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Asthma is a chronic inflammatory airway disease, characterized by generally reversible obstruction of the bronchi. The obstruction of the bronchial shaft is caused by the inflammation of the lower airways and its consequences: because of the inflammatory process, the bronchi contract, fill with liquid and produce excess mucus, reducing overall the available space for free air circulation.
As a result, bronchial asthma causes:
- Lack or difficulty in breathing
- Whistling or hissing breath
- Sense of chest tightness.
Bronchial inflammation is often caused by the sensitization of the bronchial tree to particular allergens; in practice, in contact with certain substances (pollen, pollutants, smoke, etc.) the respiratory tract of an asthmatic person responds exaggerated by inflating and shrinking. There is a talk of bronchial hyperactivity because the same stimuli, at the same dose, do not give meaningful responses to healthy subjects. Other symptoms include shortness of breath and sense of chest tightness. These symptoms vary daily, but prevail at night and early in the morning.
In the presence of asthma, bronchial hyperactivity occurs in smooth muscle, regulated by the action of the parasympathetic nervous system through the vague nerve. In the course of bronchial inflammation, mast cells, eosinophilsand T lymphocytes release chemical mediators that directly affect: musculature, glands, and capillaries. During an asthmatic crisis, the inhaled air reaches the alveoli, but the presence of bronchial obstruction prevents it from escaping with exhalation. So air can enter, but it can not get out of the holes.
Asthma is particularly widespread among the population, as it affects approximately 5% of Italians and almost 10% of infants on average. These data should then be added to all those cases where the subject is sick without knowing it. It may happen that the symptoms of asthma are malformed or underestimated by the patient, especially if they are young; a certain portion of the population tends to ignore the typical symptoms of the disease without giving too much weight to the alarm signals sent by the body.
When a person suffers from asthma, he or she experiences such symptoms as:
- Wheezy, more or less persistent cough, which may appear or accentuate duringnighttime or awakening, sometimes associated with stuffy nose or repeated sneezing
- Difficulty in breathing ordyspnea (tired breath, short breath)
- The breath is wheezing even if this characteristic is not always perceived by the patient
All of these symptoms do not occur at the same time in the same person, nor do they always occur with the same intensity (when they are very intense they also speak of an asthma crisis) and can develop at different times throughout their lives. Finally, one must never forget that even if for long periods of time it does not show signs of itself, asthma is a chronic illness that, if neglected, threatens with sometimes severe exacerbations.
Importance of early diagnosis
In any case, if symptoms such as coughing, shortness of breath and wheezing occur, it is necessary to carry out appropriate investigations, as asthma, unfortunately, is certainly not a disease to be taken lightly. It should also be remembered that although it affects mainly young people, asthma may arise at any age. In particular, after thirty years, this disease affects mainly women, tendentially has no allergic origin and is poorly responsive to drug therapy. The important thing in any case is to diagnose asthma as soon as possible as the cures exist, they are effective and allow the patient to lead an absolutely normal life.
The presence of one of these signs and symptoms should induce suspicion of asthma:
- Frequent (more than once a month) episode of wheezing breath
- Cough or wheezing breath induced by physical strain
- Cough especially at night, even outside respiratory infections
- Absence of a seasonal pattern of symptoms
- Symptoms are persistent over 3 years
Symptoms worsen in the presence of:
- Aeroallergens (domestic powders, pet animals, cockroaches, mushrooms)
- Chemical pollutants
- Viral respiratory infections
- Intense emotions
- Symptoms respond to anti-asthma drugs
- Cold episode that ’drops to the bronchi’ or takes more than 10 days to resolve
Causes and risk factors
When it comes to asthma, one can not safely define a single cause of origin. Undoubtedly, some factors such as familiarity for pathology, allergies and hypersensitivity to particular irritant and non-toxic substances (smoking, polluting, pollen, mites, blockers, aspirin, etc.) play a very important role. Viruses and bacteria can cause inflammation of the airways, triggering asthmatic crises in the predisposed subjects.
During pregnancy, about 1/3 of asthmatic women undergo a worsening of the disease. Exercise is also a stimulus that can induce or exacerbate an asthma episode (sports asthma). In these cases, symptoms of illness only occur during sports activities or during particularly intense physical engagement. About 20% of asthmatic children do not develop asthma after adolescence.
Risk factors for asthma can be classified into genetic factors and environmental factors. The latter include all those factors that affect the development of asthma in predisposed individuals, and which cause persistent exacerbations and / or symptoms in subjects with the disease itself.
Atopy is a genetically determined predisposition to produce an excess of IgE in response to allergen exposure and is evidenced by the demonstration of increased serum levels of specific IgEs and / or a positive response to cutaneous allergy tests (CAT) carried out with a standardized inhaler allergen battery.
The proportion of asthma attributable to theatopia is about half of the cases. Theatopia is a hereditory condition; therefore, you appreciate an increased risk of developing asthma in the presence of atopic parents with asthma.
Usually atopic dermatitis precedes the development of allergic rhinitis and asthma. Allergic rhinitis is therefore an important risk factor for the development of asthma. Nonetheless, the two pathologies often coexist in the same patient and in many cases allergic rhinitis precedes the development of asthma. Another element to consider is the possible presence of wheezing recurrent in the early life of the baby. Some of these children will develop asthma.
Environmental factors that influence the development of bronchial asthma. Allergens are considered an important cause of bronchial asthma. The increase in incidence of asthma is mainly due to the perennial forms, with a significant proportion of which it is possible to detect an allergen sensitization, such as mites, pet (cat and dog) and mold. A meta-analysis of environmental factors considered responsible for the incidence and severity of asthma concluded that exposure to indoor allergens is the environmental factor with the strongest effect on asthma development.
The main allergenic sources of external environments are pollen, derived from herbaceous and arboreal and micofite plants. Other agents responsible for asthma are professional sensitizers. These are responsible for 9 to 15% of asthma cases in adults. The most commonly involved substances are isocyanates, flour, grain powder and wood and latex.
Tobacco smoke plays an important role in the development of asthma and adversely affects the control of the disease. Exposure to passive smoking, both pre-naturally occurring throught mothers during pregnancy and during childhood, is an important risk factor for the development of asthma in infancy and adulthood. Exposure in adulthood worsens the control of asthma in people affected by it.
