Take my breath away: ASTHMA

Asthma is a serious chronic lung disease causing inflammation of the lungs that is characterized by intermittent or persistent symptoms of shortness of breath, wheezing, chest tightness or cough. These symptoms are worsened in the presence of triggers, which are unique to each person.

If you have asthma, you are not alone: according to the Centers for Disease Control and Prevention, the CDC, there are a total of 39,504,323 people in the United States in 2011 that were ever told they have asthma or 129.1 people with asthma per 1000. This number has been steadily increasing every year. According to more recent statistics (2014), 7.7% of people have been diagnosed with asthma. In the state of Arizona, 9.3% (in 2014) of people have asthma. The lifetime prevalence for adults in Arizona in 2011 is 14.1%.

An important consideration in caring for yourself if you have a diagnosis of asthma is that deaths from asthma, although trending lower, are still over 3,000 per year. In 2009, 3,388 people died from asthma. Of them, 1,220 were male; 2,168 were female. Six of these people were less than 1 year old; 37 were 1-4 years old; 114 were 5-14 years old; 164 were 15-24; 215 were 25-34 years old; 295 were 35-44 years old; 399 were 65-74 years old; 520 were 75-84 years old; and 617 were over 5 years of age. In 2014, after trending down between 2001-2009, the number of deaths from asthma increased to 3,651 or 10.6 deaths per one million people in the population. 87 of these deaths were in Arizona, which made it responsible for claiming 11.7 lives per million people in the population. When one considers that we live in a developed country, these statistics are sobering.

Of patients with asthma, in 2014, 10,726,000 or 44.7% have had one or more asthma attacks in the last year, and there was a 48% rate in children and 43.6% rate in adults. There were 439,435 total hospitalizations with asthma in 2010, 136,669 for children and 302,766 for adults and an additional 1.8 million emergency department visits (2011), and 10.5 million doctor visits (2012).

As you can imagine, the cost of asthma is enormous: From 2002-2007, the total estimated cost of asthma in the United States was $56 billion, $50.1 billion from cost of direct health care and $5.9 billion from indirect costs such as lost productivity at work.

There are three hallmarks of an asthmatic lung: inflammation, mucous production, and bronchoconstriction.  Inflammation is redness, swelling, and irritation of the airway. These changes can be temporary or permanent and result in scarring, making it difficult for the airway to behave normally by exchanging oxygen and moving air properly. Bronchoconstriction is caused by tightening of the muscles that encircle the bronchial tubes that make up the asthmatic airway. Mucous is also produced by glands into the airway. The decreased caliber of the airway from bronchoconstriction, the presence of mucous and inflammatory cells makes it difficult to take a breath. Mucous can cause coughing and may plug the airway, making breathing even more difficult.

Asthma is caused by a combination of environmental, genetic and lifestyle factors. Exposure to childhood respiratory illnesses and allergens may increase the risk of asthma. Obesity and sedentary lifestyle increase the risk and severity of asthma. On the other hand, exposure to many different animals may decrease the risk of asthma. The genetics of asthma are complicated but there have been multiple genes that play into the risk and protection from asthma.

Probably the best estimate for predicting whether young children will have asthma in later life and certainly the most used prediction strategy is the Tucson Children’s Respiratory Study Stringent Index. A stringent index includes frequent wheezing during a child’s first 3 years and one major risk factor (parental history of asthma or eczema) or two of three minor risk factors (high eosinophil white blood count, wheezing without colds, and allergic rhinitis). This portends a 76% rate of active asthma by school-age. A negative stringent index predicts that there is just over 95% chance of never developing asthma between ages 6 and 13. A loose index requires any wheeze at all under the age of 3 years old plus the other risk factors. Of those children with a positive loose index, 59% will go on to develop asthma by school age.

Can asthma be prevented early by measures taken early in life?  We really are not sure. However, some population studies suggest that allergy shots, when given early in life, can prevent progression to asthma (recall that allergic rhinitis is a minor risk factor in developing asthma) (Gradman, J, 2021). Also, use of skin barrier protection techniques (like moisturization) can prevent accumulation of additional allergies in patients with eczema and in so doing, can prevent development of asthma (Khani, 2018; Kaper, 2018; Kim 2018; Myers 2010).

