Asthma is a disease that affects the bronchi.The trachea and bronchi are the tubes that carry air to the lungs. The bronchi are made of cartilage, which is the “skeleton” or “scaffolding” of their walls, muscles, and mucosa. The contraction of the muscles in the bronchial wall causes them to narrow during an asthma attack. Compared to healthy people, the bronchi in asthma sufferers contract too easily and too much. In the course of asthma, the muscles in the bronchi overgrow, become thicker, stronger, and more capable of causing the bronchial tubes to contract even more.

The bronchi are lined with a mucosa. The mucosa of the trachea and major bronchi is covered with cells with cilia. There is a thin layer of mucus on their surface. It consists of two layers:

• external, sticky and dense, to which small impurities present in the inhaled air stick
• rarerand located directly on the surface of ciliated cells. The thin layer of mucus facilitates the movement of the cilia and the movement of the mucus with sticky debris towards the trachea and larynx, where it is expelled or swallowed.

Dig. 1.The bronchi of a healthy person suffering from asthma

Interestingly, the cilia move synchronously, so the mucus only moves in one direction. Someone figuratively called this mechanism “mucociliary escalator”. Its disorders predispose to respiratory system infections, and smoking is the easiest way to damage it. In the mucosa there are also cells and glands that produce mucus, and inflammatory cells responsible for defense against bacteria and other pathogens entering the bronchi through inhaled air.

This defense is usually very effective. The nasal cavity and mouth are full of bacteria, which under normal conditions do not harm us, but can sometimes cause, for example, pneumonia. The airways below the larynx, however, are usually sterile; that is, there are no bacteria in them because they are destroyed by our immune system. Many changes occur in the bronchial wall in patients with asthma.

Asthma is caused by an inflammatory process in the bronchi. Then the number of cells of the immune system increases, and the substances secreted by some of them cause bronchospasm. The cells that build the bronchial wall (epithelial and muscle cells), which secrete various substances (so-called inflammatory mediators), are also involved in the inflammation process. This inflammation often causes paroxysmal bronchospasm, which becomes hypersensitive to various stimuli, and the gradual remodeling of the bronchial wall.

In addition to the hypertrophy of the muscles of the bronchial walls, their thickening occurs, which is caused by the hypertrophy of the glands and an increase in the number of blood vessels. Because the bronchi are “stretched” by the expanding lungs during inhalation, constriction of the bronchi makes it less difficult to inhale than exhale. Therefore, during an asthma attack,breathlessnessis typically expiratory, which means that it is difficult for you to breathe out (let the air out of your lungs).

Who gets asthma?

Asthma does not choose. People get sick regardless of age, race or gender. Over 300 million people suffer from asthma worldwide! Scientists estimate that almost 2 million people in Poland suffer from asthma, i.e. about 5% of the population. This means that 1 in 20 people have asthma. So there are a lot of us!

However, the prevalence of asthma varies from country to country. It ranges from less than 2% in Greece and Albania to almost 20% in Ireland and New Zealand. It is not known exactly why such large differences in the incidence of asthma arise.

This may be partly due to genetics, as the predisposition to develop asthma is to some extent inherited, and partly to differences in the prevalence of different allergens and lifestyle.

Interestingly, evidence from a very large international study with the acronym ISAAC shows that differences in the prevalence of asthma between countries have recently started to narrow. This information applies to children, but it is likely that a similar phenomenon can also be observed in adults.

What are the symptoms of asthma?

Bouts of breathlessness andcoughingare typical of asthma , often at night and in the morning. Most patients experience no symptoms between seizures.

Common symptoms of asthma

• dyspnoea
• cough
• compression in the chest
• wheezing.

The most common symptoms of asthma are paroxysmal. Most patients do not feel any discomfort between seizures. Dyspnoea and cough go away either spontaneously or with treatment (a fast-acting bronchodilator is usually sufficient). In some patients, the only symptom of asthma is persistent cough (then we are talking about the so-called cough variant of asthma).

Frequency and severity of symptoms

The frequency and severity of symptoms vary widely with the degree of asthma control. If asthma is uncontrolled, symptoms even occur every day (more than twice a week), wake the patient up at night and make life and work difficult. Lung function as assessed byspirometryorPEFis often abnormal (FEV₁or PEF <80% of the predicted value or in the case of PEF <80% of the best value for the patient). Patients with uncontrolled asthma may also have severe exacerbations of the disease and require treatment in a hospital. Fortunately, most people with treatment can control their asthma, and prevent symptoms and flare-ups. However, a prerequisite for achieving asthma control is the regular use of anti-inflammatory drugs.

Asthma is under control when symptoms occur intermittently (less than 3 times a week), asthma attacks do not wake you up at night, do not interfere with your daily life, and there are no exacerbations.

