ASTHMA

ASTHMA

I-Definition 

Asthma is a heterogeneous disease, usually characterized by inflammation of the lower airways, especially the bronchi. It is defined by recurrent episodes of respiratory symptoms such as wheezing  , shortness of breath , chest tightness , and/or cough, and by variable expiratory limitation that may become persistent in later stages of the disease. These symptoms and expiratory limitation characteristically vary in time and intensity, and may sometimes be absent for weeks or months. These variations are due to factors such as exercise,  allergens , irritant exposure, change in  weather , or viral infections. They are generally reversible with treatment or spontaneously.

Asthma is typically associated with bronchial hyperresponsiveness to direct or indirect stimuli, and chronic inflammation. These features typically persist even in the absence of symptoms or even when  lung function  is normal, but may normalize with treatment. ⁴

II-Phenotypes 

Allergic asthma 

usually begins during childhood and is associated with a  personal or family atopic background  (eg allergic rhinitis; eczema, food or drug allergy, etc.). These patients generally have a good response to   inhaled corticosteroids .

Non-allergic asthma 

also called non-atopic or intrinsic: some patients have asthma that is not associated with an allergy, with  negative skin tests for aeroallergens and normal total and specific serum IgE  concentrations . However, local production of IgE has been identified in some patients in this population. Neutrophilic ,  eosinophilic and paucigranulocytic  asthma   (with few inflammatory cells) are distinguished. Inhaled corticosteroids are generally less effective in this population. This phenotype is generally more severe than allergic asthma.

III-Factors promoting, triggering or aggravating 

Asthma is sensitive to several factors:

• contact with an allergen: mites, pollens, animals, etc.;
• sun and heat: the hatching and dissemination of allergenic pollens have an asthmagenic role;
• intense physical exercise  ;
• inhalation of pollutants such as fumes, exhaust gases, aerosol cans or paints;
• virus: a simple cold can cause an asthma attack after a few days;
• taking certain medications: aspirin or nonsteroidal anti-inflammatory drugs, medications for high blood pressure, certain eye drops, etc.;
• ingestion of a food leading to a food allergy;
• Gastroesophageal reflux disease  worsens asthma and may be a trigger for attacks. GERD also appears to be able to trigger adult-onset asthma in some patients. It may also be a complication of asthma in others. In any case, there is a strong association between the two.
• hormonal changes: pregnancy ²⁵ , menstruation..
• Psychological stress can worsen symptoms – stress is thought to impair the immune system and thus increase the inflammatory response of the airways to allergens and irritants. ²⁶
• strong emotions (anger, annoyance, etc.), particularly due to hyperventilation.

IV-Clinical manifestations 

The role of the bronchi is to protect the lungs from foreign agents or external aggressions, in particular by restricting the bronchial diameter. Asthma is manifested by a disproportionate reaction of the bronchi in relation to the environment. Thus, the bronchi of an asthmatic are inflamed and see their diameter reduced. The mucus produced in reaction to the inflammation and the bronchoconstriction further reduce the diameter of the bronchi, making expiration difficult; this is called expiratory bronchial obstruction.

In all types of asthma, the following symptoms are found:

• prodromal signs   of an attack may be subtle, such as tingling in the throat, runny nose, sneezing, induced by inflammatory secretions at the start of the attack;

• difficulty breathing or  dyspnea  ;
• respiratory oppression (feeling of heaviness in the chest);
• tachypnea   or conversely  bradypnea , that is to say an increase or decrease in respiratory rate ;
• a whistling sound when exhaling (known as  sibilant breathing );
• a decrease in hemoglobin oxygen saturation  , mainly in severe crises;
• tachycardia   ;​
• a  draw  in the event of a severe crisis;
• a  dry cough  that may be chronic or predominate at night and early in the morning; at the end of the attack there may be abundant viscous and sticky expectorations, grayish white or translucent, foamy and pearly (in which opalescent grains “cooked tapioca” are seen formed in the small bronchi). This is called  Laennec’s pearly sputum .
• attacks that can appear after physical activity (we then speak of exercise-induced asthma or more correctly of exercise-induced bronchoconstriction).

Only the intensity, duration and causes of these symptoms vary from one type to another.

Several repeated asthma attacks over a short period of time define an  asthma exacerbation  (formerly called  an asthma attack ).

V-Classification according to severity

Asthma attacks are also classified as follows:

1- Intermittent asthma  which is arbitrarily defined by the occurrence of, at most, two brief attacks per week, and/or two nocturnal episodes per month, and a PEF (  peak  expiratory flow ) greater than 80%.

2- Persistent asthma  which is defined when there are more than two episodes per week, and/or more than two nocturnal episodes per month, with repercussions on daily activities. It can be mild, moderate or severe.

3- Severe acute asthma  or status asthmaticus which is life-threatening. This is the most serious form of asthma in the short term, the degree of bronchial reaction can be particularly significant and sometimes fatal. It requires  urgent hospital treatment  (for example, in  France  around 2,000 people die of asthma per year, or 3.2 cases per 100,000 inhabitants) ²⁹ . 

VI-Treatments

Salbutamol   inhaler (e.g. Ventolin) is the most commonly used medication to treat asthma in France, where more than 65% of people with asthma use this bronchodilator. To treat chronic asthma, the addition of  corticosteroids is  necessary to counteract inflammation of the bronchi.

1- Background treatment

anti-inflammatory drugs, inhaled corticosteroids (eg, Flixotide which is  fluticasone propionate ). 

2-Treatment of the crisis

First-line treatment is a short-acting beta-2 mimetic (for example, Ventolin, which is  salbutamol ). This bronchodilator provides daily relief for the patient and would have an impact on the benefit/risk balance of the treatment. If the consumption of beta-2 mimetic exceeds one metered-dose inhaler per year (i.e. 2 uses per week), it is advisable to start a background treatment.

3-Special recommendation regarding allergies

It is recommended to monitor allergies and possibly treat them with  antihistamines . People suffering from allergic asthma should avoid contact with the most common allergens: cat hair, dust, pollen, etc.

4-Therapeutic education of the patient [  

This is based on different areas of skills that the patient must acquire:

• knowledge of the disease;
• ability to detect a variation in respiratory status;
• knowledge of the different treatments (background and asthma attack);
• mastery of inhalation technique;
• knowledge of the attitude to adopt in the event of a crisis;
• knowledge of the importance of having good adherence to treatments.

ASTHMA

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ASTHMA