Asthma Symptoms, Diagnosis, Management & Treatment

INTRODUCTION

It's like trying to breathe through a straw or being a fish out of water. These are just two of the many ways people have described what having an asthma attack feels like. Affecting an estimate of 6 million children nationwide (Zahran et al., 2018), asthma seems to have cemented itself as prevalent disease that warrants plenty of awareness and education in households nationwide. Locally, Asthma in New York City affects about 84,000 children (12 years old and under) with the highest rate being that of our Bronx communities, 8.1% (FIND THIS SOURCE 2 CITE!). This paper will not only aim to provided a further understanding of the types of Asthma, but also examine the risk factors that exist in our local communities and how studies today seek to explain and tackle the elevated asthma rates in the Bronx.

DESCRIPTION OF THE DISEASE

Asthma is a chronic inflammatory lung disease that can range from mild to life threatening and effects an individual's bronchiole tubes, compromising their ability to breathe. In a normal and healthy state, when a person inhales, the respiratory system is able to seamlessly carry out the necessary steps. Air is able to travel down the lungs and through the bronchiole tubes, where the body uses the mucus in these airways to trap and clear out any particles that might have found their way inside, like pollen or dust. The air would then enter these tiny air sacs called alveoli where the oxygen passes through its' thin walls to the surrounding capillaries and hemoglobin helps move oxygen from the alveoli to the blood, allowing for the circulation of oxygenated blood to the organs. In the case of asthma however, an individual's bronchiole tubes remain in a constant state of inflammation, regardless of the presence of symptoms, which in turn make the airways hyper responsive to any triggers encountered. These triggers can vary from exposure to indoor allergens like dust and cockroaches to those genrally outdoor such as pollen, air pollution or tobacco smoke. Once exposed, the bronchioles become even more inflamed, and cause the mucosa lining of the airways to produce more mucus. The smooth muscle surrounding the bronchioles will subsequently constrict, also known as bronchoconstriction, and significantly decrease the air flow. This obstruction will ultimately leave the person struggling to take full, deep breaths and in more severe cases, can lead to death. Exercise-induced bronchoconstriction (EIB), otherwise known as exercise induced asthma is also another type of Asthma. Although the previously mentioned triggers can also effect exercise-induced asthma, it's the quicker and deeper breaths we take due to the increased demand of oxygen of our body that worsen symptoms of EIB the most (www.afa.org). Since we typically inhale through our mouth instead of our nose while exercising, we are taking in cold, dry air. It's this same air that triggers the bronchoconstriction and can set off the same chain of events physiologically as the allergen induced asthma previously discussed. Any symptoms exhibited that are a characteristic of EIB are not present immediately at the start of the exercise, but while the exercise is ongoing and although it can worsen 5-10 minutes once the completed, an additional 20-30 minutes allows for it resolve itself.

Although there is no known exact cause if Asthma per se, there are multiple risk factors that are believed to strongly influence the likelihood of its development. Exposure to allergens, air pollution (including those due to occupation), smoking, family history, obesity and frequent viral respiratory infections are all recognized by the American Lung Association as risk factors for developing asthma. When looking at an urban population like that of the Bronx, additional risk factors come into play, such as access to medical care, patterns of medical care, psychological stress, socioeconomic status and housing conditions (Eggleston, 2000). In their study, Karen Warman , Ellen J. Silver and Pam R. Wood, compared modifiable risk factors in the Bronx for asthma morbidity in comparison to other inner city children in 7 other studied states (2009). The study concluded that children in the Bronx are more likely than other inner-city kids to be sensitized to exposed household allergens (86% vs. 58%; p<.001) and have worse housing conditions. Asthma has been around since as far back as the 19th century where publications in the latter part seeked to define and understand the pathology. Dr. Henry Hyde Salter was a surgeon who's own constant battle with Asthma drove him to research and ultimately publish his own treatise, where he even recommended black coffee as a treatment for it (Holgate, 2010). With his knowledgeable insight and illustrations of how airways look in asthma as well as the appearance of asthmatic sputum, Dr. Salter was able to contribute to the adopted view that asthma was a distinct disease which had specific causes, clinical consequences and requirements for treatment ( Holgate, 2010). Additional research was also provided by the founding father of modern medicine in Western societies and one of the three founders of John Hopkins Medical School, Sir William Osler, who identified Asthma as a chronic respiratory condition and several factors that worsened manifestations during that time, like the climate, violent emotion, certain foods and cold infection (Holgate 2010).

