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Asthma Essay With Conclusions

Info: 2061 words (8 pages) Nursing Essay Published: 11th Feb 2020

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• Asthma is a major noncommunicable disease (NCD), affecting both children and adults, and is the most common chronic disease among children.
• Inflammation and narrowing of the small airways in the lungs cause asthma symptoms, which can be any combination of cough, wheeze, shortness of breath and chest tightness.
• Asthma affected an estimated 262 million people in 2019 (1) and caused 455 000 deaths.
• Inhaled medication can control asthma symptoms and allow people with asthma to lead a normal, active life.
• Avoiding asthma triggers can also help to reduce asthma symptoms.
• Most asthma-related deaths occur in low- and lower-middle-income countries, where under-diagnosis and under-treatment is a challenge.
• WHO is committed to improving the diagnosis, treatment and monitoring of asthma to reduce the global burden of NCDs and make progress towards universal health coverage.

Asthma is a chronic lung disease affecting people of all ages. It is caused by inflammation and muscle tightening around the airways, which makes it harder to breathe.

Symptoms can include coughing, wheezing, shortness of breath and chest tightness. These symptoms can be mild or severe and can come and go over time.

Although asthma can be a serious condition, it can be managed with the right treatment. People with symptoms of asthma should speak to a health professional.

Asthma is often under-diagnosed and under-treated, particularly in low- and middle-income countries.

People with under-treated asthma can suffer sleep disturbance, tiredness during the day, and poor concentration. Asthma sufferers and their families may miss school and work, with financial impact on the family and wider community. If symptoms are severe, people with asthma may need to receive emergency health care and they may be admitted to hospital for treatment and monitoring. In the most severe cases, asthma can lead to death.

Symptoms of asthma can vary from person to person. Symptoms sometimes get significantly worse. This is known as an asthma attack. Symptoms are often worse at night or during exercise.

Common symptoms of asthma include:

• a persistent cough, especially at night
• wheezing when exhaling and sometimes when inhaling
• shortness of breath or difficulty breathing, sometimes even when resting
• chest tightness, making it difficult to breathe deeply.

Some people will have worse symptoms when they have a cold or during changes in the weather. Other triggers can include dust, smoke, fumes, grass and tree pollen, animal fur and feathers, strong soaps and perfume.

Symptoms can be caused by other conditions as well. People with symptoms should talk to a healthcare provider.

Many factors have been linked to an increased risk of developing asthma, although it is often difficult to find a single, direct cause.

• Asthma is more likely if other family members also have asthma – particularly a close relative, such as a parent or sibling.
• Asthma is more likely in people who have other allergic conditions, such as eczema and rhinitis (hay fever).
• Urbanization is associated with increased asthma prevalence, probably due to multiple lifestyle factors.
• Events in early life affect the developing lungs and can increase the risk of asthma. These include low birth weight, prematurity, exposure to tobacco smoke and other sources of air pollution, as well as viral respiratory infections.
• Exposure to a range of environmental allergens and irritants are also thought to increase the risk of asthma, including indoor and outdoor air pollution, house dust mites, moulds, and occupational exposure to chemicals, fumes or dust.
• Children and adults who are overweight or obese are at a greater risk of asthma.

Asthma cannot be cured but there are several treatments available. The most common treatment is to use an inhaler, which delivers medication directly to the lungs.

Inhalers can help control the disease and enable people with asthma to enjoy a normal, active life.

There are two main types of inhaler:

• bronchodilators (such as salbutamol), that open the air passages and relieve symptoms; and
• steroids (such as beclometasone) that reduce inflammation in the air passages, which improves asthma symptoms and reduces the risk of severe asthma attacks and death.

People with asthma may need to use their inhaler every day. Their treatment will depend on the frequency of symptoms and the types of inhalers available.

Using an inhaler can be difficult, especially for children and during emergency situations. Using a spacer device makes it easier to use an aerosol inhaler. This helps the medicine to reach the lungs more easily. A spacer is a plastic container with a mouthpiece or mask at one end and a hole for the inhaler in the other. A homemade spacer, made from a 500ml plastic bottle, can be as effective as commercially manufactured spacers. 

Access to inhalers is a problem in many countries. In 2021, bronchodilators were available in public primary health care facilities in half of low- and low-middle income countries, and steroid inhalers available in one third.  

It is also important to raise community awareness to reduce the myths and stigma associated with asthma in some settings.

People with asthma and their families need education to understand more about their asthma. This includes their treatment options, triggers to avoid, and how to manage their symptoms at home.

It is important for people with asthma to know how to increase their treatment when their symptoms are worsening to avoid a serious attack. Healthcare providers may give an asthma action plan to help people with asthma to take greater control of their treatment. 

WHO response

Asthma is included in the WHO Global Action Plan for the Prevention and Control of NCDs and the United Nations 2030 Agenda for Sustainable Development.

WHO is taking action to extend diagnosis of and treatment for asthma in a number of ways.

The WHO Package of Essential Noncommunicable Disease Interventions (PEN) was developed to help improve NCD management in primary health care in low-resource settings. PEN includes protocols for the assessment, diagnosis and management of chronic respiratory diseases (asthma and chronic obstructive pulmonary disease), and modules on healthy lifestyle counselling, including tobacco cessation and self-care.

Reducing tobacco smoke exposure is important for both primary prevention of asthma and disease management. The Framework Convention on Tobacco Control is enabling progress in this area as are WHO initiatives such as MPOWER and mTobacco Cessation.

Air pollution is an important risk factor for asthma, causing new cases and making existing disease worse. WHO has developed training for health care workers on air pollution which highlights this link and offers practical advice to reduce and mitigate exposure.  

1. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019 . Lancet. 2020;396(10258):1204-22

Global health estimates 2019

NCD country capacity survey

Global action plan for the prevention and control of noncommunicable diseases 2013–2020

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Be Healthy, Be Mobile: A handbook on how to implement mTobaccoCessation

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Asthma What Is Asthma?

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Asthma is a chronic (long-term) condition that affects the airways in the lungs. The airways are tubes that carry air in and out of your lungs. If you have asthma, your airways can become inflamed and narrowed at times. This makes it harder for air to flow out of your airways when you breathe out. About 1 in 13 people in the United States have asthma, according to the Centers for Disease Control and Prevention . It affects people of all ages and often starts during childhood. Certain things, such as pollen, exercise, viral infections, or cold air, can set off or worsen asthma symptoms . These are called asthma triggers . When symptoms get worse, you can experience an asthma attack .

There   is   no   cure   for   asthma,   but   treatment and an asthma action plan   can   help   you   manage   the condition. The plan may include monitoring, avoiding triggers, and using medicines.

What is Asthma?

Learn basic facts about what asthma is and how it affects your airways.

You can find asthma guides, tip sheets, and other resources through the NHLBI’s  Learn More   Breathe Better ® Asthma program.

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Stanford University School of Medicine blog

Breathing: A reflection on living with asthma

We played cards sometimes, my mother and I, during my childhood asthma attacks in the middle of the night. I would creep past the bathroom door and to my parents' bedroom door. Mom , I would whisper. Mom .

That's all I needed to say. She came to the living room, where I waited for her, and stayed up the rest of the night to watch me breathe.

Watching me breathe meant making decisions about whether to call the doctor in the middle of the night or take me into his office in the morning.

Sometimes I put my hands on my head, fingers clasped together because latching them and pressing down on my head created more energy to suck in the next breath. As I grew older, I avoided placing my hands on my head, afraid to tip my mother off about how bad the attack was.

For a long and harrowing attack, she woke my father to drive me out into the night air, which we thought helped with the breathing. We meandered through the neighborhoods bordering the hospitals, looping repeatedly down certain streets, our leisurely pace a sham, because really, he remained close to those hospital entrances in case my breathing worsened, propelling us both into the light and warmth of the busy Emergency Departments.

Sometimes watching me meant making honey, lemon and whiskey toddies, or, if we had no whiskey, just honey and lemon, so the hot liquid could break up the phlegm in my chest. But often, as I sipped on my honey and lemon, my mother rubbed my back and shoulders, which were always hunched down with the effort of breathing. Or pounded between my shoulder blades, another strategy to break up the phlegm.

If the breathing became easier, either on its own or because I'd had some of the medicine stockpiled in our cupboard, and the rattling and wheezing diminished, my mother would pull out the cards. She still needed to watch my progress; neither one of us could rest yet. We would play two-handed Euchre. Or double solitaire.

I don't know how my mother's level of anxiety fluctuated when she watched me breathe through the night, but she never smoked in the house during my asthma attacks. For intense attacks, after waking my father, she might take a break from watching me and go into the backyard with a cigarette to look at the sky. She never fretted in front of me. She remained calm and positive.

During my senior year of high school, after a stressful week of classes, a swine flu shot, and a complicated AP chemistry experiment, I suffered an asthma attack, the worst I'd had in years. My pediatrician instructed the hospital to admit me straight to a floor. Some bureaucratic glitch delayed the delivery of one of those injections I needed to open my airways and help me breathe. My mother, summoned from work, told me to keep going, just a bit longer. Later, I told her, "I think you kept me alive." She told me that she'd never been so worried. She'd thought for sure I was dying.

Years later, when she died, her own breathing remained silent until near the end. Small puffs of sound emerged from her lips, like the snore puffs she'd made on those nights I'd returned from college for a visit and lay awake with the hums and creaks of my childhood home. In the hospital, as she lay dying, her brain stem already dead, I couldn't encourage her as she exhaled her last puffs. I just listened.

"Living is about the breathing," I might have said to my mother on one of those nights I clambered through an attack. We both knew that. But sometimes it helped to hear things aloud.

This piece, originally in  longer form , is part of an ongoing collaboration with Months to Years, a nonprofit quarterly publication that showcases nonfiction, poetry and art exploring mortality and terminal illness.

Dawn Newton, a writer in East Lansing, Michigan, was diagnosed with stage IV lung cancer in November 2012 and has lived with asthma all her life. Her memoir, Winded: A Memoir in Four Stages, will be published in October by Apprentice House Press at Loyola University Maryland. Her blog is at www.dawnmarienewton.com .

Photo by Alfonso Cerezo  

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• Learn About Asthma

What Is Asthma?

• Asthma is chronic. In other words, you live with it every day.
• It can be serious, even life-threatening.
• There is no cure for asthma, but it can be managed so you live a normal, healthy life.

Asthma is a chronic lung disease causing changes in the airways of the lungs. Watch this 2-minute animated video to learn more about these changes and triggers that may cause symptoms leading to an asthma episode

Speaker 1 (00:02): Asthma is a chronic lung disease that can cause breathing problems throughout someone's lifetime. When you have asthma, there is always a little swelling or inflammation inside the airways, with or without symptoms. Your lungs react to things that may not bother other people. These are known as triggers. Asthma can cause changes within the airway, all of which narrow the opening, making it difficult to breathe. A healthy airway is clear with no interior swelling, and the muscle bands around the airways are not tight. There is no extra mucus. Air moves freely through the open airway. When you have asthma, three main changes can happen in your lungs. If your asthma is left untreated or poorly controlled, changes to the structure of the airway may be permanent. One is swelling or inflammation. This is when the airway becomes swollen and irritated. When the airway becomes inflamed, it narrows and it is hard for air to flow through. Another change that can occur with asthma is extra mucus production, which clogs the airway, making the opening even smaller. The third change that can happen with asthma is the tightening of the muscles that surround your airways, called bronchoconstriction. This reduces the opening even more. When someone with asthma comes in contact with an asthma trigger such as dust, tobacco smoke, or even when laughing, any one or all three of the airway changes can happen. This is known as an asthma attack, or episode. All of these changes contribute to the narrowing of the airways, making it hard to breathe. Learn more at lung.org/asthma.

Watch in Spanish

How Asthma Affects Your Body

With asthma, there is always a little bit of swelling inside the airways of your lungs. This makes the airways extra sensitive when exposed to viruses, allergens, irritants or even emotions. Learn more about how the air we breathe plays a role in our health .

Asthma Flare-Ups

During an asthma flare-up, the insides of your airways swell even more and can produce extra mucus. This narrows the space for the air to move in and out of the lungs. The muscles that wrap around your airways also can tighten, making breathing even harder. When that happens, it is called an asthma flare-up, asthma episode or asthma "attack."

After an asthma flare-up, you probably will feel tired. You're also at greater risk of having another flare-up for several days after an episode. For the days following a flare-up, be sure to:

• Avoid your asthma triggers
• Monitor your symptoms or check you airways using a peak flow meter

Airway Remodeling

Poor asthma management can lead to airway remodeling. Airway remodeling is a serious condition that happens when asthma is untreated or poorly managed. The lungs become scarred, asthma medicines do not work as well and less air is able to move through your airways. Airway remodeling does not have to happen. Work with a healthcare professional to minimize asthma flare-ups and find a treatment plan that works for you. Take control of your asthma .

