parts of the body In Medicine, a family history consists of information about disorders that a patient's direct blood relatives have suffered from While measurement of airway function is possible for adults, most new cases are diagnosed in children who are unable to perform such tests. Diagnosis in children is based on a careful compilation and analysis of the patient's medical history and subsequent improvement with an inhaled bronchodilator medication. The medical history or Anamnesis of a Patient is information gained by a Physician or other healthcare professional by asking specific questions A bronchodilator is a substance that dilates the bronchi and Bronchioles decreasing airway resistance and thereby facilitating airflow In adults, diagnosis can be made with a peak flow meter (which tests airway restriction), looking at both the diurnal variation and any reversibility following inhaled bronchodilator medication. A peak flow meter is a small hand-held device used to manage Asthma by monitoring airflow through the bronchi and thus the degree of obstruction in the airways A bronchodilator is a substance that dilates the bronchi and Bronchioles decreasing airway resistance and thereby facilitating airflow Asthma is a chronic Condition involving the Respiratory system in which the airways occasionally constrict become inflamed, and are

Testing peak flow at rest (or baseline) and after exercise can be helpful, especially in young asthmatics who may experience only exercise-induced asthma. Exercise-induced asthma, or EIA, is a medical condition characterized by shortness of breath induced by sustained aerobic exercise If the diagnosis is in doubt, a more formal lung function test may be conducted. Spirometry (meaning the measuring of breath) is the most common of the Pulmonary Function Tests (PFTs measuring Lung function specifically the measurement Once a diagnosis of asthma is made, a patient can use peak flow meter testing to monitor the severity of the disease. A peak flow meter is a small hand-held device used to manage Asthma by monitoring airflow through the bronchi and thus the degree of obstruction in the airways

Monitoring asthma with a peak flow meter on an ongoing basis assists with self monitoring of asthma. Peak flow readings can be charted on graph paper charts together with a record of symptoms or use peak flow charting software. Format and availability of graph paper Graph paper is available either as Loose leaf paper or bound in Notebooks It is becoming ^[34] This allows patients to track their peak flow readings and pass information back to their doctor or nurse. ^[35]

In the Emergency Department doctors may use a capnography which measures the amount of exhaled carbon dioxide,^[36] along with pulse oximetry which shows the amount of oxygen dissolved in the blood, to determine the severity of an asthma attack as well as the response to treatment. Capnography is the monitoring of the concentration or partial pressure of Carbon dioxide (CO2 in the respiratory gases Carbon dioxide ( Chemical formula:) is a Chemical compound composed of two Oxygen Atoms covalently bonded to a single Pulse oximetry is a non-invasive method allowing the monitoring of the Oxygenation of a patient's Hemoglobin.

Differential diagnosis

Before diagnosing someone as asthmatic, alternative possibilities should be considered. A differential diagnosis (sometimes abbreviated DDx, ddx A clinician taking a history should check whether the patient is using any known bronchoconstrictors (substances that cause narrowing of the airways, e. g. , certain anti-inflammatory agents or beta-blockers). Anti-inflammatory refers to the property of a substance or treatment that reduces Inflammation. Beta blockers (sometimes written as β-blocker) are a class of drugs used for various indications but particularly for the management of Cardiac arrhythmias

Chronic obstructive pulmonary disease, which closely resembles asthma, is correlated with more exposure to cigarette smoke, an older patient, less symptom reversibility after bronchodilator administration (as measured by spirometry), and decreased likelihood of family history of atopy. Chronic obstructive pulmonary disease ( COPD) is a Disease of the lungs in which the Airways become narrowed Spirometry (meaning the measuring of breath) is the most common of the Pulmonary Function Tests (PFTs measuring Lung function specifically the measurement Atopy (/ˈætəpi/ Greek ἀτοπία - placelessness or atopic syndrome is an allergic Hypersensitivity affecting parts of the body

Pulmonary aspiration, whether direct due to dysphagia (swallowing disorder) or indirect (due to acid reflux), can show similar symptoms to asthma. In Medicine, aspiration is the entry of secretions or foreign material into the trachea and Lungs The patient may either inhale the material Dysphagia should not be confused with the similarly pronounced Dysphasia, a language disorder However, with aspiration, fevers might also indicate aspiration pneumonia. Aspiration pneumonia is Bronchopneumonia that develops due to the entrance of foreign materials that enter the bronchial tree usually oral or gastric contents (including food Direct aspiration (dysphagia) can be diagnosed by performing a Modified Barium Swallow test and treated with feeding therapy by a qualified speech therapist. Speech-language pathology is the study of disorders that affect a person's Speech, Language, cognition voice swallowing ( Dysphagia) and the rehabilitative If the aspiration is indirect (from acid reflux) then treatment directed at this is indicated.

A majority of children who are asthma sufferers have an identifiable allergy trigger. Allergy is a disorder of the Immune system often also referred to as Atopy. Specifically, in a 2004 study, 71% had positive test results for more than 1 allergen, and 42% had positive test results for more than 3 allergens. ^[37]

The majority of these triggers can often be identified from the history; for instance, asthmatics with hay fever or pollen allergy will have seasonal symptoms, those with allergies to pets may experience an abatement of symptoms when away from home, and those with occupational asthma may improve during leave from work. Hay Fever is a comic play written by Noel Coward in 1924 and first produced in 1925 with Marie Tempest as the first Judith Bliss Pollen is a fine to coarse powder consisting of microgametophytes ( pollen grains) which produce the male Gametes (sperm cells of A pet is an Animal kept for companionship and enjoyment or a househeld animal as opposed to Livestock, Laboratory animals Working animals Occupational asthma is defined as "a disease characterized by variable airflow limitation and/or airway hyper-responsiveness due to causes and conditions attributable Allergy tests can help identify avoidable symptom triggers. Allergy is a disorder of the Immune system often also referred to as Atopy.

