Asthma is a chronic inflammatory disease of the airways in the lungs. This inflammation periodically causes the airways to narrow, producing wheezing and breath-lessness sometimes to the point where the patient gasps for air. This obstruction of the air flow either stops spontaneously or responds to a wide range of treatments. Continuing inflammation makes asthmatics hyper-responsive to such stimuli as cold air, exercise, dust, pollutants in the air, and even stress or anxiety.
Between 16 and 17 million Americans have asthma and the number has been rising since 1980. As many as 9 million U.S. children under age 18 may have asthma. Blacks, Hispanics, American Indians, and Alaskan natives had higher rates of asthma-control problems than whites or Asians in the United States.
The changes that take place in the lungs of asthmatics make their airways (the bronchi and the smaller bronchioles) hyper-reactive to many different types of stimuli that do not affect healthy lungs. In an asthma attack, the muscle tissue in the walls of the bronchi go into spasm, and the cells that line the airways swell and secrete mucus into the air spaces. Both these actions cause the bronchi to narrow, a change that is called bronchoconstriction. As a result, an asthmatic person has to make a much greater effort to breathe.
Cells in the bronchial walls, called mast cells, release certain substances that cause the bronchial muscle to contract and stimulate mucus formation. These substances, which include histamine and a group of chemicals called leukotrienes, also bring white blood cells into the area. Many patients with asthma are prone to react to substances such as pollen, dust, or animal dander; these are called allergens. Many people with asthma do not realize that allergens are triggering their attacks. On the other hand, asthma also affects many patients who are not allergic in this way.
Asthma usually begins in childhood or adolescence, but it also may first appear in adult life. While the symptoms may be similar, certain important aspects of asthma are different in children and adults. When asthma begins in childhood, it often does so in a child who is likely, for genetic reasons, to become sensitized to common allergens in the environment. Such a child is known as an atopic person. In 2004, scientists in Helsinki, Finland, identified two new genes that cause atopic asthma. The discovery might lead to earlier prediction of asthma in children and adults. When these children are exposed to dust, animal proteins, fungi, or other potential allergens, they produce a type of antibody that is intended to engulf and destroy the foreign materials. This has the effect of making the airway cells sensitive to particular materials. Further exposure can lead rapidly to an asthmatic response. This condition of atopy is present in at least one third and as many as one half of the general population. When an infant or young child wheezes during viral infections, the presence of allergy (in the child or a close relative) is a clue that asthma may well continue throughout childhood.
Allergenic materials may also play a role when adults become asthmatic. Asthma can start at any age and in a wide variety of situations. Many adults who are not allergic have such conditions as sinusitis or nasal polyps, or they may be sensitive to aspirin and related drugs. Another major source of adult asthma is exposure at work to animal products, certain forms of plastic, wood dust, metals, and environmental pollution.
Causes & symptoms
In most cases, asthma is caused by inhaling an allergen that sets off the chain of biochemical and tissue changes leading to airway inflammation, bronchoconstriction, and wheezing. Because avoiding (or at least minimizing) exposure is the most effective way of treating asthma, it is vital to identify which allergen or irritant is causing symptoms in a particular patient. Once asthma is present, symptoms can be set off or made worse if the patient also has rhinitis (inflammation of the lining of the nose) or sinusitis. When, for some reason, stomach acid passes back up the esophagus in a reaction called acid reflux, this condition also can make asthma worse. In addition, a viral infection of the respiratory tract can inflame an asthmatic reaction. Aspirin and drugs called beta-blockers, often used to treat high blood pressure, also can worsen the symptoms of asthma. But the most important inhaled allergens giving rise to attacks of asthma are:
- animal dander
- dust mites
- fungi (molds) that grow indoors
|INHALED ALLERGENS MOST OFTEN TRIGGERING ASTHMA ATTACKS|
|Indoor fungi (molds)|
|Occupational allergens such as chemicals, fumes, particles of industrial materials|
- cockroach allergens
- occupational exposure to chemicals, fumes, or particles of industrial materials
- tobacco smoke
- air pollutants
