Asthma is a chronic (long term) inflammatory lung disease which leads to constriction (narrowing) of the airways. It is not known why this inflammation develops but asthma tends to be more common in those with a family history of asthma, children whose parents were smokers and also in those with a past history of allergic disorders such as hayfever and eczema. It’s likely therefore that genetic factors combined with certain environmental factors influences whether or not someone develops asthma. Asthma can start at any age but most commonly starts in childhood. Asthma is not currently preventable or curable, but it is controllable and most people who have it can lead active and relatively normal lives.
Asthma is a disease of the airways. The airways in our lungs are composed of tubes called bronchi and bronchioles. Bronchi are muscular tubes that carry air throughout the lungs, transporting it to and from smaller airway branches called bronchioles. Asthma affects these smaller tubes (bronchioles) by causing inflammation within the tubes. This causes the walls of the bronchioles to swell and produce extra fluid (mucus), which narrows the airway and makes it more difficult to breathe. Asthma also causes the muscles around the bronchioles to constrict which in turn narrows the airways further. The combination of these factors can cause a cough, wheeze or shortness of breath which are the main symptoms of asthma.
These symptoms may vary in severity depending on how bad the narrowing in the airways is and how long it lasts for, and asthma affects people to different extents. If the narrowing in the airways is quite severe this may result in an asthma attack where the person finds it quite difficult to breathe as very little air can flow along the airways. The attack may be so severe that the person needs to be admitted to hospital or even be put on a ventilator to help them breathe. At other times during an attack the airways may be less narrow and the person may have mild symptoms such as a cough or a slight wheeze. It is thought that there are certain “triggers” which irritate the airways and cause the symptoms of asthma. Everyone’s asthma is different and a person may have several triggers. However a lot of the triggers for asthma are due to people being allergic to particular substances which are called allergens. Asthma attacks can be triggered in these people if they come into contact with these substances. In these patients the airways over-react to allergens in the air such as pollen, pollution, mould, dust mites, animals, particles, and fumes and this causes the airways to constrict and become inflamed. Asthma attacks may also be caused by other triggers such as stress, strong emotional responses (laughing, crying, and anger), exercise, viral infections, and cold air. Sometimes asthma can be triggered by dust or fumes at work (‘occupational asthma’), for example people who work in chemical processing, food processing, metal work, spray painting, woodwork or farming. Medicines such as beta-blockers, aspirin and ibuprofen can also trigger attacks. Rarely, sulfites found in wine and dried fruit can cause episodes of asthma in some people. Asthma attacks can occur at any time but are especially frequent at night and in the morning.Inhalers are used to treat asthma and work by opening up the airways making it easier to breathe. This is usually by relaxing the muscles around the airways so that they open up (usually called a “reliever inhaler” e.g Ventolin). Other inhalers, such as steroid inhalers, work by reducing the inflammation in the airways that caused it to narrow in the first place. This effect is not immediate however and it takes some time for the inflammation to reduce. Because of this, these sorts of inhalers are usually used regularly to prevent asthma attacks and do not work to relieve an acute attack. Steroid tablets however also work in a similar way, and are often used for a short while together with inhalers in patients who are having a severe exacerbation (worsening) of their asthma. Although the effects are not immediate, they often help to reduce inflammation within a day or so reducing the risk of a severe attack that may require hospitalisation. They can also be used regularly as a preventative treatment in patients with extremely severe or uncontrolled symptoms. As the severity of asthma will differ for different people, some people will only need to use reliever inhalers. Others may need to use a preventer inhaler as they have regular attacks and those with really severe symptoms may be on long term oral steroids. Other oral medications may also be used in asthma. Montelukast is a tablet that blocks the effect on the airways of a substance called leukotriene, which causes inflammation in the airways. Another medication called theophylline works on relaxing the muscles around the airways.
