Asthma Complexities
What do all of these individuals have in common? An active 13 year-old becomes breathless shortly after her soccer games and coughs when exposed to a cold winter's night. A young woman has a dry, hacking cough that has persisted for a year after her last "cold." A teenager is awakened early every morning with chest tightness and difficulty breathing. The answer is that they all may have asthma.
In asthma complexities, we will describe the more unusual and less expected presentations of asthma. For instance, an unexplained, persistent cough that does not go away should be a "red flag" for the patient to be evaluated by an allergy-asthma specialist. Furthermore, there are a number of medical conditions that can mimic asthma. We will review these other conditions and highlight how they differ from or can aggravate asthma. We will also explain why and how asthma gets worse at night and after strenuous exercise.
The many faces of asthma - "Unexpected"
Asthma is clearly a complex disorder. We have seen that many different triggers can activate the symptoms of asthma. These symptoms can be very subtle and may vary from individual to individual. Sometimes, the symptoms may not seem to have an obvious relationship to the respiratory system. Being aware of these "unexpected" symptoms can help avoid delays in the diagnosis of asthma. Furthermore, effective treatment of the asthma will likely relieve those symptoms even though they do not appear to be related to asthma.
Unusual or "Hidden" symptoms
The following symptoms appear to be "hidden" since they do not seem to be associated with the lungs. However, they may be an early warning of an impending asthma attack.
Some early warning or "hidden" symptoms may include: - Rapid breathing
- Sighing
- Fatigue ; inability to exercise properly
- Difficulty sleeping
- Anxiety ; difficulty concentrating
- Nocturnal asthma
More than 90% of asthmatics experience nighttime wheezing and coughing. Asthma symptoms are most common between midnight and 8 a.m. Consequently, many asthmatics experience insomnia and sleep deprivation. These frequent awakenings indicate a lack of proper control of your asthma and should prompt a visit to your asthma specialist for a re-adjustment in your maintenance asthma regimen. The ability of your lung to function may decline by up to 50% from your normal capacity during an episode of nocturnal asthma. The reasons are not clear, but possible explanations include: - Allergen exposure at night to dust mites or animal danders.
- A decrease in cortisone and adrenaline levels, resulting in increased bronchial reactivity.
- Reflux of stomach acid or heartburn.
- Cooling of the airways, thereby causing bronchospasm.
Asthma Assist
You can test for nocturnal asthma by taking your peak airflow measurements upon wakening in the morning and during the evening. A small, portable peak flow meter is used to take these measurements. An asthma specialist can teach you the correct technique for obtaining these readings. A greater than 20% decrease in your peak flow measurement from the evening to the morning reading suggests a worsening of your asthma during the night. This increases the likelihood that the aggravation of your symptoms at night is due to nocturnal asthma.
Other medical problems can affect your breathing at night and worsen your asthma. These conditions include chronic sinusitis and post-nasal drip , sleep apnea syndrome, and acid reflux (backwash of acid from the stomach into the esophagus). Often, a proper control of these associated conditions, along with allergy prevention measures, if indicated, will improve nocturnal asthma symptoms.
Could my cough be due to asthma?
A nagging, dry cough may be your only symptom if you have the cough-variant form of asthma. With this condition, there is chronic coughing, but no wheezing. The cough may first appear after a memorable "cold" or "flu-like" illness. It may also start as a "tickle" in the throat that is followed by the typical cough to clear excess mucus from the bronchial tubes. Affected persons may cough after laughing or exercise; at nighttime or any time of the day, without provocation. This cough may be the first and only sign that you have asthma.
Cough-variant asthma does not improve with cough suppressants, antibiotics, or "cough drops." For proper treatment, this condition requires an appropriate diagnosis with breathing tests and specific anti-asthma medications. The cough should not be ignored because it does not resolve on its own. A referral to an asthma specialist is usually recommended for any cough that does not resolve on its own within 6 weeks.
