The
Diagnosis of Asthma
When we think of asthma, we think of wheezing, but asthma
is not always so obvious. Some asthmatics cough, and
some only complain of shortness of breath. Many do not
complain at all, so you will not discover the problem
unless you ask. Likewise, asthma control is more than
just the absence of wheezing. 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
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