Respiratory Disorder  Bronchial Asthma

The asthma is an important disorder, the incidence of which is on the rise all over the world. The number of admissions due to exacerbation of asthma in age group 1-4 has increased 7 fold in recent years and the incidence in age 5-11 has increased to 3 fold. The incidence of this disease ranges from 5-15% of the population. The incidence in India ranges between 5-10% and in states it ranges between 5-15%. Even in UK the incidence is 5-8%. It forms 15% of the acute hospital admissions in children. In US there are 15 million people are afflicted with this episodic disease and in India approximately 10-20 million suffer from this disease. It is an important public health problem facing the developed and developing countries. As I grew up this disease has debilitated the lives of my neighbours and that is what making me to write briefly about this disease. My aim is to increase the awareness of this disease and control this disease in a better way.

Incidence- means number of new diseases reported or diagnosed in a population in a specific period of time (usually a year).

Prevalence- total number of cases of a disease in a population group as of a specific interval of time.

What is asthma?

Asthma is respiratory disorder with recurrent episodic attacks of breathlessness (dyspnoea), wheezing (musical sound while breathing) and cough with or with out chest pain or tightness in the chest. It is chronic disease and can be controlled but difficult to cure. It is due to the narrowing of the air tubes (bronchioles), which reduces the airflow in and out of the lungs and makes breathing difficult.

What are air tubes or bronchioles?

Bronchioles are the tertiary branches of the windpipe that is trachea which first divides in to 2 primary bronchi that is right and left and then the bronchi divides in to secondary bronchi and tertiary bronchi which finally ends as air bags or alveoli where gas exchange takes place. Alveoli are lined by small blood vessels where oxygen we breath goes in to the blood vessels and the unwanted CO2 (carbon dioxide) moves from the blood to the alveoli and finally breathed out. So in alveoli gas exchange of O2 and CO2 takes place between alveoli and blood vessels.

What is the mechanism of asthma developing or pathogenesis?

Three mechanisms play bigger role in causing airflow obstruction in the air tubes.

       I.      The muscles in the bronchi constrict and narrow the diameter and decrease the airflow.

     II.      The lining covering the air tubes or bronchi and bronchioles increase the mucous production and finally this mucous gets clogged and obstructs the airway

  III.      The lining of air tubes called mucosa swells and undergoes inflammation.

What are the precipitants or triggers that causes acute asthma?

Animal dander, smoke, pollen, toxic fumes, paints, aerosols, dust, pollution, allergy to food and drugs, upper respiratory tract infection with viruses (cold) and bacteria, exercise, cold air, atopy (sensitivity of the individual) are all triggering factors. 80% of the cases are triggered by viral infection. These pathogens makes airway more irritable and expose the nerve ending of the lining of the air tubes and makes them more vulnerable to irritation.

How do you recognize that your asthma is not controlled?

1. Inability to complete a task and becoming breathless for simple task
2. Inability to speak at a stretch or complete few sentences
3. Increasing chronic cough with flem or expectoration
4. Tightness of the chest or chest pain
5. The need to take heavy doses of inhalers or the treatment not having no effect
6. Need for an steroid
7. PEFR (peak expiratory flow rate)- your ability to breath out air in a unit time with a flow metre. This is very sensitive and may give a clue before the clinical symptoms appear or on the rise
8. Preceding viral or upper respiratory infection
9. Laboured breathing or the use of accessory muscles (neck muscle contraction)
10. Palpitation or awareness of increase in heart rate
11. Increase in respiratory rate

What do you mean by mild, moderate and severe asthma?

If you have more than three attacks in a year lasting more than a day it is classified as severe asthma. According to the PEFR flow rate device if the reading is less than 50% of the base line or predicted on measurement then it is severe, between 50-70% reading on the device then moderate and more than 70% of the base line or predicted then it is mild asthma

What are the symptoms (what patients complains to the doctor)?

1. Increasing shortness of breath (dyspnoea)
2. Cough which may be dry or with expectoration
3. Chest pain which increases on coughing
4. Wheezing (musical sound while breathing), more on expiration
5. Lethargy and weakness
6. No effect of inhalers or other treatment
7. Difficult to sleep at night
8. More difficulty in breathing in morning
9. Attacks after exposure to dander, dust, smokes or food intake (allergy), exercise.

 What are signs of asthma?

 

1. Increase in heart rate (tachycardia) usually more than 100/min
2. Increase in respiratory rate (tachypnoea) usually more than 20/min
3. Use of neck muscles and intercostals muscle for breathing
4. Wheezing can be heard without a stethoscope if moderate or severe
5. Chest tenderness (pain on examination)
6. bluishness of the lips and fingernails (cyanosis)
7. sweating, agitation and nervousness in severe attacks
8. Barrel chest in severe cases
9. In extreme cases decreasing level of consciousness and silent chest
10. Pulse oximetry showing low saturation (ability to oxygenate blood gets affected)
11. Spirometry showing low expiratory volumes (FEV1)
12. PEFR (peak expiratory flow rate less than 70% predicted)
13. Chest X ray may show big lungs with more air shadows
14. ECG shows fast heart rate or irregular rhythm.