Asthma is diagnosed with a detailed medical history and physical examination and either spirometry or pulmonary function testing that shows a partially reversible airflow obstruction (i.e. difficulty blowing air out of the lungs). Asthma is characterized by some or all the recurrent symptoms of shortness of breath, wheezing, chest tightness, or cough that worsens with certain triggers. Sometimes other tests are required to rule out other conditions or definitively diagnose asthma.

According to the National Heart, Lung and Blood Institute (NHLBI), your asthma may be uncontrolled if you have 2 or more asthma attacks per year requiring systemic steroids; wake up one or more nights per week with symptoms of asthma; and/or have wheezing, chest tightness, cough, or shortness of breath two or more times per week. The frequency of symptoms of asthma such as those mentioned underlie the classification of asthma severity as mild, moderate, and severe with further description of intermittent or persistent. The severity dictates recommended medications and interventions.

After determining severity, asthma is classified as intermittent, mild, moderate, or severe by the Allergist-Immunologist. This is important, as treatment is based on frequency and severity of symptoms and on ability of short-acting bronchodilators to control symptoms.

After classifying asthma, the next step is to identify triggers that cause flares and attempt avoidance.

The typical triggers are foods and/or additives, exercise, lung infections and other infections, stress, allergic inhalants (such as mold spores, pollen, pet dander, dust mite and/or cockroach parts), irritants (such as chemicals, smoke), change in weather and temperature, strong emotion and stress, medications, vocal cord dysfunction, acid reflux and hormonal changes. These triggers should be avoided where possible. If avoidance is not possible, eliminating them as a source of problem (such as allergy immunotherapy, so called “allergy shots”) is ideal. Premedication (for example, increasing medication or using rescue 20 minutes before being exposed to the trigger, such as exercise) can help. These flares, as you can imagine are different throughout the year. For example, some asthmatics can be well controlled without medication or at the lowest level of medication throughout the summer but require maximum medication in the spring when their pollens are outside and again when there is a radical temperature drop in the fall around Halloween.

Other conditions that impact asthma also need to be identified and remediated as a step-in asthma care. These include sinusitis, rhinitis, acid reflux or “GERD”, obesity, obstructive sleep apnea, vocal cord dysfunction, depression, and stress. Here again, attempting to avoid these important issues that may even create or worsen the flare is the best. Treating issues before they occur, by vaccinating against influenza and pneumonia prevent flares from infections.

Assessing airway volume and function is critical for understanding severity in adults and children old enough to perform spirometry or a pulmonary function testing. Essentially large and small airway volumes are estimated and compared to the population with similar age, weight, size, and sometimes ethnicity. A decrease in the large or small airway is known as an obstruction, meaning the patient has difficulty exhaling gas from their lungs. When that can be improved after administration of a bronchodilator, the lung issue is then known as reversible. Asthma is considered a chronic reversible obstructive asthma disease.

Medical Treatment of Asthma

At the beginning of treatment, your physician should evaluate all of the data mentioned above and start treatment. An Asthma Action Plan is important for those patients that understand their asthma enough to be comfortable making decisions based on symptoms on a day-to day basis.

A stepwise approach is taken to treat asthma and use of step-up and step-down treatment is common. Essentially, treatment is started, and improvement is assessed at regular intervals. If control is not adequate at that point, the treatment is increased and if control is adequate after 3-6 months, there may be an attempt of stepping down once other factors that affect asthma are remediated.

Treatment has two important roles:

1. Rescue: Rescue inhalers are meant for quick increase in the size of the airway, in situations in which the patient is struggling to get a breath. The rescue inhaler is usually used as needed for shortness of breath, wheezing, chest tightness, and cough due to asthma. If it does not last long enough to be safe, the treating physician will also add a maintenance medication.
2. Maintenance:  Maintenance can be in the form of a pill, an inhaler, or an injection. It is meant to decrease the inflammatory component of asthma, which in turn increases the caliber of the airway and decreases mucous production over time. It is not rapidly acting like the rescue. It takes time to affect inflammation so the success of these medications is usually decided 1-3 months after initiation, not right away.

If you would like to be tested for asthma or your allergies are out of control or believe you might be a good candidate for asthma medication, allergy treatment, or allergy shots, Dr. Wendt and the staff at Relieve Allergy, Asthma & Hives would love to help.

Relieve Allergy Asthma & Hives is located near Kierland Commons, Scottsdale Quarter, DC Ranch and Grayhawk at 21803 N. Scottsdale Road Ste. 200, on the corners of Deer Valley and Scottsdale Roads, and has convenient evening and early morning hours to accommodate your schedule.

