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'''Original Editor '''- [[Open Physio]]  
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'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}|Akano Oluwadara Tomisin=}}    
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}|Akano Oluwadara Tomisin=}} &nbsp; 
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== Definition &amp; Description  ==
== Introduction ==
[[File:Asthma attack-illustration NIH.jpeg|right|frameless|451x451px]]
Asthma is a relatively common condition that is characterised by at least partially reversible inflammation of the airways and reversible airway obstruction due to airway hyperreactivity. It can be acute, subacute or chronic<ref name=":2">Radiopedia Asthma Available from:https://radiopaedia.org/articles/asthma-1 (accessed 25.5.2021)</ref> and [[Exercise Induced Asthma|exercise induced]].


Asthma is a chronic lung disease and a very common respiratory condition. It is also known as a reactive airway disease which is inconvenient most of the time but manageable. Asthma attacks all age groups but often starts in childhood. It is a disease characterized by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person. In an individual, they may occur from hour to hour and day to day.This condition is due to inflammation of the air passages in the lungs and affects the sensitivity of the nerve endings in the airways so they become easily irritated. In an attack, the lining of the passages swell causing the airways to narrow and reducing the flow of air in and out of the lungs.[https://www.who.int/respiratory/asthma/definition/en/]
Asthma:  


<br>Asthma is caused by inflammation and constriction of bronchial walls due to hyper-reactivity of their smooth muscle, thereby leading to a series of spasmodic attacks of wheezing and shortness of breath (SOB). Various factors can contribute to the cause of asthma: exposure to cigarette smoke, climate change, physical exertion or emotional stress. It normally begins during childhood and the disease is commonly triggered by viral infection.
* Is a major noncommunicable disease (NCD), affecting both children and adults.  
 
* Affected an estimated 262 million people in 2019 and caused 461000 deaths.<ref name=":2" />
Asthma can be diagnosed by the presence of the various signs and symptoms. Diagnosis is normally confirmed by presenting a response to a inhaled bronchodialator. In addition, [[Pulmonary Function Test|pulmonary function tests]], chest x-rays and blood tests can also be carried out to confirm the diagnosis.  
* Is the most common chronic disease among children.
 
* Inhaled medication can control asthma symptoms and allow people with asthma to lead a normal, active life.
In childhood, the first symptoms may appear before the age of five years. However, diagnosing asthma in young children under 5 years is difficult due to the fact that other childhood conditions may have similar symptoms. Therefore, the doctor is reliant upon the child's medical history, their symptoms and physical examinations in order to confirm a diagnosis. Moreover, the doctor could also carry out a 4-6 week asthma medication trial and monitor the child's response (US department of health and human services 2009).
* Avoiding asthma triggers can also help to reduce asthma symptoms.
* Most asthma-related deaths occur in low- and lower-middle income countries, where under-diagnosis and under-treatment is a challenge.<ref name=":3">WHO Asthma Available from: https://www.who.int/news-room/fact-sheets/detail/asthma<nowiki/>(accessed 25.5.2021)</ref>


== Epidemiology  ==
== Epidemiology  ==
[[File:Asthma death 2012.png|483x483px|thumb|Deaths from Asthma in 2012 per million persons. Statistics from WHO grouped by deciles. Lightest yellow 0-10 through to red 96-251]]
Asthma is one of the most common chronic diseases in the world. It is a common pathology, affecting around 15% to 20% of people in developed countries and around 2% to 4% in less developed countries. It is significantly more common in children.<ref name=":4">Hashmi MF, Tariq M, Cataletto ME, Hoover EL. [https://www.ncbi.nlm.nih.gov/books/NBK430901/ Asthma] 2020.Available from:https://www.ncbi.nlm.nih.gov/books/NBK430901/ (accessed 25.5.2021)</ref>


According to the Global Burden of Disease Study (GBD)<ref>http://www.healthdata.org/gbd</ref>, the most recent revised global estimate of asthma suggests that as many as 334 million people worldwide have been diagnosed with the condition. The majority of people affected are in low- and middle-income countries, and its prevalence is estimated to be increasing fastest in those countries.
Asthma:  
 
[[Image:800px-Asthma world map - DALY - WHO2004.svg.png|center]]<br>
 
In South Africa, particularly Durban and Soweto, there has been an increase in hospital admissions over the past 25 years, with reports of a 25-200 times increase <ref>Jeena,P., Luyt, D., Morris,A. (2004). What is Asthma? Department of Health. Retrieved on April,11, 2009, from http://www.capegateway.gov.za/eng/pubs/public_info/W/67819</ref>. For South Africa, the mortality rate was estimated to be 77.6 deaths per one million people. It has the second largest mortality rate in the world after South Korea with 86.9 deaths per one million people, followed by Georgia with an estimated 59.2 deaths per one million people after South Africa.


In the UK, approximately 5.4 million people are currently receiving treatment for asthma, this includes 1.1 million children (1 in 11) and 4.3 million adults (1 in 12) <ref>http://www.asthma.org.uk/asthma-facts-and-statistics</ref>. This means that asthma affects 1 in 5 households in the UK. Asthmatic conditions normally begin before the age of 5, however it can occur for the first time at any age, even in adulthood. If asthma occurs for the first time in adulthood, the condition will usually persist, whilst children often outgrow it in their teenage years <ref>Jeena,P., Luyt, D., Morris,A. (2004). What is Asthma? Department of Health. Retrieved on April,11, 2009, from http://www.capegateway.gov.za/eng/pubs/public_info/W/67819</ref>. On average, 3 people a day die from asthma. Although the UK still has some of the highest asthma prevalence rates in Europe, its prevalence is thought to have plateaued since the late 1990s. In Scotland, approximately 368,000 (1 in 14) people are currently receiving treatment for asthma: 72,000 children and 296,000 adults. The UK NHS spends in excess of £1 billion a year treating and caring for people with asthma, whilst in Scotland the spend is in excess of £130 million <ref>Mome, M., Gupta, R., Farr, A., Heaven, M., Stoddart, A., Nwaru, B.I., Fitzsimmons, D., et al, 2014, "Estimating the incidence, prevalence and true cost of asthma in the UK: secondary analysis of national stand-alone and linked databases in England, Northern Ireland, Scotland and Wales—a study protocol." BMJ open 4, no. 11: e006647.</ref>.  
* Affected an estimated 262 million people in 2019 and caused 461000 deaths.<ref name=":3" />  
* May occur at any age (significantly more common in children), most patients with asthma experience their first symptoms before the age of 5 years old and about 66% are diagnosed before the age of 18 years.
* Almost 50% of children with asthma have a decrease in severity or disappearance of symptoms during early adulthood.<ref name=":2" />  
* Prevalence is greater in extreme of ages due to airway responsiveness and lower levels of lung function<ref name=":4" />.  
* In many countries, including the US, asthma kills one out of every 100,000 persons.
* Results in millions of school and workdays lost. In the US alone, close to 2 million asthmatics seek regular care in the emergency department, which also increases the costs of healthcare<ref name=":4" />.


== Aetiology  ==
== Aetiology  ==


Asthma has many possible causes as the exact mechanism of onset is still unknown. This is due to asthma not being defined as a single disease, but a variety of multiple diseases with similar clinical features, resulting from different genetic and environmental causes <ref>Ober C, Yao T. The genetics of asthma and allergic disease: a 21st century perspective. Immunol Rev 2011;242(1):10-30.</ref> mainly developing at an early age, The complex interplay between hereditary and environmental factors which are occurring at this critical time in development, lead to the onset of the disease <ref>LeSouef P. Genetics of asthma: What do we need to know? Pediatr Pulmonol 1997;24(S15):3-8.</ref><ref>Ober C, Hoffjan S. Asthma genetics 2006: the long and winding road to gene discovery. Genes Immun 2006;7(2):95-100.</ref>.  
Inflammation plays a major role in asthma and involves multiple cell types and mediators. The factors that initiate the inflammatory process are complex and still under investigation. Genetic factors (e.g. [[Cytokines|cytokine]] response profiles) and environmental exposures (such as allergens, pollution, [[Communicable Diseases|infections]], microbes, [[Stress and Health|stress]]) at a crucial time in the development of the [[Immune System|immune system]] are known to be involved.<ref name=":2" />
 
