This is yet another of those detestable entities. That it can be difficult to manage is a reality and so here is a brief overview of , and pathogenisis of asthma with a discussion on exacerbating factors

Asthma is a common disease characterised by airway inflammation and reversable obstruction .

Causes, incidence, and risk factors :
Bronchial asthma is usually intrinsic (no cause can be demonstrated), but is occasionally caused by a specific allergy .Commonly in younger patients exaccerbation of asthma is linked to ongoing exposure to allergens such as dust mites , cockroaches and animal dander wheras in the elderly viral infections is added to this list . Chronic sinusitis is often directly related to severety of lower airway diseass as its felt that aspirated upper airway secretions irritate the mucosa of the lower respitory tract (thus sinusitis should be aggressively managed ) Similarly GERD ( gastro esophageal reflux disorder is commonly associated with asthma . . . Although most individuals with asthma will have some positive allergy tests, the allergy is not necessarily the cause of the asthma symptoms.
Symptoms can occur spontaneously or can be triggered by respiratory infections, exercise, cold air, tobacco smoke or other pollutants, stress or anxiety, or by food allergies or drug allergies.Emotional stress , thyroid disorders and use of medication such as aspirin and other nsaid or beta blockers should be unerthed and dealt with as asthma precipitants. The muscles of the bronchial tree become tight and the lining of the air passages become swollen, reducing airflow and producing the wheezing sound. Mucus production is increased.
Typically, the individual usually breathes relatively normally, and will have periodic attacks of wheezing. Asthma attacks can last minutes to days, and can become dangerous if the airflow becomes severely restricted. Asthma affects 1 in 20 of the overall population, but the incidence is 1 in 10 in children. Asthma can develop at any age, but some children seem to outgrow the illness. Risk factors include self or family history of eczema, allergies or family history of asthma.

Symptoms

* wheezing
* usually begins suddenly
* composed of a sequence of attacks (episodic)
* may be worse at night or in early morning
* aggravated by exposure to cold air
* aggravated by exercise
* resolves spontaneously
* good relief from bronchodilators (drugs that open the airways)
* rales
* cough with sputum (phlegm) production containing mucus (mucoid sputum)
* cough increasing recently
* shortness of breath aggravated by exercise
* shortness of breath occurs only when wheezing
* breathing requires increased work
* intercostal retractions
Emergency symptoms:

* extreme difficulty breathing
* bluish color to the lips and face
* severe anxiety
* rapid pulse
* sweating
Additional symptoms that may be associated with this disease:

* nasal flaring
* coughing up blood
* chest pain
* breathing, absent temporarily
* a feeling of chest tightness
* increased front-to-back diameter of the chest (barrel shaped chest)
* abnormal breathing pattern, exhalation takes more than twice as long as inspiration

Signs and Tests
Listening to the chest (auscultation) reveals wheezing during an episode. However, lung sounds are usually normal between episodes.
Tests may include:

* pulmonary function tests
* chest X-ray
* CBC shows increase in eosinophils
* arterial blood gas
This disease may also alter the results of the following tests:

* Immunoelectrophoresis - serum
* eosinophil count - absolute
* CPK

Treatment ( to go directly to treatment samples click here)
Treatment is aimed at avoiding known allergens and controlling symptoms through medication.
A variety of medications for treatment of asthma are available and include:

* anti-inflammatory medications
* inhaled corticosteroids (Azmacort, Vanceril, AeroBid)
* oral or intravenous corticosteroids (such as prednisone, methylprednisolone, and hydrocortisone)
* nedocromil sodium
* bronchodilators
* inhaled or oral (Proventil, Alupent, Bronkosol, and others)
* cromolyn sodium (Intal)--used to prevent attacks, not for treatment during an attack
* aminophylline or theophylline

