The Medical Minute: Asthma - more than just wheezing

By John Messmer
Penn State Family & Community Medicine
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine

What do John F. Kennedy, Leonard Bernstein, Ernesto (Che) Guevara, Calvin Coolidge, Charles Dickens, Theodore Roosevelt, Marcel Proust, Woodrow Wilson and Antonio Vivaldi have in common? All were asthmatics, just like 15 million Americans, one-third of whom are children. The mental picture many people have of asthma is a wheezing person with an inhaler, but asthma is more than just wheezing. While many asthmatics from the past suffered with frequent wheezing and shortness of breath, current medical therapy can control asthma very well.

What is asthma?

Simply put, asthma is a condition of inflammation of the air passages of the lungs. Inflammation is what happens when the immune system attacks something. The immune response in asthmatics can be triggered by allergies, such as to cats, dust, mold or pollen; by irritants, such as smoke, dust or cold air; or by infections, such as cold and flu viruses. Once the immune response is started, chemicals from the inflammatory process are released in the air passages, causing them to swell and constrict, reducing the amount of air the person can get into and out of the lungs. Asthmatics may cough or wheeze, or simply feel short of breath. In serious cases, airflow is reduced significantly, causing collapse or even death. About 500,000 Americans are hospitalized and around 4,000 die from it each year.

Who gets asthma?

There is a strong tendency for asthma to run in families. Boys tend to get it more than girls, but in adults, it is more common for women to have asthma. It can develop at any age. There is some evidence to suggest exposure to cigarette smoke increases the possibility of asthma, particularly for young children. Since the prevalence of asthma is increasing, researchers have looked at everything from diet and obesity to environmental influences to explain it, but there is no concrete explanation for the increase.

What are the symptoms?

Wheezing is the hallmark symptom, but cough and shortness of breath, particularly if induced by exercise, cold air or a virus could be asthma. If severe, a person experiences tightness in the chest. In mild cases, it can be difficult to be sure, since the cough and difficulty breathing may be fairly mild. Not all wheezing is asthma, so self-diagnosis is not a good idea. Gastroesophageal reflux and heart disease also can cause wheezing.

How is it diagnosed?

A physician will evaluate the symptoms a person is experiencing and examine the heart and lungs. If wheezing is heard in association with a history consistent with asthma, a presumptive diagnosis can be made. Many times, a pulmonary function test (PFT) which measures lung function, can be used to help secure the diagnosis. If the PFT is consistent with asthma, it might be repeated after treatment with asthma medication to see if the abnormalities clear up. Since the PFT could be normal while the person is not having symptoms, sometimes it will be done after exposure to a medication known to induce asthma, methacholine. If methacholine causes asthmatic changes on the PFT, it supports the diagnosis.

How is asthma treated?

The most important part of asthma treatment is to control inflammation, which will stop the disease process. An inhaled steroid, a form of cortisone, very often is the foundation of treatment. These medications treat the inflammation very well and tend to have minimal side effects. They should be continued even if there are no symptoms. A leukotriene inhibitor may be beneficial in some people. This is another type of anti-inflammatory that is not a steroid, but it does not work for all asthmatics. A long-acting bronchodilator helps keep the airways open to improve airflow. Short-acting bronchodilators should be used minimally; if they are used more than a couple times a week, the asthma is not sufficiently controlled. Sometimes asthmatics stop using their anti-inflammatory and long-acting bronchodilators in favor of the rapid-acting medications because they feel the latter is working. It is possible to become insensitive to the effect of short-acting inhalers if used alone, making emergency treatment less successful. Death could result. Theophylline has been used for decades, but can have some serious side effects. More typically, it is added to other therapies in adult asthmatics if needed. Cromolyn and related compounds can control the release of histamine and can be a useful adjunct in appropriate people.

What's the prognosis?

Excellent, in most cases. There's no reason for asthmatic people to stay on the sidelines or limit their activities. Asthmatics can excel in all walks of life. Even some Olympic gold-medal winners have been asthmatic. Working with one's doctor on a treatment and monitoring plan can allow most asthmatics to manage their disease with minimal problems.

Asthmatics should get regular check-ups and be certain they understand what medications to take and how to use them. They should have a plan for self-monitoring and treatment if the asthma worsens. Asthmatics should never smoke and should make every effort to avoid exposure to smoking. Many times, children's asthma resolves by adulthood. With proper treatment, there can be fewer lost work and school days, and more importantly, fewer deaths from asthma.