Asthma can start at any age. Sometimes, people have asthma when they are very young and as their lungs develop, the symptoms go away, but it is possible that it will come back later in life. Sometimes people get asthma for the first time when they are older.

Learn The Basics

If you are a person living with asthma, a friend, family member or co-worker of someone with asthma, or a frontline healthcare professional, take some time to learn more about asthma by participating in our online learning module, Asthma Basics. Also available in Spanish.

Reviewed and approved by the American Lung Association Scientific and Medical Editorial Review Panel.

Page last updated: April 19, 2023

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Asthma is a type of chronic inflammatory disorder; more specifically, it's a disorder of the airways where there's increased responsiveness to stimuli, such as cellular components, allergens, and irritants. In those with this chronic condition, inflammation can cause wheezing, chest tightness, shortness of breath, and coughing. These specific episodes occur due to the airflow obstruction seen in the constriction of muscles. In most cases, narrowing of the airways is reversible. However, irreversible airflow obstruction can occur in those with chronic […]

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• Published: 16 October 2014

A woman with asthma: a whole systems approach to supporting self-management

• Hilary Pinnock 1 ,
• Elisabeth Ehrlich 1 ,
• Gaylor Hoskins 2 &
• Ron Tomlins 3  

npj Primary Care Respiratory Medicine volume  24 , Article number:  14063 ( 2014 ) Cite this article

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A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and international and national guidelines emphasise the importance of providing a written asthma action plan. Effective implementation of this recommendation for the lady in this case study is considered from the perspective of a patient, healthcare professional, and the organisation. The patient emphasises the importance of developing a partnership based on honesty and trust, the need for adherence to monitoring and regular treatment, and involvement of family support. The professional considers the provision of asthma self-management in the context of a structured review, with a focus on a self-management discussion which elicits the patient’s goals and preferences. The organisation has a crucial role in promoting, enabling and providing resources to support professionals to provide self-management. The patient’s asthma control was assessed and management optimised in two structured reviews. Her goal was to avoid disruption to her work and her personalised action plan focused on achieving that goal.

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A 35-year-old sales representative attends the practice for an asthma review. Her medical record notes that she has had asthma since childhood, and although for many months of the year her asthma is well controlled (when she often reduces or stops her inhaled steroids), she experiences one or two exacerbations a year requiring oral steroids. These are usually triggered by a viral upper respiratory infection, though last summer when the pollen count was particularly high she became tight chested and wheezy for a couple of weeks.

Her regular prescription is for fluticasone 100 mcg twice a day, and salbutamol as required. She has a young family and a busy lifestyle so does not often manage to find time to attend the asthma clinic. A few weeks previously, an asthma attack had interfered with some important work-related travel, and she has attended the clinic on this occasion to ask about how this can be managed better in the future. There is no record of her having been given an asthma action plan.

What do we know about asthma self-management? The academic perspective

Supported self-management reduces asthma morbidity.

The lady in this case study is struggling to maintain control of her asthma within the context of her busy professional and domestic life. The recent unfortunate experience which triggered this consultation offers a rare opportunity to engage with her and discuss how she can manage her asthma better. It behoves the clinician whom she is seeing (regardless of whether this is in a dedicated asthma clinic or an appointment in a routine general practice surgery) to grasp the opportunity and discuss self-management and provide her with a (written) personalised asthma action plan (PAAP).

The healthcare professional advising the lady is likely to be aware that international and national guidelines emphasise the importance of supporting self-management. 1 – 4 There is an extensive evidence base for asthma self-management: a recent synthesis identified 22 systematic reviews summarising data from 260 randomised controlled trials encompassing a broad range of demographic, clinical and healthcare contexts, which concluded that asthma self-management reduces emergency use of healthcare resources, including emergency department visits, hospital admissions and unscheduled consultations and improves markers of asthma control, including reduced symptoms and days off work, and improves quality of life. 1 , 2 , 5 – 12 Health economic analysis suggests that it is not only clinically effective, but also a cost-effective intervention. 13

Personalised asthma action plans

Key features of effective self-management approaches are:

Self-management education should be reinforced by provision of a (written) PAAP which reminds patients of their regular treatment, how to monitor and recognise that control is deteriorating and the action they should take. 14 – 16 As an adult, our patient can choose whether she wishes to monitor her control with symptoms or by recording peak flows (or a combination of both). 6 , 8 , 9 , 14 Symptom-based monitoring is generally better in children. 15 , 16

Plans should have between two and three action points including emergency doses of reliever medication; increasing low dose (or recommencing) inhaled steroids; or starting a course of oral steroids according to severity of the exacerbation. 14

Personalisation of the action plan is crucial. Focussing specifically on what actions she could take to prevent a repetition of the recent attack is likely to engage her interest. Not all patients will wish to start oral steroids without advice from a healthcare professional, though with her busy lifestyle and travel our patient is likely to be keen to have an emergency supply of prednisolone. Mobile technology has the potential to support self-management, 17 , 18 though a recent systematic review concluded that none of the currently available smart phone ‘apps’ were fit for purpose. 19

Identification and avoidance of her triggers is important. As pollen seems to be a trigger, management of allergic rhinitis needs to be discussed (and included in her action plan): she may benefit from regular use of a nasal steroid spray during the season. 20

Self-management as recommended by guidelines, 1 , 2 focuses narrowly on adherence to medication/monitoring and the early recognition/remediation of exacerbations, summarised in (written) PAAPs. Patients, however, may want to discuss how to reduce the impact of asthma on their life more generally, 21 including non-pharmacological approaches.

Supported self-management

The impact is greater if self-management education is delivered within a comprehensive programme of accessible, proactive asthma care, 22 and needs to be supported by ongoing regular review. 6 With her busy lifestyle, our patient may be reluctant to attend follow-up appointments, and once her asthma is controlled it may be possible to make convenient arrangements for professional review perhaps by telephone, 23 , 24 or e-mail. Flexible access to professional advice (e.g., utilising diverse modes of consultation) is an important component of supporting self-management. 25

The challenge of implementation

Implementation of self-management, however, remains poor in routine clinical practice. A recent Asthma UK web-survey estimated that only 24% of people with asthma in the UK currently have a PAAP, 26 with similar figures from Sweden 27 and Australia. 28 The general practitioner may feel that they do not have time to discuss self-management in a routine surgery appointment, or may not have a supply of paper-based PAAPs readily available. 29 However, as our patient rarely finds time to attend the practice, inviting her to make an appointment for a future clinic is likely to be unsuccessful and the opportunity to provide the help she needs will be missed.

The solution will need a whole systems approach

A systematic meta-review of implementing supported self-management in long-term conditions (including asthma) concluded that effective implementation was multifaceted and multidisciplinary; engaging patients, training and motivating professionals within the context of an organisation which actively supported self-management. 5 This whole systems approach considers that although patient education, professional training and organisational support are all essential components of successful support, they are rarely effective in isolation. 30 A systematic review of interventions that promote provision/use of PAAPs highlighted the importance of organisational systems (e.g., sending blank PAAPs with recall reminders). 31 A patient offers her perspective ( Box 1 ), a healthcare professional considers the clinical challenge, and the challenges are discussed from an organisational perspective.

Box 1: What self-management help should this lady expect from her general practitioner or asthma nurse? The patient’s perspective

The first priority is that the patient is reassured that her condition can be managed successfully both in the short and the long term. A good working relationship with the health professional is essential to achieve this outcome. Developing trust between patient and healthcare professional is more likely to lead to the patient following the PAAP on a long-term basis.

A review of all medication and possible alternative treatments should be discussed. The patient needs to understand why any changes are being made and when she can expect to see improvements in her condition. Be honest, as sometimes it will be necessary to adjust dosages before benefits are experienced. Be positive. ‘There are a number of things we can do to try to reduce the impact of asthma on your daily life’. ‘Preventer treatment can protect against the effect of pollen in the hay fever season’. If possible, the same healthcare professional should see the patient at all follow-up appointments as this builds trust and a feeling of working together to achieve the aim of better self-management.

Is the healthcare professional sure that the patient knows how to take her medication and that it is taken at the same time each day? The patient needs to understand the benefit of such a routine. Medication taken regularly at the same time each day is part of any self-management regime. If the patient is unused to taking medication at the same time each day then keeping a record on paper or with an electronic device could help. Possibly the patient could be encouraged to set up a system of reminders by text or smartphone.

Some people find having a peak flow meter useful. Knowing one's usual reading means that any fall can act as an early warning to put the PAAP into action. Patients need to be proactive here and take responsibility.

Ongoing support is essential for this patient to ensure that she takes her medication appropriately. Someone needs to be available to answer questions and provide encouragement. This could be a doctor or a nurse or a pharmacist. Again, this is an example of the partnership needed to achieve good asthma control.

It would also be useful at a future appointment to discuss the patient’s lifestyle and work with her to reduce her stress. Feeling better would allow her to take simple steps such as taking exercise. It would also be helpful if all members of her family understood how to help her. Even young children can do this.

From personal experience some people know how beneficial it is to feel they are in a partnership with their local practice and pharmacy. Being proactive produces dividends in asthma control.

What are the clinical challenges for the healthcare professional in providing self-management support?

Due to the variable nature of asthma, a long-standing history may mean that the frequency and severity of symptoms, as well as what triggers them, may have changed over time. 32 Exacerbations requiring oral steroids, interrupting periods of ‘stability’, indicate the need for re-assessment of the patient’s clinical as well as educational needs. The patient’s perception of stability may be at odds with the clinical definition 1 , 33 —a check on the number of short-acting bronchodilator inhalers the patient has used over a specific period of time is a good indication of control. 34 Assessment of asthma control should be carried out using objective tools such as the Asthma Control Test or the Royal College of Physicians three questions. 35 , 36 However, it is important to remember that these assessment tools are not an end in themselves but should be a springboard for further discussion on the nature and pattern of symptoms. Balancing work with family can often make it difficult to find the time to attend a review of asthma particularly when the patient feels well. The practice should consider utilising other means of communication to maintain contact with patients, encouraging them to come in when a problem is highlighted. 37 , 38 Asthma guidelines advocate a structured approach to ensure the patient is reviewed regularly and recommend a detailed assessment to enable development of an appropriate patient-centred (self)management strategy. 1 – 4

Although self-management plans have been shown to be successful for reducing the impact of asthma, 21 , 39 the complexity of managing such a fluctuating disease on a day-to-day basis is challenging. During an asthma review, there is an opportunity to work with the patient to try to identify what triggers their symptoms and any actions that may help improve or maintain control. 38 An integral part of personalised self-management education is the written PAAP, which gives the patient the knowledge to respond to the changes in symptoms and ensures they maintain control of their asthma within predetermined parameters. 9 , 40 The PAAP should include details on how to monitor asthma, recognise symptoms, how to alter medication and what to do if the symptoms do not improve. The plan should include details on the treatment to be taken when asthma is well controlled, and how to adjust it when the symptoms are mild, moderate or severe. These action plans need to be developed between the doctor, nurse or asthma educator and the patient during the review and should be frequently reviewed and updated in partnership (see Box 1). Patient preference as well as clinical features such as whether she under- or over-perceives her symptoms should be taken into account when deciding whether the action plan is peak flow or symptom-driven. Our patient has a lot to gain from having an action plan. She has poorly controlled asthma and her lifestyle means that she will probably see different doctors (depending who is available) when she needs help. Being empowered to self-manage could make a big difference to her asthma control and the impact it has on her life.

The practice should have protocols in place, underpinned by specific training to support asthma self-management. As well as ensuring that healthcare professionals have appropriate skills, this should include training for reception staff so that they know what action to take if a patient telephones to say they are having an asthma attack.

However, focusing solely on symptom management strategies (actions) to follow in the presence of deteriorating symptoms fails to incorporate the patients’ wider views of asthma, its management within the context of her/his life, and their personal asthma management strategies. 41 This may result in a failure to use plans to maximise their health potential. 21 , 42 A self-management strategy leading to improved outcomes requires a high level of patient self-efficacy, 43 a meaningful partnership between the patient and the supporting health professional, 42 , 44 and a focused self-management discussion. 14

Central to both the effectiveness and personalisation of action plans, 43 , 45 in particular the likelihood that the plan will lead to changes in patients’ day-to-day self-management behaviours, 45 is the identification of goals. Goals are more likely to be achieved when they are specific, important to patients, collaboratively set and there is a belief that these can be achieved. Success depends on motivation 44 , 46 to engage in a specific behaviour to achieve a valued outcome (goal) and the ability to translate the behavioural intention into action. 47 Action and coping planning increases the likelihood that patient behaviour will actually change. 44 , 46 , 47 Our patient has a goal: she wants to avoid having her work disrupted by her asthma. Her personalised action plan needs to explicitly focus on achieving that goal.