Masqueraders of Asthma Asthma Alert
"All that wheezes is not asthma." Some common medical conditions can mimic asthma, thereby making the correct diagnosis more difficult. You may need to follow up frequently with your doctor in the early stages of your condition to confirm that it is in fact asthma. If you still have doubts, then you may need a referral to an asthma specialist for further evaluation.
Cardiac asthma
Cardiac asthma usually occurs in elderly people who have asthma-like symptoms that are due to heart failure . They wheeze because the heart is too weak to pump blood effectively, which results in fluid build-up in the lungs. A doctor can distinguish between asthma and this fluid overloading of the lungs. A chest x-ray may reveal an enlarged heart and fluid in the lung tissues. The treatment for heart failure is different from asthma treatment. When the heart failure has been adequately controlled, the wheezing will cease. Some people may suffer from asthma and heart failure simultaneously. These patients require treatment for both conditions.
Other bronchial conditions - Acute bronchitis is an infection, usually viral or bacterial, of the bronchial tubes. This condition occurs suddenly and is accompanied by a fever, cough, yellow/green mucus, and sometimes wheezing. Acute bronchitis is generally treated with antibiotics and/or anti-inflammatory medications such as corticosteroids. This combination of coughing and wheezing is sometimes referred to as "asthmatic bronchitis," or post-viral bronchial hyper-reactivity, since it affects the bronchial tubes. The coughing and wheezing usually disappear within a few weeks.
- Chronic bronchitis refers to a longstanding inflammation of the larger bronchial tubes that is usually caused by cigarette smoking . A daily cough with heavy mucus is present for years and usually occurs in the mornings. Frequent bronchial infections are common. The wheezing is caused by infected mucus that blocks the bronchial tubes and chronic inflammation of the bronchial walls. Treatment may include antibiotics, bronchodilators, and corticosteroids similar to those used for asthma. Most importantly, stopping smoking will likely reduce symptoms.
- Emphysema is a disease that permanently damages the lung's air sacs and smaller bronchial tubes. This condition is most often caused by years of cigarette smoking. The combination of chronic bronchitis and emphysema is called chronic obstructive pulmonary disease (COPD). Emphysema refers to the over-inflation of air sacs that have lost their elasticity and ability to expel air into the bronchial tree. The result is air that is "trapped" in the lungs permanently. The major symptom of emphysema is shortness of breath. Wheezing may also be present if bronchitis or asthma occur simultaneously. Treatment begins with smoking cessation and the use of inhalers. Antibiotics, oxygen, and surgery in the advanced stages of these diseases can be helpful.
Allergy Fact
There is a rare, hereditary form of emphysema that is not associated with smoking. This form occurs in young people and is due to an enzyme deficiency that can be diagnosed by a blood test. - Bronchiectasis is another chronic bronchial condition in which the bronchial tubes are damaged by repeated infections. This condition also occurs with cystic fibrosis . Affected individuals produce a very thick, infected mucus that plugs the bronchial tubes. The result is wheezing and repeated bouts of bronchitis and pneumonia . The major symptom of bronchiectasis is a persistent cough with thick, and usually green, mucus. The condition is treated with bronchodilators, antibiotics, and corticosteroids when flare-ups occur.
- Local Bronchial Obstruction: Wheezing and or coughing may be caused by an obstruction of the bronchial tubes or trachea (main windpipe) at one particular site. The wheezing is caused by air that rushes around the blocked area and the coughing may occur as the lungs try to relieve the blockage. The most common causes of this condition are foreign bodies (e.g. peanuts), bronchial tumors, and the narrowing of the trachea after a tracheostomy . Wheezing and coughing that does not respond well to the usual asthma treatments should also alert you to the possibility of a local bronchial obstruction.