 Why is asthma so important in public life?

 Asthma costs more to Governments than tuberculosis and AIDS put together. It cost in UK to Govt 1.8 billion for treatment and prevention. It is very important to educate the public and can be controlled. The cornerstone of any disease control lies in prevention than cure. The prevention depends on avoiding known allergens or respiratory irritants and taking the treatment regularly. It is important to recognize that asthma never stops though you may have symptom free period clinically. Taking treatment religiously and seeking medical attention can avoid unwanted admission and can decrease the severity of the disease.

How is asthma treated or what is the principle of treatment?

The treatment is in 2 forms

A.     Asthma relieving drugs -          These drugs which relieve acute symptoms and which act quickly and here we use drugs, which relax the bronchiole musculature and are called as bronchodilators. Short acting bronchodilators are used to treat acute asthma and are used for mild asthma. Long acting bronchodilators are used to control asthma on a long term. They are useful for long-term treatment Short acting bronchodilators Eg: Salbutamol Salbutamol (Ventolin) available as inhalers or    neubilizers or ampoules. Long acting bronchodilators: Albutarol and others.

 

B.Asthma controlling drugs  -   Corticosteroids are very useful drugs in treating acute and long-term asthma. They are safe when inhaled. They reduce airway oedema or swelling and reduce inflammation. They are safe in not causing bone loss or osteoporosis. The myth that steroids reduce growth in children is not true. They are different than steroids used by athletes where athletes used anabolic steroids, which are harmful to the body. As corticosteroids are inhaled less reaches the blood or circulation and less side effects. Even when used in the form of tablets they are safe.

Recent treatment for asthma:

Over the year the treatment of asthma has not changed much. Only evidence is that steroids reduces the hospital stay and reduces the recurrence rate of asthma. In recent years drugs like Leukotrienes inhibitors and mast cell stabilizers have cropped up and none of them are very effective on their own. Asthma can be treated with hyposensitization or taking allergy shots and may be effective in people who have definite allergy component as a trigger factor. Hypnosis, acupuncture, deep breathing exercises and relaxing exercises may help but not effective on their own. In recent time in a village in Hyderabad in India a lady is giving a paste, which is smeared on a live sardine, and claiming it cures asthma. More people are flocking that town to get cured. There is no medical evidence how this sardine therapy helps in curing or alleviating the symptoms.

How do you prevent asthma?

By avoiding the known allergens and respiratory irritants is the only way of controlling asthma. By avoiding pollen, animal dander, vacuuming house regularly, avoiding carpets in bedroom, avoiding pets and keeping pets out of the house all have been suggested. Be aware of sensitivity with Aspirin and NSAIDS (no steroidal anti-inflammatory agents) in asthmatics especially having allergic rhinitis and nasal polyps. Some time in children grow out of their asthma as they grow elder. Education forms very important tool in prevention. One can detect the flow metre reading (PEFR) metre reading low even before symptoms appear and recognizing the severity and seeking medical attention early forms important part of prevention. When asthma is exacerbated they do a medical evaluation and observe, treat with drugs. If severe patient may be admitted and in extreme cases the patient may need admission in an intensive care unit and may be put on artificial ventilation.

What are the symptoms of life threatening asthma?

1. . Inability to speak or complete even a sentence.
2.  Severe shortness of breath
3.  Severe wheeze with irritating cough
4.  Respiratory rate more than 35/minute
5.  Heart rate more than 120/minute
6.  Severe sweating, bliushness of the nails and lips
7. Neck muscles use for breathing
8. Retraction of the intercostals muscle
9. In severe cases no breath sounds are heard what we call silent chest
10. Decrease level of consciousness or sleepy feeling.

Among that bluishness of the lips, silent chest, sleepiness, sweating, exhaustion are pre-terminal signs. These people should be rushed to hospital and treated aggressively and may die before reaching hospital. Since asthma is a controllable disease no one should die of this disease but still in States and UK still people die of this disease. In America alone 500 people die in a year. That is unpardonable. The number of deaths in rural India may be 10 fold when compared to USA and UK.

To conclude that asthma is a common disease and more common in India and often neglected by the population and having a notion that it is mild disease. To have a prevalence rate of 10-15% in India one can conclude how important this respiratory disease causing loss of life and earning to the families. Though the Governments spend millions on this disease it is for the people to recognise and keep the disease under control by taking regular medication. Let the complacency will not creep and think his or hers asthma is gone is a cardinal sin. Even WHO recognized this that it is an important public health disease and started many programmes in education, prevention and in the treatment. Let us hope one day there may be cure from this episodic and recurrent respiratory disease. Those of you wonder what is asthma it is called “Ghoor” in colloquial Kannada and is called “Oosmoad” in Konkani.

 By D. Nagarkar, Date-1/08/2003

 

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