As providers of self-management support, health professionals must work with patients to identify goals (valued outcomes) that are important to patients, that may be achievable and with which they can engage. The identification of specific, personalised goals and associated feasible behaviours is a prerequisite for the creation of asthma self-management plans. Divergent perceptions of asthma and how to manage it, and a mismatch between what patients want/need from these plans and what is provided by professionals are barriers to success. 41 , 42

What are the challenges for the healthcare organisation in providing self-management support?

A number of studies have demonstrated the challenges for primary care physicians in providing ongoing support for people with asthma. 31 , 48 , 49 In some countries, nurses and other allied health professionals have been trained as asthma educators and monitor people with stable asthma. These resources are not always available. In addition, some primary care services are delivered in constrained systems where only a few minutes are available to the practitioner in a consultation, or where only a limited range of asthma medicines are available or affordable. 50

There is recognition that the delivery of quality care depends on the competence of the doctor (and supporting health professionals), the relationship between the care providers and care recipients, and the quality of the environment in which care is delivered. 51 This includes societal expectations, health literacy and financial drivers.

In 2001, the Australian Government adopted a programme developed by the General Practitioner Asthma Group of the National Asthma Council Australia that provided a structured approach to the implementation of asthma management guidelines in a primary care setting. 52 Patients with moderate-to-severe asthma were eligible to participate. The 3+ visit plan required confirmation of asthma diagnosis, spirometry if appropriate, assessment of trigger factors, consideration of medication and patient self-management education including provision of a written PAAP. These elements, including regular medical review, were delivered over three visits. Evaluation demonstrated that the programme was beneficial but that it was difficult to complete the third visit in the programme. 53 – 55 Accordingly, the programme, renamed the Asthma Cycle of Care, was modified to incorporate two visits. 56 Financial incentives are provided to practices for each patient who receives this service each year.

Concurrently, other programmes were implemented which support practice-based care. Since 2002, the National Asthma Council has provided best-practice asthma and respiratory management education to health professionals, 57 and this programme will be continuing to 2017. The general practitioner and allied health professional trainers travel the country to provide asthma and COPD updates to groups of doctors, nurses and community pharmacists. A number of online modules are also provided. The PACE (Physician Asthma Care Education) programme developed by Noreen Clark has also been adapted to the Australian healthcare system. 58 In addition, a pharmacy-based intervention has been trialled and implemented. 59

To support these programmes, the National Asthma Council ( www.nationalasthma.org.au ) has developed resources for use in practices. A strong emphasis has been on the availability of a range of PAAPs (including plans for using adjustable maintenance dosing with ICS/LABA combination inhalers), plans for indigenous Australians, paediatric plans and plans translated into nine languages. PAAPs embedded in practice computer systems are readily available in consultations, and there are easily accessible online paediatric PAAPs ( http://digitalmedia.sahealth.sa.gov.au/public/asthma/ ). A software package, developed in the UK, can be downloaded and used to generate a pictorial PAAP within the consultation. 60

One of the strongest drivers towards the provision of written asthma action plans in Australia has been the Asthma Friendly Schools programme. 61 , 62 Established with Australian Government funding and the co-operation of Education Departments of each state, the Asthma Friendly Schools programme engages schools to address and satisfy a set of criteria that establishes an asthma-friendly environment. As part of accreditation, the school requires that each child with asthma should have a written PAAP prepared by their doctor to assist (trained) staff in managing a child with asthma at school.

The case study continues...

The initial presentation some weeks ago was during an exacerbation of asthma, which may not be the best time to educate a patient. It is, however, a splendid time to build on their motivation to feel better. She agreed to return after her asthma had settled to look more closely at her asthma control, and an appointment was made for a routine review.

At this follow-up consultation, the patient’s diagnosis was reviewed and confirmed and her trigger factors discussed. For this lady, respiratory tract infections are the usual trigger but allergic factors during times of high pollen count may also be relevant. Assessment of her nasal airway suggested that she would benefit from better control of allergic rhinitis. Other factors were discussed, as many patients are unaware that changes in air temperature, exercise and pets can also trigger asthma exacerbations. In addition, use of the Asthma Control Test was useful as an objective assessment of control as well as helping her realise what her life could be like! Many people with long-term asthma live their life within the constraints of their illness, accepting that is all that they can do.

After assessing the level of asthma control, a discussion about management options—trigger avoidance, exercise and medicines—led to the development of a written PAAP. Asthma can affect the whole family, and ways were explored that could help her family understand why it is important that she finds time in the busy domestic schedules to take her regular medication. Family and friends can also help by understanding what triggers her asthma so that they can avoid exposing her to perfumes, pollens or pets that risk triggering her symptoms. Information from the national patient organisation was provided to reinforce the messages.

The patient agreed to return in a couple of weeks, and a recall reminder was set up. At the second consultation, the level of control since the last visit will be explored including repeat spirometry, if appropriate. Further education about the pathophysiology of asthma and how to recognise early warning signs of loss of control can be given. Device use will be reassessed and the PAAP reviewed. Our patient’s goal is to avoid disruption to her work and her PAAP will focus on achieving that goal. Finally, agreement will be reached with the patient about future routine reviews, which, now that she has a written PAAP, could be scheduled by telephone if all is well, or face-to-face if a change in her clinical condition necessitates a more comprehensive review.

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Hilary Pinnock & Elisabeth Ehrlich

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Pinnock, H., Ehrlich, E., Hoskins, G. et al. A woman with asthma: a whole systems approach to supporting self-management. npj Prim Care Resp Med 24 , 14063 (2014). https://doi.org/10.1038/npjpcrm.2014.63

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• Continuing Education Activity

Asthma is a chronic inflammatory respiratory condition characterized by hallmark symptoms of intermittent dyspnea, cough, and wheezing. However, due to the nonspecific nature of these symptoms, distinguishing asthma from other respiratory illnesses can sometimes be challenging. A confirmed diagnosis of asthma relies on consistent respiratory symptoms and the identification of variable expiratory airflow obstruction documented on spirometry. Clinicians prioritize symptom control and prevention of future exacerbations through tailored treatment, considering symptom frequency, severity, and potential risks in a step-wise approach. Early recognition and intervention of asthma exacerbations are crucial to prevent the progression of asthma to severe, life-threatening stages. Fatalities related to asthma highlight missed opportunities in recognizing disease severity and escalating therapy, emphasizing the critical role of continual patient education and routine symptom control assessment for successful long-term management. 

The development of asthma, often presenting in childhood, involves a complex interplay of genetic and environmental factors associated with atopy. Researchers strive to develop predictive systems for identifying individuals at risk of continued symptoms into adulthood. Despite significant advancements in understanding the underlying genetic loci, environmental triggers, and risk factors, clinical strategies remain lacking to mitigate the risks of persistent asthma development into adolescence and adulthood. This activity covers the epidemiology, pathophysiology, and assessment of asthma, along with initiating pharmacological treatment and developing monitoring strategies tailored for adolescents and adults. These strategies closely align with evidence-based recommendations from the National Asthma Education and Prevention Program and the Global Initiative for Asthma.

• Identify the hallmark symptoms of asthma, including dyspnea, cough, and wheezing.
• Implement evidence-based treatment strategies for asthma management, considering individual patient characteristics and preferences.
• Assess asthma severity, control, and exacerbation risk regularly during follow-up visits.
• Collaborate with interdisciplinary healthcare team members to optimize asthma care and patient outcomes.
• Introduction

Asthma is a prevalent chronic inflammatory respiratory condition affecting millions of people worldwide and presents substantial challenges in both diagnosis and management. This respiratory condition is characterized by inflammation of the airways, causing intermittent airflow obstruction and bronchial hyperresponsiveness. The hallmark asthma symptoms include coughing, wheezing, and shortness of breath, which can be frequently exacerbated by triggers ranging from allergens to viral infections. The prevalence and severity of asthma are determined by a complex interplay between genetic and environmental factors. Despite treatment advancements, disparities persist in asthma care, with variations in access to diagnosis, treatment, and patient education across different demographics.

The development of asthma, often presenting in childhood, is associated with other atopic features, such as eczema and hay fever. [1] [2] [3]  Severity varies from intermittent symptoms to life-threatening airway closure. Healthcare professionals establish a definitive diagnosis through patient history, physical examination, pulmonary function testing, and appropriate laboratory testing. Spirometry with a post-bronchodilator response (BDR) is the primary diagnostic test. Treatment focuses on providing continued education, routine symptom assessment, access to fast-acting bronchodilators, and appropriate controller medications tailored to disease severity.

Asthma manifests with diverse phenotypes, likely influenced by intricate interactions between genetic and environmental factors. [4] [5]  Genomewide association studies have linked childhood-onset asthma to markers near the ORMDL sphingolipid biosynthesis regulator 3 ( ORMDL3 ) and gasdermin B ( GSDMB ) genes on chromosome 17q21, encoding ORM1-like protein 3 and gasdermin-like protein. [6]  Other associations include genes such as interleukin-33 ( IL33 ), IL-1 receptor-like 1 ( IL1R1 ) genes, and a novel susceptibility locus at the IF-inducible protein X ( PYHIN1 ) gene, particularly affecting individuals of African descent. [7]  

The EVE Consortium also identifies a susceptibility locus for thymic stromal lymphopoietin ( TSLP ), an epithelial cell–derived cytokine implicated in asthma-related inflammation initiation. [8]  Asthma patients exhibit higher TSLP expression in their airways compared to healthy controls. Additional genetic loci involved in asthma include major histocompatibility complex class II DQ α1 ( HLA-DQA1 ), HLA-DQB1 antisense RNA 1 ( HLA-DQB1 ), Toll-like receptor 1 ( TLR1 ), IL-6 receptor ( IL6R ), zona pellucida-binding protein 2 ( ZPBP2 ), and gasdermin A ( GSDMA ).

Genetics may also be pivotal in asthma treatment. The hydroxy-δ-5-steroid dehydrogenase, 3-beta- and steroid δ-isomerase 1 ( HSD3B1 ) genotype is associated with glucocorticoid resistance among patients. In addition, single-nucleotide polymorphisms in protein kinase cGMP-dependent 1 ( PRKG1 )   and SPATA13 antisense RNA 1 ( SPATA13-AS1 )   are associated with BDR in Black children. [9]

Differing concordance rates among monozygotic twins suggest that exposure to environmental factors has an essential role in the development of asthma. Specific alleles have different effects depending on the environmental exposures. For example, exposure to secondhand smoke associates variations in the  N -acetyltransferase 1 ( NAT1 ) gene with the development of asthma in children. A study involving 983 children with single-nucleotide polymorphisms related to  ORMDL3  and  GSDMB  at chromosome locus 17q21 reveals that the same genotype poses genetic risk while also offering environmental protection. [10]

Risk Factors

Risk factors for asthma development encompass exposures throughout a patient's lifespan, including the perinatal period. The most substantial known risk factor is atopy, which is characterized by the genetic tendency to produce specific immunoglobulin E (IgE) antibodies in response to common environmental allergens. Nearly one-third of children with atopy will develop asthma later in life. 

Prenatal and Perinatal Factors

Prematurity is the most crucial risk factor influencing asthma incidence during this period. [11] [12] [13] [14]  Preterm birth, occurring before 36 weeks, is associated with an elevated risk of asthma throughout childhood, adolescence, and adulthood. Researchers posit that impaired lung development in preterm infants, even in those without early respiratory complications, increases the long-term risk of asthma. [15] Exposure to maternal smoking during pregnancy causes diminished pulmonary function in newborns and an increased probability of developing childhood asthma. Moreover, smoking during pregnancy correlates with several adverse pregnancy outcomes, including premature delivery, further elevating the asthma risk.

The incidence of childhood asthma increases with a maternal age of 20 or younger and decreases with a maternal age of 30 or older. Maternal diet during pregnancy holds significance, with researchers suggesting that vitamin D deficiency contributes to early-life wheezing and asthma primarily by impacting the immune function of various cell types, notably dendritic and T regulatory cells. Additionally, vitamin D plays a role in fetal lung development. [16] [17]  Although some studies present conflicting findings regarding the association between maternal vitamin D levels and childhood asthma, a meta-analysis of 2 large studies indicates that maternal vitamin D intake offers protection against wheezing or asthma in offspring up to the age of 3. [16]  

The Copenhagen Prospective Studies on Asthma in Childhood (COPSAC2010) reveals that 17% of children born to mothers with diets high in omega-3 polyunsaturated fatty acids developed persistent wheeze or asthma during the first 3 years of life compared to nearly 24% in the group with diets high in omega-6 polyunsaturated fatty acids. Vitamins E and C and zinc may also have protective effects. Administering vitamin C at a dose of 500 mg/d to pregnant mothers appears to offer protection against the harmful effects of tobacco exposure. Offspring of mothers who receive vitamin C supplementation exhibit a wheezing incidence of 28%, while those without vitamin C supplementation have a higher incidence of 47%. [18] [19]

Wheezing caused by viral infections, particularly respiratory syncytial virus and human rhinovirus, may predispose infants and young children to develop asthma later in life. In addition, early-life exposure to air pollution, including combustion by-products from gas-fired appliances and indoor fires, obesity, and early puberty, also increases the risk of asthma. 