SYMPTOMS

There are common symptoms that have led general health practioners to quickly identify what can most likely be asthma in children and adults alike and who is having an attack. Wheezing for example, is one of the indicatiors physicians look for when diagnosing patients. ** which is caused by the whistling sound the air makes as it struggles to travel through the narrowed airways. While sometimes not audible from a distance, physicians can identify this with certainty with the help of their stethoscope. Coughing is also another, often dismissed symptom of asthma. The coughing comes about because of the excess mucus production from the mucosa lining in our bronchioles and and the continued state of inflammation they exist in. Lastly, a tightening sensation of the chest which patients have described as if something heavy is on their chest, is attributed to the smooth muscles of the bronchioles constricting. In an asthma attack all these symptoms worsen to the point where there is not enough oxygen being transported to the rest of the organs and death can be the end result.

TRANSMISSION OF DISEASE

Asthma is not a disease that can be passed along from one person to another. Being around an individual with this condition doesn't make a person any more likely to develop the symptoms or diagnosis. On the contrary, asthmatics surrounded by others who might have a common respiratory infection like the flu, pneumonia or a cold, risk contracting that infection which although not entirely understood why, studies have found effects asthmatics much worse with symtpoms lasting longer than those without asthma (Busse WW, Lemanske RF Jr & Gern JE, 2010).

TREATMENT

While the exact cause of asthma is still unknown, the treatment for it has been refined throughout the years in order to devise the most optimal plan not only treat but more importantly prevent. Working with a primary care physician to develop an Asthma Action Plan allows one to clearly outline the steps that need to be taken should should symptoms start to arise and worsen. The action plan essentially contains the following five steps:

1. Instructions on proper use of asthma meds
2. Necessary actions when you or your child is has symptoms or a low peak flow reading
3. Signs of an episode/attack
4. When to seek emergency care
5. Emergency contact info In terms of actual medication used to treat asthma, there are two main categories form which doctors prescribed medication from.

The first category is also looked as the primary treatment because they are known as relievers which provide rapid, short-term relief of asthma symptoms to prevent a flare or attack . Reliever or rescue medications can be either short-acting beta agonists, ipratropium or oral and intravenous corticosteroid. The short-acting beta agonists can be taken as inhalers that include albuterol (ProAir HFA, Ventolin HFA, etc.) and levalbuterol (Xopenex) or via a nebulizer were the medication is delivered through a face mask or mouthpiece. Both forms of these bronchodialators aim to reduce the tightness of the airways so we can breathe more comfortably. Like the short-acting beta agonist, ipratropium (Atrovent) is also delivered through an inhaler and although it's more frequently used for cases of emphysema and chronic bronchitis, it's also been used to treat asthma attacks. The last of the reliever medications are corticosteroids like prednisone and methylprednisolone, which can be taken oraly or intravenously (www.MayoClinic.org). Although they are meant to provide immediate relief, these medications are not for long term use and it is recommend to seek a doctor if the reliever is being used more frequently than was discussed between a patient and their physician.

Maintaining control of one's asthma goes beyond the immediate relief provided by a resuce medication. It also entails adhering to a daily treatment regimen if required, to help prevent the occurance of an asthma attack. In these instances, long-term asthma control medications, otherwise known as preventative medications are a crucial component to this. Among them are leukotriene modifiers, long-acting beta agonists, combination inhaelrs and theophylline. Both leukotriene modifiers like montelukast(Singulair) and theophylline (Elixophyllin) come in tablet form and help relieve asthma symptoms for up to 24 hours and function as a bronchodilator to relax airways respectively. Combination inhalers like the Advair Diskus and long-acting beta agonist inhalers like Serevent and Foradil are the last two additional options for preventive medications for airway opening. However, some research has shown that long-acting beta agonist should not be used on it's own and instead combined with an inhaled corticosteroid to avoid the risk of having a severe asthma attack (www.nhlbi.nih.gov). For patients who who been diagnosed with exercise indiced asthma, the treatment regimen also includes short and long-acting beta agonists/bronchodilators in addition to mast cell stabalizers (www.aafa.org). When taking these medications, it's important to be aware that these medications are most effective when taken under the suggested time frames when used to treat EIB vs. non-exercise induced asthma. Short-acting bronchodilators for example help prevent symptoms for up to four hours, but must be taken 10-15 minutes prior to exercising. Long-acting bronchodilators must also be taken before any activity, specifically 30-60 minutes beforehand and only once within a 12 hour period. (www.aafa.org) These types of medications are strictly for the prevention of symptoms only and unlike the short-acting bronchodilators, long-acting bronchodilators will not provide any reversal or relief of EIB symptoms. Lastly, mast cell stabilizers are medications that should be taken 15-20 minutes prior to exercising and like the long-lasting bronchodilators will not relieve symptoms once they begin. This group of medication is often prescribed as part of combination therapy where it is combined with short-acting bronchodilators as well.

