Allergy Clinical Services

Asthma

What is asthma?

Asthma is a chronic lung disease in which the lungs overreact to various materials in the air and some respiratory infections. These "triggers" start inflammation in the airways which causes two problems:

  1. Airways become more narrow, making it hard for air to move in and out. Tightening of the muscles surrounding the airways (bronchoconstriction), extra mucus and swelling of the airway linings all add to the narrowing, which is called obstruction.
  2. Airways become super-sensitive or hyper-reactive to things that do not bother people with normal lungs. The "twitchy" lungs over-react even to cold air, exercise and smoke. The airway narrowing or obstruction and "twitchiness" cause the asthma symptoms which usually come in new "waves" called flares or attacks.

The two illustrations on the right side of the page show the difference between normal airways and inflamed asthmatic airways.

Children and adults with asthma are born with this problem. There are many different patterns of symptoms. Some people start having problems very early in life, others much later. Every asthma patient has asthma attacks, but some have more. Some patients have no problems between attacks or flares, but many have symptoms everyday. This is called "persistent" asthma, and the common cause is continuing exposure to allergy triggers and/or irritants like smoke. There can be years when all symptoms seem to have gone away, but everyone with asthmatic lungs is at risk for new problems. Therefore all asthma patients and caregivers must know how to tell when they are in trouble and how to care for the problems, especially new flare-ups.

Reactive airways is simply another term that some clinicians may use for asthma. But when asthma symptoms keep coming, and there are no other lung problems, asthma is the best term to use. Some patients have a different, major lung disease (such as cystic fibrosis or bronchopulmonary dysplasia) in addition to the second problem of asthma symptoms. Here we say the patient has that specific lung disease complicated by reactive airways, without using the term asthma.

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What are the symptoms of asthma?

The most important symptoms are cough, shortness of breath, chest tightness or pain, and wheezing.

It is easy to see how the obstruction can lead to shortness of breath or chest pain. Coughing can come from the need to cough up mucus stuck in the lungs or from the irritation of the airways (twitchiness).

Wheeze is the musical noise made by air coming out of narrow lung passages (like whistling). It is important to know that not everyone with asthma will show wheezing. This is a common reason for failure to diagnose asthma. Also, when the airways get very narrow and tight, wheezing may stop. When this happens, the patient is worse, not better. Using "wheeze" alone to diagnose and follow asthma attacks can be unreliable and tricky.

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How is the diagnosis of asthma made?

Your asthma specialists first will look for classic asthma symptoms, and then how they cause a typical pattern of problems. Do they come in cycles or attacks? Do asthma medicines help relieve the symptoms? Sometimes this is enough to make the diagnosis. We will also check for other conditions that might look like asthma. For example, we will evaluate your child for cystic fibrosis, disorders of the immune system and so on if your child's history and lung function tests hint that other problems might be present.

Lung tests may be important to help make the diagnosis. Spirometry can measure the obstruction in the airways and also show that obstruction can be relieved with asthma medicines. Other tests can show that the lungs are extra "twitchy." For example, lung function can be measured during exercise to look for obstruction. Finally, daily use of a peak flow meter at home can reveal that your child's lungs are going in and out of periods of obstruction or tightness either during attacks or even after exercise.

When asthma symptoms begin early in life, such as the first year, a final diagnosis of asthma is usually not given until your child shows that the symptoms and attacks continue beyond the third year. As time goes by, your asthma specialist will review your child's symptoms and response to the prescribed medicines to better advise you about your child's final diagnosis and need for medicines.

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What causes asthma symptoms?

People with asthma have airways that are super-sensitive to things that do not bother other people with normal lungs. These triggers start lung inflammation and asthma symptoms.

There are three major groups of triggers:

  1. Infections such as colds and sinus infections. Every asthma patient has a problem with this trigger.
  2. Allergies to pollen (tree, grass, weeds), molds, pets, dust mites and cockroaches are very common triggers.
  3. Irritants such as tobacco smoke and chemical fumes from heaters are important triggers too.

If asthma is not well controlled, simple things like exercise, weather changes, cold air and emotion (showing strong feelings like laughing, anger) can trigger asthma symptoms in an irritated lung.

Your child may have additional problems that can make asthma worse or harder to control. For example, gastroesophageal reflux can make the lungs more twitchy and tight.