After a pulmonary function test has been carried out, radiological tests, such as a chest X-ray or CT scan, may be required to exclude the possibility of other lung diseases. Spirometry (meaning the measuring of breath) is the most common of the Pulmonary Function Tests (PFTs measuring Lung function specifically the measurement A chest X-ray, commonly abbreviated CXR, is a projection radiograph ( X-ray) taken by a Radiographer, of the Thorax which is used Computed tomography (CT is a Medical imaging method employing Tomography. In some people, asthma may be triggered by gastroesophageal reflux disease, which can be treated with suitable antacids. Gastroesophageal reflux disease ( American English and Canadian English) or Gastro-oesophageal reflux disease ( British English, Hiberno-English An antacid is any substance generally a base or Basic salt, which counteracts stomach acidity. Very occasionally, specialized tests after inhalation of methacholine — or, even less commonly, histamine — may be performed. A methacholine challenge test is a Medical test used to assist in the Diagnosis of Asthma. Histamine is a Biogenic amine involved in local immune responses as well as regulating physiological function in the gut and acting as a Neurotransmitter

Asthma is categorized by the United States National Heart, Lung and Blood Institute as falling into one of four categories: intermittent, mild persistent, moderate persistent and severe persistent. The United States of America —commonly referred to as the The National Heart, Lung, and Blood Institute (or NHLBI) is a division of the National Institutes of Health, located in Bethesda The diagnosis of "severe persistent asthma" occurs when symptoms are continual with frequent exacerbations and frequent night-time symptoms, result in limited physical activity and when lung function as measured by PEV or FEV₁ tests is less than 60% predicted with PEF variability greater than 30%.

Prevention

Current treatment protocols recommend prevention medications such as an inhaled corticosteroid, which helps to suppress inflammation and reduces the swelling of the lining of the airways, in anyone who has frequent (greater than twice a week) need of relievers or who has severe symptoms. Corticosteroids are a class of Steroid hormones that are produced in the Adrenal cortex. Inflammation ( Latin, inflamatio, to set on fire is the complex biological response of vascular tissues to harmful stimuli such as Pathogens If symptoms persist, additional preventive drugs are added until the asthma is controlled. With the proper use of prevention drugs, asthmatics can avoid the complications that result from overuse of relief medications.

Asthmatics sometimes stop taking their preventive medication when they feel fine and have no problems breathing. This often results in further attacks, and no long-term improvement.

Preventive agents include the following.

• Inhaled glucocorticoids are the most widely used of the prevention medications and normally come as inhaler devices (ciclesonide, beclomethasone, budesonide, flunisolide, fluticasone, mometasone, and triamcinolone). Glucocorticoids (GC are a class of Steroid hormones characterised by an ability to bind with the glucocorticoid receptor ( GR) and trigger similar effects Ciclesonide is a Glucocorticoid used to treat Obstructive airway diseases. Beclometasone dipropionate ( INN modified or beclomethasone dipropionate ( USAN, former BAN) also referred to as beclometasone (INN Budesonide is a Glucocorticoid Steroid for the treatment of Asthma, non-infectious Rhinitis (including Hay fever and other allergies Flunisolide (marketed as AeroBid, Nasalide, Nasarel) is a Corticosteroid often prescribed as treatment for Allergic rhinitis. Fluticasone is a potent synthetic Corticosteroid often prescribed as treatment for Asthma and Allergic rhinitis. Mometasone furoate (also referred to as Mometasone) is a moderately potent Glucocorticoid Steroid used in the treatment of inflammatory skin disorders Triamcinolone (trade names Kenalog Aristocort Nasacort Tri-Nasal Triderm Azmacort Trilone Volon A Tristoject, Fougera, Tricortone, Triesence
  Long-term use of corticosteroids can have many side effects including a redistribution of fat, increased appetite, blood glucose problems and weight gain. Glucose (Glc a Monosaccharide (or simple Sugar) also known as grape sugar, is an important Carbohydrate in Biology. In particular high doses of steroids may cause osteoporosis. Osteoporosis is a Disease of Bone that leads to an increased risk of fracture. For this reasons inhaled steroids are generally used for prevention, as their smaller doses are targeted to the lungs unlike the higher doses of oral preparations. Nevertheless, patients on high doses of inhaled steroids may still require prophylactic treatment to prevent osteoporosis.
  Deposition of steroids in the mouth may cause a hoarse voice or oral thrush (due to decreased immunity). Oral Candidiasis is an infection of Yeast fungi of the genus Candida on the mucous membranes of the Mouth. This may be minimised by rinsing the mouth with water after inhaler use, as well as by using a spacer which increases the amount of drug that reaches the lungs. An Asthma spacer is a type of add-on device used by an asthmatic person to increase the effectiveness of a Metered-dose inhaler.
• Leukotriene modifiers (montelukast, zafirlukast, pranlukast, and zileuton). Leukotrienes are naturally produced Eicosanoid lipid mediators, which may be responsible for the effects of an inflammatory response Montelukast (trade name Singulair) is a Leukotriene receptor antagonist (LTRA used for the maintenance treatment of Asthma and to relieve symptoms of seasonal Zafirlukast is an oral Leukotriene receptor antagonist Pranlukast is a cysteinyl leukotriene receptor-1 antagonist. This drug works similarly to Merck & Co Zileuton ( INN) is an Asthma drug. It blocks Leukotriene synthesis by inhibiting 5-lipoxygenase, an Enzyme of the Eicosanoid
• Mast cell stabilizers (cromoglicate (cromolyn), and nedocromil). A mast cell (or mastocyte) is a resident cell of several types of tissues and contains many granules rich in Histamine and Heparin Nedocromil sodium is a Medication used to prevent wheezing shortness of breath and other breathing problems caused by Asthma.
• Antimuscarinics/anticholinergics (ipratropium, oxitropium, and tiotropium), which have a mixed reliever and preventer effect. Ipratropium (as ipratropium Bromide, trade name Atrovent) is an Anticholinergic drug Tiotropium (ˌtaɪəˈtroʊpiəm (administered as tiotropium bromide is a long-acting 24 hour Anticholinergic Bronchodilator used in the management of Chronic (These are rarely used in preventive treatment of asthma, except in patients who do not tolerate beta-2-agonists. )
• Methylxanthines (theophylline and aminophylline), which are sometimes considered if sufficient control cannot be achieved with inhaled glucocorticoids and long-acting β-agonists alone. Theophylline, also known as dimethylxanthine, is a Methylxanthine drug used in therapy for Respiratory diseases such as COPD or Asthma Aminophylline is a Bronchodilator Drug combination that contains Theophylline and Ethylenediamine in 21 ratio
• Antihistamines, often used to treat allergic symptoms that may underlie the chronic inflammation. A histamine antagonist is an agent which serves to inhibit the release or action of Histamine.
• Hyposensitization, (also known as immunodesensitisation therapy) may be recommended in some cases where allergy is the suspected cause or trigger of asthma. Hyposensitization (or allergy desensitization) is a form of Immunotherapy in which the patient is Vaccinated with progressively larger doses of an Hyposensitization (or allergy desensitization) is a form of Immunotherapy in which the patient is Vaccinated with progressively larger doses of an Depending on the allergen, it can be given orally or by injection.
• Omalizumab, an IgE blocker; this can help patients with severe allergic asthma that does not respond to other drugs. Omalizumab (marketed under the name Xolair) is a Monoclonal antibody made by Genentech / Novartis and used mainly in Allergy -related In Biology, Immunoglobulin E ( IgE) is a class of Antibody (or Immunoglobulin " Isotype " that has only been found in However, it is expensive and must be injected.
• Methotrexate is occasionally used in some difficult-to-treat patients.
• If chronic acid indigestion (GERD) contributes to a patient's asthma, it should also be treated, because it may prolong the respiratory problem. Gastroesophageal reflux disease ( American English and Canadian English) or Gastro-oesophageal reflux disease ( British English, Hiberno-English

