Asthma Research Paper
The Asthma Epidemic:
Diagnosis, Treatments and Management, all prospects towards a better future
Asthma is a multifactorial chronic disorder that has displayed a significant increase in prevalence and incidence worldwide over the past two decades, particularly in developed countries (Hazeldine, 2013). The World Health Organization estimates that 235 million people currently suffer from this common respiratory condition. Despite this growth, over that same period of time, global asthma mortality has clearly decreased, corresponding with marked advances in asthma diagnosis and management. Nonetheless, the majority of occurring deaths are preventable (Rebuck, 2013). Concerted efforts to find and improve asthma treatments, diagnostic tools …show more content…
and management strategies are imperative to further reduce the burden of this disease, its morbidity rate and prevent its onset. Asthma remains under-diagnosed, under-treated and an overall descriptive term. Although, there is no universally recognized precise definition, asthma is commonly defined as a chronic inflammatory disorder of the airways that causes recurrent airflow obstruction and airway hyper responsiveness characterized by wheezing, dyspnea, intermittent chest tightness and shortness of breath, and is reversible on treatment (Rees, Kanadar, Pattani, 2010).
This research paper aims to provide a concise overview of asthma by focusing on its diagnosis, treatments and management. The decrease in asthma mortality has been shown to coincide with significant change and better understanding of these critical components (Rebuck, 2013).
Discussion
Asthma classification and clinical presentation It is widely recognized that asthma is considered a heterogeneous disease for which multiple clinical, physiological and inflammatory manifestations combine to produce a variety of pathogenesis and severity ranging from mild to life threating (Hashimoto & Bel, 2012). Because of its multifaceted aspect, there is still no established classification system or measurement scheme used to define asthma and its subtypes. Ongoing intensive researches have recently migrated towards clinical phenotype classification (Szefler, 2011). Although, pivotal clinical studies have provided new insights into pathogenic mechanisms underlying asthma, more efforts are required to further detail its critical components of pathogenesis such as phenotypes, composite genetic and molecular markers (Holtzman, 2012). Nonetheless, it has been establish that exposure to asthma inducers stimulates rapid degranulation of mast cells in the bronchial mucosa, releasing a variety of chemical mediators. These mediators result in increased airway inflammation, bronchospasms and, mucus hypersecretion leading to airway obstruction, which is reversible on treatment (Rees et al., 2010).
Asthma diagnosis
Establishing a secure diagnosis is primordial to ensure the selection of the most effective treatment. Despite the substantial progress in this field, accurately diagnosing asthma still remains a challenge specifically with difficult-to-treat asthmatics. In a case study, 12% of the patients were misdiagnosed with a respiratory disorder such a chronic obstructive pulmonary disease (Hashimoto & Bel, 2012). Diagnosis is based on a combination of both subjective and objective data. Thorough history taking and examination supported by laboratory evaluation are necessary in order to accurately identify asthma. The pertinent symptoms to look for if asthma is¬¬¬¬¬¬¬ suspected are episodic wheezing and airflow limitation along with chest tightness. Furthermore, demonstration of airway obstruction reversibility, after administration of a bronchodilator, is a required diagnostic marker (Rees et al., 2010; Lougheed et al., 2010).
Spirometry is the most practical means to validate a clinical suspicion. This device measures the total volume of air expired in 1 second (FEV) along with the maximum volume of air expired after a full inspiration (FVC), both during a forced expiratory maneuver. Although most asymptomatic patients will exhibit normal results, a decrease in FEV and FEC/FVC ratio reveals the presence and degree of airway obstruction. To increase diagnostic accuracy, spirometry testing should not only be repeated, but also evaluated during presence of symptoms. Evidence of airway reversibility is confirmed by a FEV amelioration of at least 12% from the baseline following administration of 200mL of a bronchodilator (Lougheed et al, 2010).
