Asthmatic Complexities

What do all of these individuals have in common? An active 13 year-old becomes breathless shortly after her soccer games and coughs on a cold winter's night. A young woman has a dry, hacking cough that has persisted for a year after her last "cold." A teenager sleeps poorly and is awakened early every morning with chest tightness and difficulty breathing. What these individuals have in common is the possibility that they all may have asthma.

Unusual symptoms of asthma

Patients suffering from episodes of asthma do not always have the typical symptoms of asthma such as shortness of breath, chest tightness, and wheezing (symptoms of airway narrowing). Instead, patients can have symptoms that may not appear to be related to asthma. These "unusual" asthma symptoms include:

• rapid breathing
• sighing fatigue
• inability to exercise properly
• difficulty sleeping anxiety
• difficulty concentrating
• chronic cough without wheezing

To complicate matters, symptoms of asthma are not consistent and often vary from time to time in an individual. In some patients symptoms are influenced by diurnal factors, for example some patients experience asthma primarily at night (nocturnal asthma) rather than during the day. Furthermore, episodes of asthma can be triggered by many different factors such as allergens, dust, smoke, cold air, exercise, infections, medications, and acid reflux. Finally, other illness such as heart failure, bronchitis, and dysfunction of the vocal cords can cause symptoms that mimic those of asthma. For these reasons, accurately diagnosing and treating asthma can be a challenge.

For a comprehensive review of symptoms, causes, and treatments of asthma, and for a better understanding of the normal anatomy of the airways (trachea, bronchi, bronchioles and the lung), please visit the asthma article.

Can a cough without wheezing be due to asthma?

Chronic coughing is frequently defined by doctors as a cough that lasts longer than 3 weeks. Chronic cough can have several causes such as postnasal drip, pneumonia, bronchitis, cigarette smoking, acid reflux, heart disease, lung cancer, and medications such as ACE inhibitors used for treating high blood pressure. Asthma also can cause chronic cough. A chronic cough may be the only symptom of asthma. The cough may first appear after a cold or an upper respiratory tract infection. The cough may also start as a "tickle" in the throat. In some patients with asthma, laughing or exercise can bring on coughing. Other patients tend to cough at night while others cough at any time of day without provocation. Coughing due to asthma usually does not respond to cough suppressants, antibiotics, or cough drops but only to medications for asthma. Therefore, accurately diagnosing asthma (by using pulmonary function tests) is important. Thus, a doctor, preferably a lung specialist or an allergist, should evaluate any cough that does not resolve on its own within 3-6 weeks.

Nocturnal asthma

More than 90% of patients with asthma experience nighttime wheezing and coughing. Symptoms of asthma are most common between midnight and 8 a.m. and are important causes of insomnia and sleep deprivation among patients with asthma. In fact, sleep disturbances in patients with asthma usually mean that there is inadequate control of the asthma and should prompt a visit to the doctor to re-evaluate the treatment being used for the asthma. Function of the lungs in a patient with asthma can decline by up to 50% during an episode of nocturnal asthma. The reasons are not clear, but possible explanations include:

• Exposure to allergens at night such as dust mites or animal dander.
• A decrease in cortisone and adrenaline levels that normally occurs at night, resulting in increased reactivity of the airways.
• Reflux of stomach acid into the esophagus.
• Cooling of the airways that cause spasm of the major airways.
• Sinusitis and postnasal drip
• Sleep apnea

It is possible to test for nocturnal asthma by taking measurements of airflow out of the lungs during expiration in the evening and again upon awakening in the morning. This is done with a small, portable meter that measures the flow of air. (An asthma specialist can demonstrate the correct technique for making these measurements.) A greater than 20% decrease in the peak flow measurement from the evening to the morning suggests nocturnal asthma.

Masqueraders of asthma

"All that wheezes is not asthma." Other medical conditions can mimic asthma and make the correct diagnosis of asthma more difficult.