It is important you know how and when to take your medications, and when to seek medical attention. Your doctor may give you written instructions (‘asthma action plans’) which can help you to take control of your own asthma. Asthma reviews help you make sure that you are getting the right treatment and that you know how to use your inhalers properly. If you are a smoker then one of the best things you can do to help your asthma, or your child’s asthma, is to stop smoking
There is no single test which can prove a diagnosis of asthma. Asthma symptoms can vary from day to day so if you have one normal test result it doesn’t mean you don’t have asthma. Asthma is commonly diagnosed from history with a patient having the classical symptoms of asthma. However, tests such as lung function tests can also be useful to help diagnose asthma and to distinguish asthma from other lung diseases. These lung function tests are also used to keep an eye on patients who have asthma to monitor their progress and during severe attacks to help determine treatment. Other tests such as lung inflammation tests can help improve accuracy of diagnosis. Blood tests may also help to identify allergies that may be making asthma worse.
Lung Function Tests
- These are simple breathing tests which measure the amount of air you can blow out from your lungs or how quickly you can blow air out from your lungs. This may be done by blowing into a machine called a spirometer or a small hand held device called a peak flow meter. Spirometry: Spirometry is a test to measure how much air you can blow out of your lungs and how quickly you can do so. It calculates two main things. Firstly, the amount of air you can blow out in one second (called forced expiratory volume in 1 second or FEV1) and secondly the total amount of air you can blow out of your lungs in one breath (called forced vital capacity or FVC). After this, a ratio of the two values is calculated, and this is called the FEV1/FVC ratio. As you would expect in asthma if your airways are narrowed and inflamed you will not be able to blow out all the air out from your lungs and it will take you longer to do so. An FEV1/FVC value of <70% indicates that you have narrowed airways, often called obstructive lung disease. This can occur in asthma but in other lung diseases too. However, an improvement in the value after treatment to open up the airways (e.g. an inhaler) is typical of asthma. Therefore, spirometry may be repeated after using an inhaler to see if there is any improvement. It is important to remember however that as asthma symptoms are variable a normal result does not mean that you do not have asthma. However a normal result usually excludes any other lung disease from causing your symptoms.
- Peak flow testing: Unlike spirometry which measures the amount of air you can breathe out from your lungs, peak flow testing only looks at how hard and how quickly you can blow air out from your lungs. If your airways are narrowed, as in asthma, you will not be able to blow out air as hard or as quickly as would be expected for your age and size. As asthma symptoms vary and are usually worse in the morning and night, you may be asked to keep a diary of the peak flow results .If you are asthmatic it would be typical to see a variation in the results with the worse results being in the morning and the evening.If your results are worse when you are at work and better at home this might suggest occupational asthma, triggered by allergens such as dust or fumes at work.
- Reversibility testing: This is when tests such as spirometry and other lung function tests are done before and after a treatment for asthma e.g. an inhaler or steroid tablets. If a patient is asthmatic it would be expected that the results would improve dramatically after treatment.
Trial of treatment: Similarly doctors or nurses may prescribe asthma medications to see if your symptoms respond to treatment. If they do it is a good indication that you have asthma but if they don’t, taking them would not have done you any harm.
Additional tests and Imaging Studies
- Pulse oximetry – This measures the amount of oxygen in the blood by placing a small plastic device over the end of a finger. The amount of oxygen in the body would be expected to be normal in asthma patients unless they are having a severe attack which is stopping them from breathing properly. Therefore this test may be used for a person having a severe asthma attack to see if enough oxygen is getting around the body. It is also helpful in ruling out diseases other than asthma, as if a person was not having an acute asthma attack but had low oxygen levels, it is likely that their symptoms may be caused by another lung disease.
- Chest x-ray – to look for signs of infections or other lung diseases that may mimic asthma An x-ray may also be used to look for signs of asthma as the lungs are often larger than normal due to loss of elastic recoil in asthmatic lungs. Elastic recoil is the ability of the lungs to rebound back to their normal position after being stretched by breathing in. As this is often lost in asthma the tissue of the lungs may not be packed as tightly and therefore the lungs may appear “hyper-inflated”on x-ray. This is usually more common in those with severe or long standing asthma symptoms. Therefore the chest x-ray is often normal in asthmatic patients and a normal x-ray does not mean you do not have asthma.