== Risk Factors ==
Patients who are atopic have a genetic predisposition for developing the disease due to a hypersensitivity of the airways to environmental triggers. An allergic reaction to antigens that normally do not cause a response, predisposes to asthma onset demonstrating the genetic component of the disease. Asthmatics can commonly suffer from other allergies including food, drug and skin allergies <ref>Ober C, Yao T. The genetics of asthma and allergic disease: a 21st century perspective. Immunol Rev 2011;242(1):10-30.</ref>. <br>The increased prevalence of asthma in developed countries and urbanised areas <ref>Beasley R, Crane J, Lai CK, Pearce N. Prevalence and etiology of asthma. J Allergy Clin Immunol 2000;105(2):S466-S472.</ref><ref>Shimwela M, Mwita JC, Mwandri M, Rwegerera GM, Mashalla Y, Mugusi F.Asthma prevalence, knowledge, and perceptions among secondary school pupils in rural and urban coastal districts in Tanzania. BMC Public Health. 2014; 14: 387. doi: 10.1186/1471-2458-14-387
[[File:Asthma causes.png|right|frameless|499x499px]]
</ref>&nbsp;supports the theory of environmental exposure contributing to the disease. Sufferers are chronically-exposed to substances when inhaled lead to an allergic response in the airways. <br>The following risk factors increase possibility of disease development;<br><br>'''Hereditary'''
Include:
*Family History
*Susceptibility to Allergic Reactions
 
<br>'''Environmental'''<ref>Hough A. Physiotherapy in Respiratory and Cardiac Care: An Evidence-Based Approach. Nelson Thornes; 2013.</ref>
 
*Tobacco Smoke/Passive Smoking
*Prenatal Smoking
*Dust, Dust Mites
*Damp Homes
*Carpets
*Upholstered Furniture
*Pet Hair
*Pollens
*Pollutants
*Occupation (Chemical Exposure)
*Urbanisation
 
<br>'''Other Causes'''
 
*Premature Birth with Ventilation Use
*Low Birth Weight<ref>Mu M, Ye S, Bai MJ, Liu GL, Tong Y, Wang SF, Sheng J. Birth weight and subsequent risk of asthma: a systematic review and meta-analysis. Heart Lung Circ. 2014;23(6):511-9. doi: 10.1016/j.hlc.2013.11.018. </ref>
*Early Age Antibiotic Use
*Bronchiolitis as a Child<ref>Koponen P, Helminen M, Paassilta M, Luukkaala T, Korppi M. Preschool asthma after bronchiolitis in infancy. European Respiratory Journal. 2012; 39: 76-80; DOI: 10.1183/09031936.00040211
</ref><ref>Backman K, Nuolivirta K, Ollikainen H, Korppi H,  Piippo-Savolainen E. '''Low eosinophils during bronchiolitis in infancy are associated with lower risk of adulthood asthma'''. ''Pediatric Allergy and Immunology'', 2015; 26 (7): 668 DOI: [http://dx.doi.org/10.1111/pai.12448 10.1111/pai.12448]</ref>
*Viral Infection <ref>Lemanske RF, Jackson DJ, Gangnon RE, Evans MD, Li Z, Shult PA, et al. Rhinovirus illnesses during infancy predict subsequent childhood wheezing. J Allergy Clin Immunol 2005;116(3):571-577.</ref>
*Diet <ref>Fogarty A, Britton J. The role of diet in the aetiology of asthma. Clinical and Experimental Allergy 2000;30(5):615-627.</ref>
 
<br>Asthma triggers initiate an asthma attack. Some causes of the manifestation of asthma may also trigger an attack.
 
<br>'''Triggers for an Asthma Attack''' <ref>www.asthma.org.uk/knowledge-triggers-a-z?gclid=CLOn57bNpcUCFerjwgodVKEA9Q</ref>[[Image:Triggers.png|right|400x280px]]  
 
*Exercise
*Cold Air
*Climate Change
*Emotions
*Medications (aspirin, NSAIDs, beta-blockers)  
*Respiratory Infection
*Irritant Inhalation
*Dust Mites
*Pollen
*Environmental Pollutants
*Stress
*Allergic Reaction
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<br>
 
== Pathophysiology  ==
 
In asthma, airway constriction is caused by a combination of bronchial constriction (bronchoconstriction) and bronchial inflammation. This leads to chronic lung pathology in which the bronchial airways are prone to narrowing, causing episodes of wheezing, chest tightness, coughing and breathlessness (SOB) that range in severity from mild to potentially life threatening<ref>http://www.ncbi.nlm.nih.gov/pubmed/10849466</ref>.
 
Entrance of allergens through the oral or nasal cavity results in swelling of an already compromised and highly sensitive airway&nbsp;<ref>http://www.atsjournals.org/doi/abs/10.1164/rccm.200809-1512OC</ref>. As a result, constriction of smooth muscle in the walls of the airway and excessive release of mucus into the area causes airway narrowing and ultimately reduces the amount of air circulating in and out of the lungs <ref>http://www.atsjournals.org/doi/abs/10.1164/rccm.200809-1512OC</ref>. Due to these differences in airway flow rate, the lungs become hyperinflated.
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;[[Image:Pathology.jpg]]
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<br> When the [[Lung Volumes|tidal volume (V<sub>T</sub>)]]&nbsp;of the lungs reaches a capacity similar to that of the pulmonary dead space, it is termed alveolar hypoventilation and results in a ventilation-perfusion (Va/Q) mismatch. This Va/Q mismatch is ultimately&nbsp;worsened by vasoconstriction&nbsp;<ref>http://m.jap.physiology.org/content/107/4/1285.short</ref>.&nbsp;
 
A reduction in arterial oxygen supply (hypoxia) can result from the Va/Q&nbsp;mismatch. Diffusion of carbon dioxide (CO<sub>2</sub>) across the alveolar capillary membranes prevents high levels of carbon dioxide in the blood (hypercapnia) during the early stages of an acute asthmatic exacerbation/attack. Therefore, although these patients have hypoxia, the low levels of oxygen (low PaO<sub>2</sub>) trigger hyperventilation and therefore decrease PaCO<sub>2 </sub>to prevent hypercapnia and the retention of carbon dioxide. During the first stages of an acute episode, alveolar hyperventilation can result in respiratory alkalosis. However, if airway obstruction worsens and there is a further increase in Va/Q mismatch, it can lead to CO<sub>2</sub> retention, hypercapnia and compensatory metabolic acidosis.
 
In asthmatic patients, chronic airway inflammation is associated with:
 
*Increased in heart rate
*Bronchospasms
*Increased work of breathing (WOB)
*Wheezing
*Shortness of breath (SOB)
*Coughing due to exposure to allergens, environmental irritants, exercise, cold air or viruses.
 
In some chronic asthmatic patients, limitation of airflow may only be partially reversible. This is a result of airway remodeling from the chronic untreated condition, more specifically hyperplasia and hypertrophy of smooth muscle, angiogenesis, and sub-epithelial fibrosis in the tissues of the airway.
 
== Types of Asthma  ==
 
'''Allergic asthma''':  


*It is also called extrinsic asthma, this type of asthma that is triggered by allergies(substance that is responsible to cause allergic reaction more especially in sensitive people). Allergic asthma is airway obstruction and inflammation that is partially reversible with medication. It is the most common form of asthma, affecting over 50% of the 20 million asthma sufferers. Many of the symptoms of allergic and non-allergic asthma are the same (coughing, wheezing, shortness of breath or rapid breathing, and chest tightness). However, allergic asthma is triggered by inhaled allergens such as dust mite allergen, pet dander, pollen, mold, etc. resulting in asthma symptoms
* Asthma is more likely if other family members also have asthma – particularly a close relative, such as a parent or sibling.
* Asthma is more likely in people who have other allergic conditions, eczema and rhinitis (hay fever).
* Urbanisation is associated with increased asthma prevalence, probably due to multiple lifestyle factors.
* Events in early life affect the developing lungs and can increase the risk of asthma. E.g. low-birth weight, prematurity, exposure to tobacco smoke and other sources of air pollution, viral respiratory infections.
* Exposure to a range of environmental allergens and irritants are also thought to increase the risk of asthma, eg indoor and outdoor air pollution, house dust mites, moulds, and occupational exposure to chemicals, fumes, or dust.
* Children and adults who are overweight or obese are at a greater risk of asthma.


<br>
== Pathophysiology ==
[[File:Pathology.jpg|alt=|right|frameless|399x399px]]
Asthma is a condition of acute, fully reversible airway inflammation, often following exposure to an environmental trigger. The pathological process begins with the inhalation of an irritant (e.g., cold air) or an allergen (e.g., pollen), which then, due to bronchial hypersensitivity, leads to airway inflammation and an increase in mucus production. This leads to a significant increase in airway resistance, which is most pronounced on expiration.