Trigger avoidance

As is common with respiratory disease, smoking is believed to adversely affect asthmatics in several ways, including an increased severity of symptoms, a more rapid decline of lung function, and decreased response to preventive medications. Tobacco Smoking is the inhalation of smoke from burned dried or cured leaves of the Tobacco plant most often in the form of a Cigarette. ^[38] Automobile emissions are considered an even more significant cause and aggravating factor. Automobile emissions control covers all the technologies that are employed to reduce the Air pollution -causing emissions produced by Automobiles Exhaust emissions [1] Asthmatics who smoke or who live near traffic [2] typically require additional medications to help control their disease. Traffic on Roads may consist of Pedestrians ridden or herded Animals Vehicles Streetcars and other Conveyances either singly Furthermore, exposure of both non-smokers and smokers to wood smoke, gas stove fumes and second-hand smoke is detrimental, resulting in more severe asthma, more emergency room visits, and more asthma-related hospital admissions. ^[39] Smoking cessation and avoidance of second-hand smoke is strongly encouraged in asthmatics. ^[40]

For those in whom exercise can trigger an asthma attack (exercise-induced asthma), higher levels of ventilation and cold, dry air tend to exacerbate attacks. Exercise-induced asthma, or EIA, is a medical condition characterized by shortness of breath induced by sustained aerobic exercise For this reason, activities in which a patient breathes large amounts of cold air, such as skiing and running, tend to be worse for asthmatics, whereas swimming in an indoor, heated pool, with warm, humid air, is less likely to provoke a response. ^[4]

Air Filters

If an asthmatic lives with a smoker, use of air filter or room air cleaner is likely to be helpful. Secondhand smoke can worsen the symptoms. The same is true for those with hay fever (allergic rhino sinusitis) or COPD (emphysema or chronic bronchitis). Room air cleaners remove small particles that are in the air near the air cleaner. However, room air cleaners do not remove small allergen particles that are caused by local disturbances, such as the microscopic house dust mite feces that surround a pillow when your head hits it or you turn over in bed. There are several types of air filters available. ^[41]

• Mechanical air filters use a fan to force air through a special screen that traps particles such as smoke, pollens, and other airborne allergens. The high-efficiency particulate air (HEPA) filter is the best-known air filter. HEPA (which is a type of filter, not a brand name) was developed during World War II to prevent radioactive particles from escaping from laboratories.
• Electronic air filters use electrical charges to attract and deposit allergens and irritants. If the device contains collecting plates, the particles are captured within the system; otherwise, they stick to room surfaces and have to be cleared away.
• Hybrid air filters contain elements of both mechanical and electrostatic filters.
• Gas phase air filters use activated carbon granules to remove odors (volatile organic compounds or VOCs) and non-particulate pollution such as cooking gas, gases emitted from paint or building materials (such as formaldehyde), and perfume.
• Germicidal air cleaners use ultraviolet (UV) lights to kill bacteria, viruses, and molds that pass through the area with the UV light. Ultraviolet ( UV) light is Electromagnetic radiation with a Wavelength shorter than that of Visible light, but longer than X-rays The Bacteria ( singular: bacterium) are a large group of unicellular Microorganisms Typically a few Micrometres in length bacteria have A virus (from the Latin virus meaning Toxin or Poison) is a sub-microscopic infectious agent that is unable Such UV lights can be included with other air cleaner devices, which use a fan.
• Ozone generators are devices that intentionally produce high concentrations of ozone to clean the air in a room. They are often used to decontaminate rooms after smoke exposure following a fire.

