UNDERSTANDING ASTHMA: INSIGHTS FROM LUNG SPECIALIST:

ASTHMA is a chronic inflammatory disease of airways ( Bronchi, hence called Bronchial asthma) . 'Asthma' is a term derived from a Greek word, which means 'to pant heavily' . In Hindu vedic medicine it was called Tamaka Swasa. The inflammation causes narrowing, swelling of the airways, increased mucus production and thereby causing obstruction of the air ways which results in repeated episodes of ' Wheeze, Breathing difficulty, Chest tightness and Cough' (any one or two of them or all of them may be present), particularly at night.

Prevelance rate: About 2 to 5 % of population in India are said to be suffering from bronchial asthma. It is more common in children in the age of 5 to 14 years , especially males. But it is often UNDERDIAGNOSED and UNDERTREATED. Initially asthma is reversable and can be controlled with appropriate medication as advised by a Pulmonologist or a Lung specialist. But when undiagnosed and undertreated the obstruction in asthma may become irreversable overtime.

THE FACTORS RESPONSIBLE FOR GENESIS OF ASTHMA: The disease is due to a combination of genetic, environmental and immunological factors.

Genetic factors: Asthma is usually associated with a family history of asthma and allergies in first degree relatives of patients suggesting the genetic nature.

Environmental factors: Exposure to aeroallergens like pollen, fungalspores, house dust mite, cat and dog dander may precipitate asthma. Viral infections like RSV, Parainfluenza may trigger asthma in children. Outdoor and Indoor pollution, smoke, exposure to chemical vapors, gases may cause occupational asthma.

Immunological factors: Both allergic and non allergic factors play a role. About 40% of the patients with nasal allergy (allergic rhinitis) have bronchial asthma also. Similarly

80 % of asthma patients have nasal symptoms like sneezing, itching, watering, nasal block etc. These are due to allergic inflammation in both " nose and bronchi "and therefore called as " One Airway and One Disease". But allergy is not demonstrated in 50 % of asthamatics. Non allergic mechanism also plays a role in genesis of asthma.

WHEN TO SUSPECT ASTHMA ?

When the patient presents with cough/breathlessness/chest tightenning/ wheeze which worsen at night or may disappear spontaneously. Symptoms are associated with triggers like pollen /cat and dog dander/cold air/perfumes etc., especially when accompanied by a family or personal history of allergy or eczema. Triggers may include exercise, menstruation, stress, emotions, gastric reflux etc.

HOW DOES A PULMONOLOGIST DIAGNOSE?

The diagnosis depends on history details, simple spirometry and peak expiratory flow rate ( PEFR) measurement and others.

1.Spirometry : It is a cornor stone test regulary advised by a pulmonologist in which Forced Expiratory Volume in one second (FEV1) is measured and is found to be reduced in asthamatics. After a bronchodialator, a 12% and 200ml of improvement in FEV1 confirms reversible nature of asthma.

2.Peak Expiratory Flow Rate (PEFR) : Peak flow meter is a simple, inexpensive and portable device with which PEFR is measured and found to be reduced in asthamatics. It can also be used at home to find diurnal variation by the patient himself. Over 24 hrs period of time PEFR is measured using the device at regular intervals. Any drop im PEFR by 20% or more anytime in a day can be a diagnostic indicator of bronchial asthma. It can also be used to assess respose to the treatment.

A NORMAL FEV1 OR PEFR MAY NOT ALWAYS RULE OUT BRONCHEAL ASTHMA.

3. Bronchial Provocation Test: With this test Bronchial Hyper Reactivity (BHR) is measured using methacholine challenge. This test may rarely be necessary for cases with normal spirometry but persistent symptoms.

4. FENO (Fractional Exhaled Nitric Oxide Concentration) : This test may be useful in diagnosis of asthma due to eosinophalic airway inflamation. It is useful to monitor asthma control.

5. Chest X ray: It may be necessary if other conditions like COPD, viral bronchiolitis have to be excluded.

6. Allergen Tests: These tests include allergy skin tests and measurement of allergen specific serum IgE.

PULMONOLOGIST'S APPROACH TO A PATIENT WITH ASTHMA:

After diagnosing asthma the patient is explained that asthma is controllable with appropriate medications in the form of inhalation therapy, the importance of adherence to the medication and the need to avoid triggers / allergens.

ASTHMA MANAGEMENT

The main stay of asthma therapy "Inhalation therapy". It consists of the combination of inhaled corticosteriods (ICS), which is "controller" and inhaled long acting beta 2 agonists (LABA), which is "reliever".

Inhaled Corticosteriods ( ICS : eg. budesonide and fluticasone) very crucial in the control of asthma. They reduce airway inflammation, hyperreactivity and obstruction and relieve symptoms.

Inhaled Beta 2 agonists: {Long acting (LABA ), short acting (SABA), Ultra Long Acting (ULABA)}. eg. : salmeterol, formoterol, salbutamol. They have rapid , potent broncho dialatory effect and open the narrowed airways and provide relief.

The combined use of controller and reliever inhaler therapy ( MART: Maintenance And Reliever Therapy) is the mainstay of asthma control.

Leukotriene Modifier (LTM): They act on the cysteinyl leukotrienes which cause air flow obstruction. eg. Montelukast. LTMs reduce edema, mucus secretion and airway narrowing. But generally they are less effective than ICS.

Biologic therapies: These agents are useful in SEVERE asthamatics where disease control is difficult. These are called 'Target therapies' acting on various immune system pathways responsible for asthma. Eg: Omalizumab, Mepolizumab,Reslizumab.

Other available treatment options are Allergen immunotherapy, dietary manipulations and weight loss in obese individuals and seasonal vaccinations.

THE CENTRAL ROLE OF INHALER THERAPY

Thorough knowledge of inhaler devices, techniques, iindications, advantages are very essential to the asthma patient. The various devices used in inhalation therapy are Metered Dose Inhalers (pMDI) with or without spacer, Dry Powder Inhalers ( DPI: single, multidose) , Soft Mist Inhaler (SMI), Breath Actuated Inhaler (BAI) and Nebulization therapy.

MISBELIEF?

Many patients fear the use of inhalers for fear of addiction to inhalers but the fact is, in the inhalation therapy the dose of the medication, like a beta2 agonist or steroid is very small. If same medicine is given orally the dose is much larger causing more side effects.

Secondly in Inhaler therapy, the medicine will directly reach the lungs and act locally over the bronchial walls. Therefore absorption into the blood is very little and hardly any side effects are seen.

The action is rapid, more effective and gives prompt relief.

The precision dosing is made possible.

It is important that the patient follows the correct technique as instructed by the Pulmonologist / Asthma specialist. Asthma treatment is "STEPPED UP or STEPPED DOWN" based on how well asthma is controlled. With good compliance and regular follow up an asthamatic can live a NORMAL, HEALTHY AND ACTIVE LIFE.

DO YOU KNOW WHICH CELEBRITIES HAVE ASTHMA BUT LEAD AN ACTIVE LIFE?

BigB Amitabh Bachan, Bollywood stars Priyanka chopra and Hirthic Roshan, legendary football player David Beckham, famous Bowler Stuart Broad, heavy weight Boxer Shannon Briggs, Tollywood actress Kajal Agarwal etc etc.......

ASTHMA IS CONTROLLABLE!!

BREATHE BETTER , LIVE BETTER!!!