'''Non-allergic asthma''':  
Airway obstruction occurs due to the combination of:


*It is also called intrinsic asthma and it usually develops after the age of 30 years where allergies do not play any role.Non-Allergic (intrinsic) asthma is triggered by factors not related to allergies, it is likely triggered by respiratory irritation substances (e.g cleaning agents, perfume and smoking). Like allergic asthma, non-allergic asthma is characterized by airway obstruction and inflammation that is at least partially reversible with medication, however symptoms in this type of asthma are not associated with an allergic reaction. Many of the symptoms of allergic and non-allergic asthma are the same, but non-allergic asthma is triggered by other factors such as anxiety, stress, exercise, cold air, dry air, hyperventilation, smoke, viruses or other irritants. In non-allergic asthma, the immune system is not involved in the reaction.
# Inflammatory cell infiltration.
# Mucus hypersecretion with mucus plug formation.
# Smooth muscle contraction.


<br>
These irreversible changes may become irreversible over time due to


'''Exercise Induced Asthma''':
# Basement membrane thickening, collagen deposition, and epithelial desquamation.
# Airway remodeling occurs in chronic disease with smooth muscle hypertrophy and hyperplasia.


*Exercise induced asthma is a type of asthma triggered by exercise or physical exertion.It affects anyone and at any age. It is caused by lack of heat and moisture in the [[Lung Anatomy|lungs]] which occurs during strenuous exercises. Many people with asthma experience some degree of symptoms with exercise. However, there are many people without asthma, including Olympic athletes, who develop symptoms only during exercise. With exercise-induced asthma, airway narrowing peaks 5 to 20 minutes after exercise begins, making it difficult to catch your breath. The symptoms begin within few minutes of exercise and peak or worsen a few minutes after stopping exercise. Symptoms of an asthma attack which is wheezing and coughing may be present.  
If not corrected rapidly, asthma may become more difficult to treat, as the mucus production prevents the inhaled medication from reaching the mucosa. The inflammation also becomes more edematous. This process is resolved (in theory complete resolution is required in asthma, but in practice, this is not checked or tested) with beta-2 agonists (e.g., salbutamol, salmeterol, albuterol) and can be aided by muscarinic receptor antagonists (e.g., ipratropium bromide), which act to reduce the inflammation and relax the bronchial musculature, as well as reducing mucus production.<ref name=":4" />


<br>
== Clinical Presentation ==
The classical symptoms of asthma are wheeze, [[Dyspnoea|shortness of breath]], chest tightness or difficulty [[Breathing Pattern Disorders|breathing]] and cough. These symptoms are typically variable and can be absent for long periods of time, with possible episodic exacerbations often triggered by factors such as exercise, allergen or irritant exposure, cold air or [[Viral Infections|viral]] respiratory infections.


'''Nocturnal Asthma''':  
The diagnosis of asthma is clinical and relies on the recognition of a characteristic pattern or respiratory symptoms and signs in the absence of an alternative explanation. Features that increase the probability of asthma are:


*It is also called nighttime asthma and it is the type of asthma that attacks people when they are asleep. The victims tend to sleep earlier and they wake up in the middle of the night (1-4am) due to difficulties with breathing and they will drink a glass of water to try to relieve the symptoms.<ref>http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.1978.tb00464.x/abstract</ref> S<section> Nocturnal asthma, with symptoms like chest tightness, shortness of breath, cough, and wheezing at night, can make sleep impossible and leave you feeling tired and irritable during the day. These problems may affect your overall quality of life and make it more difficult to control your daytime asthma symptoms.  Nocturnal or nighttime asthma is very serious. It needs a proper asthma diagnosis and effective asthma treatment. </section>ymptoms include chest tightness, shortness of breath, cough, and wheezing at night and can make sleep impossible and leave the victim tired and irritable during the day. These problems may affect the overall quality of life and make it more difficult to control the daytime asthma symptoms. Nocturnal or nighttime asthma is very serious. It needs a proper asthma diagnosis and effective asthma treatment. The exact reason that asthma is worse during sleep is not known, but there are explanations that include increased exposure to allergens; cooling of the airways; being in a reclining position; and hormone secretions that follow a circadian pattern. Sleep itself may even cause changes in bronchial function
* More than one of the following symptoms: wheeze, cough, difficulty breathing and chest tightness.
<section> Symptoms are chest tightness, shortness of breath, cough, and wheezing at night, and they can make sleep impossible and leave the patient tired and irritable during the day. These problems may affect the overall quality of life and make it more difficult to the daytime asthma symptoms.Nocturnal or nighttime asthma is very serious. It needs a proper asthma diagnosis and effective asthma treatment </section>
* Episodic symptoms that are worse at night and in the early morning, and occur in response to certain triggers, e.g. [[Exercise Induced Asthma|exercise]], allergen exposure, cold air.
* Personal history of an atopic disorder or family history of an atopic (allergic) disorder and/or asthma
* Widespread wheeze on [[auscultation]]


<br>
* [[Pulmonary Function Test|Lung function tests]] are useful in the evaluation of a patient with asthma to assess the presence, severity and reversibility of the airflow obstruction. On [[spirometry]] an FEV1/FEV ratio less than 0.7 confirms obstruction. In asthmatic patients, there is usually a large bronchodilator response (typically an increase of at least 12-15% in FEV1) 3, and it is also typically an abnormally high variability of the peak expiratory flow. A normal spirometry, particularly if performed when the patient is asymptomatic, does not exclude the diagnosis of asthma<ref name=":2" /><br>  
 
'''Occupational Asthma''':
 
*It is the asthma that's caused by breathing in chemical fumes, gases, dust or other substances in the working environment. Occupational asthma can result from exposure to a substance the victim is sensitive to — causing an allergic or immunological response — or to an irritating toxic substance. Like other types of asthma, occupational asthma can cause chest tightness, wheezing and shortness of breath. People with allergies or with a family history of allergies are more likely to develop occupational asthma.
 
<br>
 
'''Steroids Resistance Asthma''':
 
*Overuse of asthma medications which leads to status asthmatic and severe asthma that does not respond with any medication. Such patients are considered to have severe, steroid-resistant asthma, which is associated with more frequent exacerbations, greater likelihood of hospitalizations, and worse quality of life compared with other patients with asthma. In clinical practice, they are often treated with high-dose steroids and bronchodilators, but they do not respond well to these therapies, <br>
 
== Signs and Symptoms  ==
 
Asthmatics will present with varying signs and symptoms depending on disease classification and severity. Asthma attacks will exasperate symptoms leading to medication administration. Symptoms most commonly occur early morning, at night or during an attack&nbsp;<ref>http://www.nationalasthma.org.au/uploads/publication/asthma-lung-function-tests-hp.pdf</ref>.
 
'''Signs and Symptoms<ref>https://www.westerncape.gov.za/general-publication/what-asthma#2</ref><ref>http://asthma.about.com/od/asthmabasics/a/basic_managingasthma.htm</ref>'''
 
*Wheeze
*Dry Cough&nbsp;
**Increased with Exercise
**Worse Early Morning/Night
*Chest Tightness
*Sputum (stringy, thick)
*Fatigue
*Itchy Throat
*Runny Nose
*Headache
*Dyspnoea
 
{{#ev:youtube|S04dci7NTPk|300}}<ref>toms weisiong. Understanding Asthma - 360p [Animation]. Available from: https://www.youtube.com/watch?v=S04dci7NTPk [last accessed 18/5/15]</ref>
 
These symptoms occur due to the pathophysiology of the disease. Bronchoconstriction causes an audible wheeze and subsequent cough. Chest tightness can be felt and a shortness of breath (dyspnoea) from a constriction of the bronchial walls. Sputum is produced due an inflammatory response in the airways <ref>Evans CM, Kim K, Tuvim MJ, Dickey BF. Mucus hypersecretion in asthma: causes and effects. Curr Opin Pulm Med 2009 Jan;15(1):4-11.</ref> adding to the difficulty of breathing.<br>
 
'''Clinical Features'''
 
*Hyperventilation/Increased Respiratory Rate
*Increased Work of Breathing
*Decreased Peak Expiratory Flow Rate
**FEV<sub>1</sub>
**FEV<sub>1</sub>/FVC
*Decreased PaO<sub>2</sub> (partial pressure of oxygen in blood)
*Increased PaCO<sub>2 </sub>(partial pressure of carbon dioxide in blood)
*Increased Heart Rate
 
