The Sound of Wheezing and Asthma
Julie Andrews, the star of the movie classic “The Sound of Music”, was a trained soprano with a voice lauded for being pure and crisp. She must have had a healthy normal pair of lungs. People affected with lung disease however, specifically bronchial asthma, can barely talk straight especially during episodes of acute exacerbation.
Asthma is a common, chronic respiratory disease defined by the history of pulmonary symptoms such as wheeze (high pitch whistling sound made during breathing), shortness of breathing, chest tightness and cough that vary over time (Global Initiative for Asthma 2017 or GINA definition). In asthma, the airways are always inflamed. They become more swollen, and muscles around the airways can tighten when some things trigger the symptoms. This makes it difficult for air to move in and move out of the lungs. It may be triggered by exercise, allergens, irritant exposure, weather changes, or viral respiratory infections. It is important to note that the clinical impression of asthma increases when a person has a combination of these symptoms especially if it occurs at night or early morning.
The number of people with asthma continues to grow. Currently, it affects 1-8 % of the wwpopulation across all countries. According to The Global Asthma Report, more than half of people with asthma have had an asthma attack, and more children than adults have had an attack. Women were more likely than men and boys, and more likely than girls, to have asthma. Less than half of people with asthma were taught how to avoid triggers, and among those who were taught, almost half do not follow this advice. A significant case of asthma among adults is work- related. It is likewise more prevalent among the obese.
Diagnosis is fairly easy for those with classic symptoms. Childhood or family history of recurrent colds, eczema or allergy, increases the likelihood that these symptoms may be due to asthma. Physical examination can be normal, though the most frequent auscultatory finding is expiratory wheezing. Most of the time, a pulmonary function test (PFT) is needed to determine variability in airflow and reversibility or rapid improvement with the use of bronchodilators like inhaled salbutamol. In some patients, airflow limitations may be absent at the time of initial evaluation. One option is to assess airway hyper responsiveness through bronchial provocative testing called a Methacholine challenge test wherein a positive test indicates that the person has asthma. Allergy testing may also be done to assess the presence of atopy or the genetic tendency to develop allergic diseases such as allergic rhinitis.
The key to long-term management of asthma is to achieve good symptom control, minimize risk of exacerbation, fix airflow limitation and to lessen side effects of medications. Good asthma management requires partnership between the person with asthma/relative/caregiver and their physician. Treatment also involves recognizing triggers, taking steps to avoid them and monitoring symptoms to make sure these are under control.
Categories of asthma medication fall into three main types as follows – Controller medication (regular maintenance to reduce airway inflammation, and reduce exacerbation, e.g. Inhaled corticosteroids); Reliever-rescue medication to provide relief of breakthrough symptoms, (e.g. short acting beta 2-agonist); and Add-On therapies for patients with severe asthma,( e.g. Tiatropium, and anti IgE).
In clinical practice, the choice of medication, device, and dose is based on assessment of symptom control, risk factors, patient preference and other practical issues (cost, ability to use the device, and adherence). It is important to monitor response to treatment and any adverse effect, and to adjust dose accordingly. Once good asthma control has been achieved and maintained for 3 months, and lung function has improved, treatment can be successfully adjusted.
Other therapies include Immunotherapy if allergy plays a major role; administering Influenza vaccination that may significantly reduce morbidity and mortality in patients with asthma and the general population; and Vitamin D supplementation, though level of evidence is still low. Non-pharmacologic intervention includes a healthy diet, weight control, smoking cessation, breathing exercises, and avoidance of indoor allergens and air pollutants.
While the majority of patients with asthma can be usually managed by a Primary Care physician, some clinical conditions warrant referral to experts for advice regarding diagnosis and management. The Institute of Pulmonary Medicine at St. Luke’ s Medical Center has a team of specialists and the latest state-of-the-art equipment to cater to asthma patients.
As the nation celebrates the World Asthma Day on May 2, let us all raise awareness, care and support for those with this condition.
Dr. Adelaida G. Yanga Gaddi is an active consultant at Institute of Pulmonary Medicine (IPM) of St. Luke’s Medical Center-Quezon City. She finished her residency in Internal Medicine and fellowship in Pulmonary Medicine at the same institution. Currently, she is the executive secretary of IPM.