Exposure to environmental pollutants is often associated with an exacerbation of preexisting asthma. The most common external pollutants are: oxides of nitrogen, ozone, PM10 thin particulate, carbon monoxide and sulfur dioxide. They increase mainly during the winter months in cities, for the most frequent vehicular traffic, for domestic heating and for climatic environmental conditions favorable to their concentration.
Modern constructions, characterized by a reduced air exchange, can contribute to a greater exposure to chemical pollutants (smoke and vapor irritants) present in internal environments resulting from combustion of gas and detergents.
Nasal polyps, rhinitis, sinusitis, gastroesophageal reflux can contribute to the manifestation of asthma. Control of these diseases, therefore, also promotes asthma control, reducing the frequency of exacerbations.
Risk factors for the onset of asthma
Professional sensitizers (latex, chemicals, flours, animal skin derivatives…)
Tobacco smoke (active and passive)
Eating habits (diet poor in antioxidants) and medicines (such as antibiotics and antipyretics in childhood)
Prevalent life in internal environments
Various studies have shown that the hereditary component affects about 30-60% (more or less importantly, asthma or atopia in the two parents) and that the mother has a predominant role.
Asthma and gastroesophageal reflux
Gastroesophageal reflux is a particular situation due to an incontinence of the homozygous sphincter (gastroesophageal). In asthma sufferers this condition can cause attacks that occur predominantly at night and in particular when you are on the run after a meal. Because of the incontinence of this sphincter that normally allows the passage of foods in a single direction, it may happen that some of the gastric contents go through the esophagus. The subsequent passage of small amounts of food into the respiratory tract triggers the asthmatic crisis in the predetermined subjects.
To assess the progress of asthma there are small and simple devices employed; they provide the patient with a general indication of the health of their bronchi. For a more in-depth diagnosis, however, a specialist visit is required.
Even in this case, the examination is very simple: it consists of exhaling strongly in a mouthpiece connected to a device called spirometer. Depending on the results of spirometry (FEV1 or PEF) and the analysis of symptoms, it is possible to classify asthma.
The goal of treating asthma is to reach and maintain control of clinical manifestations of the disease for prolonged periods.
That is to meet the following points:
- No (or minimal) chronic symptom(s).
- None (or at most rare) exacerbation(s).
- No emergency visit or hospitalization for asthma.
- No (or minimum) need for additional use of Beta-2 agonists for the relief of symptoms.
- No limitation during exercise.
- PEF daily change of 20%.
- Normal lung function or as best as possible.
- No (or minimal) effect / side effects of the medications.
To achieve these goals, the guidelines recommend developing a service plan organized into four related components:
- Encourage the patient to develop a close relationship of collaboration with the doctor.
- Identify and reduce exposure to risk factors.
- Evaluate, treat and monitor asthma.
- Manage asthma exacerbation.
Asthma, by definition, is a chronic disease and as such it should be followed in time both from a diagnostic point of view and from a therapeutic point of view. In fact, this is an asymptomatic pathway alternating with sometimes severe exacerbations.
For this reason, asthma therapy is based on the use of:
- ’Baseline’ anti-asthmatic drugs, to be continuously taken to keep the disease under control,ie without any symptoms
- Drugs ’at the need’, to be taken only before a real need
Unfortunately, alternating phases ’authorizes’ somehow patients to self-suspend the underlying therapy or to follow it in their own way. Unfortunately, all this freedom can cost really dear, as it increases the risk of exacerbations and can even aggravate the disease.
An asthmatic crisis is in fact determined by the reduction in the number of bronchi, which in turn is responsible for decreased oxygen supply to the various tissues. Every time this happens the body suffers a damage that is summed up to the previous one, amplifying the symptoms and aggravating the disease.
So we come to define a fundamental rule that an asthmatic should never forget:
In the presence of asthma, therapy should never be abandoned or suspended in advance, even if the symptoms decline
If very often the patient feels like it is wrong to continue receiving therapy, while in reality this improvement is undoubtedly due to the efficacy of anti-asthma drugs.
The great revolution in pharmaceuticals began in the 1970s with the advent of bronchodilators and inhaled cortisone. Thanks to pharmacological evolution, access to hospitals has been greatly reduced and asthma treatment has become all-round home.
In order to cure this disease, predominantly inhaled therapy is used, as this way the medication arrives faster in the respiratory tract and gives immediate benefit. Each can contains a different active ingredient, chosen and prescribed by the physician or the specialist who cares for the patient.
Inside one can find:
- Short-acting bronchodilators and long-lasting action: they act primarily by dilating the airways and releasing smooth bronchial musculature. Invert and / or inhibitbronchocostriction and acute acne-related symptoms, but do not reverse airway inflammation and do not reduce bronchial hyperreactivity;
- Corticosteroids: used inhaled directly into bronchi, reducing the side effects typical of cortisone by mouth;
- Non-steroidal anti-inflammatory drugs: they are more effective than bronchodilator treatment in long-term control of symptoms, to improve respiratory airway function.
Even in the field of bronchodilators, not all drugs are the same. Some produce an immediate bronchodilation effect, but disappears just as rapidly (short-term bronchodilators), while others are indicated for prolonged use. If you often feel the need to use short-acting bronchodilators (recurrent asthma attacks), you should contact a specialist for a check-up visit.
The use of inhaled medications, although extremely effective, is fraught with the difficulties associated with the method of administering the drug itself. To further complicate the situation then we put the different application systems for common use sprays.
- When using an inhaler, it is good to remember to shake the can before use. The leaflet will in any case suggest the best procedure to use it.
- Keep the corpus erect and exhale deeply.
- Bring the inhaler into the mouth or in front of it, inhaling and simultaneously pressing the can.
- At this point, hold your breath for a dozen seconds, after which exhale deeply.
- Repeat the operation if the therapy involves a second inhalation.
All these difficulties have pushed the pharmaceutical industry to produce new inhaler powders.
Asthma therapy may provide, in the case of poor response to the high-dose medicines exposed so far, the use of other medicines, second-choice because of a worse-than-expected risk / benefit ratio. Among these drugs are methylxanthines (theophylline and its derivative Aminofillin), to be taken systemically, or anticholinergics (ipratropium bromide) for aerosols.