<br>Asthma is an [[COPD (Chronic Obstructive Pulmonary Disease)|obstructive lung disease]]. Narrowing of the airways (bronchospasm) due to constriction of the bronchial muscles in the wall, lead to decreased air flow and difficulty with breathing. Bronchospasm causes decreased peak expiratory flow rate, which in turn leads to decreased PaO<sub>2</sub> and increased PaCO<sub>2</sub> of the blood. Heart rate increases to compensate for a lack of oxygen being transported in the blood. To increase oxygen during inspiration, hyperventilation will occur in the patient. However work of breathing will be increased due to the narrowed bronchi which make it more difficult to breathe <ref>Anees W, Moore VC, Burge PS. FEV1 decline in occupational asthma. Thorax 2006 September 2006;61(9):751-755.</ref>.<br>  


'''When does asthma become life threatening?'''  
'''When does asthma become life threatening?'''  
Line 180: Line 81:


When these signs and symptoms presents, a person should be aware and are advice to consult with your general practitioner as soon as possible.  
When these signs and symptoms presents, a person should be aware and are advice to consult with your general practitioner as soon as possible.  
== Investigations and Diagnosis ==


== Risk Factors and Prevention  ==
Diagnosis of asthma is confirmed based upon various factors<ref>National heart, lung and blood institute. Asthma 2014. available from http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/diagnosis</ref>:  
 
There are a few risk factors associated with asthma that can lead to the onset of asthma, an attack or other respiratory symptoms
 
*the closeness of home or work to airports, industries and shopping centers(environmental irritants)
*the dampness level of home or work
*being a smoker, living with a smoker or working with a smoker
*the use of spray insecticides or insect oils
*having pets at home, allergies and sinusitis
*having mats or carpets that can easily trap dust particles
*insufficient education and information
 
Prevention of an attack or an episode is better in the case of asthma because it cannot be cured
 
*education on the disease and medication that is used
*follow the doctor's instructions on how to use medicine and how to keep symptoms under control
*identify the aggravating factors e.g. smoke, dust, etc.
*keep record of recurrent symptoms and try and maintain control
*go to doctor for regular checkups<br>
 
Many substances can trigger allergies and the same applies to asthma. Common allergens that triggers asthma are pollen, mold, dust mites and pet dander. Other irritants are smoke, pollution fumes, sprays and cleaning chemicals. Asthma symptoms can therefore be reduced by avoiding exposure to known respiratory irritants and allergens.<br>
 
== Investigations and Diagnosis  ==
 
Diagnosis of asthma is confirmed based upon various factors<ref>http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/diagnosis</ref>:  


*'''Medical History'''
*'''Medical History'''


The patient is initially asked to explain their various symptoms, including their description, frequency, duration and aggravating factors. Substance exposure may have also lead to the onset of asthmatic symptoms, in which case exposure to tobacco smoke, chemical fumes, dust or other airborne irritants is determined. Additional questioning may include relevant health problems, the patient’s occupation and medications that may cause airway irritation.  
*'''Family History:''' If the patient has a family history of asthma or allergies, they are more likely to also suffer from asthmatic symptoms.


*'''Family History'''
*'''Physical Assessment:''' The patient’s nose, throat and [[Upper Respiratory Airways|upper airways]] will be examined for signs of asthma or allergies. Assessment of the patient’s respiratory rate and breathing pattern will be carried out in conjunction with [[auscultation]] S & S include: Wheezing (high-pitched whistling sounds when the patient exhales) Coughing, chest tightness, Shortness of breath (SOB), A runny nose, Swollen nasal passages.<ref>Mayo Clinic. Asthma: steps in testing and diagnosis. available from


If the patient has a family history of asthma or allergies, they are more likely to also suffer from asthmatic symptoms.  
http://www.mayoclinic.org/diseases-conditions/asthma/in-depth/asthma/art-20045198
</ref>.


*'''Physical Assessment'''
== '''Diagnostic Tests''' ==
[[File:Spirometry1.jpg|right|frameless|399x399px]]
The following tests are used to assess the patient’s breathing as well as to monitor the effectiveness of asthma treatment.


Firstly, the patient’s nose, throat and [[Upper respiratory airways|upper airways]] will be examined for signs of asthma or allergies. Assessment of the patient’s respiratory rate and breathing pattern will be carried out in conjunction with [[auscultation]] (using a stethoscope) in order to listen for signs of asthma or allergies that may aid diagnosis. These signs include:
[[Pulmonary Function Test|Lung function tests]]''<ref>Web MD. Diagnosing Asthma. Available from


*Wheezing (high-pitched whistling sounds when the patient exhales)
http://www.webmd.com/asthma/guide/diagnosing-asthma?page=4
*Coughing, chest tightness
</ref>''
*Shortness of breath (SOB)
*A runny nose
*Swollen nasal passages.


The patient’s skin will also be examined for signs of allergic skin conditions (e.g. eczema and hives)<ref>http://www.mayoclinic.org/diseases-conditions/asthma/in-depth/asthma/art-20045198</ref>.
[[Pulmonary Function Test|Spirometry,]]


*'''Diagnostic Tests'''
[http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/living-with-asthma/managing-asthma/measuring-your-peak-flow-rate.html Peak flow testing]
 
The following tests are used to assess the patient’s breathing as well as to monitor the effectiveness of asthma treatment.
 
''Lung function tests<ref>http://www.webmd.com/asthma/guide/diagnosing-asthma?page=4</ref>:''
 
*[[Pulmonary function test|Spirometry]]<br>Spirometry may be used to assess lung function by measuring the amount of expired air as well as the speed of expiration. It is used to confirm the presence of airway obstruction and can accurately measure the degree of lung function impairment. Spirometry is used to measure the sensitivity of the airways and lung function during [[physical activity]], or following the inspiration of increasing doses of cold air or a special chemical However, it is only recommended for adults and children over the age of 5.
*[http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/living-with-asthma/managing-asthma/measuring-your-peak-flow-rate.html Peak flow testing]<br>Peak flow testing is a self-assessment lung function test using a peak flow meter to provide an objective measure of airway function based upon peak expiratory flow rate (PEFR). Peak flow is described as the highest airflow velocity that can be achieved, with any drop in the peak flow measurement indicating airway obstruction.


''Other tests:''  
''Other tests:''  
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*Allergy testing  
*Allergy testing  
*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617850/ Bronchoprovocation]  
*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617850/ Bronchoprovocation]  
*Tests to rule out other conditions with similar asthmatic symptoms (reflux disease, vocal cord dysfunction, [[Sleep Apnea-Hypopnea Syndrome|sleep apnea]])
*[[Chest X-Rays|Chest X-ray]]
*Chest X-ray  
*[https://www.webmd.com/heart-disease/electrocardiogram-ekgs#1 Electrocardiogram (ECG)]<br>
*[https://www.webmd.com/heart-disease/electrocardiogram-ekgs#1 Electrocardiogram (ECG)]  
*Asthma in older adults is frequently underdiagnosed and has higher morbidity and mortality rates compared to their younger counterparts. A detailed history and physical examination as well as judicious testing are essential to establish the asthma diagnosis and exclude alternative ones. Medical comorbidities, such as cardiovascular disease, cognitive impairment, depression, arthritis, gastroesophageal reflux disease (GERD), rhinitis, and sinusitis are common in this population and should also be assessed and treated. Non-pharmacologic management, including asthma education on inhaler technique and self-monitoring, is vital.<ref name=":0">Anil Nanda, Alan P. Baptist, Rohit Divekar, Neil Parikh, Joram S. Seggev, Joseph S. Yusin & Sharmilee M. Nyenhuis. Asthma in the older adult,                                  Journal of Asthma (2019);                                                                      DOI: 10.1080/02770903.2019.1565828</ref><br>


== Medical Management  ==
== Treatment ==
[[File:Kids with Asthma.jpeg|right|frameless|399x399px]]
The goal of the treatment is to control the symptoms, prevent exacerbations and loss of lung function and reduce associated mortality.