In addition, there are three important factors that regularly produce attacks in certain asthmatic patients, and they may sometimes be the sole cause of symptoms. They are:
- inhaling cold air (cold-induced asthma)
- exercise-induced asthma (in certain children, asthma attacks are caused simply by exercising)
- stress or a high level of anxiety
Wheezing often is obvious, but mild asthmatic attacks may be confirmed when the physician listens to the patient's chest with a stethoscope. Besides wheezing and being short of breath, the patient may cough or report a feeling of tightness in the chest. Children may have itching on their back or neck at the start of an attack. Wheezing often is loudest when the patient exhales. Some asthmatics are free of symptoms most of the time but may occasionally be short of breath for a brief time. Others spend much of their days (and nights) coughing and wheezing until properly treated. Crying or even laughing may bring on an attack. Severe episodes often are seen when the patient gets a viral respiratory tract infection or is exposed to a heavy load of an allergen or irritant. Asthmatic attacks may last only a few minutes or can go on for hours or even days. Being short of breath may cause a patient to become very anxious, sit upright, lean forward, and use the muscles of the neck and chest wall to help breathe. The patient may be able to say only a few words at a time before stopping to take a breath. Confusion and a bluish tint to the skin are clues that the
|OCCUPATIONS ASSOCIATED WITH ASTHMA|
|Snow Crab and Egg Processing|
oxygen supply is much too low and that emergency treatment is needed. In a severe attack, some of the air sacs in the lung may rupture so that air collects within the chest, which makes it even harder to breathe. The good news is that almost always, even patients with the most severe attacks will recover completely.
Apart from listening to the patient's chest, the examiner should look for maximum chest expansion while taking in air. Hunched shoulders and contracting neck muscles are other signs of narrowed airways. Nasal polyps or increased amounts of nasal secretions are often noted in asthmatic patients. Skin changes, like dermatitis or eczema, are a clue that the patient has allergic problems. Inquiring about a family history of asthma or allergies can be a valuable indicator of asthma. A test called spirometry measures how rapidly air is exhaled and how much is retained in the lungs. Repeating the test after the patient inhales a drug that widens the air passages (a bronchodilator) will show whether the narrowing of the airway is reversible, which is a very typical finding in asthma. Often patients use a related instrument, called a peak flow meter, to keep track of asthma severity when at home.
Frequently, it is difficult to determine what is triggering asthma attacks. Allergy skin testing may be used, although an allergic skin response does not always mean that the allergen being tested is causing the asthma. Also, the body's immune system produces an antibody to fight off the allergen, and the amount of antibody can be measured by a blood test. The blood test will show how sensitive the patient is to a particular allergen. If the diagnosis is still in doubt, the patient can inhale a suspect allergen while using a spirometer to detect airway narrowing. Spirometry also can be repeated after a bout of exercise if exercise-induced asthma is a possibility. A chest x-ray will help rule out other disorders.
There are many alternative treatments available for asthma that have shown promising results. One strong argument for these treatments is that they try to avoid the drugs that allopathic treatment (combating disease with remedies to produce effects different from those produced by the disease) relies upon, which can be toxic and addictive. Mainstream journals have reported on the toxicity of asthma pharmaceuticals. A 1995 New Zealand study showed that before 1940, death from asthma was very low, but that the death rate promptly increased with the introduction of bronchodilators. The New England Journal of Medicine in 1992 reported that albuterol and other asthma drugs cause the lungs to deteriorate when used regularly. A 1989 study in the Annals of Internal Medicine showed that respiratory therapists, who are exposed to bronchodilator sprays, develop asthma five times more often than other healthcare professionals, which could imply that the drugs themselves may induce asthma. Theophylline, another popular drug, has been reported to cause personality changes in users. Steroids can also have negative effects on many systems in the body, particularly the hormonal system. Thus, natural and non-toxic methods for treating asthma are the preferred first choice of alternative practitioners, while drugs are used to manage extreme cases and emergencies.
