The diagnosis of asthma sometimes requires a high index of suspicion. Even patients with moderate to severe asthma may not complain about breathing problems. For them, their dysfunction is part of the status quo. Studies have shown that asthmatic patients do not appreciate their dysfunction. In addition to inquiring about the typical asthma symptoms – wheezing, coughing, shortness of breath, we need to ask about disruption of sleep patterns, and perhaps most importantly, exercise tolerance. Of course, many patients will attribute their poor exercise tolerance to their age, their weight, or their sedentary lifestyle, and certainly these contribute significantly to their underlying condition. Asthma needs to be included in the differential diagnosis (along with heart disease).

Once you suspect asthma, pulmonary function testing (spirometry) can confirm the diagnosis, but it cannot exclude it. The main problem with spirometry is that it measures air flow, whereas asthma is principally a disease of inflammation. A therapeutic trial is warranted. Improvement in lung function or, more importantly, in the patient’s symptoms and ability to function after an appropriate trial of anti-inflammatory medications supports the diagnosis.

The focus of therapy is to heal and prevent inflammation, and Inhaled Corticosteroids (ICS) are the main tool prescribed to achieve this effect. Long-acting beta-agonists and leukotriene antagonists may be added to the ICS, and leukotriene antagonists may be used as monotherapy in milder asthmatics. Short-acting beta-agonists are still required as rescue medications. Once the disease is controlled, the medications can be tapered to the lowest effective dose. At this stage, it is imperative that the physician continues to monitor the patient on a regular basis to ensure that symptom control and pulmonary function are maximal. If the patient requires rescue inhalers twice a week, the asthma is not sufficiently controlled. It is important to make sure that the patient does not have any physical restraints from respiratory disease.

By and large, patients are as poor at taking their medications as they are at identifying their symptoms. Even patients who feel a clear improvement in their symptoms may be non-compliant with their medications and often require reminders. Allergic asthma can be ameliorated by decreasing the patient’s exposure or by decreasing the patient’s sensitivity to relevant allergens. The former is usually difficult, because it is almost impossible to control the myriad of allergens that may be provoking the inflammation,.

Allergy immunotherapy can decrease a patient’s reactivity to allergen triggers, and in children has been shown to prevent the development of asthma. While adult asthmatics often benefit from allergy immunotherapy, allergists consider asthmatic children to be even better candidates, because their asthma is usually purely allergic (Adult asthma may have both allergic and non-allergic components).

About The Author
Gary B. Moss M.D
www.allergydocs.net