Various medication exists that help the control of asthma by reducing inflammation of the airway and bronchial constriction, these medications are administered orally, via aerosol or an inhaler. (Cleveland Clinic. 2009). Pharmacologic management includes standard asthma therapies such as inhaled corticosteroids (ICS), inhaled corticosteroid-long acting β-agonist combinations (ICS-LABA), leukotriene antagonists, long acting muscarinic antagonists (LAMA), and short acting bronchodilators (SABA). Newly approved biologic agents may also be utilized. Older adults are more vulnerable to polypharmacy and medication adverse events, and this should be taken into account when selecting the appropriate asthma treatment. Non-pharmacologic management, including asthma education on inhaler technique and self-monitoring, is vital.<ref name=":0" />
# Drugs used for control of asthma depend on the severity of the disease. Short-acting β2-agonists can be used in patients with mild occasional symptoms. Inhaled steroids (oral steroids might be required in severe cases) and long-acting β2-agonists can be used for long-term control. Oxygen, short-acting β2-agonists, inhaled anticholinergics and systemic steroids are used in acute exacerbations.


One form of an inhaler is a bronchodilator, which allows dilatation of the bronchioles and in turn relieves some of the symptoms. It also aids in mucus removal from lungs. There are two forms of bronchodilators:
*'''Short-acting beta 2-agonists''' (quick acting or rescue medicine): these drugs are used best to treat sudden and severe or new asthma symptoms as they open the airways and relieve symptoms within 20 minutes and lasts four to six hours. It can also be used before physical activity about 15-20 minutes before the time to prevent exercise-induced asthma.
*'''Long-acting beta 2-agonists''': these drugs are not used to for a quick relief of asthma symptoms, instead they are used to control symptoms and their effect lasts 12 hours.


#'''Short-acting beta 2-agonists''' (quick acting or rescue medicine): these drugs are used best to treat sudden and severe or new asthma symptoms as they open the airways and relieve symptoms within 20 minutes and lasts four to six hours. It can also be used before physical activity about 15-20 minutes before the time to prevent exercise-induced asthma.
2, Mechanical ventilation may be necessary for severe exacerbations that do not respond to medical treatment. Non-pharmacological measures, such as smoking cessation and avoidance of occupational sensitisers, are also important.
#'''Long-acting beta 2-agonists''': these drugs are not used to for a quick relief of asthma symptoms, instead they are used to control symptoms and their effect lasts 12 hours.<br>


== Physiotherapy Management  ==
3. Non-pharmacologic management, including asthma education on inhaler technique and self-monitoring, is vital.<ref name=":0">Anil Nanda, Alan P. Baptist, Rohit Divekar, Neil Parikh, Joram S. Seggev, Joseph S. Yusin & Sharmilee M. Nyenhuis. Asthma in the older adult,                                  Journal of Asthma (2019);                                                                      DOI: 10.1080/02770903.2019.1565828</ref>


The majority of patients suffering from asthma will seek physiotherapy for dyspnoea and hyperventilation <ref>Thomas M, Bruton A. Breathing exercises for asthma. Breathe 2014;10(4):312-322. (level of evidence 3a)</ref>.&nbsp;Physiotherapists treat asthma in a variety of ways with the aim to improve breathing technique. Physiotherapy techniques for asthma are in addition to medication and should never be used as a replacement to prescribed medication, however may reduce the dosage required.
== Prognosis ==
Asthma is a disease with variable progression and severity of symptoms over time. The prognosis depends on the severity of the disease and the degree of control with treatment. Some patients can be symptom-free for long periods, whereas a few patients with severe persistent asthma develop progressive loss of lung function. Death due to asthma is very rare.<ref name=":2" />


'''Breathing Techniques'''
Even though asthma is a reversible disorder, poor lifestyle and lack of management can lead to airway remodeling that leads to chronic symptoms, which are disabling.<ref name=":4" />


1. Breathing Retraining Techniques <ref>Bott J, British Thoracic Society Physiotherapy Guideline Development Group. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. BMJ Publ. Group; 2009. (level of evidence 5)</ref>   
== Physiotherapy Management  ==
[[File:Breathing relaxing.jpg|right|frameless]]
The majority of patients suffering from asthma will seek physiotherapy for dyspnea and hyperventilation <ref>Thomas M, Bruton A. Breathing exercises for asthma. Breathe 2014;10(4):312-322. (level of evidence 3a)</ref>.Physiotherapists treat asthma in a variety of ways with the aim to improve breathing technique. Physiotherapy techniques for asthma are in addition to medication and should never be used as a replacement for prescribed medication, however may reduce the dosage required.
 
'''1. Breathing Retraining Techniques''' <ref>Bott J, British Thoracic Society Physiotherapy Guideline Development Group. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. BMJ Publ. Group; 2009. (level of evidence 5)</ref>   


Breathing techniques may have more benefit on mild – moderate asthma <ref>Lord of Physiotherapy. Postural Drainage. Available from: http://www.youtube.com/watch?v=TPZsP1ujg0U[last accessed 08/02/13] (level of evidence 5)</ref>. The aim of breathing retraining is to normalise breathing patterns by stabilising respiratory rate and increasing expiratory airflow. Instructions are given from the physiotherapist on how to complete this technique, with the following components:
Breathing techniques may have more benefit on mild – moderate asthma <ref>Lord of Physiotherapy. Postural Drainage. Available from: http://www.youtube.com/watch?v=TPZsP1ujg0U[last accessed 08/02/13] (level of evidence 5)</ref>. The aim of breathing retraining is to normalise breathing patterns by stabilising respiratory rate and increasing expiratory airflow. Instructions are given from the physiotherapist on how to complete this technique, with the following components:
Line 269: Line 145:
*Relaxation (Relaxed, controlled breathing)  
*Relaxation (Relaxed, controlled breathing)  
*Decreasing Air Leaving (Decreased expiratory flow through pursed lip breathing)  
*Decreasing Air Leaving (Decreased expiratory flow through pursed lip breathing)  
*These retraining techniques help control breathing and reduce airflow turbulence, hyperinflation, variable breathing pattern and anxiety.<br>
*These retraining techniques help control breathing and reduce airflow turbulence, hyperinflation, variable breathing pattern and anxiety.<br>  
 
[[Image:Buteyko.png|right|320x190px]]Buteyko Breathing Technique<ref>Cowie RL, Conley DP, Underwood MF, Reader PG. A randomised controlled trial of the Buteyko technique as an adjunct to conventional management of asthma. Respir Med 2008;102(5):726-732. (level of evidence 1b)</ref>
2. Buteyko Breathing Technique<ref>Cowie RL, Conley DP, Underwood MF, Reader PG. A randomised controlled trial of the Buteyko technique as an adjunct to conventional management of asthma. Respir Med 2008;102(5):726-732. (level of evidence 1b)</ref>
 
The Buteyko breathing technique is another breathing retraining technique; however it is specific to reducing hyperinflation. It was developed based on the theory that asthmatic bronchospasm is caused by hyperventilation, leading to a low PaCO<sub>2</sub> and therefore all asthmatic symptoms are due to this. The narrowed airways induce an “air hunger” causing a switch to mouth-breathing and an increased respiratory rate leading to hyperinflation. Buteyko believes that this hyperinflation then also contributes to bronchoconstriction. The Buteyko technique aims to reduce ventilation and subsequently [[Lung volumes|lung volume]], as a treatment for asthma and other respiratory diseases. A qualified practitioner is necessary to train the patient <ref>Hough A. Physiotherapy in Respiratory and Cardiac Care: An Evidence-Based Approach. Nelson Thornes; 2013. (level of evidence 5)</ref>.<br>  


The Buteyko Technique<ref>http://www.buteyko.co.uk/ (level of evidence 5)</ref>[[Image:Buteyko.png|right|320x190px]]
* The Buteyko breathing technique is another breathing retraining technique; however, it is specific to reducing hyperinflation. It was developed based on the theory that asthmatic bronchospasm is caused by hyperventilation, leading to a low PaCO<sub>2</sub> and therefore all asthmatic symptoms are due to this. The narrowed airways induce an “air hunger” causing a switch to mouth-breathing and an increased respiratory rate leading to hyperinflation. Buteyko believes that this hyperinflation then also contributes to bronchoconstriction. The Buteyko technique aims to reduce ventilation and subsequently [[Lung Volumes|lung volume]], as a treatment for asthma and other respiratory diseases. A qualified practitioner is necessary to train the patient <ref>Hough A. Physiotherapy in Respiratory and Cardiac Care: An Evidence-Based Approach. Nelson Thornes; 2013. (level of evidence 5)</ref>.
*Breathe normally through the nose for 2-3 mins  
*  The Buteyko Technique<ref>http://www.buteyko.co.uk/ (level of evidence 5)</ref>
*Breathe out normally, close nose with fingers, and hold  
**Breathe normally through the nose for 2-3 mins
*Record number of seconds  
**Breathe out normally, close nose with fingers, and hold
*On first need to breathe, release nose and return to nasal breathing (Control Pause)  
**Record number of seconds
*Wait 3 minutes  
**On first need to breathe, release nose and return to nasal breathing (Control Pause)
*Repeat and hold breath for as long as possible (Maximum Pause)<br>
**Wait 3 minutes
**Repeat and hold breath for as long as possible (Maximum Pause)<br>


<br>
[[Breathing Pattern Disorders|Breathing pattern]] retraining and relaxed breathing techniques are two approaches to physiotherapy management of asthma. The aim of breathing pattern retraining is to develop a more efficient pattern of respiration, thereby reducing breathlessness. This is usually accomplished by slowing the breathing rate, and encouraging relaxed, ‘abdominal’ breathing (Bruton, 2006). Another potential mechanism for breathing pattern retraining is that by encouraging a longer expiratory time, the effects of any static/ dynamic hyperinflation may be reduced.  
 