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What is an asthma attack or flare?

Asthma attacks or flares come and go. When an attack begins, you will notice that your child's symptoms become worse and increase rapidly. You will think of using medicines to open the airways and provide relief. During these times, you will see the following picture.

  1. Toughest symptoms occur after midnight, even though the problems of excessive cough, wheeze, shortness of breath, or chest pain are continuing all day. New night-time symptoms are signs that a new flare has started.
  2. The lungs are making lots of mucus. Your child is trying to cough it out. Some children may even gag or vomit.
  3. The lungs become very twitchy. It will be a lot easier for cough, wheeze, shortness of breath or chest pain to come on with exercise, cold air, excitement, laughing or rough-housing.

If the attacks become more severe, breathing can be very difficult, like trying to breathe through a straw. Your child may become less active and appear tired. We will teach you about the times you should call your doctor.

It is important to know that some children do not show many symptoms even when their lungs become tight. If your child has such a tendency, your asthma specialist will set out a plan to help you learn important symptoms to watch. These children need home peak flow monitoring, more frequent follow-up visits and lung testing.

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How can asthma be controlled?

Work closely with your primary doctor and asthma specialist team to control your child's asthma.

First, learn how to control the inflammation in your child's lungs. There are two things to do:

  1. Remove triggers of inflammation! Do the best you can to improve your child's environment.
  2. Have your child take enough anti-inflammatory medicines each day to control inflammation, even when she seems well.

Keep working on these two goals:

  1. Between attacks, when your child's condition is best, there should be no asthma symptoms. The lung tests your asthma team uses will help prove the lungs are under control.
  2. Know how to treat new attacks right at the time they begin.

To control an asthma flare, you will need an action plan. To make it work, remember:

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Two kinds of asthma medications

Anti-inflammatory medicines

Prevent and reduce the bronchospasm, swelling, extra mucus and "twitchiness" of the airways. When first started, they usually take time to work, sometimes weeks. They are used as a controller medicine to heal the lungs and prevent symptoms. They will do two things:

  1. Prevent every day problems during the times between flare-ups or attacks.
  2. Reduce attacks, both the number and severity.

Do not stop the daily anti-inflammatory medications until your asthma specialist recommends it. If you stop these medicines after you gain control, inflammation might return, along with symptoms and more asthma attacks.

Examples of controller medicines include inhaled steroids (e.g., FLOVENT and PULMICORT). There are also non-steroid drugs. These include "leukotriene modifiers" (SINGULAIR and ACCOLATE) and another group which includes INTAL (cromolyn) and TILADE.

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Bronchodilators

These medicines work very differently from anti-inflammatory medicines. They open the airways by relaxing the muscles that surround them. There are two kinds:

  1. Short-acting bronchodilators are used for quick relief of asthma symptoms. They are also called reliever or rescue medicines. Examples include PROVENTIL and VENTOLIN (or albuterol), MAXAIR and the newer drug XOPENEX.
  2. Long-acting bronchodilators help control asthma symptoms because they stay active for a long time. These medicines do not act fast enough for quick relief, so they are not used in treatment of new attacks. Long-acting bronchodilators are not anti-inflammatory medicines when given by themselves, but they can help inhaled steroids to work when both are prescribed together.

Your asthma specialist team will discuss how the medicines work, when to use them, what to expect and how to recognize any side-effects. You will need to learn about them before becoming comfortable and knowledgeable enough to use them safely and effectively.

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The goals of treatment

Why are follow-up visits important?

Follow-up visits allow you to continue to learn about your child's asthma and treatment plan, including how the his pattern of asthma symptoms is changing. It's also an opportunity to check on asthma control when your child is well. Are all of her symptoms and problems truly controlled? Are lung function tests remaining stable or improving?

During these visits, your child's asthma team may adjust his daily preventative medicines to the lowest effective doses. You also can discuss any concerns that you might have about your child's side effects. Your child's asthma team can make sure that your child's medicines are being taken properly, including spacer use.

You can also identify any problems you might have with getting the care you need: insurance coverage, access to appointments, ability to get medicines, organizing the medicine schedule.

Asthma resources

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Reviewed by: Allergy Section
Date: January 2001

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