When suffering from asthma you should never forget some simple hygienic and behavioral norms. In case of allergy to dust, it is good, for example, to remove curtains and carpets from your home. More generally, every asthmatic should be as far away from those irritant or allergenic substances that trigger the crisis (smoke, fresh varnish, animal hair, pollen, pungent odor, etc.).
Top 20 Drugs for Asthma Treatment
Although there is still no fully cure for asthma, some drugs may relieve the symptoms and keep the prodromes under control. Long-term prevention and control are key to the prevention of asthma attacks: before prescribing a drug, the patient is subjected to all medical assessments useful to diagnose the type of asthma and the severity of the condition.
It should be noted that the asthmatic patient does not manifest the typical symptoms every day: the disease is termed ’chronic’ because it is characterized by asymptomatic phases alternating to periods of exacerbations, even rather serious. Asthma may appear suddenly and the patient must be ready to intervene before the condition is worse. During asymptomatic phases, it is important not to interrupt therapy, even in healthy health: this prevents sudden asthma attacks.
The following are the classes of medicines most used in asthma therapy, and some examples of pharmacological specialties; it is up to the physician to choose the active ingredient and the most suitable posology for the patient, depending on the severity of the illness, the health of the patient and his / her response to the treatment:
- Anticholinergic bronchodilators: dilating the respiratory tract, releasing bronchial muscles allowing the patient to breathe better. Short-lasting and long-lasting bronchodilators are available: the former are referred to as ’life-saving drugs’ and are a useful aids to relieve the respiratory tract in a short time, useful for acute asthma attacks. Long-term bronchodilators are used in the prophylaxis of asthma. Bronchodilators do not interfere with inflammation in the respiratory tract, nor are they able to reduce the hyperactivity of the bronchi.
- Ipratropium bromide (e.g. Atem, Breva): The drug is available in formulations consisting solely of the active principle or in combination with beta-2 agonist drugs. By aerosol, repeat 2 inhalations (36 mcg) 4 times per day (do not exceed 12 inhalations per day). Alternatively, take a 500 mg monodose (spray solution) vial, 3-4 times daily. Ipratropium is indicated to relieve asthma symptoms in the context of COPD and for the treatment of rhinorrhea.
- Isoetarine: The drug exercises a discreet relaxed activity at the level of smooth vascular and bronchial musculature. Consult your doctor.
- Diphyline: Generally, the drug is available in association with Guaifenesin (e.g. Broncovanil, Vicks Cough Fluidific), antitussive-expectorant substance. Dosage and route of administration should be determined by the physician.
- Theophylline (e.g. Aminomal Elisir, Diffumal, Respicur): it is a xanthine drug used in therapy to reduce the bronchi-constrictor stimulus. Theophylline is indicated for the treatment of chronic bronchitis and COPD associated with asthma: the drug should be taken at a loading dose of 5 mg / kg. The drug is often recommended in association with antitussive / expectorant. There are already dosed drug preparations. Consult your doctor.
- Inhaled glucocorticoids: They reduce inflammation in the respiratory tract. Inhaled glucocorticoids are especially useful to allow the patient to breathe better and to relieve short breathing. It is important to remember that steroid drugs should not be taken in excessive amounts, nor are they recommended for long periods, as they may favor the risk of hypertension, diabetes, weakening of the bones and cataracts.
- Fluticasone (e.g. Avamys, Alisade, Fluspiral Diskus, Nasofan): For patients previously treated with bronchodilators, it is recommended to initiate therapy with 88mcg of medication twice a day (aerosol). Do not exceed 440 mcg twice a day. Instead, for asthmatics previously treated with inhaled corticosteroids, it is recommended to initiate treatment with fluticasone at dosage of 88-220 mcg, twice daily. Again, patients previously treated with oral steroids should start treatment with this drug at higher doses (aerosol: 880 micrograms, twice a day. Do not exceed 880 mg twice daily.).
- Beclomethasone (e.g. Clenil): suitable for maintenance therapy in asthma contest. It is recommended to take 40-80 mg of aerosol active (2 inhalations of 40 mcg twice daily). Do not exceed 640 mcg per day.
- Flunisolide (e.g. Flunigar, Nisoran): This drug, widely used in treatment for allergic rhinitis, is sometimes used to treat asthma. Consult your doctor.
- Ciclesonide (e.g. Alvesco): suitable for asthma maintenance. The dosage ranges from 80 to 320 mcg, to be inhaled, according to the previous treatment. For example, if the asthmatic patient has previously been treated with bronchodilatory therapy, the dose of ciclesonide is minimal, while it is maximum if the asthmatic has previously been treated with oral corticosteroids for asthma.
- Triamcinolone (e.g. Kenakort, Triamvirgi, Nasacort): Particularly suitable for treating asthma in the baby.t is recommended to administer 1-2 inhalations (75-150 mcg), 3-4 times a day. Alternatively, you can administer 2-4 inhalations (150-300 mcg), 2 times over 24 hours.
- Methylprednisolone (e.g. Advantan, Metilpre, Depo-medrol, Medrol, Urbason): For the treatment of acute asthma attacks, it is recommended to take either intravenously or intravenously an active dose of 40-80 mg per day, 1 -2 times a day. For maintenance therapy, it is advisable to take the oral medication at a dose of 7.5-60 mg, preferably in a single dose in the morning or evening.
- Budesonide (e.g. Biben, Pulmaxan): often formulated with beta-2 agonist drugs. The drug is administered by inhalation: repeat two applications (200-400 mcg) twice a day. Do not exceed 400 mcg per day. In case of previous treatment with corticosteroids, the dose can be increased up to 800 mcg per day (divided into 4 inhalations twice a day).
- Beta-2 agonists: these drugs are derived from noradrenaline. They work in very short times and are particularly well-suited to alleviate the symptoms that occur during acute asthma attacks.
- Salbutamol (Ventolin): by inhalation, it is recommended to take 0.2 mg (1 spray) for the nostrils; The drug is also available as a solution for injection in a vial of 0.5 mg. Oral administration (2-4 mg tablets) and parenteral (0.5 mg) is recommended when asthma attacks become particularly frequent and violent.