Cardiac asthma

Cardiac asthma usually occurs in elderly people who have wheezing and shortness of breath that are due to heart failure. When the heart is too weak to pump blood effectively, fluid will accumulate in the lungs. Fluid in the lungs causes shortness of breath and wheezing. A chest x-ray can be helpful in diagnosing heart failure by demonstrating an enlarged heart (usually a sign of heart failure) along with fluid in the tissues of the lung. Treatment of heart failure involves using diuretics (water pills) to rid the lungs of excess fluid and medications to help the heart muscle pump more effectively. When the heart failure has been adequately controlled, the wheezing will cease. Some people may suffer from asthma and heart failure simultaneously. These patients require treatment for both conditions.

Other bronchial conditions

Acute bronchitis: Acute bronchitis is an infection, usually viral or bacterial, of the bronchi, the larger airways or breathing tubes. The symptoms of acute bronchitis include fever, cough, yellow or green sputum, and, sometimes, wheezing. This combination of coughing and wheezing is sometimes referred to as "asthmatic bronchitis" or post-viral bronchial hyper-reactivity of the airways. Acute bronchitis is generally treated with antibiotics and/or anti-inflammatory medications such as corticosteroids. The coughing and wheezing usually subside within a few weeks.

Chronic bronchitis: Chronic bronchitis usually is defined as a daily cough with production of sputum for three months for two years in a row. The most common cause of chronic bronchitis is cigarette smoking. With chronic bronchitis there is longstanding inflammation and swelling of the inner lining of the airways, the inflammation and swelling cause narrowing of the airways. The inflammation also stimulates production of mucous within the airways that becomes the sputum produced by coughing. Infections of the airways with viruses or bacteria are common among individuals with chronic bronchitis. Infections further aggravate the inflammation and narrowing of the airways, worsening the symptoms of shortness of breath, coughing, and wheezing. Treatments include antibiotics, quitting cigarette smoking, bronchodilators to expand the airways, and corticosteroids to reduce the inflammation.

Emphysema: Emphysema is a disease where there is permanent destruction of the walls of the air sacs (alveoli) and the small airways (bronchioles). The destruction of the alveolar walls reduces the elasticity of the lung. Loss of elasticity leads to the collapse of the bronchioles, obstructing airflow out of the alveoli. Air becomes permanently "trapped" in the alveoli. Air trapped in the alveoli cannot be exchanged for room air, and this reduces the ability of the lung to get rid of carbon dioxide and take in oxygen. Emphysema is most often caused by years of cigarette smoking; however, a genetic disease, alpha 1 antitrypsin deficiency, also causes emphysema.

The combination of chronic bronchitis and emphysema is called chronic obstructive pulmonary disease (COPD). The major symptom of emphysema is shortness of breath. Patients with emphysema also may wheeze if they also suffer from chronic bronchitis and/or asthma. Treatment of these latter patients begins with smoking cessation and the use of inhalers to deliver bronchodilators and corticosteroids to the lungs. Antibiotics, oxygen, and surgery in the advanced stages of these diseases also can be helpful.

Bronchiectasis. Bronchiectasis is a chronic condition in which the bronchial tubes (larger airways) are damaged by repeated bronchial infections. The major symptom of bronchiectasis is a persistent cough with thick and usually green mucus. Bronchiectasis is treated with bronchodilators, antibiotics, and corticosteroids when flare-ups occur.

Cystic fibrosis is an inherited condition in which the affected patients can produce thick mucus that plugs the bronchial tubes. The plugging of the bronchial tubes causes repeated bouts of bronchitis and pneumonia, leading to the development of bronchiectasis.

Localized Bronchial Obstruction: Wheezing and coughing can be symptoms of a localized obstruction of the airways (the bronchial tubes or trachea). The wheezing represents the sound of air rushing around the blockage, and the coughing is the body's effort to clear the blockage. The most common causes of localized airway obstruction are foreign bodies such as accidentally inhaled peanuts, bronchial tumors, and the narrowing of the trachea that occurs after a tracheostomy. The wheezing and coughing due to a localized obstruction will not respond to medications for asthma. The treatment is to relieve the obstruction.