Under the circumstances where spirometry testing is non-diagnostic, alternative tests may be performed in order to provide evidence of asthma. In such cases, a peak flow meter can be used to monitor lung function by recording the daily variability in a person’s maximal speed of expiration (PEF). A 20% variability in self-recorded PEF in comparison with the personal best measure and/or an improvement of PEF after a bronchodilator treatment confirm reversible airflow obstruction. Also, provocative testing, also known as bronchoprovocation, can be used to detect and assess airway hyperresponsiveness by stimulating airflow obstruction via exposure to suspected asthma inducer or certain pharmacologic agents. A decrease in FEV by 20% from the patient’s baseline confirms the presence of hyperresponsivenes s (Hazeldine, 2013; Rees et al., 2010; Lougheed et al., 2010; ).
Furthermore, skin prick test, clinical trial therapy along with sputum cell count are not routinely required, but can be suggestive of a diagnosis of asthma and may be useful to exclude other diagnoses. Undergoing these objectives tests can help exclude other diseases and ratify presence of asthma, especially in children where spirometry testing is often not feasible (Hashimoto & Bel, 2012).
Asthma treatments
Early recognition of asthma’s signs and symptoms is important in order to begin immediate intervention and treatment.
Throughout the past decades, new therapies have been emerging while older treatments have been refined with research advancements in asthma pathogenesis. Selecting the appropriate treatment plan is typically based on frequency and severity of asthma flare-ups and response to previous and/or on-going therapies . Also, at times, the choice of therapy is reinforced by results obtained during pulmonary function testing (Rebuck, 2013). The severity of asthma should guide the adequate starting dosage, which in most case, a moderate level dose suffices (Rees et al., 2010). Pharmacotherapy is commonly divided into two categories: short-term relief and long-term control , both aiming for a common goal: the relief asthma symptoms and enabling asthmatics to lead a normal active …show more content…
life.
Short-term Relief. This category of medication quickly relieves sudden onset of asthma symptoms and prevents occurrence of exercise-induced asthma by relaxing the smooth muscles of the airways that have tighten during an attack. Short-acting beta-2-agonist, a bronchodilation mediator, forms the central component of asthma treatment. Guidelines recommend that its administration, either via an oxygen-nebulizer or a metered dose inhaler, should reflect patient preference and clinical status. However, its excessive usage has been associated with unfavorable outcomes such tachycardia and increased asthma mortality (Hazeldine, 2013; Rees et al, 2010; Hashimoto & Bel, 2012). Patients experiencing adverse effects to selective beta-2-agonist can alternatively use anticholinergic agents. Anticholinergic treatments provoke sustained bronchodilation by reducing parasympathetic tone. Until now, its use has only been established to treat acute asthma exacerbation (Park, 2012). However, studies suggest that tiotropium, a long-lasting anticholinergic agent, can be combined with other treatments such as corticosteroids, to improve lung function, thus enhancing asthma control (Hashimoto & Bel, 2012; Park 2012).
Furthermore, antimuscarinics are currently the most effective medication to control asthma exacerbations. Early administration of this agent with beta-2-agonists has demonstrated a decrease of 30% in hospital admissions, both in adults and children (Hazeldine, 2013).
Long-term Control. This category is used treat the underlying inflammation of the airways and mucus production, thus overtime managing asthma overtime and reducing reoccurrence of attacks. Long-acting Corticosteroids are widely identified as the first line of treatment for asthma. Its regular use suppresses inflammation by inhibiting the migration and function of inflammatory cells such as eosinophils. Studies have also agreed that there is a significant correlation between the long-term use of corticosteroids and reduced hospitalization admission and length. Therefore, administering a short-term high dose it this agent can provide relief during an asthma exacerbation (Hazeldine, 2013; Hashimoto & Bel, 2012; Rees et al., 2010).
Combining corticosteroids with long-term beta-2-agonists has been proven to improve the outcome and efficiency of asthma therapy. Long-term beta-2-agonists, via a different acting mechanism than the short-term agents, treat bronchoconstriction and nocturnal asthma.