- Salmeterol (Serevent): At the dose of 0.25 mg per spray (to inhale 1-2 times per nostril daily), this drug is recommended for maintenance treatment.
- Formoterol (e.g. Oxis Turbohaler, Sinestic Mite, Symbicort Mite, Kurovent): suitable for the maintenance of asthma. It is recommended to take 12 mcg of medication (1 sprays) for the nostril every 12 hours. Do not exceed 24 mcg. The drug is also available as inhaled capsules.
- Antileucotrienes: These drugs are sometimes used in asthma therapy because they are able to block CYS and LT1 receptors at the level of bronchi and lungs.
- Montelukast (e.g. Singulair): reduces the frequency of asthma attacks and bronchial swelling. Indicatively, it is recommended to take 10 mg of active substance per os, once a day.
- Zafirlukast (e.g. Accoleit, Zafirst): The recommended dose for asthma maintenance therapy is 20 mg, to be taken orally twice a day, preferably one to two hours before meals.
When asthma is directly related to allergic reactions, the most commonly used drugs are antihistamines; choosing a drug rather than another is of medical expertise. In addition, allergic asthma can be treated with immunotherapy, based on the administration of immunomodulatory drugs such as Omalizumab (e.g. xolair): it is recommended that this 75-375 mg injection drug every 2-4 weeks, depending on the severity and intensity of asthma.
Pharmacological treatment of acute symptoms occurs by inhalation of beta-2 agonists and by oral corticosteroids. In very severe cases, they can be injected during hospitalization. Prevention of acuities requires the avoidance of triggering mechanisms, such as contact with allergens or irritants. One may choose to use corticosteroids inhaled constant pharmacological use, sometimes supported by long-acting beta-agonists or antileucotrienic agents.
World asthma diagnoses have increased significantly since 1970 onwards. In 2011, 235-300 million people are recognized as asthmatics and 250,000 are deceased.
According to what has been said so far, asthma would seem like a disease that only affects the respiratory tract. However, some forms are affected by a number of oral allergic factors, their cross-reactivity and other predisposing conditions. Some of these affect the etiologic mechanism of broncoconstriction, others significantly emphasize the complications of the pathology itself.
Asthma attack definition
What is an asthmatic crisis, how does it manifest itself, are there pre-eminent signs? The asthmatic crisis can be defined as a sudden worsening of asthma symptoms, which arise in a rather intense way causing major respiratory difficulties. Asthmatic crises are related to the contraction of the muscles that form the wall of the bronchi and the consequent reduction of the space around the air (bronchoconstriction); in addition, the inside of the bronchi swells and flashes, producing a dense mucus which constitutes an additional obstacle to free air circulation.
All these factors – bronchospasm, inflammation and mucous hypersecretion, responsible for the classic symptoms of asthma crisis such as dyspnoea, cough, shortness of breath, and difficulty in performing normal daily activities – are triggered by allergic and irritant stimuli (dust, animals, smoke, pollen), viral infections (influences, colds) or intense physical exertion.
An asthmatic crisis may be minor, with symptoms that improve with prescribed home treatment by the doctor, or severe. Mild asthma attacks are generally more common. Usually, respiratory tract regurgitates within about a few minutes or in a few hours after treatment. Severe asthmatic crises are less common, but last for longer, cause more severe symptoms and require immediate medical attention. A severe asthma attack that does not improve with home treatment can become a health emergency that endangers the life of the patient.
Recognizing the symptoms is therefore crucial; it is still important to recognize and treat even the milder symptoms of an asthma attack, so as to prevent serious episodes and keep the asthma under control. Serious exacerbations may also occur in subjects with a history of mild asthma, but are more likely in subjects with moderate to severe asthma.
Asthma pregnancy or breastfeeding
Specifically, asthma may have a genetic (hereditary) and familial base quite important, so some women tend to make life-style changes quite relevant since conception. First of all, remember that blocking drug therapy by increasing the risk of fetal hypoxia (due to poor pathological control or potential serious exacerbation) is considered a very risky approach. It is advisable to take the usual medicines at low doses and in the presence of continuous medical monitoring.
However, there are still some doubts about nutrition. Many believe that asthma food prevention is already beginning with pregnancy and lactation. That is why some pregnant or nursing mothers avoid taking potentially allergic foods, adopting the so-called ’hypoallergenic elemental diet’.
On the other hand, no statistical correlation has been demonstrated between this nutritional style and the reduction in the incidence of asthma (in the mother or in the child). As it is a highly restrictive food regime (potentially subject to nutritional deficiency), almost all doctors suggest that they should not be used unless there are certain risk factors (e.g. familiarity with an allergy in particular).
In nursing, the diet free of potentially allergenic molecules has a much higher value. It helps avoid contact between the baby and some allergens that may prove fatal (by anaphylactic reaction) but, in that case, has less to do with the onset of asthma than the most severe food allergy. Breastfeeding rather than artificial formulas is a preventative factor from any disease.
Asthma and obesity
There was a significant correlation between the onset of obesity and the diagnostic incidence (or worsening) of asthmatic condition (especially in recent years). Obesity is the most serius among asthma risk factors due to the following: reduction of respiratory function due to accumulation of fat, which is pro-inflammatory metabolic state induced by excessive adipose tissue (common to asthma). In addition, the comorbidity between severe asthmatics and overweight can be related to the so-called ’western lifestye’, namely: physical inactivity, few antioxidants, and long-term stay in closed environments. Ultimately, obesity is a non-allergic, predictive and independent factor in asthma.
Another dietary factor that seems to alter the incidence and severity of asthma is the presence of antioxidants. The antioxidant group is chemically very heterogeneous; it has the function of limiting oxidative stress by acting at various levels (depending on the specific molecule), but the action of the single element is amplified by that of all others.
Without going too far into the specific, remember that antioxidants can be endogenous (produced by the body) and exogenous (taken with the foods). Obviously, the greater the proportion of the molecules introduced with the diet, the higher the defensive level. In addition to fighting free radicals, antioxidants are able to exert anti-inflammatory, antitumor, hypocolesterolemic, hypoglycemic, and atherosclerotic action, and so on. Antioxidants play a protective role from asthma because of their ability to prevent systemic inflammation, which, as we have seen in obesity, is involved in the aetiology of this disorder.