Vocal cord dysfunction (VCD)

Vocal cord dysfunction is an episodic condition involving sudden closure of the voice-box (larynx) as a result of the two vocal cords sticking together. The symptoms of vocal cord dysfunction are the sudden onset of difficulty breathing and talking, panic, and a shrill sound much like the sound made by a child suffering from croup. Vocal cord dysfunction often is misdiagnosed and treated as asthma because both conditions may have symptoms of wheezing; however, with vocal cord dysfunction, wheezing usually occurs during inspiration (breathing in) while with asthma, wheezing occurs during expiration (breathing out). Medications used for treating asthma are not effective for treating vocal cord dysfunction.

Since a correct diagnosis of vocal cord dysfunction can be difficult, affected persons may have repeated episodes that are inappropriately treated as attacks of asthma. The diagnosis often requires a careful, direct inspection of the vocal cords, typically by an ear, nose, and throat specialist. The attacks of vocal cord dysfunction usually resolve spontaneously (on their own). Occasionally, however, a tracheotomy tube needs to be inserted to prevent the obstruction and problems with breathing. vocal cord dysfunction often is associated with acute panic or anxiety attacks that require anti-anxiety medications, speech therapy, and psychotherapy in order to prevent episodes.

Other hypersensitivity (allergic) reactions

Inhaled mold spores and particles from bird droppings and feathers (such as from parrots) can cause hypersensitivity (allergic) reactions in the bronchial tubes and the lungs. For example, when Aspergillus fungal spores cause an allergic reaction in the bronchial tubes, the condition is called allergic bronchopulmonary aspergillosis. Affected individuals have both asthma and bronchiectasis which require treatment with both bronchodilators and corticosteroids over a prolonged period of time. When the lung tissues develop an allergic reaction to the inhaled bacteria, fungi, or bird particles, the condition is called hypersensitivity pneumonitis (HP). HP is differentiated from acute asthma by the lack of wheezing, the presence of a fever, and the pattern of pneumonia on the chest x-ray. HP is treated by avoiding the allergens and administering corticosteroids.

Exercise and Sports

Sports and asthma are not mutually exclusive. In the 1996 Olympic Games, 1 out of every 6 athletes had asthma. These Olympians competed in a variety of sports such as track and field, mountain biking, kayaking, cycling, and rowing. The following is an abbreviated list of athletes who have competed despite their asthma:

• Jackie Joyner Kersey - track and field
• Jerome Bettis - NFL running back
• Amy Van Dyken - swimming
• Dennis Rodman - NBA basketball
• Ray Borque - NHL ice hockey
• Exercise Induced Asthma (E.I.A.)

Exercise is a common trigger for asthma and may cause symptoms such as chest tightness, shortness of breath, and coughing in 80 to 90% of patients with asthma. The symptoms usually start about 10 minutes into the exercise or 5 to 10 minutes after completing the activity, although some people experience symptoms about 4 to 8 hours after exercise. Although exercise induced asthma may affect all ages, it is most common in children and young adults. All athletes, from weekend warriors to professionals and Olympians, can be affected.

This common occurrence of exercise induced asthma among individuals with asthma has led to the misconception that asthmatic patients cannot exercise. As a result, children with asthma often stay in the library or homeroom while the rest of the class is in the gym. Adult asthma patients may attribute their breathing difficulties during exercise to being "out of shape" and hence curtail their level of exercise. For most asthma patients, however, exercise induced asthma is treatable and preventable, thereby allowing children and adults with asthma to fully participate in sports and exercise. Regular exercise is beneficial for the heart, circulatory system, muscles (including breathing muscles), and mental health, but it will not cure the asthma.

Exercise induced asthma is diagnosed by a pattern of asthmatic symptoms prompted by exercise. When the diagnosis is unclear, it can be confirmed in a doctor's office by performing breathing tests at rest and after exercise.

What causes exercise induced asthma?