[[Breathing Pattern Disorders|Breathing pattern]] retraining and relaxed breathing techniques are two approaches to physiotherapy management of asthma. The aim of breathing pattern retraining is to develop a more efficient pattern of respiration, thereby reducing breathlessness. This is usually accomplished by slowing the breathing rate, and encouraging relaxed, ‘abdominal’ breathing (Bruton, 2006). Another potential mechanism for breathing pattern retraining is that by encouraging a longer expiratory time, the effects of any static/ dynamic hyperinflation may be reduced.<br>


Mild asthmatics can hold their breath for up to twenty seconds, moderate asthmatics for fifteen seconds and severe asthmatics for up to ten seconds. The aim of this method is to increase the control pause to 60 seconds and the maximum pause to 2 minutes. It is practiced twice a day, with the practitioner there to help with breath holding and ensure safety. Its aim is to reduce minute volume through reduction of respiratory rate, and increasing carbon dioxide levels through breath holding, reducing bronchospasm caused by hyperventilation in the asthmatic patient.  
Mild asthmatics can hold their breath for up to twenty seconds, moderate asthmatics for fifteen seconds and severe asthmatics for up to ten seconds. The aim of this method is to increase the control pause to 60 seconds and the maximum pause to 2 minutes. It is practiced twice a day, with the practitioner there to help with breath holding and ensure safety. Its aim is to reduce minute volume through reduction of respiratory rate, and increasing carbon dioxide levels through breath holding, reducing bronchospasm caused by hyperventilation in the asthmatic patient.  


'''Physical Training'''  
'''2. Physical Training'''


<br>Physical training with asthma is advised when taking the proper precautions, and should not be avoided. The American College of Sports Medicine (ACSM) Guidelines provide tips and safety precautions for asthmatics to exercise safely<ref>https://www.acsm.org/docs/current-comments/allergiesandasthmatemp.pdf (level of evidence 5)</ref>.  
* Physical training with asthma is advised when taking the proper precautions and should not be avoided. The American College of Sports Medicine (ACSM) Guidelines provide tips and safety precautions for asthmatics to exercise safely<ref>https://www.acsm.org/docs/current-comments/allergiesandasthmatemp.pdf (level of evidence 5)</ref>.  
* [[Physical Activity and Respiratory Conditions|Physical training]] should be prescribed by physiotherapists for asthmatics to increase fitness and [https://en.wikipedia.org/wiki/Cardiorespiratory_fitness cardiorespiratory performance], reduce symptoms such as breathlessness and improve quality of life <ref>Bott J, British Thoracic Society Physiotherapy Guideline Development Group. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. BMJ Publ. Group; 2009. (level of evidence 5)</ref>. Breathlessness, chest tightness and wheezing can occur when exercising, deterring patients from physical exertion <ref>Turner S, Eastwood P, Cook A, Jenkins S. Improvements in symptoms and quality of life following exercise training in older adults with moderate/severe persistent asthma. Respiration 2011;81(4):302-310. (level of evidence 1b)</ref>. Fear avoidance can contribute to a further deterioration of physical health and quality of life, leading to anxiety and depression. It has been shown <ref>Fanelli A, Cabral ALB, Neder JA, Martins MA, Carvalho CRF. Exercise training on disease control and quality of life in asthmatic children. Med Sci Sports Exerc 2007;39(9):1474. (level of evidence 1b)</ref> that maintaining physical training in asthmatics improves disease symptoms and quality of life, therefore making it a crucial management strategy.
* A study protocol suggests behavior change intervention focussing on increasing participation in physical activity may exert control over asthma and quality of life<ref>Freitas PD, Xavier RF, Passos NF, Carvalho-Pinto RM, Cukier A, Martins MA, Cavalheri V, Hill K, Stelmach R, Carvalho CR. [https://www.ncbi.nlm.nih.gov/pubmed/31428433 Effects of a behaviour change intervention aimed at increasing physical activity on clinical control of adults with asthma: study protocol for a randomised controlled trial]. BMC Sports Science, Medicine and Rehabilitation. 2019 Dec;11(1):1-9.</ref>. <br>


<br>[[Physical Activity and Respiratory Conditions|Physical training]] should be prescribed by physiotherapists for asthmatics to increase fitness and [https://en.wikipedia.org/wiki/Cardiorespiratory_fitness cardiorespiratory performance], reduce symptoms such as breathlessness and improve quality of life <ref>Bott J, British Thoracic Society Physiotherapy Guideline Development Group. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. BMJ Publ. Group; 2009. (level of evidence 5)</ref>. Breathlessness, chest tightness and wheezing can occur when exercising, deterring patients from physical exertion <ref>Turner S, Eastwood P, Cook A, Jenkins S. Improvements in symptoms and quality of life following exercise training in older adults with moderate/severe persistent asthma. Respiration 2011;81(4):302-310. (level of evidence 1b)</ref>. Fear avoidance can contribute to a further deterioration of physical health and quality of life, leading to anxiety and depression. It has been shown <ref>Fanelli A, Cabral ALB, Neder JA, Martins MA, Carvalho CRF. Exercise training on disease control and quality of life in asthmatic children. Med Sci Sports Exerc 2007;39(9):1474. (level of evidence 1b)</ref> that maintaining physical training in asthmatics improves disease symptoms and quality of life, therefore making it a crucial management strategy. <br>
'''3. Respiratory Muscle Training'''


'''Respiratory Muscle Training'''
* Hyperinflation in asthma causes increased lung volume, leading to altered inspiratory muscle mechanics. [[Muscles of Respiration|Inspiratory muscles]] are shortened resulting in a sub-optimal length-tension relationship for contraction. There is a decreased capacity for tension generation when breathing, resulting in accessory muscles of inspiration being utilised <ref>Silva IS, Fregonezi GA, Dias FA, Ribeiro CT, Guerra RO, Ferreira GM. Inspiratory muscle training for asthma. The Cochrane Library 2013. (level of evidence 1a)</ref>
* Breathing exercises are carried out using an external device to make breathing more difficult. This helps to strengthen the inspiratory muscles, making it easier to breathe in everyday life.<br>A breathing device is used which sets up a load to breathe against. During inspiration air is only released if enough effort is used to force open the valves of the device. [[Respiratory Muscle Training|Respiratory muscles]] are forced to work harder, increasing their strength, leading to diaphragmatic breathing becoming easier, reducing hyperinflation. <br>


<br>Hyperinflation in asthma causes increased lung volume, leading to altered inspiratory muscle mechanics. [[Muscles of Respiration|Inspiratory muscles]] are shortened resulting in a sub-optimal length-tension relationship for contraction. There is a decreased capacity for tension generation when breathing, resulting in accessory muscles of inspiration being utilised <ref>Silva IS, Fregonezi GA, Dias FA, Ribeiro CT, Guerra RO, Ferreira GM. Inspiratory muscle training for asthma. The Cochrane Library 2013. (level of evidence 1a)</ref> 
'''4. Removal of secretions'''
 
*[[Percussion|Percussions]]
<br>Breathing exercises are carried out using an external device to make breathing more difficult. This helps to strengthen the inspiratory muscles, making it easier to breathe in everyday life.<br>A breathing device is used which sets up a load to breathe against. During inspiration air is only released if enough effort is used to force open the valves of the device. [[Respiratory Muscle Training|Respiratory muscles]] are forced to work harder, increasing their strength, leading to diaphragmatic breathing becoming easier, reducing hyperinflation. <br><br>
 