The most significant risk factors for adult-onset asthma include tobacco smoke, occupational exposure, and adults with rhinitis or atopy. Studies also suggest a modest increase in asthma incidence among postmenopausal women taking hormone replacement therapy. 

Furthermore, the following factors can contribute to asthma and airway hyperreactivity:

• Exposure to environmental allergens such as house dust mites, animal allergens (especially from cats and dogs), cockroach allergens, and fungi
• Physical activity or exercise
• Conditions such as hyperventilation, gastroesophageal reflux disease, and chronic sinusitis
• Hypersensitivity to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), as well as sulfite sensitivity
• Use of β-adrenergic receptor blockers, including ophthalmic preparations
• Exposure to irritants such as household sprays and paint fumes
• Contact with various high- and low-molecular-weight compounds found in insects, plants, latex, gums, diisocyanates, anhydrides, wood dust, and solder fluxes, which are associated with occupational asthma
• Emotional factors or stress

Aspirin-Exacerbated Respiratory Disease

Aspirin-exacerbated respiratory disease   (AERD) is a condition characterized by a combination of asthma, chronic rhinosinusitis with nasal polyposis, and NSAID intolerance. Patients with AERD present with upper and lower respiratory tract symptoms after ingesting aspirin or NSAIDs that inhibit cyclooxygenase-1 (COX-1). This condition arises from dysregulated arachidonic acid metabolism and the overproduction of leukotrienes involving the 5-lipoxygenase and cyclooxygenase pathways. AERD affects approximately 7% of adults with asthma.

Occupational-Induced Asthma

Two types of occupational asthma exist based on their appearance after a latency period: 

• Occupational asthma triggered by workplace sensitizers results from an allergic or immunological process associated with a latency period induced by both low- and high-molecular-weight agents. High-molecular-weight substances, such as flour, contain proteins and polysaccharides of plant or animal origin. Low-molecular-weight substances, like formaldehyde, form a sensitizing neoantigen when combined with a human protein.
• Occupational asthma caused by irritants involves a   nonallergic or nonimmunological process induced by gases, fumes, smoke, and aerosols.
• Epidemiology

The worldwide incidence of asthma is estimated to affect 260 million individuals. [20] Recent studies examining asthma prevalence across 17 countries reveal varying rates, ranging from 3.4% to 6% for adults and children in India, Taiwan, Kosovo, Nigeria, and Russia, and higher rates of 17% to 33% for Honduras, Costa Rica, Brazil, and New Zealand. [21]  Despite data showing the death rate consistently declining for asthma between 2001 and 2015, asthma continues to account for approximately 420,000 deaths per year. [22]  Factors such as under-prescription of inhaled glucocorticoids and limited access to emergency medical care or specialist care all play a role in asthma-related deaths.

Asthma prevalence in the United States differs among demographic groups, including age, gender, race, and socioeconomic status. The United States Centers for Disease Control and Prevention (CDC) estimates that around 25 million Americans are currently affected by asthma. Among individuals younger than 18, boys exhibit a higher prevalence compared to girls, while among adults, women are more commonly affected than men. Additionally, asthma prevalence is notably higher among Black individuals, with a prevalence of 10.1%, compared to White individuals at 8.1%. Hispanic Americans generally have a lower prevalence of 6.4%, except for those from Puerto Rico, where the prevalence rises to 12.8%. Moreover, underrepresented minorities and individuals living below the poverty line experience the highest incidence of asthma, along with heightened rates of asthma-related morbidity and mortality. 

Similar to worldwide data, the mortality rate of asthma in the United States has also undergone a consistent decline. The current mortality rate is 9.86 per million compared to 15.09 per million in 2001. However, mortality rates remain consistently higher for Black patients compared to their White counterparts. According to the CDC, from 1999 to 2016, asthma death rates among adults aged 55 to 64 were 16.32 per 1 million persons, 9.95 per 1 million for females, 9.39 per 1 million for individuals who were not Hispanic or Latino, and notably higher at 25.60 per 1 million for Black patients.

• Pathophysiology

Asthma is a syndrome characterized by diverse underlying mechanisms and involves intricate interactions among inflammatory and resident airway cells. These mechanisms lead to airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness (see Image.  Pathophysiology of Asthma). 

Airway Inflammation

The activation of mast cells by cytokines and other mediators plays a pivotal role in the development of clinical asthma. Following initial allergen inhalation, affected patients produce specific IgE antibodies due to an overexpression of the T-helper 2 subset (Th2) of lymphocytes relative to the Th1 type. Cytokines produced by Th2 lymphocytes include IL-4, IL-5, and IL-13, which promote IgE and eosinophilic responses in atopy. Once produced, these specific IgE antibodies bind to receptors on mast cells and basophils. Upon additional allergen inhalation, allergen-specific IgE antibodies on the mast cell surface undergo cross-linking, leading to rapid degranulation and the release of histamine, prostaglandin D2 (PGD2), and cysteinyl leukotrienes C4 (LTC4), D4 (LTD4), and E4 (LTE4). [23] [24] This triggers contraction of the airway smooth muscle within minutes and may stimulate reflex neural pathways. Subsequently, an influx of inflammatory cells, including monocytes, dendritic cells, neutrophils, T lymphocytes, eosinophils, and basophils, may lead to delayed bronchoconstriction several hours later. 

Airflow Obstruction

The narrowing of the airway lumen throughout the tracheobronchial tree is caused by the contraction of airway smooth muscle, thickening of the airway wall due to edema, mucus plugging in the airways, and airway remodeling, which collectively contributes to varying levels of airflow obstruction.

Mediators such as histamine and leukotrienes, released from inflammatory cells or through reflex neural pathways, trigger the contraction and relaxation of airway smooth muscle. The precise mechanism leading to airway hyperresponsiveness, characterized by an excessive tightening of the airway's smooth muscles in response to various physical, chemical, or environmental triggers, remains unclear. Some researchers propose alterations in breathing patterns where smooth muscles contract excessively or fail to relax adequately during deep breaths as a potential explanation.

Airway remodeling, which involves thickening of the basement membrane, deposition of collagen, and shedding of epithelial cells, can lead to irreversible changes in the airways. This process accelerates the decline in lung function, particularly in individuals with severe and early-onset asthma. [25]  In addition, remodeling contributes to the heightened bronchial sensitivity observed in asthma.

Arachidonic acid metabolism by the enzyme 5-lipoxygenase (5-LO) leads to the generation of leukotrienes, which serve as potent bronchoconstrictors. The metabolism of arachidonic acid by the 2 cyclooxygenase (COX) isoforms—COX-1 and COX-2—generates prostaglandins and thromboxanes. PGD2 is a potent bronchodilator, while PGE2 suppresses the production of leukotrienes. Patients with AERD have dysregulated arachidonic acid metabolism, causing decreased production of PGE2 and loss of control of leukotriene production. [26]

Patients with occupational-induced asthma can undergo an immunologically mediated response similar to those without occupational-induced asthma. Alternatively, others may present with nonimmunological occupational asthma. The possible underlying mechanisms of the nonimmunological form are denudation of the airway epithelium, direct β-2 adrenergic receptor inhibition, or elaboration of substance P by injured sensory nerves.

• History and Physical

The 4 cardinal symptoms associated with asthma are wheezing, cough (often worse at night), shortness of breath, and chest tightness. Individuals may experience 1 or more of these symptoms. Asthma symptoms typically occur intermittently, lasting for hours to days, and resolve upon the removal of triggers or the administration of asthma medications. Nighttime exacerbation of symptoms or onset triggered by exercise, cold air, or allergen exposure suggests asthma. In contrast to exertional dyspnea, which manifests shortly after beginning exertion and resolves within 5 minutes of cessation, exercise-induced asthma symptoms typically emerge around 15 minutes into activity and dissipate within 30 to 60 minutes afterward. Patients may also have a history of other forms of atopy, such as eczema and hay fever.

During patient history-taking, healthcare professionals should inquire about particular triggers that exacerbate symptoms. Common household triggers include dust, animals, and infestations of rodents and cockroaches. Some individuals may experience intermittent asthma symptoms related to their work shifts. A strong family history of asthma and allergies, or a personal history of atopic conditions and childhood asthma symptoms, suggests asthma in patients exhibiting suggestive symptoms.

Physical Examination

During physical examination, widespread, high-pitched wheezes are a characteristic finding associated with asthma. However, wheezing is not specific to asthma and is typically absent between acute exacerbations. Findings suggestive of a severe asthma exacerbation include tachypnea, tachycardia, a prolonged expiratory phase, reduced air movement, difficulty speaking in complete sentences or phrases, discomfort when lying supine due to breathlessness, and adopting a "tripod position." [27]  The use of the accessory muscles of breathing during inspiration and pulsus paradoxus are additional indicators of a severe asthma attack.

Healthcare professionals may identify extrapulmonary findings that support the diagnosis of asthma, such as pale, boggy nasal mucous membranes, posterior pharyngeal cobblestoning, nasal polyps, and atopic dermatitis. Nasal polyps should prompt further inquiry about anosmia, chronic sinusitis, and aspirin sensitivity to evaluate for AERD. Although AERD is uncommon in children or adolescents, the presence of nasal polyps in a child with lower respiratory disease should prompt an evaluation for cystic fibrosis. Clubbing, characterized by bulbous fusiform enlargement of the distal portion of a digit, is not associated with asthma and should prompt evaluation for alternative diagnoses. Please see StatPearls' companion resource, " Nail Clubbing ," for further information.

Intermittent symptoms consistent with asthma, in addition to wheezing observed during physical examination, strongly indicate asthma. Confirming the diagnosis involves the exclusion of alternative diagnoses and a demonstration of variable airflow limitation, usually seen in spirometry. 

Spirometry assesses forced expiratory volume in 1 second (FEV 1 ) and forced vital capacity (FVC) by measuring a maximal inhalation followed by rapid and forceful exhalation into a spirometer. Asthma typically presents as an obstructive pattern on spirometry, indicated by a reduced FEV 1 to FVC ratio. [28] Additionally, a visual examination of the expiratory flow-volume loop can reveal an obstructive pattern. A scooped, concave appearance in the expiratory portion of the flow-volume loop indicates diffuse intrathoracic airflow obstruction characterizes asthma. In rare cases where complete exhalation is impossible, the FEV 1 /FVC ratio may appear normal, falsely suggesting a restrictive pattern if not assessed along with flow-time curves.

Patients showing airflow limitations on spirometry receive 2 to 4 puffs of a short-acting bronchodilator like albuterol, followed by repeat spirometry in 10 to 15 minutes. According to the European Respiratory Society/American Thoracic Society guidelines, a positive BDR is determined by a change in FEV 1 or FVC compared to their predicted value. Clinicians calculate the patient's BDR using the formula:

BDR=([Post-bronchodilator value – Pre-bronchodilator value] × 100) / Predicted value of either FEV 1 or FVC

Increases exceeding 10% are considered significant. [28]  

According to the Global Initiative for Asthma, a significant BDR is indicated by an increase in the FEV 1  of 12% or 200 mL or more. In addition, the slow vital capacity, or the maximal amount of air exhaled in a relaxed expiration from full inspiration to residual volume over 15 seconds, may also be helpful when the FVC is reduced and airway obstruction is present. During slow exhalation, airway narrowing is less pronounced, and the patient can produce a larger vital capacity. In cases of restrictive disease, both slow and fast exhalations result in reduced vital capacity.

Spirometry results may be normal in asymptomatic individuals or those with cough-variant asthma. Bronchodilator responsiveness is evident in asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, non-cystic fibrosis bronchiectasis, and bronchiolitis. However, patients with asthma may yield false negative results if they are on chronic controller medications, exhibit underlying airway remodeling, have minimal symptoms during testing, or have recently used bronchodilators before the test. Ideally, clinicians should conduct baseline spirometry before commencing treatment. [29] [30]

Bronchoprovocation Testing

During bronchoprovocation testing, clinicians induce bronchoconstriction using inhaled methacholine or mannitol, exercise, or eucapnic hyperventilation of dry air. This testing method can be beneficial for patients presenting with atypical symptoms or an isolated cough. Patients receive incremental doses of the provocative agent followed by spirometry to generate a dose-response curve. A fall in FEV 1  of 20% or more from baseline with the standard dose of methacholine or a decline of 15% or more with the standard dose of hypertonic saline, mannitol, or hyperventilation indicates a positive test. [31]  Clinicians may also conduct additional provocative testing using exercise, aspirin, and exposure to environmental triggers encountered in the workplace.

