Asthma history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Philip Marcus, M.D., M.P.H. [2]; Associate Editor(s)-in-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [3]

Overview

The clinical presentation of asthma varies with individuals both, with and without clinical therapies; meaning asthma can manifest as environmental stimulated or therapy-resistant. In some, asthma is characterized by chronic respiratory impairment while others experience episodic attacks secondary to a number of triggering events including: upper respiratory tract infection, stress, cold air, exercise, exposure to allergen (such as pets, dust, mites, pollen) or air pollutants (such as smoke or traffic fumes). The cardinal symptoms of asthma include loud expiratory wheeze, nocturnal cough and dyspnea. The majority of patients who develop asthma prior to adolescence may experience subsequent remission around puberty. These same asthmatics, however, have the potential for increased frequency of recurrences several years after puberty. Thereby, the National Asthma Education and Prevention Program emphasized the importance of assessment of frequency, severity, duration, limitations of daily activities and future risk of exacerbations to monitor the patient's level of asthma control.

History

• In a vast majority of cases, it is often difficult to diagnose asthma entirely on the basis of history and clinical examination findings. Thereby, a strong clinical suspicion is required if:

• A patient has a personal or family history suggestive of underlying allergic disorders such as allergic rhinitis or eczema.
• There is history of childhood asthma

• Documentation of social and occupational history may reveal the possible triggering factors and factors that contribute to non-adherence of therapy.

Common Symptoms

Symptoms include:

• Cough with or without sputum (phlegm) production
• Pulling in of the skin between the ribs when breathing (intercostal retractions)
• Shortness of breath that gets worse with exercise or activity
• Wheezing:
  • Comes in episodes with symptom-free periods in between
  • May be worse at night or in early morning
  • May go away on its own
  • Gets better when using drugs that open the airways (bronchodilators)
  • Gets worse when breathing in cold air
  • Gets worse with exercise
  • Gets worse with heartburn (reflux)
  • Usually begins suddenly

Emergency symptoms:

• Bluish color to the lips and face
• Decreased level of alertness such as severe drowsiness or confusion, during an asthma attack
• Extreme difficulty breathing
• Rapid pulse
• Severe anxiety due to shortness of breath
• Sweating

Associated symptoms include:

• Abnormal breathing pattern (breathing out takes more than twice as long as breathing in)
• Breathing temporarily stops
• Chest pain
• Nasal flaring
• Tightness in the chest

Episodic Asthma (Asthmatic Attack)

Allergens, exercise or viral infections may trigger an acute exacerbation of asthma. An acute exacerbation of asthma can be characterized by:

• Sudden onset of wheeze (primarily upon expiration, but can be in both respiratory phases)
• Dyspnea and/ or cough with clear sputum that lasts for hours, days or weeks
• Patients with episodic asthma have paroxysms of symptoms with intervening asymptomatic episodes.

Severe Acute Asthma (Status Asthmaticus)

Severe acute asthma is a life-threatening condition, characterized by severe airway obstruction and persistence of symptoms despite initial administration of bronchodilators and corticosteroids. Symptoms include:

• Rapidly progressive dyspnea
• Non-productive cough
• Profuse sweating
• Cyanosis
• And/ or loss of consciousness secondary to severe hypoxia.

Patients adopt a tripod position to assist the use of accessory muscles of respiration (such as the sternocleidomastoid and scalene muscles). At this stage, the airway obstruction is significantly reduced and results in severe impairment of air motion that leads to a silent chest with the absence of wheeze suggestive of an imminent respiratory arrest and death.

Chronic Asthma

Chronic symptoms include:

• Episodic wheeze
• Exertional dyspnea
• Chronic cough associated with mucoid sputum secondary to non- compliance to medical therapy.
• Nocturnal cough or wheeze with typical early morning awakening may be present. However, patients with chronic asthma are more predisposed to frequent recurrent exacerbations.

Less Common Symptoms

Other non-specific symptoms such as severe shortness of breath, chest tightness, stridor in the absence of a wheeze may be confused with a COPD-type of disease and hence it is difficult to diagnose asthma based upon the history alone.