For a mild to moderate asthma diagnosis, leukotriene inhibitors can be prescribe to reduce inflammation. Although they cannot mediate asthma symptoms during an attack, they can prevent one from reoccurring (Rees et al., 2010).
Other adjuvant therapy such as Anti-IgE therapy , a mast-cell stablizer, and Magnesium Sulphate, a bronchodilator, can be prescribed for patients who do not see clinical signs of improvement to conventional treatment (Rees et al., 2010; Hazeldine, 2013).
Bronchial Thermoplasty. Treating patients who present with acute severe asthma can be challenging. Bronchial thermoplasty has recently been approved as a promising option for difficult-to-treat asthmatics that do not respond to pharmacological treatment. In the past decade, this safe procedure has been developed to reduce the excessive amount of smooth airway muscle present with severe asthma, therefore reducing the airway wall thickness. By advancing a flexible catheter in the airways, thermal energy can be delivered to the walls to reduce its smooth muscle mass and disrupt myosin function, dercreasing the potential smooth muscle-mediated bronchoconstriction. Although, fundamental studies have confirmed improvement of life quality, health care utilization and efficacy lasting up to 5 years, no data are available on its long-term side effects and benefits (Hashimoto & Bel, 2012; Boulet & Laviolette, 2012).
Management
Despite pivotal advancements in asthma pathogenesis and therapies, asthma morbidity still remains significant.
Suboptimal control of the condition and non-adherence to medication regimen has been suggested as potential causes of asthma-related deaths (Lindsay & Heaney, 2013). It is therefore of paramount importance to ensure proper asthma management. Self-management plans should promptly begin upon diagnosis and should involve a collaborative partnership between the clinician and the patient. Education along with environmental control is crucial during this process. Reducing or controlling exposure to asthma-inducers decreases the chance of exacerbation reoccurrences. Clinician should ensure that patients understand the proper use of prescribed medication, the proper techniques of administration, what encompasses asthma control and how to monitor it. Education can be improved through referral to asthma clinics. Furthermore, periodically reviewing this action plan, modifying it if need be, along with performing routinely lung function measurements (PEF & FEV) helps monitor the adequacy of asthma management and control. A management plan should reflect a shared goal and should be tailored to a patient’s level of readiness to participate. Becoming proactive in one’s self-management plan and targeting risk for non-adherence by clinicians are essential in successfully achieving asthma control (Lougheed et al., 2010; Este, 2011; Szefler,
2011).
Conclusion and Future Studies Asthma is a clinical respiratory syndrome in which a person’s airways become narrow, inflamed and reversibility obstructed, making them hypersensitive to asthma-inducers or irritants. It is typically characterized by wheezing, difficulty in breathing, and chest tightness. Due to its multifaceted aspect, knowledge gaps still remain in the mechanism underlying its development. Diagnosis is based on presence of key symptoms, trial therapy and lung function tests designed to measure significant changes in forced expiratory volume and peak expiratory flow. Although, asthma cannot be cured, its symptoms can be controlled with effective treatment and management. Long-term control medications, taken daily, are dedicated to manage asthma by reducing inflammation and mucus production overtime. Quick-relief predications, often used in conjunction with corticosteroids, are taken to rapid reversal of an attack by mediating bronchodilation. Asthma management is focused on controlling the disorder via compliancy to an action plan, education and lung function reassessment. Thus, helping asthmatics have a productive and physically active life along with preventing long-term complications and morbidity. Despite all research advancements, diagnosing asthma still remains a challenge. The American Medical Association has acknowledged that misdiagnosed is in part due to doctors who do not updated themselves with current developments in this field or who refuse to accept new information about asthma (Hashimoto & Bel, 2012). As misdiagnosis becomes more prevalent, potentially due to the surges in numbers of children suffering from asthma, more cooperation is imperative between health care officials and clinicians to improve asthma education. If misdiagnosis continues to occur while the prevalence of childhood asthma rises, what is to be said to the future impact of this disease? In response to the increasing burden of asthma, public health researches and clinicians have identified childhood asthma as an imperative focus of study in future researches (Rebuck. 2013; Szelter, 2011).