The most common dietary antioxidants are:
- Vitamins:provitamin A (carotenoids), vitamin C (ascorbic acid) and vitamin E (tocopherols or tocotrienols)
- Mineral salts: Zinc and selenium
- Phenolic substances:anthocyanins, flavonoids, flavones, phenolic acids, phenolic alcohols, secoridoids, hydroxycanylimic acids etc.
- Caffeine and the like.
Asthma and allergens
Almost all the allergens are substances naturally present in the environment entering the body by inhalation, with food or with drugs. It is therefore possible to deduce that food allergens – in particular egg, milk, nuts and fish – may be responsible for the onset of asthma. On the other hand, it has not yet been shown that allergens present in foods have the power to trigger an asthmatic symptomatically independently.
In asthma of a professional nature (different from the aggravation of an existing form), there is a certain incidence among workers working in food establishments (flour-meal manufacture) or food additives. These shapes, together with other types of professional asthma, account for up to 15% of the total.
Once again responsible for adverse effects on human health, some food additives have been accused of triggering respiratory depression (acute dyspnoea). Among them, most importantly, are preservatives and colorants, potentially responsible for bronchospasm.
It seems that poor tolerance or excessive intake of sulphites can induce a bronchial constriction that can be overlapped by a real asthma attack. The most damaging forms are those of sodium and potassium metabisulfites, or E223 and E224, mainly used in vinification. Not only that, even the azoic dye E107 or Yellow 2G can trigger a bronchial symptom that can be superimposed on the asthmatic state; this synthetic additive is used to yellow the foods such as mayonnaise.
Due to concerns about the side effects of asthma medicines, scientific progress has been directed towards finding foods or nutrients that can control the onset and aggravation of asthma. These dietary interventions are primarily aimed at reducing the overall inflammatory response. An experimental 2014 publication entitled Dietary Interventions In Asthma revealed that saturated fatty acids can increase inflammatory response by activating pattern recognition receptors.
The opposite, is also true, omega-3 polyunsaturated fatty acids can play an anti-inflammatory action by modifying the production of good eicosanoids. Moreover, the antioxidants mentioned in the previous chapters can exert significant anti-inflammatory effects such as, for example, the removal of free radicals (by preventing the activation of certain transcription factors such as NF-kB).
Finally, as anticipated, obesity is able to increase systemic inflammation due to the release of chemical mediators by the adipose tissue.
From what is mentioned in the previous chapters and according to what is specified in the research, it seems clear that a good asthma diet should have the following characteristics:
- Calories needed to keep weight or reduce it (in case of excessive)
- Increased desirable physical activity (if tolerated)
- Prevalence of unsaturated fatty acids on saturates with emphasis on polyunsaturated omega-3 (alpha-linolenic, EPA and DHA)
- Reduction, not only percentage but absolute, of saturated fat
- Increase, not only percentage but absolute, of omega-3 fats
- Wealth of anti-inflammatory antioxidants such as, for example, vitamins, minerals and phenolic
- Absence of potentially harmful food additives for asthma.
In practical terms, it can be stated that: if the weight is excessive, the asthma diet should favorslimming in conjunction with a motor activity protocol established with the treating physician and a sports technician. Eliminate all the fatty cheeses, many of the seasoned ones and the fatty meats (which include mainly cold meats, fresh sausages, bacon, ribs, etc.)
- Cook white meats and fish; these, if they are rich in omega-3, can also be with higher fat percentages.
- Dress your meals only with extra virgin olive oil or, moderately, with other cold squeezed vegetable oils rich in antioxidants,phytosterolsand unsaturated fats
- Consume at least 2 servings of vegetables and 2 fruits per day
- Minimize processed, refined and packaged foods
- Remove wines containing sulphites from your ur diet; prefer biological or biodynamic wines and consume them in moderation.
Allergic asthma is an inflammatory disease of the respiratory system, caused by excessive reactivity to various allergenic stimuli (e.g. pollen, mold, dust mites or domestic hair) present in the external environment. This pathology typically manifests itself with cough and bronchospasm (i.e. sudden abrupt airway narrowing), which are responsible for repeated episodes of dyspnoea (respiratory distress) of varying gravity. Allergic asthma also causes sense of chest tightness and wheezing breath.
The symptomatology of this affection is usually chronic or intermittent. In any case, the severity and variety of demonstrations are highly subjective, as they vary according to the affected person: asthma attacks may vary from a mere silence to severe respiratory failure, which necessitates hospitalization. Diagnostic framing of allergic asthma is based on anamnesis, target examination, and respiratory function tests. The treatment involves controlling triggering factors and drug therapy, most commonly with bronchodilators, beta-2 agonists and inhaled corticosteroids.
An allergy is a condition characterized by an abnormal reactivity of the immune system towards one or more substances (called allergens) present in the environment and is usually harmless to most individuals. The body of allergy sufferers recognizes these allergens as a danger and tries to fight them by producing a particular type of antibodies, called immunoglobulins E (IgE).
Contact with the substance against which the sensitization occurs causes a disproportionate defense mechanism by the body, which generates an inflammatory reaction resulting in various respiratory manifestations (e.g. asthma, rhinitis and nasal congestion), gastrointestinal tract (vomiting, diarrhea, etc.) or skin (such as urticaria). In extreme cases, an anaphylactic shock occurs, a severe allergic manifestation that involves the whole body, causing, in particular, respiratory difficulties and hypotension to the loss of knowledge and death. Anaphylactic shock represents a medical emergency requiring immediate and appropriate treatment.
Typical allergens include: pollen, dust mites, hair and saliva of cats and dogs, certain foods, and drugs and poisons of some insects. In general, the greater the predisposition and exposure to environmental allergens, the more premature the onset of the disease.
Technically, allergic asthma is an inflammation of the bronchial tree, caused by exposure to allergens that are usually dispersed in the environment and harmless to healthy subjects; among the possible allergens, the most common are pollen, hair and dandruff of domestic animals, dust mites and molds.