Vocal cord dysfunction (VCD)
Vocal cord dysfunction is often misdiagnosed and treated as asthma because it occurs with sudden "attacks" of difficulty with breathing. The major symptom is a noticeable, shrill sound during breathing, much like the sound that a child makes with the croup . During these attacks, the vocal cords become stuck in the closed position, resulting in extreme panic and difficulty with breathing or talking. Wheezing may also be heard, although it usually occurs while breathing "IN" rather than while breathing "OUT," which is typical of asthma. Since a correct diagnosis of VCD can be difficult, affected persons may have repeated episodes that are inappropriately treated as asthma attacks. The diagnosis often requires a careful, direct inspection of the vocal cords, typically by an ear, nose, and throat specialist. The attacks of VCD usually resolve spontaneously. Occasionally, however, a tracheotomy tube needs to be inserted to relieve the obstruction and to prevent respiratory failure. VCD is often associated with acute panic or anxiety attacks that require anti-anxiety medications, speech therapy, and psychotherapy in order to prevent future episodes. Anti-asthma medications are ineffective in treating VCD and they should be discontinued if they have been previously prescribed.
Other hypersensitivity reactions
Inhaled mold spores, such as Aspergillus , or particles from bird or parrot droppings and feathers can cause an immune response in the bronchial tubes and the lungs. When the Aspergillus fungus causes this allergic type of reaction, the condition is called allergic bronchopulmonary aspergillosis (ABPA). Affected individuals have both asthma and bronchiectasis, which require treatment with both bronchodilators and corticosteroids for a long period of time. When the immune reaction is due to inhaled bacteria, fungi, or bird particles, the condition is called hypersensitivity pneumonitis (HP). HP is differentiated from acute asthma by the lack of wheezing, the presence of a fever, and pneumonia patterns on the chest x-ray. HP is treated by avoiding the triggering agents and administering corticosteroids.
Exercise and Sports
Sports and asthma are not mutually exclusive. In the 1996 Olympic games, 1 out of 6 athletes had a history of asthma or was being treated for the disease. These Olympians competed in a variety of sports, such as track and field, mountain biking, kayaking, cycling, and rowing. Previously, swimming had been the primary sport in which asthmatics competed for reasons we will discuss later.
The following is an abbreviated list of athletes who have competed despite their asthma. - Jackie Joyner Kersey - track and field
- Jerome Bettis - NFL running back
- Amy Van Dyken - swimming
- Dennis Rodman - NBA basketball
- Ray Borque - NHL ice hockey
Exercise Induced Asthma (E.I.A.)
Exercise is a common trigger for asthma and may cause symptoms in 80 to 90% of asthmatics. Shortness of breath, wheezing, coughing, or chest tightness may occur. The symptoms usually start about 10 minutes into the exercise or 5 to 10 minutes after completing the activity. Some people experience a late onset asthmatic reaction about 4 to 8 hours after exercise. The frequency of E.I.A. has led to the misconception that asthmatics cannot exercise. As a result, asthmatic children are often left in the library or homeroom while the rest of the class is in the gym. Adult asthmatics may attribute their breathing difficulties during exercise to being "out of shape" and will stop or reduce their exercise. For both of these groups, however, asthma should not preclude exercise in most cases. E.I.A. is both preventable and treatable, thereby allowing children and adults with asthma to fully participate in sports and exercise. Athletic activities will not cure or treat the asthma itself. However, there are benefits to your heart, circulatory system, muscles (including breathing muscles), and mental health.
E.I.A. is diagnosed by a pattern of asthmatic symptoms being prompted by exercise. When the diagnosis is unclear, it can be confirmed in a doctor's office by performing breathing tests at rest and after exercise.
What causes E.I.A.?
Although E.I.A. may affect all ages, the condition is most common in children and young adults. All athletes, ranging from weekend warriors to professionals and Olympians, can be affected. Environmental allergens (such as spring and fall conditions), pollutants, or irritants inhaled during exercise may help trigger the symptoms. Prolonged, strenuous exercises without rest periods and in cool dry conditions are most likely to prompt episodes of E.I.A. There are two theories for why this occurs. - Rapid breathing during exercise does not allow the air to be warmed and humidified by the nose. This cold, dry air cools the bronchial tubes, thus producing bronchospasm. After the exercise, the bronchial tubes warm up, which in asthmatics causes them to swell and become inflamed. This might help explain why the asthma occurs after the exercise. You can sometimes see this phenomenon when you re-warm previously cold fingers, thereby causing them to get red and swollen.