Diagnosis, Treatments and Management, all prospects towards a better future
Asthma is a multifactorial chronic disorder that has displayed a significant increase in prevalence and incidence worldwide over the past two decades, particularly in developed countries (Hazeldine, 2013). The World Health Organization estimates that 235 million people currently suffer from this common respiratory condition. Despite this growth, over that same period of time, global asthma mortality has clearly decreased, corresponding with marked advances in asthma diagnosis and management. Nonetheless, the majority of occurring deaths are preventable (Rebuck, 2013). Concerted efforts to find and improve asthma treatments, diagnostic tools …show more content…
and management strategies are imperative to further reduce the burden of this disease, its morbidity rate and prevent its onset. Asthma remains under-diagnosed, under-treated and an overall descriptive term. Although, there is no universally recognized precise definition, asthma is commonly defined as a chronic inflammatory disorder of the airways that causes recurrent airflow obstruction and airway hyper responsiveness characterized by wheezing, dyspnea, intermittent chest tightness and shortness of breath, and is reversible on treatment (Rees, Kanadar, Pattani, 2010).
This research paper aims to provide a concise overview of asthma by focusing on its diagnosis, treatments and management. The decrease in asthma mortality has been shown to coincide with significant change and better understanding of these critical components (Rebuck, 2013).
Discussion
Asthma classification and clinical presentation It is widely recognized that asthma is considered a heterogeneous disease for which multiple clinical, physiological and inflammatory manifestations combine to produce a variety of pathogenesis and severity ranging from mild to life threating (Hashimoto & Bel, 2012). Because of its multifaceted aspect, there is still no established classification system or measurement scheme used to define asthma and its subtypes. Ongoing intensive researches have recently migrated towards clinical phenotype classification (Szefler, 2011). Although, pivotal clinical studies have provided new insights into pathogenic mechanisms underlying asthma, more efforts are required to further detail its critical components of pathogenesis such as phenotypes, composite genetic and molecular markers (Holtzman, 2012). Nonetheless, it has been establish that exposure to asthma inducers stimulates rapid degranulation of mast cells in the bronchial mucosa, releasing a variety of chemical mediators. These mediators result in increased airway inflammation, bronchospasms and, mucus hypersecretion leading to airway obstruction, which is reversible on treatment (Rees et al., 2010).
Asthma diagnosis
Establishing a secure diagnosis is primordial to ensure the selection of the most effective treatment. Despite the substantial progress in this field, accurately diagnosing asthma still remains a challenge specifically with difficult-to-treat asthmatics. In a case study, 12% of the patients were misdiagnosed with a respiratory disorder such a chronic obstructive pulmonary disease (Hashimoto & Bel, 2012). Diagnosis is based on a combination of both subjective and objective data. Thorough history taking and examination supported by laboratory evaluation are necessary in order to accurately identify asthma. The pertinent symptoms to look for if asthma is¬¬¬¬¬¬¬ suspected are episodic wheezing and airflow limitation along with chest tightness. Furthermore, demonstration of airway obstruction reversibility, after administration of a bronchodilator, is a required diagnostic marker (Rees et al., 2010; Lougheed et al., 2010).
Spirometry is the most practical means to validate a clinical suspicion. This device measures the total volume of air expired in 1 second (FEV) along with the maximum volume of air expired after a full inspiration (FVC), both during a forced expiratory maneuver. Although most asymptomatic patients will exhibit normal results, a decrease in FEV and FEC/FVC ratio reveals the presence and degree of airway obstruction. To increase diagnostic accuracy, spirometry testing should not only be repeated, but also evaluated during presence of symptoms. Evidence of airway reversibility is confirmed by a FEV amelioration of at least 12% from the baseline following administration of 200mL of a bronchodilator (Lougheed et al, 2010).