{{#ev:youtube|nd5U7mDhFi4|300}}<ref>POWERbreatheUK. POWERbreathe - How it works. Available from:https://www.youtube.com/watch?v=nd5U7mDhFi4 [last accessed 18/5/15] (level of evidence 5)</ref> (
 
<br>
 
The following physiotherapy management techniques would also be beneficial:
 
'''Removal of secretions'''  
*Percussions  
*Shaking  
*Shaking  
*Vibrations,  
*Vibrations,  
*Postural drainage and  
*Postural drainage and  
*Effective coughing
*Effective coughing
A randomized crossover study<ref>Felicio-Júnior EL, Barnabé V, de Almeida FM, Avona MD, de Genaro IS, Kurdejak A, Eller MC, Verganid KP, Rodrigues JC, Tibério ID, Martins MD. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970279/#!po=44.1176 Randomized trial of physiotherapy and hypertonic saline techniques for sputum induction in asthmatic children and adolescents.] Clinics. 2020;75.</ref> examining the ability of physiotherapy techniques in sputum induction in children and adolescent patients with Asthma suggested that specific physiotherapy maneuvers may facilitate the collection of mucus, yielding the same amount of sputum as the gold-standard technique (hypertonic saline). The study confirms that sputum induction through physiotherapy maneuvers is safe in well-controlled asthmatic and enables physical therapists to mobilize secretions without causing bronchospasm in patients.


'''Range of motion exercises''' for patients who need hospitalisation.
'''5. Range of motion exercises'''


'''Education'''
* Exercises for patients who need hospitalisation.
*About condition
*On use of a bronchodilator and any other medication<br>
*How to prevent chest infection from occurring<br>
*Correct posture in standing and sitting which assists in the management of asthma attacks by allowing the chest to expand appropriately and the lungs to function optimally


<br>  
'''6. Education'''
*About condition
*On use of a bronchodilator and any other medication
*How to prevent chest infection from occurring
*Correct posture in standing and sitting which assists in the management of asthma attacks by allowing the chest to expand appropriately and the lungs to function optimally.
== Evidenced-Based Physiotherapy Management  ==
Due to the high prevalence of asthma and associated healthcare costs, it is important to identify low-cost alternatives to traditional pharmacotherapy. One of these low-cost alternatives is the use of inspiratory muscle training (IMT), which is a technique aimed at increasing the strength and endurance of the diaphragm and accessory muscles of respiration. IMT typically consists of taking voluntary inspirations against a resistive load across the entire range of vital capacity while at rest. In healthy individuals, the most notable benefits of IMT are an increase in diaphragm thickness and strength, a decrease in exertional dyspnea, and a decrease in the oxygen cost of breathing. IMT has been shown to decrease dyspnea, increase inspiratory muscle strength, and improve exercise capacity in asthmatic individuals.<ref>Ren-Jay Shei, Hunter L. R. Paris, Daniel P. Wilhite, Robert F. Chapman & Timothy D. Mickleborough.                                                        The role of inspiratory muscle training in the management of asthma and exercise-induced bronchoconstriction. The Physician and Sportsmedicine (2016);                                                                                                                44:4,327-334,      </ref>


Unfortunately, there is no cure for this illness but there are ways of effectively managing the disease. However, this should involve the active participation of both the person suffering from the disease and his/her doctor.
Also, in a systematic review done by Vera et al. (2012), it was found out that exercise can provoke asthma symptoms, such as dyspnoea, in children with asthma. Exercise-induced bronchoconstriction (EIB) is prevalent in 40–90% of children with asthma. and it was concluded physical exercise is safe and can be recommended in children with asthma. A training programme should have a minimum duration of 3 months, with at least two 60 min training sessions per week, and a training intensity set at the (personalised) ventilatory threshold.<ref>Wanrooij VH, Willeboordse M, Dompeling E, Kim D van de Kant. Exercise training in children with asthma: a systematic review. Br J Sports Med 2014;48:1024-1031</ref> Another systematic review by Cristina et al (2018) demonstrated that aerobic physical exercise may improve nocturnal asthma in children and adults by reducing the prevalence and frequency of nocturnal symptoms.<ref>Cristina de Oliveira Francisco, Swati Anil, W. Darlene Reid, Azadeh Y. Effects of physical exercise training on nocturnal symptoms in asthma: Systematic review. PLoS One. 2018; 13(10): e0204953
 
</ref>  A study protocol will provide the effectiveness of physiotherapy on the quality of life of children with asthma<ref>Zhang W, Liu L, Yang W, Liu H. [https://www.ncbi.nlm.nih.gov/pubmed/31261560 Effectiveness of physiotherapy on quality of life in children with asthma: Study protocol for a systematic review and meta-analysis]. Medicine. 2019 Jun;98(26).</ref>.
== Evidenced Based Physiotherapy Management  ==
Due to the high prevalence of asthma and associated healthcare costs, it is important to identify low-cost alternatives to traditional pharmacotherapy. One of these low cost alternatives is the use of inspiratory muscle training (IMT), which is a technique aimed at increasing the strength and endurance of the diaphragm and accessory muscles of respiration. IMT typically consists of taking voluntary inspirations against a resistive load across the entire range of vital capacity while at rest. In healthy individuals, the most notable benefits of IMT are an increase in diaphragm thickness and strength, a decrease in exertional dyspnea, and a decrease in the oxygen cost of breathing. IMT has been shown to decrease dyspnea, increase inspiratory muscle strength, and improve exercise capacity in asthmatic individuals.<ref>Ren-Jay Shei, Hunter L. R. Paris, Daniel P. Wilhite, Robert F. Chapman & Timothy D. Mickleborough.                                                        The role of inspiratory muscle training in the management of asthma and exercise-induced bronchoconstriction. The Physician and Sportsmedicine (2016);                                                                                                                44:4,327-334,      </ref>
 
Also, in a systematic review done by Vera et al.(2012),it was found out that exercise can provoke asthma symptoms, such as dyspnoea, in children with asthma. Exercise-induced bronchoconstriction (EIB) is prevalent in 40–90% of children with asthma. and it was concluded physical exercise is safe and can be recommended in children with asthma. A training programme should have a minimum duration of 3 months, with at least two 60 min training sessions per week, and a training intensity set at the (personalised) ventilatory threshold.<ref>Wanrooij VH, Willeboordse M, Dompeling E, Kim D van de Kant. Exercise training in children with asthma: a systematic review. Br J Sports Med 2014;48:1024-1031</ref> Another systematic review by Cristina et al (2018) demonstrated that aerobic physical exercise may improve nocturnal asthma in children and adults by reducing the prevalence and frequency of nocturnal symptoms.<ref>Cristina de Oliveira Francisco, Swati Anil, W. Darlene Reid, Azadeh Y. Effects of physical exercise training on nocturnal symptoms in asthma: Systematic review. PLoS One. 2018; 13(10): e0204953
</ref>


== Other Health Professional Management  ==
== Other Health Professional Management  ==


Asthma patients will be involved with a multidisciplinary team to manage their condition. Other health professionals treating the patient include:  
Asthma patients will be involved with a multidisciplinary team to manage their condition. Other health professionals treating the patient include:  
*Doctor  
#Doctor  
**Initial diagnosis and treatment.  
#*Initial diagnosis and treatment.
*Consultant  
#Consultant  
**Specialised in asthma, to help with reducing symptoms and recognising triggers.  
#*Specialised in asthma, to help with reducing symptoms and recognising triggers.
*Specialised Nurse  
#Specialised Nurse  
**To provide help, education, medication advice and general information.  
#*To provide help, education, medication advice and general information.
*Pharmacist  
#Pharmacist  
**Medication distribution.  
#*Medication distribution.
*Dietitian  
#Dietitian  
**Advice on proper to diet to not induce symptoms.  
#*Advice on proper to diet to not induce symptoms.
*Health Psychologist  
#Health Psychologist  
**To help with anxiety/depression associated with symptoms<br>
#*To help with anxiety/depression associated with symptoms<br>
 
== Prevention and Physiotherapist Role In Prevention  ==
 
Asthma may not be fully preventable due to the pathology progression and the differing possible causes of onset. However, there are ways of avoiding triggers for the disease and reducing symptoms. Being aware of triggers is vital on an individual basis as these will differ amongst sufferers.
 
