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INTRODUCTION

Definition and Epidemiology

Asthma is a syndrome characterized by airflow obstruction that varies both spontaneously and with specific treatment. Chronic airway inflammation causes airway hyperresponsiveness to a variety of triggers, leading to airflow obstruction and respiratory symptoms including dyspnea and wheezing. Although asthmatics typically have periods of normal lung function with intermittent airflow obstruction, a subset of pts develop chronic airflow obstruction.

The prevalence of asthma has increased markedly over the past 30 years. In developed countries, approximately 10% of adults and 15% of children have asthma. Most asthmatics are atopic, and they often have allergic rhinitis and/or eczema. The majority of asthmatics have childhood-onset disease. Most asthmatics have atopy, and asthmatics often have atopic dermatitis (eczema) and/or allergic rhinitis. A minority of asthmatic pts do not have atopy (negative skin prick tests to common allergens and normal serum total IgE levels). These individuals, occasionally referred to as intrinsic asthmatics, often have adult-onset disease. Occupational asthma can result from a variety of chemicals, including toluene diisocyanate and trimellitic anhydride, and also can have an adult onset.

Asthmatics can develop increased airflow obstruction and respiratory symptoms in response to a variety of different triggers. Inhaled allergens can be potent asthma triggers for individuals with specific sensitivity to those agents. Viral upper respiratory infections (URIs) commonly trigger asthma exacerbations. β-Adrenergic blocking medications can markedly worsen asthma symptoms and should typically be avoided in asthmatics. Exercise often triggers increased asthma symptoms, which usually begin after exercise has ended. Other triggers of increased asthma symptoms include air pollution, cold air, occupational exposures, and stress.

Clinical Evaluation of the Patient History

Common respiratory symptoms in asthma include wheezing, dyspnea, and cough. These symptoms often vary widely within a particular individual, and they can change spontaneously or with age, season of the year, and treatment. Symptoms may be worse at night, and nocturnal awakenings are an indicator of inadequate asthma control. The severity of a pt's asthmatic symptoms, as well as the pt's need for systemic steroid treatment, hospitalization, and intensive care treatment, are important to ascertain. Types of asthmatic triggers for the particular pt, and their recent exposure to them, should be determined. Approximately 1–5% of asthmatics have sensitivity to aspirin and other cyclooxygenase inhibitors; they typically are nonatopic and have nasal polyps. Cigarette smoking leads to more hospital admissions and more rapid decline in lung function; smoking cessation is essential.

Physical Exam

It is important to assess for signs of respiratory distress, including tachypnea, use of accessory respiratory muscles, and cyanosis. On lung exam, there may be wheezing and rhonchi throughout the chest, typically more prominent in expiration than inspiration. Localized wheezing may indicate an endobronchial lesion. Evidence of allergic nasal, sinus, or skin disease should be assessed. When asthma is adequately controlled, the physical exam may be normal.

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