Alternative medicine tends to view asthma as the body's protective reaction to environmental agents and pollutants. As such, the treatment goal is often to restore balance to and strengthen the entire body and provide specific support to the lungs, immune and hormonal systems. Asthma sufferers can help by keeping a diary of asthma attacks in order to determine environmental and emotional factors that may be contributing to their condition.
Alternative treatments have minimal side effects, are generally inexpensive, and are convenient forms of selftreatment. They also can be used alongside allopathic treatments to improve their effectiveness and lessen their negative side effects.
Dietary and nutritional therapies
Some alternative practitioners recommend cutting down on or eliminating dairy products from the diet, as
these increase mucus secretion in the lungs and are sources of food allergies. Other recommendations include avoiding processed foods, refined starches and sugars, and foods with artificial additives and sulfites. Diets should be high in fresh fruits, vegetables, and whole grains, and low in salt. Asthma sufferers should experiment with their diets to determine if food allergies are playing a role in their asthma. Some studies have shown that a sustained vegan (zero animal foods) diet can be effective for asthma, as it does not contain the animal products that frequently cause food allergies and contain chemical additives. A vegan diet also eliminates a fatty acid called arachidonic acid, which is found in animal products and is believed to contribute to allergic reactions. A 1985 Swedish study showed that 92% of patients with asthma improved significantly after one year on a vegan diet. On the other hand, some people feel weaker on a vegan diet. In addition, many people are allergic to vegetables rather than to meat.
Plenty of water should also be drunk by asthma sufferers, as water helps to keep the passages of the lungs moist. Onions and garlic contain quercetin, a flavonoid (a chemical compound/biological response modifier) that inhibits the release of histamine, and should be a part of an asthmatic's diet. Quercetin also is available as a supplement, and should be taken with the digestive enzyme bromelain to increase its absorption.
As nutritional therapy, vitamins A, C and E have been touted as important. Also, the B complex vitamins, particularly B6 and B12, may be helpful for asthma, as well as magnesium, selenium, and an omega-3 fatty acid supplement such as flaxseed oil. A good multivitamin supplement also is recommended. In 2004, a study of supplements at Cornell University showed that high levels of beta-carotene and vitamin C along with selenium lowered risk of asthma. However, the same study found that vitamin E had no effect.
Chinese medicine has traditionally used ma huang, or ephedra, for asthma attacks. It contains ephedrine, which is a bronchodilator used in many drugs. However, the U.S. Food and Drug Administration (FDA) issued a ban on the sale of ephedra that took effect in April 2004 because it was shown to raise blood pressure and stress the circulatory system, resulting in heart attacks and strokes for some users. Ginkgo has been shown to reduce the frequency of asthma attacks, and licorice is used in Chinese medicine as a natural decongestant and expectorant. There are many formulas used in traditional Chinese medicine to prevent or ease asthma attacks, depending on the specific Chinese diagnosis given by the practitioner. For example, ma huang is used to treat socalled "wind-cold" respiratory ailments.
Other herbs used for asthma include lobelia, also called Indian tobacco; nettle, which contains a natural antihistamine; thyme; elecampane mullein: feverfew; passionflower: saw palmetto: and Asian ginseng. Coffee and tea have been shown to reduce the severity of asthma attacks because caffeine works as a bronchodilator. Tea also contains minute amounts of theophylline, a major drug used for asthma. Ayurvedic (traditional East Indian) medicine recommends the herb Tylophora asthmatica.
Mind/body medicine has demonstrated that psychological factors play a complex role in asthma. Emotional stress can trigger asthma attacks. Mind/body techniques strive to reduce stress and help asthma sufferers manage the psychological component of their condition. A 1992 study by Dr. Erik Peper at the Institute for Holistic Healing Studies in San Francisco used biofeedback, a treatment method that uses monitors to reveal physiological information to patients, to teach relaxation and deep breathing methods to 21 asthma patients. Eighty percent of them subsequently reported fewer attacks and emergency room visits. A 1993 study by Kaiser Permanente in Northern California worked with 323 adults with moderate to severe asthma. Half the patients got standard care while the other half participated in support groups. The support group patients had cut their asthma-related doctor visits in half after two years. Some other mind/body techniques used for asthma include relaxation methods, meditation, hypnotherapy,, mental imaging, psychotherapy, and visualization.