Although there is no well-defined starting age, the first contact with these substances usually occurs during childhood, especially in the case of family predisposition. After this event, the patient starts producing IgE against the specific allergen. When the contact is repeated, the sensitized subject goes through an abnormal and excessive reaction of the immune system, resulting in a series of phenomena that affect the bronchi (essential structures for the passage of air into the lungs).
These events trigger, in particular, a flogic process that is responsible for the respiratory tree, which alters its normal function: inflammatory cells (mast cells, eosinophils and lymphocytes) infiltrate the walls of the bronchi, more or less marked, making the walls thickened, edema-like and hypersensitive (hyperreactive) to external stimuli, even minimal. In addition, the muscular cells surrounding the airways may contract more or less violently, narrowing the bronchial lumen (bronchospasm). These mechanisms hinder the passage of the air, resulting in so-called asthma attacks, recurrent episodes of respiratory crises characterized by excessive cough, hissing breath and chest tightness.
When asthma is not under control, prolonged exposure to the allergen causes chronic inflammation of the bronchi; in this case, an attack can also be triggered by physical effort (strain asthma), by inhalation of cold air or by a banal viral infection.
Factors that can trigger an allergic asthma attack include:
- Irritating gas exposure;
- Cold air;
- Exercise and intense efforts;
- Stress and strong emotions;
- Respiratory infections.
In the presence of triggering factors, allergic asthma causes inflammation of the airways, resulting in involuntary and reversible contraction of bronchial musculature (bronchospasm) and irregular pulmonary ventilation.
The symptoms of allergic asthma vary from person to person, by frequency and severity, but generally include:
- Cough, initially dry and coarse, often before the actual asthmatic attack;
- Exfoliation of dense and flowing mucus, especially at night and in the early morning;
- Feeling of chest tightness;
- Dyspnoea (respiratory distress);
- Impaired breathing (called ’wheezing’) characterized by noises (whistles andmoanings), especially during exhalation, due to the very limited airflow;
- Sleep disorders;
- Difficulty to make physical efforts and, in the most serious forms, to carry out daily actions, such as climbing stairs, walking or impossibility to speak.
Generally, signs and symptoms of allergic asthma are reversible with timely treatment. Crises can occur acutely, chronic (persistent) or intermittent, even at a distance of a long time by one episode and the other. Symptomatology disappears from one attack to the other, although some asymptomatic patients may feel mild swelling during forced exhalation, rest or physical exertion.
The diagnosis of allergic asthma is formulated first and foremost, taking into account the clinical history of the patient (period and season of exposure to allergens, occupation, lifestyle, eating habits, leisure activities, familiarity with the allergy, presence of animals at home, etc.) and the characteristics of the attacks (when the symptoms first appeared, their nature and frequency, the triggering factors already identified, etc.) The collection of the anamnestic data should be supplemented with a general examination (weight, blood pressure, etc.), visit from the motorola (to exclude other pathological conditions), allergic tests and tests on the respiratory functions.
In addition to symptomatology and anamnesis, the diagnosis of allergic asthma is formulated through:
- Spirometryto measure pulmonary capacity;
- Respiratory function tests to evaluate the degree of bronchial obstruction and its reversibility;
- Skin allergic tests (prick test);
- Serologic tests for the detection ofimmunoglobulins (specific IgEs) responsible for allergic reaction and for responsible allergen recognition (Rast test).
Allergic asthma can also be diagnosed through more specific examinations such as:
- Bronchial provocation test for the measurement of nitric oxide present in the air emitted (exhaled), indicating the level of inflammation;
- Diagnostics of images, such as radiographs and computerized tomography, that is, investigations that may indicate possible anomalies of lungs and airways in general;
- Bronchial provocation test withmetacolin (simulates the arrival of a stimulus that causes asthma);
- Examination of the examiner;
- Spiral Flow Measurement;
Hyper-bronchial reactivity and a bronchial challenge test
A bronchial challenge test with methacholine is a wide-ranging study in the field of pneumology, where it is used for the study of bronchial hyperactivity. This condition, typical of asthmatic subjects, consists of an abnormal bronchoconstrictive response to various stimuli, which can be both internal (emotional states, emotions) and external to the organism (allergens, cold and humid air, physical exertion, viral infections).
When the organism is exposed to such stimuli, the respiratory tract of a subject with bronchial hyperactivity tends to close with excessive ease and intensity. It is referred to hyper-activity bronchitis precisely because the same stimuli, at the same dose, do not result in significant responses in healthy subjects. In addition to asthmatics, excessive bronchial responsiveness can also be observed in obese subjects and in the last months of pregnancy.
Hyper-reactivity is also characterized by various pathologies such as COPD (chronic obstructive bronchopneumopathy), bronchiectasis, atopic dermatitis, allergic and non-allergic rhinitis, cystic fibrosis, heart failure, and viral infections of the respiratory tract.
The diagnostic significance of the methacholine test is still linked mainly to the study of bronchial asthma. Its wide use in clinical practice is due to the good reproducibility of results and good safety, with low risk of systemic side effects (no deadly events or serious side effects associated with the implementation of bronchial challenge test are reported in the literature). The sensitivity of the test is also very good, while considering the various possible causes of bronchial hyperactivity already listed, the specificity of the methacholine test is moderate.
Ultimately, the methacholine test is a more useful test than to rule out the diagnosis of bronchial asthma. In fact, the negative predictive value of the test is higher than the positive predictive value. In this sense, it is particularly useful when symptoms, spirometry and reversibility tests do not allow or confirm or exclude diagnosis. If asthma is already known, the methacholine test helps to evaluate the severity of the asthmatic attack.
The methacholine test makes use of a particular feature of this substance. Methacholine is a synthetic muscarinic agonist of acetylcholine that, at doses used in this test, can trigger a small post-mortem asthma crisis only in subjects with bronchial hyperresponsiveness. After its occurrence, this crisis can be effectively controlled and resolved by administering a bronchodilator by inhalation (spray or aerosol).
To evaluate and quantify the degree of bronchial reactivity, the test involves the administration of metacolone increasing doses of aerosol, followed by spirometry after each single inhalation. The results of this study are related to those of basal spirometry performed before the test is started to evaluate any pre-existing bronchial obstruction. This results in a dose-response curve that expresses the degree of subject’s bronchial responsiveness. The lesser the methacholine dose that can cause bronchial constriction, the greater the degree of bronchial hyperresponsiveness.