Peak Flow Meter

Although consistent reductions of 20% during symptomatic periods, followed by a gradual return to baseline as symptoms resolve, indicate asthma, clinicians typically use peak flow measurement to monitor patients with known asthma rather than for initial diagnosis. To measure peak flow, the patient takes a maximal breath and seals the peak flow meter between their lips before blowing forcefully for 1 to 2 seconds. Please see StatPearls' companion resource, " Peak Flow Measurement ," for additional information regarding peak flow measurement and its clinical significance in the evaluation and management of asthma.

Patients repeat this process 3 times, recording the highest reading as the current peak flow measurement. Patients can compare their recorded values to established graphs based on age and height for adults and height for adolescents to determine their predicted value. Notably, reduced peak flow values are not specific to asthma. Patients with either an obstructive or restrictive pattern on spirometry can have decreased peak flow values. Additionally, the accuracy of results is highly contingent on patient effort. 

Exhaled Nitric Oxide

Eosinophilic airway inflammation causes an upregulation of nitric oxide synthase in the respiratory mucosa,  leading to elevated nitric oxide levels in exhaled breath. In certain asthma patients, the fractional exhaled nitric oxide (FE NO ) surpasses levels observed in individuals without asthma. A FE NO of measurement exceeding 40 to 50 ppb can aid in confirming an asthma diagnosis. 

Pulse Oximetry

Pulse oximetry can help assess the severity of an asthma attack or monitor for deterioration. Notably, pulse oximetry measurements may exhibit a lag, and the physiological reserve of many patients implies that a declining oxygen level on pulse oximetry is a late stage, indicating an increasingly unwell or peri-arrest patient.

No specific laboratory tests are necessary for diagnosing asthma. However, patients who present with a severe asthma exacerbation should undergo a complete blood count to evaluate eosinophil levels and check for anemia, which may be the underlying cause of the patient's dyspnea. A significantly elevated eosinophil count should prompt further investigation for conditions, including parasitic infections such as Strongyloides , drug reactions, and syndromes characterized by pulmonary infiltrates with eosinophilia. These syndromes include allergic bronchopulmonary aspergillosis, eosinophilic granulomatosis with polyangiitis, and hypereosinophilic syndrome (see Image.  Allergic Bronchopulmonary Aspergillosis on CT Scan). 

Non-smoking patients who present with irreversible airflow obstruction should undergo serum α1-antitrypsin level testing to rule out emphysema caused by homozygous α1-antitrypsin deficiency. Allergy testing may prove beneficial for patients experiencing symptoms upon exposure to specific allergens. Clinicians should obtain total serum IgE levels in patients with moderate-to-severe persistent asthma, particularly when considering treatment with anti-IgE monoclonal antibodies or when there is suspicion of allergic bronchopulmonary aspergillosis. Please refer to the Treatment/Management  section for further details on anti-IgE monoclonal antibodies.

Chest radiographs in asthma patients are often normal; however, during acute exacerbations, abnormal findings such as hyperinflation, pneumomediastinum, and bronchial thickening may be observed (see Image.  A Chest Radiograph Depicting Asthma). A chest radiograph is recommended for patients aged 40 or older with new-onset, moderate-to-severe asthma to rule out conditions that can mimic asthma, such as a mediastinal mass with tracheal compression or heart failure.

Additional indications for chest radiography include patients experiencing symptoms that are difficult to control, fever, chronic purulent sputum production, persistently localized wheezing, hemoptysis, weight loss, clubbing, inspiratory crackles, significant hypoxemia, and moderate or severe airflow obstruction that does not reverse with bronchodilators. High-resolution computed tomography is necessary to clarify any abnormalities noted on chest radiographs or for patients with other suspected conditions that may not be well visualized on routine radiographs.

Evaluation During an Acute Exacerbation

Each patient should undergo a rapid assessment of their vital signs, including oxygen saturation. Measuring the peak flow can indicate the severity of the exacerbation and monitor the response to therapy. Predicted peak flow measurements vary based on age and height; however, a peak flow below 200 L/min indicates severe obstruction except in patients aged 65 or older or with very short stature. A peak flow measurement below 50% predicted or the patient's personal best is considered severe, while between 50% and 70% is considered moderate. Chest radiographs are not uniformly necessary unless the diagnosis of acute asthma exacerbation is uncertain, the patient requires hospitalization, or evidence of a comorbid condition is present.

Identification of Patients at Risk of Fatal or Near-Fatal Asthma

Most asthma-related deaths are preventable if risk factors are identified and addressed early. Major risk factors that place patients at high risk for future fatal asthma exacerbations include:

• A recent history of poorly controlled asthma
• A prior history of near-fatal asthma
• A history of endotracheal intubation for asthma 
• A history of intensive care unit admission for asthma

Minor risk factors include exposure to aeroallergens and tobacco smoke, illicit drug use, older patients, aspirin sensitivity, long duration of asthma, and frequent hospitalizations for asthma-related issues.

• Treatment / Management

Patient Education

Multiple sources of patient education are available. According to the National Asthma Education and Prevention Program's Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, personalized education from the patient's primary clinician is especially impactful. Studies reveal that such education reduces the number of asthma exacerbations and hospitalizations. Healthcare professionals should provide culturally specific asthma education that includes understanding asthma and its symptoms, identifying the patient's specific triggers, and strategies for their avoidance. Each patient should understand how to properly use an inhaler and be familiar with medications that serve as rescue options, those used for symptom control, and those that may fulfill both roles. Clinicians should inquire about any obstacles hindering medication adherence and work collaboratively with patients to overcome concerns or barriers, thus enhancing overall adherence.

Although the data on effectiveness are limited, a general consensus among experts exists that individuals with asthma should possess a personalized "action plan" to follow at home (please refer to the link to an action plan download in the  Deterrence and Patient Education section). This action plan provides a structured maintenance medication regimen and delineates steps to take when symptoms exacerbate. Clinicians develop an action plan based on symptoms or peak flow readings and divide it into 3 zones—green, yellow, and red. 

Patients in the green zone are asymptomatic, with peak flows at 80% or higher than their personal best. They feel well and continue with their long-term control medication. Peak flow readings falling within the yellow zone range between 50% and 79% of the patient's personal best, accompanied by symptoms such as coughing, wheezing, and shortness of breath, which begin to interfere with activity levels. In the red zone, patients experience peak flow readings below 50% of their best, severe shortness of breath, and an inability to perform everyday activities.

Asthma Severity

Guidelines established by the National Asthma Education and Prevention Program (NAEPP) and the Global Initiative for Asthma (GINA) determine therapy based on the frequency and severity of asthma symptoms, the degree of respiratory impairment, and the risk of future exacerbations. Risk factors contributing to future exacerbations include frequent asthma symptoms, a history of intensive care unit admission for asthma, obesity, poor medication adherence, chronic rhinosinusitis, and a low FEV 1 . The severity categories and treatment guidelines vary based on age. This activity will address asthma severity and management in adolescents and adults aged 12 or older. Please see StatPearls' companion resource, " Pediatric Asthma ," for additional information regarding the treatment of asthma in infants and children. 

Every patient should have access to a bronchodilator with a rapid onset of action. Traditionally, this has been a short-acting β-agonist (SABA) such as albuterol. However, GINA recommends a low-dose glucocorticoid/formoterol inhaler, such as 80 to 160 mcg budesonide/4.5 mcg formoterol inhaled by mouth 1 or 2 times daily,  for asthma symptoms. Notably, this is an off-label indication for this preparation.

Treatment progresses in a stepwise manner, with the highest severity category in which the patient experiences any symptoms, designating the treatment category from which the patient receives treatment (see Image.  Asthma Severity Classification by National Asthma Education and Prevention Program). Tables 1 and 2 below include the NAEPP and GINA asthma severity classifications and treatment initiation guidelines based on the patient's symptoms and lung function.

Table 1. National Asthma Education and Prevention Program: Expert Panel Working Group Initial Asthma Therapy in Adolescents and Adults.

Abbreviations: FEV 1 , forced expiratory volume in 1 second; ICS, inhaled corticosteroid; LABA, long-acting β-agonist; LAMA, long-acting muscarinic antagonist; LTRA, leukotriene receptor antagonist; SABA, short-acting β-agonist.

Table 2. Global Initiative for Asthma Initial Asthma Therapy in Adolescents and Adults.

Abbreviations: ICS, inhaled corticosteroid; LABA, long-acting β-agonist; LAMA, long-acting muscarinic antagonist; LTRA, leukotriene receptor antagonist; OCS, oral corticosteroid; SABA, short-acting β-agonist.

Routine follow-up every 1 to 6 months is necessary to ensure adequate symptom management. Upon reevaluation, patients facing inadequate asthma symptom management, exacerbations necessitating systemic glucocorticoids, or those at high risk of exacerbation on their current therapy level should escalate to the next level of therapy. Therapy adjustments proceed incrementally until symptoms are adequately managed. After maintaining control for 3 to 6 months, clinicians may consider gradual therapy reduction following the stepwise protocols outlined by GINA or NAEPP guidelines.

Severe Asthma

Adults and adolescents with severe asthma that remains uncontrolled despite Step 4 recommended therapy should receive a LAMA, such as tiotropium, alongside their inhaled glucocorticoid and LABA regimen. Clinicians should direct these patients for phenotypic assessment and consideration for biological therapy options. Anti-IgE monoclonal antibody therapy with omalizumab may be helpful for those still experiencing inadequate control and possessing documented sensitivity to a perennial allergy with IgE levels ranging between 30 and 700 IU/mL.

Patients with severe eosinophilic asthma who are not adequately controlled can utilize mepolizumab and reslizumab, monoclonal antibodies against IL-5, benralizumab, a monoclonal antibody against the IL-5 receptor α-subunit, and dupilumab a monoclonal antibody against the IL-4 receptor α-subunit. Tezepelumab is a human monoclonal IgG2-λ antibody that binds to TSLP, preventing its interaction with the TSLP receptor complex. [32]

Acute Exacerbation

Patients experiencing an acute asthma exacerbation may manage symptoms at home or need urgent medical care depending on their symptom severity and risk factors for fatal asthma. These risk factors include prior life-threatening exacerbations, exacerbations despite glucocorticoid use, more than 1 asthma-related hospitalization or 3 emergency room visits in the past year, and comorbidities such as cardiovascular or chronic lung disease. Immediate medical attention is warranted for patients showing significant breathlessness, inability to speak beyond short phrases, reliance on accessory muscles, or peak flow measurements at 50% or less of their baseline measurement.

All patients require a fast-acting β-agonist. Potential options include the LABA formoterol combined with ICS, the SABA albuterol combined with budesonide, or albuterol alone. Combination with ICS is the preferred choice. Albuterol dosing is 2 to 4 puffs from a metered dose inhaler (MDI) at home and 4 to 8 puffs in the office with a valved holding chamber or spacer every 20 minutes for 1 hour as needed. Albuterol may also be nebulized. ICS-formoterol dosing is 1 to 2 puffs every 20 minutes for 1 hour as required, with a maximum of 8 puffs per day. 

Patients whose symptoms improve after administering a bronchodilator and whose peak flow returns to 80% of their baseline or better can continue to manage their symptoms at home. Oral glucocorticoids equivalent to 40 to 60 mg prednisone daily for 5 to 7 days are warranted for the following patients:

• Those experiencing recurrent symptoms over the following 1 to 2 days.
• Those whose peak flow remains less than 80% of their normal baseline (high-dose ICSs are an alternative).
• If they do not improve after 1 to 3 doses of a fast-acting bronchodilator.
• If they have recently completed a course in OCS.
• Those who are on a maximal dose of controller medications.

Patients with a peak flow value of 50% or lower despite administering a bronchodilator or continuing to worsen should seek immediate medical care while continuing to administer their fast-acting bronchodilator. 

Office management is similar to home management, with the addition that according to GINA guidelines, all patients with oxygen saturation below 90% should receive oxygen to maintain saturation above 92% or 95% for pregnant individuals. Albuterol treatment can be administered via an MDI or nebulizer, with a dosage of 4 to 8 puffs or 2.5 to 5 mg every 20 minutes for 1 hour, respectively. Research comparing the efficacy of an MDI combined with a valved-holding chamber to nebulizer delivery, both administering the same β-agonist but with significantly lower doses via MDI, demonstrates similar enhancements in lung function and risk reduction for hospitalization. [33] [34] [35]  

If oral glucocorticoids are unavailable, intramuscular steroids such as triamcinolone suspension (40 mg/mL) 60 to 100 mg can be an alternative. However, it is noteworthy that intramuscular glucocorticoids have a delayed onset of action of 12 to 36 hours. Patients meeting certain criteria such as a respiratory rate of 30 breaths per minute, a heart rate of more than 120 bpm, a continued peak flow of less than 50% predicted, oxygen saturation of less than 90%, or the inability to speak in full sentences should be transferred to the emergency department. 