Yoga and breathing methods
Studies have shown that yoga significantly helps asthma sufferers, with exercises specifically designed to expand the lungs, promote deep breathing, and reduce stress. Pranayama is the yogic science of breathing, which includes hundreds of deep breathing techniques. These breathing exercises should be done daily as part of any treatment program for asthma, as they are a very effective and inexpensive measure.
Many people believe that those with asthma should not exercise. This is particularly true among parents of children with asthma. In a 2004 study, researchers reported that 20% of children with asthma do not get enough exercise. Many parents believe it is dangerous for their children with asthma to exercise, but physical activity benefits all children, including those with asthma. Parents should work with the child's healthcare provider and any coach or organized sport leader to carefully monitor his or her activities.
Acupuncture can be an effective treatment for asthma. It is used in traditional Chinese medicine along with dietary changes. Acupressure can also be used as a self-treatment for asthma attacks and prevention. The Lung 1 points, used to stimulate breathing, can be easily found on the chest. These are sensitive, often knotted spots on the muscles that run horizontally about an inch below the collarbone, and about two inches from the center of the chest. The points can be pressed in a circular manner with the thumbs, while the head is allowed to hang forward and the patient takes slow, deep breaths. Reflexology also uses particular acupressure points on the hands and feet that are believed to stimulate the lungs.
Aromatherapists recommend eucalyptus, lavender, rosemary, and chamomile as fragrances that promote free breathing. In Japan, a common treatment for asthma is administering cold baths. This form of hydrotherapy has been demonstrated to open constricted air passages. Massage therapies such as Rolfing can help asthma sufferers as well, as they strive to open and increase circulation in the chest area. Homeopathy uses the remedies Arsenicum album, Kali carbonicum, Natrum sulphuricum, and Aconite.
Allopaths recommend that asthma patients should be periodically examined and have their lung functions measured by spirometry. The goals are to prevent troublesome symptoms, to maintain lung function as close to normal as possible, and to allow patients to pursue their normal activities, including those requiring exertion. The best drug therapy is that which controls asthmatic symptoms while causing few or no side effects.
The chief methylxanthine drug is theophylline. It may exert some anti-inflammatory effect and is especially helpful in controlling nighttime symptoms of asthma. When, for some reason, a patient cannot use an inhaler to maintain long-term control, sustained-release theophylline is a good alternative. The blood levels of the drug must be measured periodically, as too high a dose can cause an abnormal heart rhythm or convulsions.
Beta-receptor agonists (drugs that trigger cell response) are bronchodilators. They are the drugs of choice for relieving sudden attacks of asthma and for preventing attacks from being triggered by exercise. Some agonists, such as albuterol, act mainly in lung cells and have little effect on the heart and other organs. These drugs generally start acting within minutes, but their effects last only four to six hours. They may be taken by mouth, inhaled, or injected. In 2004, a new lower concentration of albuterol was approved by the FDA for children ages two to 12.
Steroids are drugs that resemble natural body hormones. They block inflammation and are effective in relieving symptoms of asthma. When steroids are taken by inhalation for a long period, asthma attacks become less frequent as the airways become less sensitive to allergens. Steroids are the strongest medicine for asthma, and can control even severe cases over the long term and maintain good lung function. However, steroids can cause numerous side effects, including bleeding from the stomach, loss of calcium from bones, cataracts in the eye, and a diabetes-like state. Patients using steroids for lengthy periods may also have problems with wound healing, may gain weight, and may suffer mental problems. In children, growth may be slowed. Besides being inhaled, steroids may be taken by mouth or injected, to rapidly control severe asthma.