Treatment

The most effective treatment for asthma is identifying triggers, such as pets or aspirin, and limiting or eliminating exposure to them. If trigger avoidance is insufficient, medical treatment is available. Desensitization is currently the only known "cure" to the disease. For medical purposes desensitization is a method to reduce or eliminate an organism's negative reaction to a substance or stimulus ^[42] Other forms of treatment include relief medication, prevention medication, long-acting β2-agonists, and emergency treatment.

Medical

The specific medical treatment recommended to patients with asthma depends on the severity of their illness and the frequency of their symptoms. Specific treatments for asthma are broadly classified as relievers, preventers and emergency treatment. The Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (EPR-2)^[40] of the U. S. National Asthma Education and Prevention Program, and the British Guideline on the Management of Asthma^[43] are broadly used and supported by many doctors. On August 29, 2007 the final Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma was officially released. Bronchodilators are recommended for short-term relief in all patients. For those who experience occasional attacks, no other medication is needed. For those with mild persistent disease (more than two attacks a week), low-dose inhaled glucocorticoids or alternatively, an oral leukotriene modifier, a mast-cell stabilizer, or theophylline may be administered. For those who suffer daily attacks, a higher dose of glucocorticoid in conjunction with a long-acting inhaled β-2 agonist may be prescribed; alternatively, a leukotriene modifier or theophylline may substitute for the β-2 agonist. In severe asthmatics, oral glucocorticoids may be added to these treatments during severe attacks.

The discovery in 2006 by researchers at Harvard Medical School that asthma may be caused by over-proliferation of a special type of natural "killer" cell may ultimately lead to the development of better and more targeted drugs. Natural killer T cells seem to be resistant to the corticosteroids, one of the mainstays of current treatment. ^[29]

Pharmaceutical

Symptomatic control of episodes of wheezing and shortness of breath is generally achieved with fast-acting bronchodilators. A bronchodilator is a substance that dilates the bronchi and Bronchioles decreasing airway resistance and thereby facilitating airflow These are typically provided in pocket-sized, metered-dose inhalers (MDIs). An inhaler or puffer is a medical device used for delivering medication into the body via the lungs In young sufferers, who may have difficulty with the coordination necessary to use inhalers, or those with a poor ability to hold their breath for 10 seconds after inhaler use (generally the elderly), an asthma spacer (see top image) is used. An Asthma spacer is a type of add-on device used by an asthmatic person to increase the effectiveness of a Metered-dose inhaler. The spacer is a plastic cylinder that mixes the medication with air in a simple tube, making it easier for patients to receive a full dose of the drug and allows for the active agent to be dispersed into smaller, more fully inhaled bits.

A nebulizer which provides a larger, continuous dose can also be used. In Medicine, a nebulizer is a device used to administer medication to people in the form of a mist inhaled into the lungs Nebulizers work by vaporizing a dose of medication in a saline solution into a steady stream of foggy vapour, which the patient inhales continuously until the full dosage is administered. There is no clear evidence, however, that they are more effective than inhalers used with a spacer. Nebulizers may be helpful to some patients experiencing a severe attack. Such patients may not be able to inhale deeply, so regular inhalers may not deliver medication deeply into the lungs, even on repeated attempts. Since a nebulizer delivers the medication continuously, it is thought that the first few inhalations may relax the airways enough to allow the following inhalations to draw in more medication.

Relievers include:

• Short-acting, selective beta₂-adrenoceptor agonists, such as salbutamol (albuterol USAN), levalbuterol, terbutaline and bitolterol. Beta2-adrenergic agonists, also known as Beta2-adrenergic receptor agonists, are a class of drugs used to treat Asthma and other Salbutamol ( INN) or albuterol ( USAN) is a short-acting β2-adrenergic receptor agonist used for the relief of Bronchospasm United States Adopted Names are unique nonproprietary names assigned to Pharmaceuticals marketed in the United States. Levosalbutamol ( INN) or levalbuterol ( USAN) trade name Xopenex, is the R - Enantiomer of the short-acting β2-adrenergic Terbutaline ( Trade names Brethine, Bricanyl, or Brethaire) is a β2-adrenergic receptor agonist, used as a fast-acting Bitolterol mesylate (Tornalate is a β2-adrenergic receptor agonist used for the relief of Bronchospasm in conditions such as Asthma and
  Tremors, the major side effect, have been greatly reduced by inhaled delivery, which allows the drug to target the lungs specifically; oral and injected medications are delivered throughout the body. Tremor is an unintentional somewhat rhythmic muscle movement involving to-and-from movements (oscillations of one or more parts of the body There may also be cardiac side effects at higher doses (due to Beta-1 agonist activity), such as elevated heart rate or blood pressure; with the advent of selective agents, these side effects have become less common. The heart is a muscular organ in all Vertebrates responsible for pumping Blood through the Blood vessels by repeated rhythmic Patients must be cautioned against using these medicines too frequently, as with such use their efficacy may decline, producing desensitization resulting in an exacerbation of symptoms which may lead to refractory asthma and death.
• Older, less selective adrenergic agonists, such as inhaled epinephrine and ephedrine tablets, have also been used. The adrenergic receptors (or adrenoceptors) are a class of G protein-coupled receptors that are targets of the Catecholamines Adrenergic receptors Ephedrine (EPH is a Sympathomimetic Amine commonly used as a Stimulant, appetite suppressant concentration aid Decongestant, and to treat Cardiac side effects occur with these agents at either similar or lesser rates to albuterol. ^{[44] [45]} When used solely as a relief medication, inhaled epinephrine has been shown to be an effective agent to terminate an acute asthmatic exacerbation. ^[44] In emergencies, these drugs were sometimes administered by injection. Their use via injection has declined due to related adverse effects.
• Anticholinergic medications, such as ipratropium bromide may be used instead. An anticholinergic agent is a substance that blocks the Neurotransmitter acetylcholine in the central and the Peripheral nervous system. Ipratropium (as ipratropium Bromide, trade name Atrovent) is an Anticholinergic drug They have no cardiac side effects and thus can be used in patients with heart disease; however, they take up to an hour to achieve their full effect and are not as powerful as the β₂-adrenoreceptor agonists.
• Inhaled glucocorticoids are usually considered preventive medications; however, a randomized controlled trial has demonstrated the benefit of 250 microg beclomethasone when taken as an as-needed combination inhaler with 100 microg of albuterol. Glucocorticoids (GC are a class of Steroid hormones characterised by an ability to bind with the glucocorticoid receptor ( GR) and trigger similar effects A randomized controlled trial (RCT is a type of scientific Experiment most commonly used in testing the Efficacy or Effectiveness of Healthcare Beclometasone dipropionate ( INN modified or beclomethasone dipropionate ( USAN, former BAN) also referred to as beclometasone (INN Salbutamol ( INN) or albuterol ( USAN) is a short-acting β2-adrenergic receptor agonist used for the relief of Bronchospasm ^[46]

Long-acting β₂-agonists

Long-acting bronchodilators (LABD) are similar in structure to short-acting selective beta₂-adrenoceptor agonists, but have much longer side chains resulting in a 12-hour effect, and are used to give a smoothed symptomatic relief (used morning and night). While patients report improved symptom control, these drugs do not replace the need for routine preventers, and their slow onset means the short-acting dilators may still be required. In November of 2005, the American FDA released a health advisory alerting the public to findings that show the use of long-acting β₂-agonists could lead to a worsening of symptoms, and in some cases death. ^[47]

Currently available long-acting beta₂-adrenoceptor agonists include salmeterol, formoterol, bambuterol, and sustained-release oral albuterol. Long acting beta-adrenoceptor agonists are usually prescribed for moderate to severe persistent Asthma patients or patients with COPD. Salmeterol is a long-acting Beta2-adrenergic receptor agonist drug that is currently prescribed for the treatment of Asthma and chronic obstructive pulmonary Formoterol ( INN) or eformoterol (former BAN) is a long-acting β2-agonist used in the management of Asthma and/or Bambuterol ( INN, marketed by AstraZeneca under the trade names Bambec and Oxeol) is a Long acting beta-adrenoceptor agonist used in Salbutamol ( INN) or albuterol ( USAN) is a short-acting β2-adrenergic receptor agonist used for the relief of Bronchospasm Combinations of inhaled steroids and long-acting bronchodilators are becoming more widespread; the most common combination currently in use is fluticasone/salmeterol (Advair in the United States, and Seretide in the United Kingdom). The combination preparation fluticasone/salmeterol is a formulation containing fluticasone propionate and salmeterol xinafoate used in the management of Asthma The combination preparation fluticasone/salmeterol is a formulation containing fluticasone propionate and salmeterol xinafoate used in the management of Asthma Another combination is budesonide/formoterol which is commercially known as Symbicort. Budesonide is a Glucocorticoid Steroid for the treatment of Asthma, non-infectious Rhinitis (including Hay fever and other allergies Formoterol ( INN) or eformoterol (former BAN) is a long-acting β2-agonist used in the management of Asthma and/or Budesonide/formoterol is a combination formulation containing Budesonide and Formoterol used in the management of Asthma and Chronic obstructive pulmonary

A recent meta-analysis of the roles of long-acting beta-agonists may indicate a danger to asthma patients. The study, published in the Annals of Internal Medicine in 2006, found that long-acting beta-agonists increased the risk for asthma hospitalizations and asthma deaths 2- to 4-fold, compared with placebo. ^[48] "These agents can improve symptoms through bronchodilation at the same time as increasing underlying inflammation and bronchial hyper-responsiveness, thus worsening asthma control without any warning of increased symptoms," said Shelley Salpeter in a press release after the publication of the study. The release goes on to say that "Three common asthma inhalers containing the drugs salmeterol or formoterol may be causing four out of five US asthma-related deaths per year and should be taken off the market". ^[49] This assertion has drawn criticism from many asthma specialists for being inaccurate. As Dr. Hal Nelson points out in a recent letter to the Annals of Internal Medicine, "Salpeter and colleagues also assert that salmeterol may be responsible for 4000 of the 5000 asthma-related deaths that occur in the United States annually. However, when salmeterol was introduced in 1994, more than 5000 asthma-related deaths occurred per year. Since the peak of asthma deaths in 1996, salmeterol sales have increased about 5-fold, while overall asthma mortality rates have decreased by about 25%, despite a continued increase in asthma diagnoses. In fact, according to the most recent data from the National Center for Health Statistics, U. S. asthma mortality rates peaked in 1996 (with 5667 deaths) and have decreased steadily since. The last available data, from 2004, indicate that 3780 deaths occurred. Thus, the suggestion that a vast majority of asthma deaths could be attributable to LABA use is inconsistent with the facts. "