The test is discontinued when the administered metacholine dose results in slight bronchial obstruction (as evidenced by a reduction of 20% or more of the initial VEMS – spirometric parameter) or after inhalation of the maximum prescribed dose. If a major bronchial obstruction appears, the doctor intervenes by administering a bronchodilator (spray or aerosol).
Since bronchial hyperactivity may vary over time, increasing during exacerbations and decreasing during inhaled steroid treatment, it is advisable to take specific precautions, such as suspending some of the therapies in use, prior to methacholine testing.
Fasting is not necessary but before the bronchial provocation with methacholine it is generally required to abolish the smoke for at least 24 hours and along with it:
- Tea, coffee, guarana, mate, coca cola and other sources of caffeine for at least 24 hours
- Short-acting bronchodilators (e.g. Ventolin, Broncovaleas): for at least 8-12 hours
- Long-lasting bronchodilators: for at least 24 hours
- Antileucotrienic (Montegen, Singulair, Lukasm, Zafirst etc.) for at least 24 hours
- Ipratropium bromide (Atem) – oxitropium for at least 24-48h
- Tiotropium bromide (Spiriva) for at least 48h-1 week
- Antihistamines (e.g. Formistin, Aerius) for at least 72 hours
- Hormones – corticosteroids: for at least 4 weeks
- Teofillin with medium duration of action (Theo Dur, Ansimar) for at least 24 hours
- Long-lasting theophyllins (Respicur, TheoNova) for at least 48 hours
Suspension periods recommended for individual drugs may vary slightly depending on the methacholine provocation medical center.
While these factors diminish the physiological response to methacholine, others amplify it; this is the case, for example, of exposure to allergens or to sensitizers in the working environment, viral respiratory infections, atmospheric pollutants, cigarette smoke, chemical irritants and B-blockers.
- Bronchial stimulation with methacholine is contraindicated in the following cases:
- Recent stroke or angina pectoris episodes in the last three months;
- Recent ischemia or cerebral haemorrhage (last three months);
- Known arterial aneurysm;
- Serious unmonitored hypertension: systolic> 200mmHg, diastolic> 100mmHg;
- Epilepsy in pharmacological treatment;
- Pregnancy or lactation;
- Inability to properly perform spirometry;
- Current use of cholinesterase inhibitors (used in the treatment of severe myasthenia);
- Severe flow limitation: FEV1 <50% of the predetermined or
- Moderate FEV1 <60% flow limitation or
Unfortunately, despite the large amount of new medicines available for the treatment of bronchial asthma, patients around the world continue experiencing severe asthma attacks. Asthmatic crises should under no circumstances be taken lightly or underestimated. It is true that with well-organized basic therapy, asthma can go asymptomatic for awhile, but the therapy should never be discontinued. Respiratory difficulty triggered by individual irritants can occur at any moment, potentially causing such severe and ’unforeseeable’ asthmatic crises that can in some cases also lead to death.
Here we will try to explain what the difference between the presumption of a non-dangerous illness and the reality is unfortunately contrary to its imagined innocence. The potential lethality of asthmatic illness, too often supposed to be ’unpredictable,’ but it is anything but that. We are now referring to all that series of errors, weaknesses, omissions, inaccuracies and underestimation of the seriousness of the illness that ultimately may become responsible for acute and serious asthma crisis that can cause the death of the patient.
So let’s see what these uncontrolled situations we are referring to, trying for each of them to find a solution that will bring asthma, even potentially deadly, back into a minor risk area that limits the danger of an extreme event.
The main brake on a prudential policy is the dangerous underestimation of asthma disease by many patients and the potential seriousness of it in certain conditions. Asymptomatic smokers, for example, fall within the category of subjects to whom asthma seems to be not dangerous.
So much to be considered superior to the bronchial inflammation that smoke generates, which is then the basis from which any casual and occasional disturbance can trigger a severe respiratory crisis. Such asthmatic crisis of particular gravity, through respiratory insufficiency secondary to bronchus obstruction or as a result of severe heart arrhythmias, then becomes directly responsible for acute complications that also justify a possible lethal event.
Another uncommon problem, partly dependent on the previous point, is the habit of certain patients not to scrupulously follow the therapy prescribed by the specialist or even worse to self-prescribe and to self-manage the cure according to, sometimes taking the therapy improperly, without respecting the mode and timing of the drug prescription or, worse, suspending the treatment without consulting the specialist only because they experience an improvement.
Nothing can be more wrong and dangerous. As those who are in hypertension therapy would never think to suspend the intake of antihypertensive drugs only because the pressure is under control, as long as pressure is traced back to damages, so the asthmatic who breathes normally through therapy should never suspend it without first hearing the opinion of the specialist, with whom they can best agree on a reassessment of pharmacological care.
Unfortunately, many asthmatics still seem to be worried more about the side effects of drugs used to treat asthma rather than the disease itself and its risks, especially as regards the use of cortisone medicines. Asthma that is not treated or treated badly causes many more harm to any unwanted pharmacological effect, representing the worst side effects over time.
Another serious problem is not to accept the patient often to adapt the therapy in the event of a changed respiratory condition, especially in the phasing-out phase, again because of the risk of having too many medications. Many cases of deadly asthma represent the consequence of this situation, in the sense that in many cases of fatal events reported by the chronicles, a few days prior to the lethal incident asthma has often been underway for a few days during which nothing has been done to deal with the progressive aggravation of the isease, in the useless and dangerous expectation of asthma to take care of itself.
We advise asthmatic patients to never forget, especially when they feel good, to have a quick-acting bronchodilator (salbutamol or formoterol) with a pre-sprayed dose. In the case of an asthmatic crisis, the availability of this medication can make a difference in anticipation of a more advanced therapy.
There is often a great difficulty for asthmatics to accept that, especially in the case of allergic asthma, abstaining from contact with the responsible allergen is the basis for controlling the disease. Many of them, in fact, feel that they can play football in the grassy meadows in the spring, although allergic to the grasses, or to be able to attend dusty venues even if sensitized to domestic dust mites, just because the treatment of bronchodilators and cortisone is in place.
