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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
Dr. Gary B. Moss received a BA in Biology from the University of
Chicago and an MS in Human Physiology from Georgetown University.
He graduated from the Medical College of Virginia, where he also
completed his Internship and Residency in Internal Medicine. He
served as a Fellow of Allergy and Immunology at Barnes-Jewish Hospital
and Washington University at the St. Louis School of Medicine.
He is Board Certified in Internal Medicine and in Allergy and Immunology.
Dr. Moss is on staff at Sentara Norfolk General Hospital, Sentara
Leigh Memorial Hospital, Bon Secours De Paul Hospital, and Chesapeake
General Hospital.
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