Cough

The cough in people with asthma is usually dry (no sputum production). Only sometimes the coughing attack ends with the coughing up of a small amount of whitish, thick sputum. Coughing is often accompanied by shortness of breath. Sometimes the patient “coughs” into an attack of asthma – at the beginning there is a cough that increases, and finally shortness of breath and wheezing join in. Coughing fits may wake the sick person at night. For some people, coughing is the only symptom of asthma. This is called cough variant of asthma. However, remember that not all chronic coughs are symptoms of asthma. It is not easy to distinguish between diseases that cause coughing. If the cough persists chronically beyond the period ofcolds, it is necessary to visit a doctor who, based on the symptoms, may order an appropriate diagnosis.

A feeling of tightness in the chest

The feeling of tightness in the chest most often accompanies shortness of breath. Many patients describe it by referring to the hoop that hugs the chest and does not allow you to breathe freely. Remember thatchest painis not an asthma symptom! If you experience chest pain, especially not temporarily associated with asthma attacks (eg burning sensation behind the breastbone, pain in the lower half of the chest, pain increasing with deep breathing), see your doctor.

Wheezing

Wheezing is also a symptom of breathlessness. The constriction of the bronchial tubes that causes an asthma attack makes it more difficult to exhale than to inhale. During an attack, the exhalation may be significantly prolonged – the air from the lungs “squeezes” through the narrowed bronchi. This may be accompanied by wheezing sounds. The doctor assesses their presence and intensity during auscultation of the lungs with a stethoscope. Sometimes, however, the whistles are so loud that they can be heard by the patient or even those around him.

Factors that trigger asthma attacks

It is typical of asthma to experience attacks of breathlessness and coughing at night and in the morning. However, nocturnal symptoms do not occur in all patients. Dyspnoea often occurs after exercise (a seizure usually develops after exercise is stopped).

Other factors that cause attacks of breathlessness include:

• in patients with atopic asthma (allergic) contact with an allergen to which the patient is allergic (e.g. exposure to dust, pollen or entering the room where the cat was)
• irritating factors (e.g. aerosols, paint vapors) that may be related to occupational exposure
• stress or strong emotions
• tobacco smoke (active smoking or passive exposure to tobacco smoke)
• air pollution
• certain medications (e.g. acetylsalicylic acid or other NSAIDs).

Longer-lasting asthma exacerbations are often caused by viral infections of the upper respiratory tract.

In about half of patients, asthma has an atopic background, i.e. it is associated with an allergy to common environmental allergens, such as pollen. In these situations, asthma symptoms may worsen during the pollen season (e.g. in spring or early summer). Some of these patients do not develop asthma symptoms at all except during the pollen season. Patients with atopic asthma often have symptoms of other allergic diseases, such asrhinitisand conjunctivitis. In order to diagnose an allergy,skin testsare performed or the concentration ofIgE antibodiesspecific for a particular allergen is determined in the blood. Patients allergic to pollen should consultthe pollen calendar. Thanks to it, you can check when the concentration of pollen in the air is the highest.

Other allergens that commonly cause symptoms in asthma include house dust mite, mold, cockroach and cat allergens. If the tests have shown an allergy to specific allergens, it is worth remembering about the methods of avoiding exposure. They vary depending on the allergen causing the sensitization.

Viral infections in the respiratory tract (“colds”) can worsen or worsen asthma control. If your colds last longer than 10 days or cause asthma symptoms, please tell your doctor at your next visit. Together, you can arrange a cold-time asthma treatment modification that will prevent adverse bronchial symptoms.

With proper treatment, you can prevent the onset of exercise-induced breathlessness and cough. Often it is necessary to take the drug prophylactically.

Exercise is one of the more common triggers for asthma symptoms, which usually begin shortly after exercise ends. Symptoms are more common when the air is cold and dry (which is why they are more common, for example, when practicing cross-country skiing than when swimming in a swimming pool). In some patients, it causes a reluctance to active lifestyle and sports. This is a mistake! Effort, active, active life and playing sports are the most desirable. With proper treatment, you can prevent the onset of exercise-induced breathlessness and cough. Often it is necessary to take the drug prophylactically (before exercise).

Worsening of symptoms

Asthma attacks vary in severity. Some are almost imperceptible, and the heaviest ones can be life-threatening. You must learn to recognize severe asthma attacks in order to respond appropriately. Most of us know our condition well enough to know when a seizure is severe, when it doesn’t go away as quickly as usual, and we’ll need a doctor. Most patients do not have very severe attacks of the disease, so it is worth remembering a few symptoms that should prompt you to call for help.

Symptoms requiring urgent medical attention

These are among others:

• Inability to utter a complete sentence (only single words can be uttered due to breathlessness)
• dizzinessand increasing light headedness
• fatigue and increasing sleepiness
• no improvement and further worsening of breathlessness despite treatment with a fast-acting bronchodilator.