PROGNOSIS

Although incurable, the prognosis for patients with asthma is generally quite good. There are multiple forms of therapies that doctors can prescribed, whether it's in pill form or an inhaler as well as multiple options of the actual medicine. With the different classes of medications and the options within those classes, there is that flexibility the doctor has to find a prescription ideal for each individual patient whether it's in the form of one medication as monotherapy or with combination therapy instead. Leading a normal life is very much attainable with this condition, and may only sometimes be punctuated by the occasional asthma attack and/or the long-term preventative medicaitons that are taken daily (www.erdwhitebook.org) . Moreover, throughout the years, there has been quite some research done on both excerise induced asthma and allergen asthma that have allowed the public to become more aware and knowledgeable on the subject matter. The NYC Health Department has even launched campaigns in Northern Manhattan, Central Brooklyn and the entire Bronx which are the areas in New York City with the higesht rates of ER visits and hospitalization for asthma. The goal of this campaing is to educate parents on asthma being more than just an episode, but rather a chronic illness that requires every day management (www1.nyc.gov).

FUTURE FOR ASTHMA

Current research in asthma has been focusing more and more on understanding why disparities exist across certain communities as well as racial and ethnic groups in relation to asthma rates and hospitalizations. According to the New York State Asthma Surveilance Summary Report (2013), New York City residents had higher rate of emergency room visits (135.0 per 10, 000 residents) than of New York State overall (54.2 per 10,000 residents). The disparity of this rate was even more pronounced when observing the collected data from the Bronx, which was concluded to have the highest rate of ER visit (231.4 per 10,000 residents) out of NYC and NYS. Researchers now look to use Geographic Information Science, or GIScience to analyze characterisitcs like housing conditions, socioeconomic status, and the air pollution unique to specific areas in NYC and find any correlations . In their study Urban Asthma and the Neighbourhood Environment in New York City, Corburn et al. used GIScience to determine how exactly a child's external environment, particularly their neighborhood, effects their asthma, concluding that it is often a specific combination of factors such as poor housing conditions, outdoor air pollution and noxious land uses that are responsible for the increased incidence of asthma in impoverished neighborhoods (2004). They found that the South Bronx and Morrisania/Blemont neighborhoods were among the highest rates of asthma hospitalizations relative to their population across all others in the city (Corburn et al. , 2004). The findings from this study are important because it gives us concrete facts supported by statistical evidence that show that although Asthma may not necessarily be such a pressing matter nationwide, there are communities where this is still very much a cause for concern. More recently, there is an ongoing branch of a research study at Albert Einstein College of Medicine in the Bronx looking to also understand why adults of Hispanic and Black/African American descent frequent the ER or are hospitalized more and work to lower those rates. In the PREPARE study, Dr. Elliot Israel will compare the asthma outcomes of two groups of participants, all of whom require some medication for the daily management of their persistent asthma (www.preparestudy.net). While enrolled participants still see their own physician for their asthma management and overall healthcare, the PREPARE study will provide one group with an additional medication, a short acting bronchodilator, and the other will be showed a new to keep their usual reliever and rescue medications on them at all times. Although still in the very early stages of recruitment, the possible findings the Bronx site of this study can obtain is important in determining if approaches like this, with follow-up phone interviews and questionnaires over the 15 month period of the study, make the desired impact of reducing the rates of adults of Latinx or Black/African American descent and minimizing the disparity this disparity that exists among the other racial and ethnic groups.

CONCLUSION

Asthma is chronic lung disease that causes obstruction of the airways. It is a disease that although no exact cause is known, years of research have been able to find and further emphasize the impact of, countless risk factors that do lead to a higher predisposition of developing asthma. Though asthma may often be just thought of as allergen induced, exercise induced asthma is also another common type of this same overarching condition, that finds its' hosts struggling with some of the same symptoms as allergen induced asthma. With how prevalent asthma is, the amount of education and resources made available allow people to get more involved and become their own health advocate, instead of being a bystander to a disease that can be well managed enough for the individual to live their normal life.

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