Dr. Wendt is also available for telemedicine appointments as appropriate. Insurance plans accepted. Call 480-500-1902 today to schedule an appointment now and begin your allergy testing and treatment with Dr. Wendt at Relieve Allergy, Asthma & Hives in Scottsdale, Arizona.

Learn more about Dr. Wendt and Relieve Allergy Asthma & Hives at www.relieveallergyaz.com and FOLLOW US on Instagram, Twitter, Facebook and Linked In.

For more information about asthma, I highly recommend the following websites for trustworthy sources of information:

www.cdc.gov

www.aaaai.org

www.acaai.org

References

American Lung Association, Epidemiology and Statistics Unit; Trends in Asthma Morbidity and Mortality; 2012: 1-26.

Barnett, SB, Nurmaambetov, TA. Costs of Asthma in the United States: 2002-2007. JACI 2011; 127 (1): 145-52.

Castro-Rodriguez, JA, Holberg, CJ, Wright, AL, Wright, AL, and Martinex, FD. A Clinical Index to Define Risk of Asthma in Young Children with Recurring Wheezing; Am J Repire Crit Care Med; 2000: 1403-6.004.

Centers for Disease Control and Prevention. National Center for Health Statistics. CDC Online Database: www.cdc.gov.

Centers for Disease Control and Prevention. National Surveillance for Asthma—United States, 1980-2004. Morbidity and Mortality Weekly Report. October 19, 2007; 56 (SS08): 1-14, 18-54.

Department of Health and Human Services; National Institutes of Health; national Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program Expert Panel Report 3; Guidelines for Diagnosis and Management of Asthma; 2007: 1-417.

Department of Health and Human Services; National Institutes of Health; national Heart, Lung, and Blood Institute; Asthma Management Guidelines: Focused Updates 2021. Updated February 04, 2012.

Fedor, EL, Heighton, MCE, Freniere, VL, Ostroff, J, Ostroff, M. The 2019 GINA Guidelines for Asthma Treatment in Adults. US Pharm 2020; 45 (7/8): 18-24.

GINA Report, Global Strategy for Asthma Management and Prevention; Global Initiative for Asthma. 2021.

Gradman, J, Halken, S. Preventive Effect of Allergen Immunotherapy on Asthma and New Sensitizations. J Allergy Clin Immunol Pract 2021 May; 9 (5): 1813-1817. Doi: 10.1016/j.jaip.2021.03.010.

Kapur S, Watson W, Carr S. Atopic dermatitis. Allergy Asthma Clin Immunol. 2018;14(Suppl 2):52.

Khan SJ, Dharmage SC, Matheson MC, Gurrin LC. Is the atopic march related to confounding by genetics and early-life environment? A systematic review of sibship and twin data. Allergy. 2018;73(1):17–28.

Kim, BE, Leung, DYM. Significance of Skin Barrier Dysfunction in Atopic Dermatitis. Allergy Asthma Immunol Res. 2018. May; 10 (3): 207-215.

McGregor, M, Krings, J, Nair, P, Castro, M. Role of Biologics in Asthma. Am J Crit Care Med. February 15, 2013. DOI: 10.1164/rccm.20180-1944Cl. Accessed 12022021.

McGregor, M, Krings, J, Nair, P, Castro, M. Role of Biologics in Asthma. Am J Crit Care Med. February 15, 2013. DOI: 10.1164/rccm.20180-1944Cl. Accessed 12022021.

McGregor, M, Krings, J, Nair, P, Castro, M. Role of Biologics in Asthma. Am J Crit Care Med. February 15, 2013. DOI: 10.1164/rccm.20180-1944Cl. Accessed 12022021.

Myers, JMG, Hershey, GKK. Eczema in early life: Genetics, the skin barrier, and lessons learned from birth cohort studies. J Pediatr. 2010 November; 157 (5): 704-714.

National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda, Md.: National Heart, Lung, and Blood Institute; Revised August 2007:305. NIH publication no. 07-4051. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.

Schatz, M. Sorkness, CA, Li, JT, Marcus, P, Murray, JJ, Nathan, RA, Kosinski, M, Pendergraft, TB, and Jhingran, P. Asthma Control Test: Reliability, Validity, and responsiveness in patients not previously followed by asthma specialists. JACI 2006; 117 (3): 549-56.