Asthma

Of all the possible classifications of asthma, the one that is of most interest, from a clinical point of view, is the following:

Why is it produced?

Factors involved in the development of asthma:

• Atopia.
• Drugs: Aspirin and other anti-inflammatories.
• Non-steroidal household allergens (NSAIDs).
• Occupational allergens.
• Smoke of the tabacco.
• Environmental allergens.
• Low birth weight
• Environmental pollution.
• Respiratory virus infections.

Triggering factors for seizures:

• Exposure to allergens (house dust mites, hairy animal epithelia, pollens, fungi, cockroach allergens, occupational sensitizers, etc.).
• Respiratory virus infections.
• Stressful situations: Physical effort, Stress .
• Environmental factors: Adverse meteorological conditions, Environmental pollution.
• Drugs, Food and Additives.
• Incorrect treatment of asthma (poor inhalation technique, treatment abandonment, insufficient anti-inflammatory treatment).

Frequently used drugs capable of causing asthma attacks:

• Antibiotics: Penicillins, Cephalosporins, Tetracyclines, Sulfamides, Erythromycin, …
• Carbamazepine.
• Iron (in injection).
• Vaccines.
• Allergenic extracts.
• NSAIDs (Aspirin,…).
• Beta-blockers.

Asthma symptoms

The most characteristic symptoms of asthma are:

• Cough.
• Wheezing (wheezing)
• Dyspnoea (feeling short of breath).
• Feeling of chest tightness.

One or more of these symptoms may appear on a recurring basis, especially at night or in connection with exercise. Its presentation is usually variable, sometimes atypical, with silent periods.

How is it diagnosed?

A detailed interrogation is essential, asking for a history of processes that have occurred with the following symptoms: cough, wheezing, dyspnea, …

It should also be asked about the association of symptoms with factors related to asthma and the existence of other processes that can be associated with this disease: rhinitis , conjunctivitis , sinusitis , nasal polyposis, atopic dermatitis . As well as, due to the characteristics of the home and work environment of the patient in search of unfavorable circumstances: temperature, humidity, smoke or animal allergens, objects that accumulate dust, sensitizers or industrial irritants.

Finally, the patient should be asked about the limitation that the symptoms produce in his daily life.

Physical examination of the patient

Lung auscultation is essential, which may be normal in asymptomatic periods or may present the characteristic whistles (wheezing). Cardiology examination is also very important.

Examination of the skin, eyes and nose, to rule out the presence of other processes related to asthma: rhinitis, conjunctivitis, sinusitis, etc. Once the suspected diagnosis has been made using the clinical data obtained, we must establish the confirmatory diagnosis, for which we will use the functional respiratory examination, whose purpose is to study the basic characteristics of the asthmatic patient: bronchial obstruction, reversibility, variability and bronchial hyperresponsiveness.
Airway obstruction is assessed by:

• Forced spirometry, a test that measures the volume of an exhalation carried out with maximum effort from a maximum inspiration, up to the residual volume, as a function of time. In patients with suspected asthma, it should be performed systematically, and it may be normal or present an obstructive pattern.
• Another very useful technique to evaluate the obstruction is the measurement of the maximum expiratory flow (PEF) with the peak-flow meter.

The reversibility or recovery of the normal caliber of the airway, spontaneously or with treatment, is evaluated by:

• The bronchodilator test, which consists of repeating spirometry 15 to 20 minutes after taking two inhalations of a short-acting medication.
• The PEF value can also be used to assess reversibility.

Bronchial hyperresponsiveness is the exaggerated response of the airway to one or more stimuli. To assess it, you can use:

• Bronchial provocation test with methacholine or histamine .
• Bronchial provocation test with specific allergens: especially useful when there is suspicion of asthma caused by sensitizers in the workplace.

The variability is the daily variation of the PEF.

Other complementary examinations

Skin tests, especially the prick test, are useful when there is a well-founded suspicion of the existence of a triggering factor. The assessment is qualitative (identification of allergens) and semi-quantitative (identification of the degree of intensity).

The chest radiograph is usually normal in asthmatics but should be performed in the initial evaluation and to rule out other processes or complications. Sometimes a craniofacial sinus x-ray may be helpful.

Asthma treatment

The drugs commonly used in the treatment of asthma can be classified into two groups:

Background treatment

Medications are used whose objective is to ensure that the disease is controlled through the use of fixed, adjusted and scheduled doses. The drugs that we can find are:

Corticosteroids (inhaled or oral): they are powerful anti-inflammatory drugs and today, in their inhaled presentation, they constitute the basis of the background treatment of asthma. Oral corticosteroids are used in exacerbations of asthma and in patients with severe persistent asthma. The use of parenteral corticosteroids is limited to seizures, always bearing in mind that their action is not immediate.
Cromoglycate sodium and Nedocromil (inhaled route): they are anti-inflammatory of less power than corticosteroids. It may take 4 to 6 weeks for cromolyn to achieve its maximum effect. They can be used in mild persistent asthma in children.
Long-acting beta2-agonists (inhaled route): they are never indicated as rescue medication.
Delayed-release theophyllines (oral route): These are considered medium-strength bronchodilators with a possible anti-inflammatory effect. Their therapeutic margin is very small and they present numerous pharmacological interactions.
Antileukotrienes : this is a new group of drugs for the background treatment of asthma that act as anti-inflammatories by antagonizing leukotriene receptors. They are recommended for use in asthma with aspirin intolerance and exercise-induced bronchospasm.
Immunotherapy: its use is only recommended in very special cases since its administration can lead to serious adverse effects.

Rescue treatment

Medications are used occasionally to control the patient’s symptoms, self-administered or administered by healthcare personnel in cases where the patient consults due to a crisis. The most commonly used drugs are:

Short-acting beta2-agonists (inhalation, parenteral and oral routes ): they are powerful bronchodilators. They are indicated in any type of asthma as rescue therapy, that is, to control symptoms when they appear. They are also the first choice in the treatment of asthmatic attacks, in the prevention of exertional asthma (administration 1-5 minutes before exercise) and in the performance of the bronchodilator test.
Anticholinergics (inhaled ipratropium bromide): bronchodilator with a less potent effect and slower onset of action than short-acting beta2-agonists. It is a second-line rescue drug. It may be indicated in children under two years of age and in people over 65 years of age.

How can I avoid asthma attacks?

To avoid asthma attacks we must try to follow the following steps:

Avoid exposure to allergens in sensitized patients: pollens, house dust mites, animal epithelia, occupational allergens, etc.
Anti-smoking council.
Physical exercise: an attempt should be made to maintain the highest level of physical activity possible, according to the possibilities of each patient.
Avoid drugs that can trigger seizures: mainly aspirin and other NSAIDs, and beta-blockers. As analgesic treatment , paracetamol , dextropropoxyphene, codeine, tramadol and morphic derivatives can be used .