- The second theory involves the loss of water and humidity around the bronchial lining cells during rapid breathing. This "drying" causes the mast cells to release their chemical mediators, which results in bronchospasm and inflammation.
Is there a best exercise for people with asthma?
Swimming is one of the best exercises for those with E.I.A. Breathing the usually warm, humid air prevents cooling and drying of the airways. Rapid breathing of cold, dry air is a very potent stimulus of bronchospasm in asthmatics. Therefore, outdoor winter sports, such as skiing, may be the most problematic. It is best to choose a sport that does not require continuous vigorous outdoor exercise such as running, bicycling, or cross-country skiing. Sports that involve short bursts of exertion interspersed with rest periods would be preferable. Tennis, golf, baseball, and volleyball are among the sports meeting this description. The resting periods allow the airways to recover, which usually prevents the onset of E.I.A.
Ways to prevent and treat E.I.A. - Choose an appropriate sport.
- Make sure that your asthma is under good control before you begin exercising. Refrain from exercise and consult your doctor if your asthma is poorly controlled.
- "Warm up" for at least 10 minutes prior to exercise. This takes advantage of a "window of safety" which may last up to an hour, often preventing E.I.A.
- Avoid exercising in cold, dry air and on smoggy days. Covering the mouth and nose with a scarf in cold weather can be helpful.
- If asthma symptoms occur during exercise, stop immediately and rest. Do not attempt to "run through" the symptoms. If your breathing difficulty continues, use your "quick relief" inhaled bronchodilator.
- Following completion of exercise, do "cool down" exercises for 10 minutes to allow the bronchial tubes to re-warm slowly.
- Preventative use of inhalers that contain cromolyn sodium (Intal) or bronchodilators, such as albuterol (Ventolin, Proventil), 15 to 20 minutes before exercise is usually effective. Long-acting bronchodilators, such as salmeterol (Serevent), should be taken 60 minutes before exercise. Recently, the leukotriene modifiers, montelukast (Singulair) and zafirlukast (Accolate), taken daily in pill form, have been found to help prevent E.I.A. in some athletes.
Conditions that may worsen asthma - GERD
- Allergic rhinitis - asthma connection
- Sinusitis and asthma
Gastroesophageal Reflex Disorder (GERD)
This common disorder is caused by the regurgitation (reflux) or backwash of stomach acid into the esophagus and at times into the back of the throat. This is usually associated with a burning discomfort under the breastbone, called "heartburn", which usually occurs after meals or when lying down. Occasionally, acid reflux may not cause any typical symptoms, but will present with a cough, wheezing, or hoarseness. This "silent" reflux may be quite difficult to diagnose.
The presence of acid in the esophagus or the passage of acid into the lungs (aspiration) may cause the bronchial tubes to constrict, which also occurs with asthma. This constriction can result in wheezing and coughing that may not respond to asthma medications. These symptoms, which can be confused with those of asthma, also occur more frequently at night as a result of lying down. Interestingly, GERD is more commonly found in asthmatics, who appear to be more sensitive to the effects of stomach acid on the bronchial tubes than do non-asthmatics. It has been suggested that the condition of asthma itself or possibly its treatment in some way makes asthma patients more susceptible to acid reflux. Allergy Assist
Theophylline , an oral medication used in asthma, may promote reflux by relaxing the specialized muscles in the esophagus that normally tighten to prevent regurgitation.
When patients develop nocturnal or difficult to control asthma, it might be helpful to initiate treatment for GERD to relieve the coughing and wheezing. GERD is managed by elevating the head of the bed for sleeping, losing weight, and avoiding spicy food, caffeine, alcohol, and cigarettes. A number of very effective anti-reflux medications are also available and surgery is sometimes performed for severe cases of GERD that do not respond to medicines.