Prevention and Treatment  Treatment Guidelines

There are established guidelines for the diagnosis and management of asthma and allergic rhinitis that your doctor can follow. For asthma, these guidelines specify the goals of therapy, the roles of medications, considerations relating to the side effects of corticosteroid therapy, a four-step approach to treatment, and the form of patient education appropriate at each step. For allergic rhinitis, the guidelines specify the four general principles of management, a four-step approach for managing mild, mild to moderate, and severe rhinitis, and when to consider allergy shots (immunotherapy).		Steps to, help control asthma take out rugs and carpets because they can get dusty and mouldy Take out soft chairs ,cushions and extra pillows because they collect dust Don't let animals in house or on bed don't allow smoking or strong smells in bedroom/house Put special dust -proof covers with zippers on the mattress and pillows Don't use pillows or mattress made of feathers or straw Wash sheets and blankets weekly in very hot water. Even curtains and blinds should be washed every so often to remove dust open windows wide when it's hot or stuffy, when there is smoke from cooking or when there are strong smells If you heat with wood or kerosene keep a window open to get rid of fumes Avoid aspirin or like products( see aspirin allergy) or medications to which you may be allergic.

Asthma
Goals of Therapy
According to the National Asthma Education and Prevention Program (NAEPP) Expert Panel, the goals of asthma therapy are

* Prevent chronic and troublesome symptoms, such as coughing or breathlessness in the night, in the early morning, and after physical exertion.
* Maintain near normal lung function.
* Maintain normal activity levels, including exercise and other physical activity.
* Prevent recurrent flare-ups of asthma and minimize the need for emergency department visits or hospitalizations.
* Provide optimal drug treatment with minimal or no adverse effects.
* Meet patients' and families' expectations of, and satisfaction with, asthma care.
The Two Roles of Asthma Medications
Asthma is a chronic disease that requires long-term management. Asthma medications play two distinct roles in managing symptoms over time:

* Long-term control (controllers)
* Quick relief (rescue)
Long-term-control medications are taken daily over a long time period to achieve and maintain control of persistent asthma.Quick-relief medications are taken to provide prompt reversal of acute breathing difficulty, due to constriction of the bronchi. People who have chronic and relapsing asthma need both types of medication for effective control.

Four-Step Approach to Asthma Treatment
The NAEPP Expert Panel recommends a four-step approach to the treatment of asthma, based on its severity and persistence.The underlying theory of this approach is that more severe disease requires treatment that is more aggressive.

The four-step approach includes both long-term-control medications and quick-relief medications at each step. Quick-relief medications are used for quick relief of symptoms of an asthma attack. Long-term-control medications are used to prevent asthma attacks or reduce their severity.

Step 1. Mild, intermittent asthma. A short-acting bronchodilator (inhaled beta2-agonist) is taken only as needed for quick relief of symptoms of an asthma attack. This is the only recommended treatment, and no daily long-term-control medication is recommended.

Step 2. Mild, persistent asthma. In addition to a short-acting bronchodilator (inhaled beta2-agonist), taken as needed for an asthma attack, a low-dose, inhaled daily corticosteroid (or cromone, for initial therapy for children) is recommended.

Step 3. Moderate, persistent asthma. In addition to a short-acting bronchodilator (inhaled beta2-agonist), taken as needed for an asthma attack, daily medication can include either a medium-dose inhaled corticosteroid or a low-medium-dose inhaled corticosteroid plus a long-acting bronchodilator. This illustrates how drug dosages are increased and/or new drugs are added as the severity of the asthma increases in Steps 2 and 3.

Step 4. Severe, persistent asthma. In addition to a short-acting bronchodilator (inhaled beta2-agonist), taken as needed, daily medication can include a high-dose inhaled corticosteroid, plus a long-acting bronchodilator, plus oral corticosteroids taken long term.
A physician following this approach should review a patient's progress every one to six months. If control of the asthma is not maintained, the patient should be moved to a higher treatment step. If control is achieved, treatment should be decreased to the smallest dose and numbers of medications necessary to maintain control

People with mild asthma (infrequent attacks) may use inhalers on an as-needed basis. Persons with significant asthma (symptoms occur at least every week) should be treated with anti-inflammatory medications, preferably inhaled corticosteroids, and then with bronchodilators such as inhaled Alupent or Vanceril. Acute severe asthma may require hospitalization, oxygen, and intravenous medications.
A peak flow meter, a simple device to measure lung volume, can be used at home to check on lung functions on a daily basis. This often helps determine when medication is needed or can be tapered in the case of an exacerbation of symptoms.