In fact, the excessive allergens that reach sharply in the airways are a trauma to the bronchi which is far superior to the ability of the drugs to control the asthmatic problem, thus creating risky situations that can potentially evolve to a lethal asthma crisis. This also applies to those who, in the absence of allergens to which they are sensitized, while suffering from a clinically serious asthma form, completely abandon the therapy without consulting with the specialist, thus exposing themselves to an extremely serious asthma crisis at the moment in which such an allergen suddenly becomes available out of the forecast.
Just as stated in the previous point, always consider carefully, especially if you are an allergic patient, the place where you plan to go for a business trip or for a holiday, considering that there is no inhalatory allergen at the destination location not present at the starting place. Any sudden impact with large amounts of allergen, in fact, especially in patients without adequate pharmacological coverage unnecessary at the starting place, could cause a severe asthma crisis with all the associated risks.
Microbial infections of the airways, especially viral (including influenza) infections, can trigger acute bronchospasm in asthma patients, with mortal consequences, especially when cardiovascular disease (cardiac remission, high blood pressure, etc.) is associated with cardiovascular disease, in the course of acute respiratory disease, may be complicated with cardiac events characterized by severe arrhythmias, until the heart stops.
If an asthmatic patient develops a condition of particular respiratory distress, which is recognized as not common with the dyspnea already accused in the past, do not hesitate to immediately alert urgent help to prevent a critical resolution that can still be solved can degenerate to the point where it poses a serious risk to the patient’s survival.
Remember that the best way to avoid the unpredictability of a fatal asthma crisis is to control every single situation potentially causing the respiratory condition of the patient to degenerate to the point of bringing it to that state of no return beyond which the mortal event becomes very difficult to avoid. Let the asthmatic disease be left to the specialist’s experience and expertise of the pneumologist, strictly avoiding that dangerous natural tendency to do-it-yourself that in too many cases has proven to be capable of causing unfortunately irreparable damage. Periodic clinical examination of the asthma (specialist visit) and of its functional respiratory condition (airway perivasis) practicable with spirometry may help to better monitor the asthmatic situation of the patient by orienting the pneumologist to better patient management and to the most appropriate pharmacological therapy of asthma disease.
Emotions and asthma attacks
Strongly debated are the causes of asthma, a disorder mainly characterized by organic defects due to the constriction of the airways and the bronchial cells causing considerable respiratory difficulties. It has been shown through some studies that anxiety, anger and nervous tension may affect the smooth functioning of the respiratory system and cause an asthma attack.
A Kleeman interview with 26 patients over a period of 18 months found that 69% of their attacks were caused by anxiety and emotional stress. The bond between autonomic nervous system and airway dilatation, and the connection between S.N.A and emotions, meant that asthma studies focused primarily on emoism.
A source of stress that can causes this kind of manifestation is parent-child interaction. Through a longitudinal research, there was a determining relationship between problematic families and a high asthma rate. In addition to the incidence of the family factor that alone is not enough to explain the emergence of asthma disorder, the researchers found that 86% of asthmatic patients had a respiratory tract infection before the symptoms appeared.
However, although an innate predisposition of respiratory apparatus to develop asthma should be present, any psychological stress factor can intergrate with the diathesis and act as a stimulating factor for the occurrence of the disease.
Asthma, as well as other particularly complex illnesses with regard to causes and effects, has been considered a prototype of psychosomatic illness. However, the fact that asthma attacks may also be triggering or that the condition of asthmatics may be deteriorated by particular emotions (such as anxiety, stress, negative emotional states, etc.) is not a definite figure and many studies have criticized this hypothesis. Indeed, some research that tried to correlate anxiety states with possible exacerbations of asthma symptoms in patients failed to support the idea that asthma and emotions may be linked. A stronger link between anxiety and asthma seems to be in the case of asthmatic children.
On the contrary, it is known that asthmatic patients, especially at times when the disease manifests more seriously, may be more at risk of depression and anxiety. However, this does not establish a causal correlation between anxiety and asthma, nevertheless a bi-directional causality has been hypothesized: asthma may cause anxiety, but anxiety could increase the likelihood of the crisis. In addition, anxiety or, worse, depression, may cause the patient not to follow the prescribed therapeutic regimen, thereby increasing the risk of future asthma attacks. Some emotional states may also disturb the self-perception of symptoms and signs that precede any asthma attack.
Despite the absence of a unanimous view on possible asthma-stress correlation, it is advisable that patients avoid strong emotions and, if necessary, consider a psychological approach to managing their emotional life. From this point of view, we recommend all the approaches generally used to mitigate stress or anxiety conditions, ranging from a light physical constraint to more targeted and ‘professional’ approaches such as psychotherapy, yoga, and breathing.
Prevention is an essential weapon for controlling allergic asthma and consists of precautionary measures to avoid contact with allergens that may trigger an attack. In general, it is important to observe a frequent cleaning of the home and work environments, paying attention to armchairs, sofas, rugs, heavy curtains, pillows, beds and linens. Open the windows to ventilate closed environments, especially when there is strong smells, fumes or vapors; avoid condensation and mold formation.
Outdoors, however, it is useful to cover mouth and nose with a scarf if it is cold or a mask when it is hot or if the place where it persists is particularly polluted (for example, very busy road or close to factories and lawns) .
Your doctor may also recommend a specific immunotherapy with allergen extracts (ITS or desensitizing therapy). This approach allows to gradually modify the immune response typical of the allergic reaction, reducing the number and intensity of acute episodes. Specific immunotherapy involves daily administration under the tongue of the allergen (eggraminacea, parietaria, etc.) to which you want to de-sensitize the subject. After a first induction phase, in which the dose progressively increases, continue to administer the maximum tolerated one to three times a week (maintenance phase). The therapy lasts for 3-4 years. The effects of desensitizing therapy are generally of long duration and significantly improve the quality of life of patients.
- Consult anallergologist / immunologist to establish a proper treatment plan for your case and undergo regular check-ups;
- Avoid the environments where the allergens to which you are sensitive are present;
- Absolutely avoid smoking (even passive);
- Use masks or scarf to protect the airways;
- Avoid sudden and intense physical efforts.