Under the circumstances where spirometry testing is non-diagnostic, alternative tests may be performed in order to provide evidence of asthma. In such cases, a peak flow meter can be used to monitor lung function by recording the daily variability in a person’s maximal speed of expiration (PEF). A 20% variability in self-recorded PEF in comparison with the personal best measure and/or an improvement of PEF after a bronchodilator treatment confirm reversible airflow obstruction. Also, provocative testing, also known as bronchoprovocation, can be used to detect and assess airway hyperresponsiveness by stimulating airflow obstruction via exposure to suspected asthma inducer or certain pharmacologic agents. A decrease in FEV by 20% from the patient’s baseline confirms the presence of hyperresponsivenes s (Hazeldine, 2013; Rees et al., 2010; Lougheed et al., 2010; ).
Furthermore, skin prick test, clinical trial therapy along with sputum cell count are not routinely required, but can be suggestive of a diagnosis of asthma and may be useful to exclude other diagnoses. Undergoing these objectives tests can help exclude other diseases and ratify presence of asthma, especially in children where spirometry testing is often not feasible (Hashimoto & Bel, 2012).
Asthma treatments
Early recognition of asthma’s signs and symptoms is important in order to begin immediate intervention and treatment.
Throughout the past decades, new therapies have been emerging while older treatments have been refined with research advancements in asthma pathogenesis. Selecting the appropriate treatment plan is typically based on frequency and severity of asthma flare-ups and response to previous and/or on-going therapies . Also, at times, the choice of therapy is reinforced by results obtained during pulmonary function testing (Rebuck, 2013). The severity of asthma should guide the adequate starting dosage, which in most case, a moderate level dose suffices (Rees et al., 2010). Pharmacotherapy is commonly divided into two categories: short-term relief and long-term control , both aiming for a common goal: the relief asthma symptoms and enabling asthmatics to lead a normal active …show more content…
life.
Short-term Relief. This category of medication quickly relieves sudden onset of asthma symptoms and prevents occurrence of exercise-induced asthma by relaxing the smooth muscles of the airways that have tighten during an attack. Short-acting beta-2-agonist, a bronchodilation mediator, forms the central component of asthma treatment. Guidelines recommend that its administration, either via an oxygen-nebulizer or a metered dose inhaler, should reflect patient preference and clinical status. However, its excessive usage has been associated with unfavorable outcomes such tachycardia and increased asthma mortality (Hazeldine, 2013; Rees et al, 2010; Hashimoto & Bel, 2012). Patients experiencing adverse effects to selective beta-2-agonist can alternatively use anticholinergic agents. Anticholinergic treatments provoke sustained bronchodilation by reducing parasympathetic tone. Until now, its use has only been established to treat acute asthma exacerbation (Park, 2012). However, studies suggest that tiotropium, a long-lasting anticholinergic agent, can be combined with other treatments such as corticosteroids, to improve lung function, thus enhancing asthma control (Hashimoto & Bel, 2012; Park 2012).
Furthermore, antimuscarinics are currently the most effective medication to control asthma exacerbations. Early administration of this agent with beta-2-agonists has demonstrated a decrease of 30% in hospital admissions, both in adults and children (Hazeldine, 2013).
Long-term Control. This category is used treat the underlying inflammation of the airways and mucus production, thus overtime managing asthma overtime and reducing reoccurrence of attacks. Long-acting Corticosteroids are widely identified as the first line of treatment for asthma. Its regular use suppresses inflammation by inhibiting the migration and function of inflammatory cells such as eosinophils. Studies have also agreed that there is a significant correlation between the long-term use of corticosteroids and reduced hospitalization admission and length. Therefore, administering a short-term high dose it this agent can provide relief during an asthma exacerbation (Hazeldine, 2013; Hashimoto & Bel, 2012; Rees et al., 2010).
Combining corticosteroids with long-term beta-2-agonists has been proven to improve the outcome and efficiency of asthma therapy. Long-term beta-2-agonists, via a different acting mechanism than the short-term agents, treat bronchoconstriction and nocturnal asthma.
For a mild to moderate asthma diagnosis, leukotriene inhibitors can be prescribe to reduce inflammation. Although they cannot mediate asthma symptoms during an attack, they can prevent one from reoccurring (Rees et al., 2010).