Leukotriene modifiers are among a newer type of drug that can be used in place of steroids, for older children or adults who have a mild degree of persistent asthma. They work by counteracting leukotrienes, which are substances released by white blood cells in the lung that cause the air passages to constrict and promote mucus secretion. Other drugs include cromolyn and nedocromil, which are anti-inflammatory drugs that often are used as initial treatments to prevent long-term asthmatic attacks in children. Montelukast sodium (Singulair) is a drug taken daily that is used to help prevent asthma attacks rather than to treat an acute attack. In 2004, the FDA approved an oral granule formula of Singulair for young children.
If a patient's asthma is caused by an allergen that cannot be avoided and it has been difficult to control symptoms by drugs, immunotherapy may be worth trying. In a typical course of immunotherapy, increasing amounts of the allergen are injected over a period of three to five years, so that the body can build up an effective immune response. There is a risk that this treatment may itself cause the airways to become narrowed and bring on an asthmatic attack. Not all experts are enthusiastic about immunotherapy, although some studies have shown that it reduces asthmatic symptoms caused by exposure to dust mites, ragweed pollen, and cats.
Managing asthmatic attacks
A severe asthma attack should be treated as quickly as possible. It is most important for a patient suffering an acute attack to be given extra oxygen. Rarely, it may be necessary to use a mechanical ventilator to help the patient breathe. A beta-receptor agonist is inhaled repeatedly or continuously. If the patient does not respond promptly and completely, a steroid is given. A course of steroid therapy, given after the attack is over, will make a recurrence less likely.
Long-term allopathic treatment for asthma is based on inhaling a beta-receptor agonist using a special inhaler that meters the dose. Patients must be instructed in proper use of an inhaler to be sure that it will deliver the right amount of drug. Once asthma has been controlled for several weeks or months, it is worth trying to cut down on drug treatment, but this tapering must be done gradually. The last drug added should be the first to be reduced. Patients should be seen every one to six months, depending on the frequency of attacks. Starting treatment at home, rather than in a hospital, makes for minimal delay and helps the patient to gain a sense of control over the disease. All patients should be taught how to monitor their symptoms so that they will know when an attack is starting. Those with moderate or severe asthma should know how to use a flow meter. They also should have a written plan to follow if symptoms suddenly become worse, including how to adjust their medication and when to seek medical help. If more intense treatment is necessary, it should be continued for several days. When deciding whether a patient should be hospitalized, the physician must take into account the patient's past history of acute attacks, severity of symptoms, current medication, and the availability of good support at home.
Most patients with asthma respond well when the best treatment or combination of treatments is found and they are able to lead relatively normal lives. Patients who take responsibility for their condition and experiment with various treatments have good chances of keeping symptoms minimal. Having urgent measures to control asthma attacks and ongoing treatment to prevent attacks are important as well. More than one half of affected children stop having attacks by the time they reach 21 years of age. Many others have less frequent and less severe attacks as they grow older. A small minority of patients will have progressively more trouble breathing. Because they run a risk of going into respiratory failure, they must receive intensive treatment.
Prevention is extremely important in the treatment of asthma, which includes eliminating all possible allergens from the environment and diet. Homes and work areas should be as dust and pollutant-free as possible. Areas can be tested for allergens and high-quality air filters can be installed to clean the air. If the patient is sensitive to a family pet, removing the animal or at least keeping it out of the bedroom (with the bedroom door closed) is advised. Keeping the pet away from carpets and upholstered furniture, and removing all feathers also helps. To reduce exposure to dust mites, it is recommended to remove wall-to-wall carpeting, keep the humidity low, and use special pillows and mattress covers. Cutting down on stuffed toys, and washing them each week in hot water, is advised for children with asthma. If cockroach allergen is causing asthma attacks, controlling the roaches (using traps or boric acid rather than chemicals) can help.
It is important to not to leave food or garbage exposed. Keeping indoor air clean by vacuuming carpets once or twice a week (with the asthmatic person absent), and avoiding use of humidifiers is advised. Those with asthma should avoid exposure to tobacco smoke and should not exercise outside when air pollution levels are high. When asthma is related to exposure at work, taking all precautions, including wearing a mask and, if necessary, arranging to work in a safer area, is recommended. For chronic sufferers who live in heavily polluted areas, moving to less polluted regions may even be a viable alternative.
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