Patients who can be sent home from the office should have their controller medications advanced in 1 step. In addition, it is essential to review the correct use of their inhaler, discuss trigger avoidance strategies, ensure they have an asthma action plan, and emphasize the importance of adhering to their controller medication.

Emergency Department Care

Within the first hour, patients should receive 3 treatments of an inhaled SABA, such as albuterol, via a nebulizer or MDI, followed by repeat dosing every 1 to 4 hours. In addition to a SABA, patients with severe asthma exacerbations should also receive inhaled ipratropium, a short-acting muscarinic antagonist (SAMA), at a dosage of 500 µg by nebulization or 4 to 8 puffs by MDI, every 20 minutes for 3 doses, and then hourly as needed for up to 3 hours. Current guidelines recommend discontinuing SAMA therapy once the patient requires hospital admission, except in specific cases such as refractory asthma requiring treatment in the intensive care unit, concurrent treatment with monoamine oxidase inhibitors due to potential increased toxicity from sympathomimetic therapy due to impaired drug metabolism, presence of COPD with an asthmatic component, or asthma triggered by β-blocker therapy.

As with outpatient management, patients also receive glucocorticoids equivalent to 40 to 60 mg of prednisone daily for 5 to 7 days. A systematic review reveals no difference between a higher dose and a longer course when compared to a lower dose with a shorter course of prednisone or prednisolone. [36]  Oral and intravenous glucocorticoids have equivalent effects when administered in comparable doses. Intravenous steroids are necessary for patients with impending or actual respiratory arrest or who are intolerant of oral glucocorticoids. Some clinicians administer higher doses of glucocorticoids for severe asthma exacerbations based on their expert opinion and concern that a lower dose might be insufficient in a critically ill patient. 

Magnesium sulfate

Per GINA guidelines, magnesium is not recommended for routine use in asthma exacerbations. However, a 1-time dose of 2 g given intravenously over 20 minutes reduces hospitalization rates in adults with an FEV 1  less than 25% to 30% predicted on presentation and in those who fail to respond to initial treatment and continue to have hypoxemia. Nebulized MgSO 4  is not beneficial in the management of an acute asthma exacerbation.

A Cochrane Database review in 2014 concluded that a single infusion of intravenous MgSO 4 for patients not responding to conventional therapy results in improved lung functions and fewer hospital admissions. [37]  However, in a recent systematic review, the comparison of the same studies, eliminating those involving children and those containing only abstracts, revealed conflicting results. The review examined the effects of intravenous and nebulized MgSO 4 . Although 3 out of 9 studies addressing treatment with intravenous MgSO 4 found a significant effect on lung function compared to placebo, these results are not statistically significant. [38]  Only 2 of the 8 studies investigating hospital admission rates reveal a significant effect of MgSO 4 . [38]  Conversely, 6 of the 9 studies investigating treatment with nebulized MgSO 4 compared to placebo reveal a favorable effect on the FEV 1  and peak expiratory flow rate. [38]  These results somewhat contradict the Cochrane Database review conducted in 2014, which evaluated the same studies. [37]  

An additional study reveals a small benefit of adding inhaled magnesium to inhaled albuterol plus ipratropium in reducing hospital admissions but no significant improvement in peak expiratory flow when added to inhaled albuterol plus ipratropium or inhaled albuterol alone. [39]  

Intubation or Noninvasive Ventilation

Indications for intubation and mechanical ventilation or noninvasive ventilation include the following:

• Slowing of the respiratory rate
• Depressed mental status
• Inability to maintain respiratory effort
• Inability to cooperate with the administration of inhaled medications
• Worsening hypercapnia and associated respiratory acidosis
• Inability to maintain oxygen saturation above 92% despite face mask supplemental oxygen

A 1- to 2-hour trial of bilevel noninvasive positive pressure ventilation is appropriate for patients with an acute asthma exacerbation, but clinicians should maintain a low threshold for intubation. [40] [41]  

Additional Therapies

Occasionally, nonstandard therapies, such as ketamine, halothane, helium-oxygen mixtures, extracorporeal membrane oxygenation, and parenteral terbutaline, can be helpful for certain patients. However, these therapies are not routinely utilized due to limited evidence of efficacy. The indication for parenteral epinephrine is asthma associated with anaphylaxis and angioedema.

All patients who are smokers should be educated on the benefits of smoking cessation and provided with appropriate support and resources. Empiric antibiotics are not recommended since most infections triggering asthma exacerbations are viral. According to both GINA and NAEPP guidelines, intravenous methylxanthines such as theophylline are deemed ineffective and are no longer part of the standard of care. [42]

• Differential Diagnosis

The differential diagnoses for asthma include the following conditions:

• Bronchiectasis
• Bronchiolitis
• Chronic obstructive pulmonary disease
• Chronic sinusitis
• Cystic fibrosis
• α1-antitrypsin deficiency
• Aspergillosis
• Exercise-induced anaphylaxis
• Foreign body aspiration
• Heart failure
• Gastroesophageal reflux disease
• Tracheomalacia
• Pulmonary embolism
• Pulmonary eosinophilia
• Sarcoidosis
• Upper respiratory tract infection
• Vocal cord dysfunction
• Eosinophilic granulomatosis with polyangiitis
• Bronchogenic carcinoma
• Post-viral tussive syndrome
• Eosinophilic bronchitis
• Cough induced by angiotensin-converting enzyme inhibitors
• Bordetella pertussis infection
• Interstitial lung disease
• Recurrent oropharyngeal aspiration

The development and prognosis of asthma involve a complex interplay of genetic and environmental factors. Social determinants of health, such as poor housing quality and indoor and outdoor pollution, profoundly impact asthma prognosis. In the United States, asthma is a chronic illness characterized by a significant racial and ethnic disparity in both prevalence and prognosis. Underrepresented racial and ethnic minorities, as well as individuals living below the poverty line, experience higher morbidity rates, increased emergency room visits, hospitalizations, and mortality due to asthma. [43] [44]  Additionally, lack of access to healthcare—whether due to difficulties in accessing clinicians or lack of insurance—further exacerbates prognosis-related challenges.

The international asthma mortality rate reaches as high as 0.86 deaths per 100,000 persons in certain countries. The overall prognosis is predominantly linked to lung function, with mortality rates 8 times higher among individuals in the bottom 25% of lung function. Several factors contribute to a poorer prognosis, including inadequate asthma management, age 40 or older, a history of more than 20 pack-years of cigarette smoking, blood eosinophilia, and FEV1 of 40% to 69% of predicted values

• Complications

The complications related to asthma include disease-related complications and adverse effects of glucocorticoids, LTRA, and endotracheal intubation. The following list contains complications associated with asthma:

• Decline in lung function
• Osteoporosis
• Adrenal suppression
• Hypertension
• Peptic ulcer
• Sleep disorders
• Obstructive sleep apnea
• Mood disorders
• Cardiac arrest
• Respiratory failure or arrest  
• Pneumothorax
• Aspiration [45]
• Consultations

Healthcare professionals should seek consultation with an asthma specialist in pulmonology or allergy when the diagnosis of asthma is uncertain, the patient's symptoms remain poorly controlled, medication adverse effects become intolerable, or the patient experiences frequent exacerbations. Accessing appropriate specialist care aids in excluding alternate diagnoses, determining the need for additional diagnostic testing, and effectively escalating medical therapy.

• Deterrence and Patient Education

Patient education plays a pivotal role in the effective management of asthma by clinicians. To deter exacerbations and improve patient outcomes, clinicians should emphasize the importance of adherence to medication regimens, avoidance of triggers, and regular monitoring of symptoms. Educating patients about asthma triggers, such as allergens, air pollution, and tobacco smoke, can empower them to make informed lifestyle choices. Furthermore, clinicians should highlight the significance of having an asthma action plan, which outlines steps to take during worsening symptoms or exacerbations. See the National Heart and Lung Institute's website, " Asthma Action Plan ," for a printable version of an action plan.

Patient education should also prioritize the recognition of early warning signs of an asthma attack and prompt seeking of medical attention when necessary. Routine follow-up visits for patients with active asthma are recommended, occurring every one to six months, contingent on the severity of asthma and adequacy of control. During these follow-up visits, clinicians should assess asthma control, lung function, exacerbations, inhaler technique, adherence, adverse effects of medication, quality of life, and patient satisfaction with care. By instilling a comprehensive understanding of asthma management strategies and fostering proactive patient involvement, clinicians can significantly reduce the burden of asthma and enhance patient well-being.

• Enhancing Healthcare Team Outcomes

Asthma is characterized by complex pathophysiology involving airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness. The condition presents various signs and symptoms, such as wheezing, coughing, shortness of breath, and chest tightness. Wheezing may not always be present, particularly in cases primarily affecting small airways, and its absence does not exclude asthma. Additionally, a cough might be the sole symptom, especially one that occurs or worsens at night. Diagnostic evaluation involves spirometry, assessing lung function parameters such as FEV1 and FVC, measuring peak flow, and possibly conducting bronchoprovocation testing in some individuals.

Treatment strategies include trigger avoidance, ensuring access to rescue medications, and personalized pharmacological interventions, with inhaled corticosteroids being the preferred controller medication. Patient education, regular assessment of symptom control, and adherence to treatment plans are crucial components in effectively managing asthma. Adequate patient readiness and preparation, including the development of an asthma action plan, help minimize illness severity and optimize patient outcomes by promoting self-management and reducing healthcare utilization.

Enhancing patient-centered care, outcomes, patient safety, and team performance in asthma management demands a strategic approach. Each healthcare team member should possess the necessary clinical expertise to diagnose and treat asthma effectively, which involves interpreting spirometry findings and customizing treatment plans according to individual patient needs. Adhering to evidence-based guidelines and protocols will ensure uniform practices across healthcare settings. 

Effective interprofessional communication enables the exchange of information, collaborative decision-making, and seamless care transitions. Each healthcare team member, including physicians, advanced care practitioners, nurses, pharmacists, respiratory therapists, and social workers, contributes unique skills to asthma care, further enriching interdisciplinary collaboration. By fostering a culture of collaboration, communication, and coordination, healthcare professionals can deliver comprehensive, patient-centered asthma care, decreasing morbidity and mortality and enhancing team performance.

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Pathophysiology of Asthma. Figure A displays the location of the lungs and airways in the body. Figure B shows a cross section of a normal airway. Figure C illustrates a cross section of an airway during asthma symptoms National Institutes of Health

A Chest Radiograph Depicting Asthma. The image depicts both anterior and lateral radiographs of a patient with asthma. The image highlights the presence of pneumomediastinum and increased bronchovascular markings. Contributed by H Shulman, MD

Allergic Bronchopulmonary Aspergillosis on CT Scan. Computed tomography (CT) images reveal bronchiectasis in both upper lobes of a patient with bronchial asthma, indicative of allergic bronchopulmonary aspergillosis. Contributed by M Salahuddin, MD

Asthma Severity Classification by The National Asthma Education and Prevention Program. Contributed by R Chabra, DO

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Mary Cataletto declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Hashmi MF, Cataletto ME. Asthma. [Updated 2024 May 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Home — Essay Samples — Nursing & Health — Asthma — Asthma: Causes, Pathophysiology, and Treatment

Asthma: Causes, Pathophysiology, and Treatment

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Published: Apr 2, 2020

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Table of contents

Introduction, pathophysiology, classification, management and treatment, lifestyle modification, medications, drug used to treat asthma, ipratropium bromide.

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Asthma Investigation: Symptoms and Treatment Essay

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Pathophysiology

Standard of practice, characteristics of and resources for a patient, disparities in treating the disease, factors influencing access to care, interventions.

Asthma is a chronic condition that affects airways and results in difficulty breathing. In the United States of America, bronchial asthma is one of the most common chronic diseases in children with the prevalence rate ranging from 6% to 9% (Asthma and Allergy Foundation, 2019). In the adult population, the share of those who are affected by this disease amounts to 7,5% (Asthma and Allergy Foundation, 2019).

In patients with asthma, the condition causes the inflammation of air passages that is followed by the significant narrowing of airways. As a result, oxygen cannot be carried directly to the lungs, and a person with this condition experiences coughing, wheezing, shortness of breath, and tightness in the chest area. Early symptoms before the final onset of the condition include a frequent cough at night, shortness of breath during mild physical activities, and fatigue.

The mechanisms that explain the pathophysiology of asthma are quite complex and intricate. It has been common medical knowledge since a long time ago that the subepithelial connective tissue of the airway in asthma patients differs from that in patients without asthma. The tissue displays many more blood vessels that are identified in the same locations in healthy individuals (Sullivan, Hunt, MacSharry & Murph, 2016). Even though the important role of bronchial vessels in the pathophysiology of asthma is now firmly established, there are still significant knowledge gaps about the mechanism itself. The reason for this is the difficulty of measuring airway blood flow.