Environmental allergens, pollutants, or irritants inhaled during exercise may help trigger the symptoms. Prolonged, strenuous exercises without rest periods and exercising in cool dry conditions can also bring on exercise induced asthma. There are two theories to explain why this occurs.

Rapid breathing during exercise does not allow inspired air to be warmed and humidified by the nose. This cold, dry air cools the bronchial tubes, causing the muscles around the bronchial tubes to constrict (producing bronchospasm). After exercise, the bronchial tubes warm up. In asthma patients, warming up of the bronchial tubes causes the bronchial tubes to swell and become inflamed. This might explain why asthma occurs after exercise. This may be similar to what happens when previously cold fingers are warmed and they become red and swollen. The second theory involves the loss of humidity surrounding the cells lining the bronchial tubes during rapid breathing. This drying induces the mast cells (cells that contain chemicals that can trigger asthma and other allergic reactions) to release their chemicals, causing bronchospasm and inflammation.

What sports are best suited for exercise induced asthma? What sports are not?

Swimming is one of the best exercises for those with exercise induced asthma. Breathing the usually warm, humid air prevents cooling and drying of the airways. Sports that involve short bursts of exertion interspersed with rest periods are preferable. Tennis, golf, baseball, and volleyball are among the sports meeting this description. The resting periods allow the airways to recover, which usually prevents the onset of exercise induced asthma. Rapid breathing of cold, dry air is a potent stimulus of bronchospasm in asthmatic patients. Therefore, outdoor winter sports, such as skiing, may be the most problematic. It is best to choose a sport that does not require continuous vigorous outdoor exercise such as running, bicycling, or cross-country skiing.

Ways to prevent and treat exercise induced asthma

Choose an appropriate sport. Make sure that your asthma is under good control before you begin exercising. Refrain from exercise and consult your doctor if your asthma is poorly controlled. Warm up for at least 10 minutes prior to exercise. This takes advantage of a "window of safety" which may last up to an hour, often preventing exercise induced asthma. Avoid exercising in cold, dry air and on smoggy days. Covering the mouth and nose with a scarf in cold weather can be helpful. If asthma symptoms occur during exercise, stop immediately and rest. Do not attempt to "run through" the symptoms. If your breathing difficulty continues, use an inhaled bronchodilator. Following completion of exercise, do "cool down" exercises for 10 minutes to allow the bronchial tubes to re-warm slowly. Preventative use of inhalers that contain cromolyn sodium (Intal) or bronchodilators, such as albuterol (Ventolin, Proventil), 15 to 20 minutes before exercise is usually effective. Long-acting bronchodilators, such as salmeterol (Serevent), should be taken 60 minutes before exercise. Recently, the leukotriene modifiers, montelukast (Singulair) and zafirlukast (Accolate), taken daily in pill form have been found to help prevent exercise induced asthma in some athletes.

Conditions that may worsen asthma

Gastroesophageal Reflux Disease (GERD)

GERD is a common condition caused by the regurgitation (reflux) or backwash of stomach acid into the esophagus from the stomach. At times, the acid even may regurgitate into the back of the throat and reach the lungs. GERD usually-but not always--is associated with a burning discomfort under the breastbone, called heartburn, which occurs mostly after meals or when lying down. In some patients the symptom of acid reflux is not heartburn. Instead, they experience coughing, wheezing, hoarseness, or sore throat. The presence of acid in the esophagus or the passage of acid into the lungs (aspiration) may cause the bronchial tubes to constrict (bronchospasm), causing wheezing and coughing that may not respond to medications for asthma. Bronchospasm related to acid reflux tends to occur more frequently at night as a result of lying down. Interestingly, GERD is common among patients with asthma. Some doctors believe that asthma itself or asthma treatments in some way make asthma patients more susceptible to acid reflux. For example, theophylline, an oral medication occasionally used to treat asthma, may promote acid reflux by relaxing the specialized muscles in the esophagus that normally tighten to prevent regurgitation of acid. In patients with nocturnal or difficult to control asthma, treating acid reflux may help relieve coughing and wheezing. Treatment of GERD involves elevating the head of the bed, losing weight, avoiding spicy food, caffeine, alcohol, and cigarettes. Proton pump inhibitors such as Prilosec, Protonix, Aciphex, Prevacid, and Nexium are potent inhibitors of production of acid in the stomach and are effective treatments for asthma aggravated or caused by acid reflux. Rarely, surgery is performed to prevent acid reflux for severe cases of GERD that do not respond to medications.