Complications

* respiratory fatigue
* pneumothorax
* complications from overuse of medications (particularly inhalers)--see the specific medication

Expectations (prognosis)
Asthma is a disease that has no cure. With proper self management and medical treatment, most people with asthma can lead normal lives.

• Calling your health care provider
  Call for an appointment with your health care provider if you or your child experience mild asthma symptoms (to discuss treatment options).
  Call your health care provider or go to the emergency room if severe chest pain develops, an attack requires more intensive use of medication than usual or requires more medication than recommended in the prescription, or if shortness of breath occurs at rest.
  Call your health care provider if symptoms worsen or do not improve with treatment or if new symptoms develop.

Classification of Acute Exacerbations

An exacerbation is classified as mild, moderate, or severe. This classification is based on both clinical and physiologic assessments. It is intended to assist the pediatrician in classification of patients according to severity. The schema should be adapted to meet the needs of individual patients. The clinical and physiologic characteristics of each classification are listed in Table 1. The practice parameter for the child who has signs of bronchospasm, wheezing, and/or persistent cough is given in Table 2 and in the Algorithm.

TABLE 2. Management of Acute Exacerbations of Asthma in a Child Who Is Capable of Using a Peak Flow Meter*
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Assessment

Recommended Actions
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Does the patient have:

Altered level of consciousness
Marked dyspnea, speaks only in single words or short phrases
Severe intercostal or sternocleidomastoid retractions
Cyanosis, pallor, or diaphoresis
Inaudible breath sounds
Subcutaneous or other extrapulmonary air
Oxygen saturation <90% if oximeter available
Peak expiratory flow rate <50% of predicted norm or baseline
PCO2 >40 mm Hg if arterial blood gases are available
If any of these conditions exist:

Give Oxygen by ventimask or nasal cannula.

If unable to generate PEFR, give epinephrine subcutaneously (SC), 0.01 mL/kg/dose of 1:1000 epinephrine with a maximum dose of 0.3 mL or SC terbutaline 0.005-0.010 mg/kg/dose with a maximum dose of 0.25 mg. If able to generate PEFR,

Give nebu1ized albuterol 0.15 mg/kg/dose or 0.03 mL/kg/dose up to a maximum of 5 mg with 6 L/min of O2(Oxygen) flow.

Give systemic steroids at a prednisone equivalent of 2 mg/kg. Consider transfer to an appropriate emergency setting at an FIO2 of 0.40 or greater and intermittent albuterol treatments every 20 min or continuous albuterol treatments at 0.5 mg/kg/hr if initial response is inadequate. If patient responds well to initial albuterol treatment, repeat twice every 20 min and go to Follow-up Treatment

Does the patient have a history of:
Steroid-dependent asthma
Panic attacks with acute exacerbations
Duration of asthma >12 hr
History of respiratory failure
Premonitions of death
>/=2 visits to office or ED in 24 hr
>3 visits in 48 hr
Paroxysmal attacks especially at night THIS IS A HIGH-RISK PATIENT! Begin therapy immediately as outlined in Initial Treatment: moderate or severe exacerbation, regardless of the severity of the current episode. These are high-risk factors that should be considered in the decision to urgently transfer the patient to an appropriate emergency setting. If there is not a prompt clinical response to therapy, consider transfer and give systemic steroids (oral or parenteral) at a prednisone equivalent of 2 mg/kg before transfer.
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B. Initial Treatment
If the exacerbation is in the mild category Give albuterol by nebulizer at 0.1 mg/kg/dose or 0.02 mL/kg/dose with a minimum dose of 1.25 mg or 2-4 puffs by metered dose inhaler (with or without spacer). This may be repeated every 20 min for up to 1 hr as needed.
If the exacerbation is in the moderate or severe category Give oxygen. If an oximeter is available, keep O2 saturation >/= 93%-95%. Give nebulized albuterol at 0.15 mg/kg/dose or 0.03 mL/kg/dose up to a maximum of 5 mg or 1 mL at 6 L flow. This may be repeated every 20 min for up to 1 hr.
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