Despite the scientific challenges of researching asthma, some facts have been successfully clarified. The bronchial circulation is likely to be regulating airway caliber because an increased vascular volume is associated with airway narrowing. A possible explanation is that increased airway blood flow is needed for the removal of inflammatory mediators from the airway. The question arises as to exactly how the body of an asthma patient builds more blood vessels.

Sullivan, Hunt, MacSharry, and Murphy (2016) show that the human body may respond to the stress associated with high respiratory pressures with gene transduction and enhanced production of nitric oxide by type III (endothelial) NO synthase. One of the key components of the inflammatory response is microvascular leakage that is responsible for increased airway secretions and impeded mucociliary clearance. Some other processes that occur due to microvascular leakage are the creation of new mediators from plasma precursors and mucosal edema (liquid retention) that narrow the airways in asthma patients.

Another characteristic that has received a great deal of attention in asthma research is the primary abnormality of smooth muscle cell activity. From this standpoint, asthmatic inflammation of the airways has been explained by a persistent neural abnormality engaging the cholinergic and noncholinergic nonadrenergic bronchospastic tone. It should be noted, however, that what triggers the onset of asthma is not a single abnormality or an event.

Recent research has shown that asthma has self-exacerbating mechanisms. The chronic decline and impairment of lung function that is characteristic of asthma lead to permanent changes in the structure of the airways (Sullivan, Hunt, MacSharry & Murph, 2016). Namely, the submucosa of the bronchi (the extracellular matrix (ECM), vessels, glands, and smooth muscle) undergoes modifications in asthma patients (Sullivan, Hunt, MacSharry & Murph, 2016). These pathophysiological mechanisms manifest themselves at the early stages of the disease, which suggests that early monitoring may as well be possible.

Currently, it is recommended to take a stepwise approach to asthma therapy. The course of action depends on the severity of the disease, and its objective is to reduce the symptoms of airway obstruction and inflammation. Another important objective is to avert exacerbation and maintain healthy lung function. At present, the most effective drugs available for asthma patients are β2‐adrenoceptor agonists and glucocorticoids.

Second and third-line therapy includes drugs such as theophylline, leukotriene receptor antagonists, and anticholinergics. In general, asthma medication can be divided into two categories:

• long-term controllers (corticosteroids) that are taken on a daily basis;
• relievers (β2‐adrenoceptor agonists) that relieve bronchoconstriction.

The latter should only be used on a need basis as a rescue medication and not as a long-term solution.

In the case of mild persistent asthma, patients are given inhaled steroids, 200–500 μ µg, hormones, or, alternatively, sustained-release theophylline on a daily basis. To relieve an acute asthma flare, patients should be treated with inhaled β2‐adrenoceptor agonists; however, this treatment should not exceed three or four times a day. Treatment of moderate persistent asthma requires increased doses of inhaled corticosteroids at 800–2,000 μ µg and long-acting β2‐adrenoceptor agonists. If a patient struggles with symptoms at nighttime, he or she should be given sustained-release theophylline or long-acting oral β2‐adrenoceptor agonists.

As for acute symptoms, short-acting bronchodilators may be helpful, but their use should not exceed three-four times a day. For some people, doubling the dose of inhaled steroids might not make as much sense as adding a long-acting β2‐adrenoceptor agonist or low-dose theophylline. Lastly, severe persistent asthma requires inhaled corticosteroids at ≥800–2,000 μ µg and long-acting β2‐adrenoceptor agonists. If a patient manages to sustain control over asthma for more than three months, a gradual stepwise reduction in doses is recommended.

To researchers’ current knowledge, there is no feasible replacement for the aforementioned drugs or anything that would have superior effects. The National Health Institutes (2012) promote drug combinations of inhaled steroids, preferably with long-acting β2‐adrenoceptor agonists. They were chosen for their enhanced efficacy and the potential for a steroid-sparing effect. Treatment choices vary by country because of different levels of access to healthcare and convenience for the patient. Selecting the right medication should also take into account the occurrence of side effects. Lastly, the cost of therapy and relevant reimbursement policies also impact the choice of treatment.

Assessment, Diagnosis, and Patient Education

Guidelines for assessment, diagnosis, and patient education for medical professionals handling asthma patients can be found in the asthma care reference guide issues by the National Institutes of Health (NIH) (2012). The institutions write that the initial visit should include diagnosis, asthma severity assessment, medication prescription, action plan development, and scheduling follow-up appointments. Establishing an asthma diagnosis requires identifying symptoms of recurrent airway obstruction, based on a patient’s anamnesis and exam.

Some of the information that needs to be taken into account includes a history of cough, wheezing, difficulty breathing, and a feeling of tightness in the chest area, especially if they are recurrent. Patients are likely to be diagnosed with asthma if the aforementioned symptoms occur or worsen in the nighttime or when a patient is physically active. For patients older than five years, the NIH recommends using spirometry to determine the airway obstruction. However, it should be noted that for the sake of validity, other reasons for lung obstructions should also be considered.

The National Institutes of Health (NIH) (2012) describe asthma as a chronic but controllable disease. In its asthma care reference guide, the NIH states that asthma control serves two main purposes. Firstly, a good asthma management strategy must seek to reduce impairment: it must help to mitigate the frequency and intensity of symptoms. Besides, asthma control should help patients mitigate or eliminate functional limitations that they are currently experiencing.

The second objective of asthma control under the supervision of a medical professional is to reduce risk. It is important to avert severe asthma flares as well as the progressive decline of lung function due to organic transformations described in the previous section. Lastly, asthma control means mitigating medication side effects in which a significant role is assigned to asthma patients themselves.

Asthma control should be a mutual effort made by both medical professionals and asthma patients. A healthcare provider does monitor the progression of the disease and prescribes medication, but he or she can only do so much. The overwhelming majority of the time, asthma patients are left to their own devices, which is why they need to be educated and conscientious enough to take charge of their health. The National Health Institutes suggest that at each visit, medical professionals encourage and reinforce self-monitoring and treatment compliance. Regarding the former, patients need to be taught to assess the severity of their symptoms and be aware of the signs of worsening asthma.

As for the latter, it is essential that patients know how to use an inhaler and other devices and understand the difference between long-term and short-term medications. Long-term control medications are preventive: for instance, corticosteroids reduce inflammation of the airways. Because they have an accumulated effect that might not be noticeable at once, some patients prefer short-term medications such as short-acting beta2-agonists or SABAs that relax the muscles of the airways. Unfortunately, if these medications are abused, patients may develop resistance and find themselves in a situation where their usual way of relieving asthma no longer works. It is the duty of a health professional to warn patients about these adverse consequences and teach them responsible medication use.

Another important element of patient education is developing an action plan that should be maintainable over vast periods of time. There is no one-size-fits-all plan: any asthma control strategy needs to be customized and finely tuned to a patient’s wants and needs. Firstly, it is critical to identify environmental factors that trigger asthma flares: it can be certain foods, smells, or living spaces. After understanding personal triggers, a patient can move forward with the strategy and change their daily routines accordingly. Another valuable idea is to investigate what other medications a patient is taking and monitor their interactions with each other.

It is possible that some of the medications are not appropriate for asthma patients and can worsen their conditions. Taking all these facts into consideration, a health professional should devise a plan that is grounded in small actions that a patient can take to maintain their health and prevent adverse outcomes. At all times, a health provider should be patient and encouraging to boost a patient’s confidence in his or her ability to control the disease.

Lastly, the National Institutes of Health (2012) highlight the importance of family involvement and support. As a chronic and potentially life-threatening condition, asthma can be overwhelming to handle alone. For this reason, it is advised that health professionals communicate with a patient’s family and educate family members as well. It should be noted that not only family members but also other health professionals play a significant role in the recovery process. The NIH writes that physicians, pharmacists, nurses, respiratory therapists, and asthma educators should all unite their efforts to provide education to patients.

Comparison with Standard Practice within the Community

In the community under investigation, health professionals manage to only partly follow the asthma control guidelines outlined by the National Institutes of Health (2012). Health professionals are successfully diagnosing asthma at early stages and develop treatment plans that include both long-term and short-term medications. In the case of a severe asthma attack, patients are promptly hospitalized, which ensures a fast rate of recovery and discharge. Health professionals make sure that patients make follow-up appointments, in which they assess their state and determine whether they have been adhering to the established treatment plan.

For all the progress that the community has made with regard to treating and controlling asthma, there are still problems that require more attention. The problems can be roughly put into two categories: provider-related and patient-related. Health professionals are often pressed for time and lack resources, which impedes them from providing patients with a high-quality education. There is an apparent discrepancy between doctors’ intentions and their behavior. Boulet (2015) reports the same lack of congruency in UK medical professionals. The researcher conducted a survey that has shown that while 98.4% of physicians understood the importance of asthma education, only 12.8% offered their patients actual action plans.

Boulet (2015) also mentions the lack of medical educators to which doctors could refer patients – this problem is observed in the analyzed community as well. Another persistent issue is therapeutic communication, in which many doctors lack training and experience. Possessing the right knowledge is the norm, but spreading it in an understandable and compassionate manner is challenging for health professionals. If a patient feels unheard and misunderstood, he or she is less likely to adhere to medication. In the community analyzed, health professionals need to find ways to put medical instructions in simpler words to eliminate ambiguities and misunderstandings.

Patients tend not to put in enough effort handling the disease, even when their well-being is at stake. Even if educational programs are free or available at a minimal cost, patients are reluctant to participate. This passivity and withdrawal can happen for many reasons: some individuals do not have time, while others lack motivation or think that this kind of intervention is unnecessary. Boulet (2015) explains that decision-making is challenging for many patients: they do not have sufficient knowledge and experience to make well-informed decisions.

The second barrier is the patients’ inability to make long-term plans reported by the doctors in the analyzed community. Many affected individuals rely on short-term medications that provide brief relief. At that, they ignore long-term solutions and do not improve their health in the long run. In summation, asthma healthcare in the community is rather reactive and proactive. Formal treatment is compliant with the guidelines; however, personal and systemic barriers prevent asthma care from being more robust.

A patient who manages the selected disease well is likely to display two characteristics: resources and positive psychological qualities such as resilience, optimism, and accountability. Since asthma is a chronic disease, it is important for patients to have the financial stability to afford medication and regular appointments. Besides, good asthma management is nigh on impossible without having easy, unimpeded access to healthcare services. Nunes, Pereira, and Morais-Almeida (2017) make an optimistic prognosis: they claim that if a patient adheres to medication and manages asthma well, their life expectancy may be the same as that of a healthy person. Therefore, in the United States, an asthma patient who follows recommendations may as well live up to 79 years.

The best possible outcome would be a life with rare and mild asthma flares without a significant decline in lung function. In this case, a patient will be able to function no worse than healthy people and act on their aspirations without asthma symptoms getting in their way. Daytime and nighttime symptoms are minimal or non-existent: on average, less than two times a week. A patient who manages the selected disease well does not rely on short-term medication for a brief relief because they have been able to take more proactive measures. He or she does not suffer from any adverse side effects from the chosen medication, nor do they experience exacerbations.

Internationally, asthma management and control differ at operational and conceptual levels. For instance, Canadian asthma guidelines conceptualize the severity of the condition in a slightly different way than US guidelines. Canadian healthcare standards include additional endpoints that take into account the most recent hospital admissions and near-fatal flares (Bakel et al., 2017). At the same time, Canadian guidelines lack differentiation, where US guidelines make a point to highlight specific details such as paying attention to daytime episodes on par with nighttime episodes (Bakel et al., 2017).

UK GINA-05 provided a more detailed description of severe asthma, including limited physical activity that was not considered by US guidelines (Bakel et al., 2017). As compared to Canada, in the US, the number of SABA uses for classifying asthma as severe is not specified either.

Another difference between approaches to asthma management in developed countries lies in the definition of controlled asthma. The US guidelines suggest that a patient should have minimal or no daytime symptoms to classify their condition as controlled (Bakel et al., 2017). UK GINA-06 and Canadian guidelines reach consensus on this point but show more precision (Bakel et al., 2017). In them, well-managed asthma is characterized by less than two times a week and less than four times a week, respectively. As seen from this description, the US standards of asthma treatment do not differ much from those recognized in other developed countries: Canada, Australia, and the UK.

Asthma management requires not only knowledge and motivation but also sufficient financial resources and access to care. American Thoracic Society (2018) reports that the total annual asthma cost in the US amounts to $90 billion. When calculated on a per-person basis, the cost reaches $3,266: $1,830 for prescriptions, $640 for office visits, $530 for hospitalizations, $176 for hospital outpatient visits, and $105 for emergency room care. The Census Bureau states that the number of uninsured Americans is steadily growing: if in 2016, 27.3 million did not have insurance, by 2018, the figure had grown to 28.6 million. These costs are likely to be the most straining for those Americans who are uninsured or whose insurance plan does not cover all the necessary expenses.