Dr. Shelley Salpeter, in a letter to the Annals of Internal Medicine, responds to the comments of Dr. Nelson, "It is true that the asthma death rate increased after salmeterol was introduced, then peaked and is now starting to decline despite continued use of the long-acting beta-agonists. This trend in death rates can best be explained by examining the ratio of beta-agonist use to inhaled corticosteroids. . . In the recent past, inhaled corticosteroid use has increased steadily while long-acting beta-agonist use has begun to stabilize and short-acting beta-agonist use has declined. . . Using this estimate, we can imagine that if long-acting beta-agonists were withdrawn from the market while maintaining high inhaled corticosteroid use, the death rate in the United States could be reduced significantly. . . "

Emergency

When an asthma attack is unresponsive to a patient's usual medication, other treatments are available to the physician or hospital:^[50]

• Oxygen to alleviate the hypoxia (but not the asthma itself) that results from extreme asthma attacks. Oxygen (from the Greek roots ὀξύς (oxys (acid literally "sharp" from the taste of acids and -γενής (-genēs (producer literally begetteris the
• Nebulized salbutamol or terbutaline (short-acting beta-2-agonists), often combined with ipratropium (an anticholinergic). Salbutamol ( INN) or albuterol ( USAN) is a short-acting β2-adrenergic receptor agonist used for the relief of Bronchospasm Terbutaline ( Trade names Brethine, Bricanyl, or Brethaire) is a β2-adrenergic receptor agonist, used as a fast-acting
• Systemic steroids, oral or intravenous (prednisone, prednisolone, methylprednisolone, dexamethasone, or hydrocortisone). Prednisone is a synthetic Corticosteroid drug that is usually taken orally but can be delivered by Intramuscular injection and can be used for a great number Prednisolone is the active metabolite of Prednisone. Uses It is a Corticosteroid drug with predominantly Glucocorticoid and low Mineralocorticoid Methylprednisolone is a synthetic Glucocorticoid drug It is sold in the USA and Canada under the brand names Medrol and Solu-Medrol Dexamethasone is a potent synthetic member of the glucocorticoid class of Steroid Hormones It acts as an Anti-inflammatory and immunosuppressant Cortisol is a Corticosteroid Hormone produced by the Adrenal gland (in the Zona fasciculata of the Adrenal cortex) Some research has looked into an alternative inhaled route. ^[51]
• Other bronchodilators that are occasionally effective when the usual drugs fail:
  • Intravenous salbutamol
  • Nonspecific beta-agonists, injected or inhaled (epinephrine, isoetharine, isoproterenol, metaproterenol)
  • Anticholinergics, IV or nebulized, with systemic effects (glycopyrrolate, atropine, ipratropium)
  • Methylxanthines (theophylline, aminophylline)
  • Inhalation anesthetics that have a bronchodilatory effect (isoflurane, halothane, enflurane)
  • The dissociative anaesthetic ketamine, often used in endotracheal tube induction
  • Magnesium sulfate, intravenous
• Intubation and mechanical ventilation, for patients in or approaching respiratory arrest. Isoetarine ( INN) or isoetharine ( USAN) trade names Bronkosol and Bronkometer, is a selective Beta2-adrenergic receptor agonist Isoprenaline ( INN) or isoproterenol ( USAN, trade names Medihaler-Iso and Isuprel) is a Sympathomimetic beta Adrenergic Orciprenaline ( INN, also known as metaproterenol) is a Bronchodilator used in the treatment of Asthma. Glycopyrrolate is a Medication of the Muscarinic Anticholinergic group Atropine is a Tropane Alkaloid extracted from Deadly nightshade ( Atropa belladonna) Jimsonweed (Datura stramonium and other plants Ipratropium (as ipratropium Bromide, trade name Atrovent) is an Anticholinergic drug Theophylline, also known as dimethylxanthine, is a Methylxanthine drug used in therapy for Respiratory diseases such as COPD or Asthma Aminophylline is a Bronchodilator Drug combination that contains Theophylline and Ethylenediamine in 21 ratio Isoflurane (2-chloro-2-(difluoromethoxy-111-trifluoro-ethane is a Halogenated ether used for inhalational Anesthesia. Halothane vapour (or Fluothane) is an inhalational General anaesthetic. Enflurane (2-chloro-112-trifluoroethyl-difluoromethyl ether is a Halogenated ether that was commonly used for inhalational Anesthesia during the 1970s and 1980s Ketamine is a drug for use in human and veterinary medicine developed by Parke-Davis (today a part of Pfizer) in 1962 Magnesium sulfate is a Chemical compound containing Magnesium and Sulfate, with the formula MgSO4 In Medicine, intubation refers to the placement of a tube into an external or internal orifice of the body In Medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing when patients cannot do so on their own
• Heliox, a mixture of helium and oxygen, may be used in a hospital setting. It has a more laminar flow than ambient air and moves more easily through constricted airways.