How is asthma treated?

The patient is the doctor’s partner in the treatment of asthma.

The more a patient knows about asthma, the more consciously he can cooperate with the doctor in developing a treatment plan and the more he can independently modify the treatment according to the rules agreed with the doctor in advance.

You should develop a written asthma management plan with your doctor

It should contain key information:

• how to use medications,
• how to monitor the severity of the disease,
• when to see a doctor,
• whether and what modifications in the treatment can be made independently,
• how to deal with an exacerbation of asthma.

A written action plan is extremely useful. It helps both those who have difficulty remembering how to use their medications and those who know a lot about asthma and want to have a greater say in their treatment.

Identifying and reducing exposure to risk factors

Together with your doctor, you and your healthcare provider should try to identify the factors that are causing your asthma symptoms and find ways to reduce your exposure to these factors or reduce their adverse effects. The most common symptoms are:

• allergens in the environment,
• physical effort,
• allergens in the workplace,
• chemical substances,
• viral infections,
• strong smells,
• stress and strong emotions,
• tobacco smoke.

Physical effort

It is worth remembering that exercise is an essential component of a healthy lifestyle and should not be avoided. Effective approaches are available to prevent exercise-induced dyspnoea in patients with asthma.

Disease control assessment

The cornerstone of proper asthma control assessment is the physician’s assessment of the frequency and severity of asthma symptoms. However, the doctor will only know what the patient tells him.

Patient information is of great value as asthma symptoms and lung function change over time. They will not be replaced by a one-time examination by a doctor orspirometry. Therefore, the patient should know the symptoms of asthma and be able to assess the severity of the disease over time. A diary kept by the patient, in which he records symptoms, can be of invaluable help. Additionally, patients with severe asthma may benefit from daily PEF monitoring.

Pharmacological treatment

It is of utmost importance for you to understand the difference between disease control medications and reliever medications.

Disease control medicationsare used on a regular basis, whether or not asthma symptoms are present. Usually, they do not work immediately, and the patient does not feel the effect of their use until a few weeks later. These drugs include:

• Inhaled glucocorticosteroids– the most important medications used in asthma, are safe and effective. They inhibitthe inflammatory process in the bronchithat underlies asthma. They reduce the severity of symptoms, improve lung function, and reduce the frequency of exacerbations
• long-acting β₂-agonists– they relax the bronchi, and their effect lasts for many hours, so they are usually used twice a day. They do not significantly inhibit the inflammatory process in the bronchi, sothey must always be used together with inhaled glucocorticosteroids. This combination of drugs is effective and safe, while the use of long-acting inhaled β₂-agonists alone is likely to increase the risk of death from asthma.
• anti-leukotriene drugs – inhibit the harmful effects of leukotrienes, i.e. substances released from inflammatory cells that intensify bronchospasm and the inflammatory process. They are administered orally and are less effective than inhaled corticosteroids.
• theophylline– dilates the bronchi and has anti-inflammatory properties. It is used less frequently than other medicines as it often causes side effects. It is administered orally in the form of extended-release tablets.
• cromons– are administered by inhalation. Safe and well tolerated by patients, but their anti-inflammatory effect is very weak, so they are now used sporadically.
• Oral glucocorticosteroids– one of the basic groups of drugs used in the treatment of exacerbations. In chronic treatment, they are used as a “last resort” only when all other drugs have failed. Chronic use causes numerous, often serious side effects, so it is only used as a last resort in patients with very severe asthma.
• monoclonal antibodies against IgE– inhibit the action of immunoglobulin E, blocking an allergic reaction. Used in patients with severe allergic asthma. They are administered subcutaneously every 2 or 4 weeks.

Reliever medications– taken to reduce the severity of symptoms. They do not heal the inflammatory process in the bronchi, they merely dilate the bronchi, reducing the severity of asthma symptoms. The most commonly used are short-acting β₂-agonists. Increased demand for reliever medications (need to inhale more often than usual, use up the medicine pack faster) may indicate deterioration of asthma control and is an indication for medical consultation.

Rules for the use of drugs

1. Disease control medications are used regularly as directed by your doctor, regardless of the presence of symptoms.
   Absence of episodes of shortness of breath and coughing is not an indication for you to stop using your asthma control medications without consulting your doctor first. Only anti-inflammatory control medications affect the cause of the disease, other asthma medications merely relieve symptoms.
2. Reliever medications are taken to relieve symptoms and exacerbations of asthma and as a preventive measure before exercise. They do not affect the course of the disease, and their increased consumption should be reported to the doctor. The reliever medication should be carried with you at all times.
3. After using some inhaled glucocorticoid preparations, it is advisable to rinse the mouth and throat with water.
4. All patients should have a written asthma management plan and follow it.