Another important factor to acknowledge is patients’ eligibility for Medicaid, a cornerstone of the so-called Obamacare healthcare program. The Affordable Care Act (ACA) sought to curtail inefficient healthcare expenses and low quality of medical services by turning to proactive measures (U.S. Centers for Medicare & Medicaid Services, 2020). Before the ACA, insurance providers would rarely if ever covered preventive care. In the long run, the failure to tackle a disease at early stages would have an accumulative detrimental effect on patients. They were more likely to have a health emergency later in life, which would require much more expensive interventions.

Medicaid helps asthma patients address their condition early after the onset, averting exacerbation. Lastly, access to proper asthma care is determined by the presence of specialists in a patient’s area of residence. The University of North Carolina (2020) reports that since 2010, 126 rural hospitals have been closed across the United States. This fact means that thousands of people lost easy access to medical services and had to resort to remote providers. Given that asthma is a chronic disease that requires regular monitoring, not having a hospital in close proximity is not only inconvenient but may even be life-threatening.

Nunes, Pereira, and Morais-Almeida (2017) describe the so-called indirect costs of asthma. The researchers explain that poorly managed asthma, especially if a patient experiences exacerbations, is associated with the loss of work productivity, which, in turn, means less financial stability. The adverse effects of asthma may take the form of a temporary disability when a patient cannot fulfill their usual work duties because of asthma symptoms (Nunes, Pereira & Morais-Almeida, 2017).

In the case of a severe lung function decline, an affected individual may as well be confronted with permanent disability and early retirement. The loss of work productivity also applies to working adults who care for underage asthma patients. Because managing the disease takes time and resources, caregivers may discover that they are unable to adhere to the normal work schedule and have to take days off to help their children. In summation, asthma is associated with both direct and indirect costs: health expenses associated with treatment, medication, and appointments and adverse impact on affected individuals’ work life.

One strategy that could bring about an organizational change with regard to asthma treatment is creating and launching a so-called medical home for the asthma program. The program would target children from low-income families and seek to tackle the lack of continuity in primary care. “Medical home” can take up office space at a healthcare organization and be run by local medical professionals. The key function of the “medical asthma home” would be to provide detailed information to patients. More often than not, healthcare specialists do not have enough time to consult each patient comprehensively, even though clear and straightforward information is one of the elements of adherence promotion. “Medical home” will be a place that patients could be referred to to receive needed support.

Another objective of the planned intervention could be the creation, edition, and distribution of asthma control materials. Many patients these days seek information on the Internet, but without proper training and education, they might not have the expertise to distinguish between reliable and unreliable sources. “Medical home” could do this for them: the experts would review sources, compile them, and recommend to patients. Patient satisfaction will be the key evaluation metric for this intervention. How satisfied patients are with the experience of attending the center could be measured through regular surveys.

Another possible intervention is promoting continuing education among physicians that often lack knowledge and resources to empower asthma patients. Continuing education could take the form of a short-term study program that would not only enlighten medical professionals on the aspects of asthma management that are often ignored but also improve their communication skills. The self-regulation theory borrowed from the field of psychology could direct the development of the study program. The self-regulation theory suggests that individuals are capable of holding themselves accountable for their actions and controlling their impulses. Self-regulation, in this context, means being conscientious and aware of one’s actions.

The two main components of the seminar should include guidelines for optimal clinical practice in alignment with the standards established by the National Institutes of Health (NIH) and patient empowerment, teaching, and communication. The seminar starts with a series of brief lectures by invited asthma experts. The lectures are accompanied by videos that, among other things, demonstrate effective therapeutic communication and patient teaching techniques. Surely, outlining the key theoretical aspects suffices not: for this reason, medical professionals will be offered to solve practical cases that present common situations in asthma control and management.

Lastly, invited speakers and couches could review available sources and materials about asthma management and point out those that are appropriate for recommending patients. The success of the intervention could be measured shortly after the seminar and in the long run. Right after the event, the healthcare organization could set up a knowledge test to evaluate how well the participants have understood the material. The long-term effects might be more challenging to pinpoint: they might manifest themselves in the rehospitalization rate, treatment adherence, and patient satisfaction.

The third intervention is in line with the recent advent of technology in medicine. Merchant et al. (2018) write that even though the standards of asthma care are well-established, in practice, it is quite difficult to motivate patients to follow them. One of the greatest issues in asthma control is in patients’ overreliance on “rescue medication.” As it has been mentioned before, short-term asthma medication should only be used in the case of emergency, and patients should not resort to it more than three to four times a week. Merchant et al. (2018) propose a solution that seems to be effective in tackling the said problem and that could be used in our healthcare organization.

The intervention included electronic medication monitors (EMMs) that logged inhaler medication use. As an extra aid, Merchant et al. (2018) employed a digital platform with exhaustive information for both doctors and patients. The best evaluation metric for this intervention would be the “rescue” medication use rate. The desired outcome would be a decrease in the use of short-term asthma medication.

American Thoracic Society. (2018). Asthma costs the US economy more than $80 billion per year . Web.

Asthma and Allergy Foundation. (2019). Asthma facts and figures . Web.

Bakel, L. A., Hamid, J., Ewusie, J., Liu, K., Mussa, J., Straus, S.,… & Cohen, E. (2017). International variation in asthma and bronchiolitis guidelines. Pediatrics , 140 (5), e20170092.

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Boulet, L. P. (2015). Asthma education: An essential component in asthma management . Web.

Merchant, R., Szefler, S. J., Bender, B. G., Tuffli, M., Barrett, M. A., Gondalia, R.,… & Stempel, D. A. (2018). Impact of a digital health intervention on asthma resource utilization. World Allergy Organization Journal , 11 (1), 28.

National Institutes of Health. (2012). Guidelines for the diagnosis and management of asthma (EPR-3). Web.

Nunes, C., Pereira, A. M., & Morais-Almeida, M. (2017). Asthma costs and social impact. Asthma research and practice , 3 (1), 1.

Sullivan, A., Hunt, E., MacSharry, J., & Murphy, D. M. (2016). The microbiome and the pathophysiology of asthma. Respiratory research , 17 (1), 163.

Tolbert, J., Orgera, K., Singer, N., & Damico, A. (2019). Key facts about the uninsured population . Web.

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What to Expect During a Severe Asthma Attack

Frequently asked questions.

Severe asthma is a form of asthma that is difficult to treat and responds poorly to currently available asthma medications . It can become serious and even life-threatening if left untreated. Asthma is commonly triggered by allergens such as dust, pets, and cleaning products, and some less common triggers like weather changes and emotional distress.

This article outlines a list of asthma triggers, the symptoms to look for in a severe asthma attack , and how severe asthma is diagnosed and treated in a hospital setting.

Verywell / Theresa Chiechi

What Are the Symptoms of a Severe Asthma Attack?

Asthma is known as a progressive disease, meaning that it starts out with mild symptoms but can become severe over time. It is caused by inflammation or swelling of the airways, making it difficult for air to pass through.

The symptoms of severe asthma can vary from person to person, but the following signs could indicate a severe asthma attack:

• Coughing, especially in the morning and at night
• Tightness in the chest
• Shortness of breath
• Difficulty talking
• Blue lips or fingernails
• Feeling confused or agitated
• Symptoms that do not improve with medication

Asthma attacks are typically treated by a quick-relief bronchodilator called albuterol. A person breathes it in through a device called a rescue inhaler. If asthma symptoms do not improve with the use of this or other medications , it could be a sign that asthma is severe.

Prevalence of Severe Asthma

Although severe asthma accounts for less than 10% of people with asthma, there are more than 500,000 hospitalizations for severe asthma attacks in the United States every year.

What Causes a Severe Asthma Attack?

Severe asthma attacks typically occur when an individual is exposed to an allergen. It's important to remember that different people have different triggers, so making a plan to identify yours can help reduce the frequency of severe asthma attacks.

The most common allergens that trigger asthma attacks include:

• Tobacco smoke : According to the Centers for Disease Control and Prevention (CDC), 1 in 5 people who have asthma smoke, despite the fact that tobacco smoke is known to trigger asthma attacks. Passive smoke, often referred to as secondhand smoke, can also exacerbate asthma symptoms.
• Dust mites : Specifically the dust mite's gut is thought to contain digestive enzymes that can trigger asthma symptoms.
• Air pollution : Air pollution is one of the most challenging triggers to avoid, since there is no way for an individual to control the air around them. However, using maintenance therapies can help reduce the risk of asthma attacks due to air pollution.
• Pests : Pests include creatures like cockroaches or rodents. These types of allergens are typically found in urban-area homes and can be minimized by keeping the home clean to avoid attracting these unwanted guests.
• Pets : Not to be confused with "pests", pets can trigger asthma attacks in some people. The most common household pets are cats and dogs, with cats being more allergenic than dogs.
• Mold : Molds found both inside and outside can contribute to asthma symptoms. Mold is typically found in damp areas, so identifying spaces in and out of the home that may develop mold can help you avoid mold-triggered asthma attacks.
• Cleaning and disinfectant products: These common household items can trigger asthma attacks. The Environmental Protection Agency (EPA) has a "Safer Choice" program that can help you choose safer products for you and your family.

People with severe asthma are at a greater risk for having asthma attacks on a regular basis. Severe asthma may not respond well to regular asthma treatment, so it is crucial to identify your own triggers and try to avoid them.

Less Common Triggers

The triggers listed above are the most typical, but there are many less common triggers that might also induce a severe asthma attack. Cold and flu, sinus issues, strenuous exercise, weather changes (especially cold weather), as well as stress and emotional distress can all affect asthma symptoms.

How Is a Severe Asthma Attack Diagnosed?

A healthcare provider will perform a lung function test to determine the severity of your asthma. There are different types of lung function tests using different types of devices to measure your airflow, including:

• Spirometry : During a spirometry test, the patient will breathe into a tube that is attached to a laptop or a machine called a spirometer. As you breathe, the spirometer will measure how much and how fast air goes in and out. You can expect your provider to do this test before and after you take a medication to open up your airways, called a bronchodilator , to see if there is improvement with medication.
• Peak expiratory flow (PEF) : Peak flow measures the amount of air you can forcefully exhale. This form of measurement is helpful in monitoring severity, but is not used for diagnosing asthma.
• Fractional exhaled nitric oxide (FeNo): Asthma causes the lungs to become inflamed and produces a substance called nitric oxide. This test measures the amount of nitric oxide to determine how much inflammation is in the lungs.
• Provocation : During a provocation test, a healthcare provider will introduce different allergens to see how your airway reacts when medication is administered.

How Is a Severe Asthma Attack Treated at the Hospital?

If you experience difficulty breathing that does not improve with at-home treatment, seek medical attention.

Asthma treatment at the hospital could include typical at-home asthma medications combined with additional treatments such as supplemental oxygen, bronchodilators, and corticosteroids.

The length of hospitalization can vary from person to person. Some people with severe asthma are treated in the emergency room but never admitted to the hospital. Regardless of admission, anyone who is treated at a hospital will be sent home with instructions on how to treat their asthma at home.

Discharge instructions following an asthma attack will advise the person to avoid allergy triggers and follow up with their provider to adjust the asthma plan as needed. The instructions could also include additional medications, such as oral corticosteroids and inhaled corticosteroids, to treat and prevent future attacks.

Other options for treatment of severe asthma include biologic treatment. Biologic injections are medications derived from living organisms. They can be used to treat a variety of conditions, including severe uncontrolled asthma. Talk with your healthcare provider or allergist if this option is right for you.

Severe asthma is serious and can be life-threatening. It's recommended that people with asthma work with their healthcare provider to identify their triggers and avoid them when possible. If triggers can't be avoided or a severe asthma attack comes on, there are treatment options available, which may require hospitalization.

The symptoms of an asthma attack and panic attack can feel similar. An asthma attack is often triggered by a specific allergen, whereas a panic attack is brought on by severe anxiety.

Weather, especially cold weather, can exacerbate asthma symptoms. Warm weather can impact asthma symptoms as well.

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Centers for Disease Control and Prevention. Common asthma triggers.

Centers for Disease Control and Prevention. Percentage of people with asthma who smoke.

U.S. Environmental Protection Agency. Learn about the safer choice label .

National Heart, Lung, and Blood Institute. Asthma.

Asthma and Allergy Foundation of America. Lung function tests.

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Asthma and Allergy Foundation of America. Biologics for the treatment of asthma .

By Teresa Maalouf, MPH Maalouf holds a Master of Public Health degree, with expertise in tobacco treatment and infectious disease surveillance.