Non-medical treatments

Many asthmatics, like those who suffer from other chronic disorders, use alternative treatments; surveys show that roughly 50% of asthma patients use some form of unconventional therapy. The term alternative medicine, as used in the modern western world encompasses any healing practice "that does not fall within the realm of conventional Medicine. ^[52][53] There is little data to support the effectiveness of most of these therapies. A Cochrane systematic review of acupuncture for asthma found no evidence of efficacy. The Cochrane Collaboration is a group of over 11500 volunteers in more than 90 countries who apply a rigorous systematic process to review the effects of interventions tested in biomedical Evidence-based medicine (EBM aims to apply Evidence gained from the Scientific method to certain parts of medical practice ^[54] A similar review of air ionisers found no evidence that they improve asthma symptoms or benefit lung function; this applied equally to positive and negative ion generators. An air ioniser is a device that uses High voltage to Ionise (electrically charge air Molecules Negative ions or Anions, are particles with ^[55] A study of "manual therapies" for asthma, including osteopathic, chiropractic, physiotherapeutic and respiratory therapeutic manoeuvres, found there is insufficient evidence to support or refute their use in treating asthma;^[56] these manoeuvers include various osteopathic and chiropractic techniques to "increase movement in the rib cage and the spine to try and improve the working of the lungs and circulation"; chest tapping, shaking, vibration, and the use of "postures to help shift and cough up phlegm. Chiropractic is a Health care profession that focuses on diagnosis treatment and prevention of mechanical disorders of the Musculoskeletal system, with special emphasis Respiratory Therapy is categorized as an Allied health profession in the United States and Canada " One meta-analysis finds that homeopathy may have a potentially mild benefit in reducing the intensity of symptoms. In Statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses This article has been the subject of edit wars and has been placed on probation ^[57] However, the number of patients involved in the analysis was small, and subsequent studies have not supported this finding. ^[58] Several small trials have suggested some benefit from various yoga practices, ranging from integrated yoga programs,^[59] yogasanas, Pranayama, meditation, and kriyas, to sahaja yoga,^[60] a form of 'new religious' meditation. Yoga ( Sanskrit: योग, IAST: yóga, joːgə refers to traditional physical and mental disciplines originating in India, to the Meditation is a mental discipline by which one attempts to get beyond the conditioned "thinking" mind into a deeper state of relaxation or awareness

Treatment controversies

In November 2007 The New York Times reported a review of more than 500 studies finding that independently backed studies on inhaled corticosteroids are up to four times more likely to find adverse effects than studies paid for by drug companies. ^[61][62]

Prognosis

The prognosis for asthmatics is good; especially for children with mild disease. For asthmatics diagnosed during childhood, 54% will no longer carry the diagnosis after a decade. The extent of permanent lung damage in asthmatics is unclear. Airway remodelling is observed, but it is unknown whether these represent harmful or beneficial changes. ^[17] Although conclusions from studies are mixed, most studies show that early treatment with glucocorticoids prevents or ameliorates decline in lung function as measured by several parameters. ^[63] For those who continue to suffer from mild symptoms, corticosteroids can help most to live their lives with few disabilities. The mortality rate for asthma is low, with around 6000 deaths per year in a population of some 10 million patients in the United States. ^[4] Better control of the condition may help prevent some of these deaths.

Epidemiology

More than 6% of children in the United States have been diagnosed with asthma, a 75% increase in recent decades. The rate soars to 40% among some populations of urban children.

Asthma is usually diagnosed in childhood. The risk factors for asthma include:

• A personal or family history of asthma or atopy
• Triggers (see Pathophysiology above)
• Premature birth or low birth weight
• Viral respiratory infection in early childhood
• Maternal smoking
• Being male, for asthma in prepubertal children
• Being female, for persistence of asthma into adulthood

Current research suggests that the prevalence of childhood asthma has been increasing. History is the study of the past particularly the written record Those who study history as a Profession are called Historians Etymology Atopy (/ˈætəpi/ Greek ἀτοπία - placelessness or atopic syndrome is an allergic Hypersensitivity affecting parts of the body Asthma is a chronic Condition involving the Respiratory system in which the airways occasionally constrict become inflamed, and are Upper respiratory tract infections, ( URTI or URI) are the illnesses caused by an acute Infection which involves the upper Respiratory tract: In Epidemiology, the prevalence of a Disease in a Statistical population is defined as the total number of cases of the disease in the population at a given According to the Centers for Disease Control and Prevention's National Health Interview Surveys, some 9% of US children below 18 years of age had asthma in 2001, compared with just 3. The Centers for Disease Control and Prevention (or CDC) is an agency of the United States Department of Health and Human Services based in unincorporated 6% in 1980 (see figure). The World Health Organization (WHO) reports that some 8% of the Swiss population suffers from asthma today, compared with just 2% some 25–30 years ago. ^[64] Although asthma is more common in affluent countries, it is by no means a problem restricted to the affluent; the WHO estimate that there are between 15 and 20 million asthmatics in India. In the U. S. , urban residents, Hispanics, and African Americans are affected more than the population as a whole. Globally, asthma is responsible for around 180,000 deaths annually. ^[64]

Population disparities

Asthma prevalence, morbidity, mortality, and drug response vary greatly across populations. There is an almost 30-fold difference in asthma prevalence between some of the countries included in the International Study of Asthma and Allergy in Childhood[3], with a trend toward more developed and westernized countries having higher asthma prevalence. The term developed country, or advanced country, is used to categorize countries with developed Economies in which the tertiary and quaternary sectors The term Western world, the West or the Occident ( Latin: occidens -sunset -west as distinct from the Orient) can have multiple meanings Westernization can’t explain the entire difference in asthma prevalence between countries, however, and the disparities may also be affected by differences in genetic, social and environmental risk factors. ^[11] There are also worldwide disparities in asthma mortality, which is most common in low to middle income countries. ^[65]