Other adjuvant therapy such as Anti-IgE therapy , a mast-cell stablizer, and Magnesium Sulphate, a bronchodilator, can be prescribed for patients who do not see clinical signs of improvement to conventional treatment (Rees et al., 2010; Hazeldine, 2013).
Bronchial Thermoplasty. Treating patients who present with acute severe asthma can be challenging. Bronchial thermoplasty has recently been approved as a promising option for difficult-to-treat asthmatics that do not respond to pharmacological treatment. In the past decade, this safe procedure has been developed to reduce the excessive amount of smooth airway muscle present with severe asthma, therefore reducing the airway wall thickness. By advancing a flexible catheter in the airways, thermal energy can be delivered to the walls to reduce its smooth muscle mass and disrupt myosin function, dercreasing the potential smooth muscle-mediated bronchoconstriction. Although, fundamental studies have confirmed improvement of life quality, health care utilization and efficacy lasting up to 5 years, no data are available on its long-term side effects and benefits (Hashimoto & Bel, 2012; Boulet & Laviolette, 2012).
Management
Despite pivotal advancements in asthma pathogenesis and therapies, asthma morbidity still remains significant.
Suboptimal control of the condition and non-adherence to medication regimen has been suggested as potential causes of asthma-related deaths (Lindsay & Heaney, 2013). It is therefore of paramount importance to ensure proper asthma management. Self-management plans should promptly begin upon diagnosis and should involve a collaborative partnership between the clinician and the patient. Education along with environmental control is crucial during this process. Reducing or controlling exposure to asthma-inducers decreases the chance of exacerbation reoccurrences. Clinician should ensure that patients understand the proper use of prescribed medication, the proper techniques of administration, what encompasses asthma control and how to monitor it. Education can be improved through referral to asthma clinics. Furthermore, periodically reviewing this action plan, modifying it if need be, along with performing routinely lung function measurements (PEF & FEV) helps monitor the adequacy of asthma management and control. A management plan should reflect a shared goal and should be tailored to a patient’s level of readiness to participate. Becoming proactive in one’s self-management plan and targeting risk for non-adherence by clinicians are essential in successfully achieving asthma control (Lougheed et al., 2010; Este, 2011; Szefler,
2011).
Conclusion and Future Studies Asthma is a clinical respiratory syndrome in which a person’s airways become narrow, inflamed and reversibility obstructed, making them hypersensitive to asthma-inducers or irritants. It is typically characterized by wheezing, difficulty in breathing, and chest tightness. Due to its multifaceted aspect, knowledge gaps still remain in the mechanism underlying its development. Diagnosis is based on presence of key symptoms, trial therapy and lung function tests designed to measure significant changes in forced expiratory volume and peak expiratory flow. Although, asthma cannot be cured, its symptoms can be controlled with effective treatment and management. Long-term control medications, taken daily, are dedicated to manage asthma by reducing inflammation and mucus production overtime. Quick-relief predications, often used in conjunction with corticosteroids, are taken to rapid reversal of an attack by mediating bronchodilation. Asthma management is focused on controlling the disorder via compliancy to an action plan, education and lung function reassessment. Thus, helping asthmatics have a productive and physically active life along with preventing long-term complications and morbidity. Despite all research advancements, diagnosing asthma still remains a challenge. The American Medical Association has acknowledged that misdiagnosed is in part due to doctors who do not updated themselves with current developments in this field or who refuse to accept new information about asthma (Hashimoto & Bel, 2012). As misdiagnosis becomes more prevalent, potentially due to the surges in numbers of children suffering from asthma, more cooperation is imperative between health care officials and clinicians to improve asthma education. If misdiagnosis continues to occur while the prevalence of childhood asthma rises, what is to be said to the future impact of this disease? In response to the increasing burden of asthma, public health researches and clinicians have identified childhood asthma as an imperative focus of study in future researches (Rebuck. 2013; Szelter, 2011).