The intensity of treatment is selected by the physician based on the severity of asthma symptoms and the patient’s lung function. If treatment is not sufficient to control your asthma, your doctor will increase the intensity of your asthma. If the symptoms of the disease are controlled and asthma control lasts for at least 3 months, you can try to reduce the intensity of your treatment so that you use as little medication as possible to control your asthma.

The different levels of asthma treatment intensity are listed below. It should be remembered that this information is indicative anddoes not constitute a basis for independent (without the help of a doctor) modification of the treatment.

• Grade 1– only use reliever medication when needed, sometimes your doctor may consider low dose inhaled glucocorticoid
• Grade 2– low dose inhaled glucocorticosteroid is the preferred treatment; alternatively, an anti-leukotriene drug may be used , especially in patients withallergic rhinitis
• Grade 3– it is preferable to add a long-acting inhaled corticosteroid (bronchodilator) to the low_dose; alternatively, an anti-leukotriene drug may be added to the inhaled glucocorticosteroid, or a medium or high dose of an inhaled glucocorticosteroid may be used as the sole controlling agent
• Grade 4– medium or high dose inhaled corticosteroid is used with ≥1 additional control drug (long-acting β₂-agonist, long-acting muscarinic antagonist, anti-leukotriene drug)
• Grade 5– in addition to inhaled glucocorticosteroids, an oral glucocorticosteroid and / or antibodies against IgE or IL-5 are used (if there are appropriate indications for their use).

At all levels of treatment, patients can use a fast-acting reliever inhaler as needed (short-acting β₂-agonist or long-acting , rapid-acting β₂-agonist administered from a single inhaler of low dose inhaled glucocorticosteroid).

Please note that the treatment intensities presented above are indicative and that the treatment recommendations may differ, e.g. due to comorbidities with asthma. It is always a good idea to ask your doctor to explain what medications he prescribed and how they work. This makes it easier to follow your doctor’s instructions and increases knowledge about asthma.

What is an asthma exacerbation?

The predominant symptom of an asthma exacerbation is dyspnoea. In severe exacerbation, it may even make it difficult to speak. During an exacerbation, the PEF is reduced to less than 80% of the best value for the patient. In very severe conditions, the PEF value may drop below 60%.

For the sake of health and life, everyone with asthma should know what to do in the event of an exacerbation. Therefore, it is extremely important to prepare a written asthma management plan that includes specific information on how to behave during an exacerbation of the disease.

The main symptoms of an exacerbation, in addition to the aforementioned severe dyspnea, are:

• wheezing
• cough
• feeling of tightness in the chest.

What to do in an asthma exacerbation?

1. Take 2–6 puffs of short-acting bronchodilator as needed, using the inhaler. Usually, a fast-acting inhaled beta₂-agonist (salbutamol, fenoterol) is used. If you have an inhalation chamber (spacer), use it while taking your medication.
2. If inhalation of the drug has resolved symptoms, the PEF is at least 80% of the maximum value, and the breathlessness does not recur for several hours, it is likely that additional treatment will not be necessary (unless your doctor advises otherwise in your written management plan).
3. If inhalations of fast-acting inhaled β₂-agonists have not brought a significant improvement, apply additional treatment in your treatment plan, see a doctor or call an ambulance.
4. If breathlessness is making it difficult for you to speak, you feel that you may pass out in a moment, urgently call an ambulance. While you wait for the ambulance to arrive, continue taking your fast-acting β₂-agonist (up to 10 puffs).
5. Take with you to the hospital:
   • all your medical records (if you have not only asthma and you have never been to the hospital, ask your family doctor to prepare written information about your diagnosed diseases and treatment)
   • written on on the card the medications you are currently taking
   • proof of insurance.
6. If you have had any of the following risk factors in the past, seek early medical help in the course of an exacerbation: •
   intubation and mechanical ventilation for exacerbations of asthma • use of oral glucocorticosteroids
   in the last few months at the HED) due to asthma in the past year.
   

Management after an exacerbation

1. Analyze carefully (first yourself and then with your doctor) what factors may have led to the exacerbation (eg pollen exposure, viral infection (“cold”), stress, etc.). Together, think about what steps you can take to prevent further flare-ups.
2. Consider whether you were taking any medications as prescribed by your doctor in the pre-exacerbation period. Failure to follow your doctor’s instructions is one of the common causes of asthma exacerbations. If for any reason you do not want to take your prescribed medications, talk to your doctor about it. If you have trouble remembering to take your medications, also talk to your doctor about it – he or she may prescribe medications that can be used less frequently.
3. If you do not yet have a written asthma management plan, ask your doctor for a written asthma management plan at your next visit.