- Airway inflammation tests: Fractional exhaled nitric oxide (FeNO): This test measures levels of nitric oxide in the breath. Nitric oxide levels are raised in asthma due to inflammation of the airways. To do the test you blow steadily into a handheld device. If nitric oxide levels are above 40 parts per billion (or 35 parts per billion for children aged 5-16) this is suggestive of asthma.
- Airway responsiveness tests: these are specialist tests carried out in hospital which can be useful if other tests such as spirometry don’t give a clear picture. They can also be called ‘airway hypersensitivity tests’ or ‘bronchial challenge tests’. These tests measure how your lungs react to asthma triggers. You will breath in a substance such as histamine or methacholine, and then blow into a machine called a spirometer to see whether your airways have become narrower. If you develop asthma symptoms a specialist will be on hand to monitor or treat your symptoms.
Laboratory testing is rarely needed, but can sometimes help rule out conditions that cause symptoms similar to asthma, to identify allergies, and to help find and assess complications of asthma. During severe asthma attacks, testing may be used to look for problems with oxygen levels, the body’s acidity and signs of infection. Tests include:
- Allergy testing – blood tests, or skin prick tests for the allergen(s) suspected to be causing symptoms, such as dust mites, mould, pets, and pollens. This is normally reserved for patients with severe asthma or asthma not responding to treatment.
- Blood gases – Blood gases may be used in severe asthma attacks to check for any complications from the breathing difficulty. In this test an arterial blood sample is collected to look at acidity, oxygen, and carbon dioxide levels. This is because the difficulty in breathing can alter the levels of oxygen and carbon dioxide in the blood, the latter of which can cause dangerous pH changes in the blood stream as carbon dioxide is acidic. Therefore too much carbon dioxide or too little carbon dioxide can alter the pH of the blood. If this happens a person may need to have specific treatment to counteract this as many of the body’s normal functions do not work if the pH in the blood changes.
- FBC (Full Blood Count) – to look for signs of infection that may be complicating asthma or mimicking the signs of asthma. Infection would typically result in a raised white cell count as these cells fight infection. In addition, eosinophils a particular type of white blood cell can be increased with inflammation in some asthma patients and may help with diagnosis.
- Renal Function –to ensure the kidneys are working as they may be affected during an acute asthma attack especially if there are pH changes in the blood.
- Theophylline – therapeutic drug monitoring if a patient is taking this medication levels may be checked to ensure the concentration in the blood is adequate.
Other tests that may be occasionally requested:
- Cystic fibrosis tests – to rule out cystic fibrosis another lung disease
- Sputum culture – to diagnose lung infections caused by bacteria or fungi
- AFB smear and culture – to diagnose tuberculosis and nontuberculous mycobacteria (NTM) which are other causes of lung infection
- Lung biopsy – to look for damage to the lungs
- Sputum cytology – occasionally requested to look for abnormal cells in the lungs.
- Blood Glucose – may help rule out diabetic acidosis which can cause breathing problems and imitate symptoms of an asthma attack.
The goals with asthma treatment are to:
- Prevent or minimize the number of asthma attacks
- Resolve asthma attacks quickly and reduce A&E visits and hospitalisations
- Achieve and maintain good asthma control
- Minimise and slow the progression of lung damage
- Identify, treat, and resolve where possible, conditions that make asthma worse, complications associated with asthma or side effects from medication
- Educate patients about their condition and their treatment
- Encourage an active normal lifestyle
- Prevention of asthma attacks is achieved through a combination of avoiding substances that trigger episodes, having good asthma control, and recognizing and addressing the early signs of an impending attack. For more on this, visit the Asthma UK website.
Asthma treatment is tailored to the individual and depends upon the severity. Both long-term and short-term controls must be addressed. Even people with mild asthma may occasionally have severe asthma attacks.
Patients should work with their doctor to learn about their or their child’s asthma. Doctors can help patients keep a close eye on their asthma and ensure they get the best medicine to treat their asthma over time. They should develop a treatment plan that guides their day-to-day asthma control, guides their actions when an asthma attack occurs, and helps them determine when they should seek medical attention. Doctors will take into account the entire clinical picture and all of the drugs that they are taking when determining the best course of treatment.