The allergic rhinitis-asthma connection
The question of which comes first - allergic rhinitis (also known as hayfever) or asthma - is not so easily answered. Many patients recall developing their asthma and nasal symptoms at or about the same time. Others developed their asthma either before or after the onset of their nasal allergies. However, many patients are diagnosed with asthma first since its effects can be more noticeable and disruptive to their health. Asthma Fact
Nasal congestion from any cause can make your asthma more likely to flare. This link between nasal allergies and asthma has long been suspected. The early Greek physicians described how mucus from the upper airways (nose and sinuses) can drip down into the back of the throat, thus causing coughing and wheezing. They coined the term asthma, meaning, "panting for breath."
We now know that almost all patients with allergic asthma also have nasal allergies. Additionally, roughly one third of persons with allergic rhinitis will also develop asthma. Patients with both conditions can also expect to suffer more severe asthmatic attacks and require stronger medications to treat their asthma.
The nose and lungs are closely connected in the following ways: - The nasal and bronchial membranes are made up of almost the same type of tissues.
- The nerves that connect the upper airway (nasal cavity) and the lower airway (bronchial tubes) are the same. Both of these structures are easily assessable to the external environment. When the nasal cavity is exposed to inhaled allergens and irritants, the shared nerve endings of the upper and lower airways are stimulated, thereby causing bronchial constriction and possible acute asthma. This is sometimes referred to as the naso-bronchial reflex.
- Nasal congestion causes mouth breathing. Since this air bypasses the nose, it is not filtered of allergens and irritant particles and is not warmed or humidified. This non-conditioned air is more likely to cause bronchial hyper-reactivity and produce asthma symptoms.
- Inflammatory mucus may drip from the back of the nose into the bronchial tubes, especially during sleep. This dripping increases bronchial inflammation and causes nighttime asthma symptoms, such as coughing and wheezing.
When allergic rhinitis is properly treated, then asthma control improves as well. Asthma Alert
Allergic rhinitis is a risk factor for the development of asthma because it causes bronchial hyper-reactivity. If you suffer from allergic rhinitis, you should be vigilant about reporting any persistent coughing or wheezing to your doctor. Your doctor can them test you for asthma with a simple breathing test called a spirometry.
Sinusitis and asthma
Over the years physicians have noted that asthma and sinusitis seem to go hand in hand. In fact, 15% of patients with sinusitis also have asthma (as opposed to 5% of the normal population). An astounding 75% of severe asthmatics also have sinusitis. Additionally, asthmatics often report that their symptoms worsen when they develop sinusitis. Conversely, when the sinusitis is treated, the asthma improves.
The reasons behind this curious association are similar to those suggested for the link between allergic rhinitis and asthma. - The infected sinus secretions may drain into the bronchial tubes, thereby causing bronchitis (Sinobronchitis). This added inflammation can worsen asthma.
- The best evidence to date seems to support the idea of reflexes in the nasal, sinus, and airway lining. Sinusitis may activate a "sinobronchial reflex" and likely worsen asthma.
Greater insight into how these two conditions are related will bring us closer to learning how we may better control or even cure these common conditions. - Symptoms of asthma can be mimic other illnesses. Symptoms include rapid breathing, fatigue, sighing, difficulty sleeping, anxiety, and difficulty concentrating.
- Asthma can be mimicked by other conditions, such as heart failure, bronchitis, emphysema, bronchiectasis, bronchial obstruction, vocal cord abnormality, and hypersensitivity pneumonitis.
- Exercise is a common trigger for asthma and may cause symptoms in 80 to 90% of asthmatics.
- Exercise induced asthma is managed by choosing an appropriate sport, controlling the asthma prior to events, warm up, avoiding cold, stopping exercise during an asthma attack, cooling down after exercise, preventative use of inhalers and bronchodilators.
- Some medical conditions can cause asthma to worsen including GERD, and allergic rhinitis, sinusitis.
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