Asthma prevalence in the US is higher than in most other countries in the world, but varies drastically between diverse US populations. ^[11] In the US, asthma prevalence is highest in Puerto Ricans, African Americans, Filipinos and Native Hawaiians, and lowest in Mexicans and Koreans. ^[66][67][68] Mortality rates follow similar trends, and response to albuterol is lower in Puerto Ricans than in African Americans or Mexicans. Salbutamol ( INN) or albuterol ( USAN) is a short-acting β2-adrenergic receptor agonist used for the relief of Bronchospasm ^[69][70] As with worldwide asthma disparities, differences in asthma prevalence, mortality, and drug response in the US may be explained by differences in genetic, social and environmental risk factors.

Asthma prevalence also differs between populations of the same ethnicity who are born and live in different places. ^[71] US-born Mexican populations, for example, have higher asthma rates than non-US born Mexican populations that are living in the US. ^[72] This probably reflects differences in social and environmental risk factors associated with acculturation to the US. Acculturation is the exchange of cultural features that results when groups come into continuous firsthand contact the original cultural patterns of either or both groups may be altered

Asthma prevalence and asthma deaths also differ by gender. Males are more likely to be diagnosed with asthma as children, but asthma is more likely to persist into adulthood in females. Sixty five percent more adult women than men will die from asthma. This difference may be attributable to hormonal differences, among other things. Hormones (from Greek ὁρμή - "impetus" are chemicals released by cells that affect cells in other parts of the body In support of this, girls who reach puberty before age 12 were found to have a later diagnosis of asthma more than twice as much as girls who reach puberty after age 12. Asthma is also the number one cause of children missing school.

Socioeconomic factors

The incidence of asthma is highest among low-income populations (asthma deaths are most common in low to middle income countries [4]), which in the western world are disproportionately ethnic minorities^[73] and are more likely to live near industrial areas. Additionally, asthma has been strongly associated with the presence of cockroaches in living quarters, which is more likely in such neighborhoods. Cockroaches (or simply "roaches" are Insects of the order Blattaria.

Asthma incidence and quality of treatment varies among different racial groups, though this may be due to correlations with income (and thus affordability of health care) and geography. For example, Black Americans are less likely to receive outpatient treatment for asthma despite having a higher prevalence of the disease. They are much more likely to have emergency room visits or hospitalization for asthma, and are three times as likely to die from an asthma attack compared to whites. The prevalence of "severe persistent" asthma is also greater in low-income communities compared with communities with better access to treatment. ^[74][75]

Asthma and athletics

Asthma appears to be more prevalent in athletes than in the general population. One survey of participants in the 1996 Summer Olympic Games, in Atlanta, Georgia, U. The Summer Olympic Games or the Games of the Olympiad are an International Multi-sport event, usually quadrennial organised by the International S. , showed that 15% had been diagnosed with asthma, and that 10% were on asthma medication. ^[76] These statistics have been questioned on at least two bases. Athletes with mild asthma may be more likely to be diagnosed with the condition than non-athletes, because even subtle symptoms may interfere with their performance and lead to pursuit of a diagnosis. It has also been suggested that some professional athletes who do not suffer from asthma claim to do so in order to obtain special permits to use certain performance-enhancing drugs.

There appears to be a relatively high incidence of asthma in sports such as cycling, mountain biking, and long-distance running, and a relatively lower incidence in weightlifting and diving. Cycling is the use of Bicycles or - less commonly - Unicycles Tricycles Quadricycles and other similar wheeled Human powered vehicles Running is a means for an animal to move on Foot. It is defined in Sporting terms as a Gait in which at some point all feet are off the ground It is unclear how much of these disparities are from the effects of training in the sport, and from self-selection of sports that may appear to minimize the triggering of asthma. ^[76][77]

In addition, there exists a variant of asthma called exercise-induced asthma that shares many features with allergic asthma. Exercise-induced asthma, or EIA, is a medical condition characterized by shortness of breath induced by sustained aerobic exercise It may occur either independently, or concurrent with the latter. Exercise studies may be helpful in diagnosing and assessing this condition.

History

Asthma was long considered a psychosomatic disease, and

. . . during the 1930s–50s, was even known as one of the 'holy seven' psychosomatic illnesses. At that time, psychoanalytic theories described the aetiology of asthma as psychological, with treatment often primarily involving psychoanalysis and other 'talking cures'. Etiology (alternatively aetiology, aitiology) is the study of causation. As the asthmatic wheeze was interpreted as the child's suppressed cry for his or her mother, psychoanalysts viewed the treatment of depression as especially important for individuals with asthma. ^[78]

See also

• Reactive airway disease
• Atopy
• Hopkins syndrome
• Hygiene hypothesis
• Immune response
• Asthma and Allergy Foundation of America
• Occupational asthma

References

External links

• VIDEO Identifying Risk Factors for Childhood Asthma Presentation by James E. Gern, M. D. , at the UW-Madison Health Sciences Learning Center.
• World Health Organization site on asthma
• National Heart, Lung, and Blood Institute — Asthma – U. S. NHLBI Information for Patients and the Public page.
• MedLinePlus: Asthma – a U. S. National Library of Medicine page
• AsthmaClinicalTrials.org - Asthma Clinical Trials and Findings From Current Research
• Neurogenic factors in mechanisms of bronchial asthma
• Asthma Helpline

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