The allergic rhinitis-asthma connection

There is a clear association between allergic rhinitis (hay fever) and asthma. The question of which comes first-the allergic rhinitis or the asthma--is not easily answered. Many patients recall developing their asthma and nasal symptoms at or about the same time. Others developed their asthma either before or after the onset of their allergic rhinitis. We now know that almost all patients with allergic asthma also have allergic rhinitis. Additionally, roughly one third of persons with allergic rhinitis will develop asthma. Patients with both conditions can expect to suffer more severe asthmatic attacks and require stronger medications to treat their asthma. Patients with allergic rhinitis should be vigilant about reporting any persistent coughing or wheezing to their doctors. The presence of asthma can easily be determined with pulmonary function tests.

The possible reasons why allergic rhinitis and asthma are related are that:

• The nasal and bronchial membranes are made up of almost the same type of tissue.
• The nerves of the upper airway (nasal cavity) and the lower airway (bronchial tubes) are connected. Both the upper and lower airways are exposed to the same external environment during breathing. When allergens reach the nasal cavity there is stimulation of nerve endings in the nasal cavity. This stimulation causes reflex neural signals to be sent to the tissues of both the nasal cavity and the lower airways. In the nasal cavity, these signals cause accumulation of fluid and the formation of mucus, while in the bronchial tubes they cause bronchial constriction and possibly acute asthma. This is sometimes referred to as the naso-bronchial reflex.
• Nasal congestion causes mouth breathing. During mouth breathing air bypasses the nose. It is not filtered for allergens and irritating particles, and it is not warmed or humidified. This non-conditioned air is more likely to cause bronchial hyper-reactivity and produce asthma symptoms.
• Mucus from the nasal cavity may drip from the back of the nose into the bronchial tubes, especially during sleep. This dripping mucus increases bronchial inflammation and causes episodes of asthma at night.

Sinusitis and asthma

Over the years, physicians have noted an association between asthma and sinusitis. In fact, 15% of patients with sinusitis also have asthma (as opposed to 5% of the normal population). An astounding 75% of severely asthmatic patients also have sinusitis. Additionally, asthmatic patients often report that their symptoms worsen when they develop sinusitis. Conversely, when the sinusitis is treated, the asthma improves.

The reasons behind the association of asthma and sinusitis are similar to those suggested for the association between asthma and allergic rhinitis. The infected mucus from the sinuses may drain into the bronchial tubes, thereby causing bronchitis (sinobronchitis). The inflammation caused by the mucus may worsen asthma. The best evidence to date seems to support the idea of neural reflexes in the linings of the nose, sinuses, and airways. Sinusitis may activate a "sinobronchial reflex" and worsen asthma. Greater insight into how these two conditions are related may allow better control or even cure of these common conditions.

Asthma Complexities At A Glance

Unusual symptoms of asthma include cough, rapid breathing, fatigue, sighing, difficulty sleeping, anxiety, and difficulty concentrating. These symptoms can mimic other illnesses. Asthma can be mimicked by other conditions, such as heart failure, bronchitis, emphysema, bronchiectasis, bronchial obstruction, vocal cord dysfunction, and hypersensitivity reactions. Exercise is a common trigger for asthma and may cause symptoms in 80 to 90% of asthmatics. Exercise induced asthma is managed by choosing an appropriate sport, controlling the asthma prior to events, warming up, avoiding cold, stopping exercise during an asthma attack, cooling down after exercise, and preventing episodes with the use of inhalers and bronchodilators. Some medical conditions can cause asthma to worsen including GERD, allergic rhinitis, and sinusitis.

Source: RefillPill.com Editors' Choice