Before the onset of disease, a child should avoid causes of asthma such as passive smoking, damp and dusty living environment and allergen exposure, as well as all possible causes for the disease. However, development can be hereditary and may not be preventable.
 
Some triggers to be avoided include:
*Cold Air
*Allergens
*Tobacco smoke<br>
 
To prevent asthma attacks, precautions should be made to avoid exacerbations of symptoms and to be aware of the signs of an attack.<ref>http://www.mayoclinic.org/diseases-conditions/asthma/basics/prevention/con-20026992</ref>
*Vaccination against flu and pneumonia
*Learn to recognise warning signs of an attack
*Identify signs of attack and treat early
*Use medication as prescribed<br>
 
A physiotherapist works with the patient to promote a healthy lifestyle benefiting the patient in identifying triggers, reducing symptoms and preventing disease progression. Education, advice and physiotherapy techniques help in the overall outcome of the disease.
 
Educate on:
*Symptoms
*[[Active cycle of breathing technique|Breathing Techniques]]
*Improvement of Quality of Life<br>
 
Advice on:
*Appropriate living environment
*For family members to stop smoking, or not smoke around children
*Promoting a healthy lifestyle, free of air pollution and inhalation irritants<br>
 
Disease Progression:
*Identifying triggers
*Medication management
*Physiotherapy techniques to manage disease<br>
 
== Resources  ==
 
*[https://www.mayoclinic.org/diseases-conditions/occupational-asthma/symptoms-causes/syc-20375772]
*[https://www.pulmonologyadvisor.com/asthma/steroid-resistant-asthma-management-treatment/article/686423/]
*[https://www.webmd.com/asthma/types-asthma#1]<br>[https://www.ncbi.nlm.nih.gov/pubmed/10849466]


== References ==
== References ==


<references />
<references />
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Revision as of 09:26, 21 March 2024

Original Editor - Open Physio Top Contributors - Caoimhe Mackey, Akano Oluwadara Tomisin, Kim Jackson, Chloe Hunter, Saeed Dokhnan, Uchechukwu Chukwuemeka, Rachael Lowe, Admin, Lucinda hampton, Evan Thomas, Vidya Acharya, Ayelawa Samuel, Tony Lowe, Laura Ritchie, Scott Buxton, Julie Plas, Leana Louw, Mohit Chand, Michelle Lee and WikiSysop

Introduction[edit | edit source]

Asthma attack-illustration NIH.jpeg

Asthma is a relatively common condition that is characterised by at least partially reversible inflammation of the airways and reversible airway obstruction due to airway hyperreactivity. It can be acute, subacute or chronic[1] and exercise induced.

Asthma:

  • Is a major noncommunicable disease (NCD), affecting both children and adults.
  • Affected an estimated 262 million people in 2019 and caused 461000 deaths.[1]
  • Is the most common chronic disease among children.
  • Inhaled medication can control asthma symptoms and allow people with asthma to lead a normal, active life.
  • Avoiding asthma triggers can also help to reduce asthma symptoms.
  • Most asthma-related deaths occur in low- and lower-middle income countries, where under-diagnosis and under-treatment is a challenge.[2]

Epidemiology[edit | edit source]

Deaths from Asthma in 2012 per million persons. Statistics from WHO grouped by deciles. Lightest yellow 0-10 through to red 96-251

Asthma is one of the most common chronic diseases in the world. It is a common pathology, affecting around 15% to 20% of people in developed countries and around 2% to 4% in less developed countries. It is significantly more common in children.[3]

Asthma:

  • Affected an estimated 262 million people in 2019 and caused 461000 deaths.[2]
  • May occur at any age (significantly more common in children), most patients with asthma experience their first symptoms before the age of 5 years old and about 66% are diagnosed before the age of 18 years.
  • Almost 50% of children with asthma have a decrease in severity or disappearance of symptoms during early adulthood.[1]
  • Prevalence is greater in extreme of ages due to airway responsiveness and lower levels of lung function[3].
  • In many countries, including the US, asthma kills one out of every 100,000 persons.
  • Results in millions of school and workdays lost. In the US alone, close to 2 million asthmatics seek regular care in the emergency department, which also increases the costs of healthcare[3].

Aetiology[edit | edit source]

Inflammation plays a major role in asthma and involves multiple cell types and mediators. The factors that initiate the inflammatory process are complex and still under investigation. Genetic factors (e.g. cytokine response profiles) and environmental exposures (such as allergens, pollution, infections, microbes, stress) at a crucial time in the development of the immune system are known to be involved.[1]

Risk Factors[edit | edit source]

Asthma causes.png

Include:

  • Asthma is more likely if other family members also have asthma – particularly a close relative, such as a parent or sibling.
  • Asthma is more likely in people who have other allergic conditions, eczema and rhinitis (hay fever).
  • Urbanisation is associated with increased asthma prevalence, probably due to multiple lifestyle factors.
  • Events in early life affect the developing lungs and can increase the risk of asthma. E.g. low-birth weight, prematurity, exposure to tobacco smoke and other sources of air pollution, viral respiratory infections.
  • Exposure to a range of environmental allergens and irritants are also thought to increase the risk of asthma, eg indoor and outdoor air pollution, house dust mites, moulds, and occupational exposure to chemicals, fumes, or dust.
  • Children and adults who are overweight or obese are at a greater risk of asthma.

Pathophysiology[edit | edit source]

Asthma is a condition of acute, fully reversible airway inflammation, often following exposure to an environmental trigger. The pathological process begins with the inhalation of an irritant (e.g., cold air) or an allergen (e.g., pollen), which then, due to bronchial hypersensitivity, leads to airway inflammation and an increase in mucus production. This leads to a significant increase in airway resistance, which is most pronounced on expiration.

Airway obstruction occurs due to the combination of:

  1. Inflammatory cell infiltration.
  2. Mucus hypersecretion with mucus plug formation.
  3. Smooth muscle contraction.

These irreversible changes may become irreversible over time due to

  1. Basement membrane thickening, collagen deposition, and epithelial desquamation.
  2. Airway remodeling occurs in chronic disease with smooth muscle hypertrophy and hyperplasia.

If not corrected rapidly, asthma may become more difficult to treat, as the mucus production prevents the inhaled medication from reaching the mucosa. The inflammation also becomes more edematous. This process is resolved (in theory complete resolution is required in asthma, but in practice, this is not checked or tested) with beta-2 agonists (e.g., salbutamol, salmeterol, albuterol) and can be aided by muscarinic receptor antagonists (e.g., ipratropium bromide), which act to reduce the inflammation and relax the bronchial musculature, as well as reducing mucus production.[3]

Clinical Presentation[edit | edit source]

The classical symptoms of asthma are wheeze, shortness of breath, chest tightness or difficulty breathing and cough. These symptoms are typically variable and can be absent for long periods of time, with possible episodic exacerbations often triggered by factors such as exercise, allergen or irritant exposure, cold air or viral respiratory infections.

The diagnosis of asthma is clinical and relies on the recognition of a characteristic pattern or respiratory symptoms and signs in the absence of an alternative explanation. Features that increase the probability of asthma are:

  • More than one of the following symptoms: wheeze, cough, difficulty breathing and chest tightness.
  • Episodic symptoms that are worse at night and in the early morning, and occur in response to certain triggers, e.g. exercise, allergen exposure, cold air.
  • Personal history of an atopic disorder or family history of an atopic (allergic) disorder and/or asthma
  • Widespread wheeze on auscultation
  • Lung function tests are useful in the evaluation of a patient with asthma to assess the presence, severity and reversibility of the airflow obstruction. On spirometry an FEV1/FEV ratio less than 0.7 confirms obstruction. In asthmatic patients, there is usually a large bronchodilator response (typically an increase of at least 12-15% in FEV1) 3, and it is also typically an abnormally high variability of the peak expiratory flow. A normal spirometry, particularly if performed when the patient is asymptomatic, does not exclude the diagnosis of asthma[1]

When does asthma become life threatening?

  • Difficulty to catch a breath
  • Difficulty talking and concentrating
  • Difficulty talking and walking
  • Cyanosis of skin especially around the mouth and finger areas
  • Nasal flaring and constant wheeze

When these signs and symptoms presents, a person should be aware and are advice to consult with your general practitioner as soon as possible.

Investigations and Diagnosis[edit | edit source]

Diagnosis of asthma is confirmed based upon various factors[4]:

  • Medical History
  • Family History: If the patient has a family history of asthma or allergies, they are more likely to also suffer from asthmatic symptoms.
  • Physical Assessment: The patient’s nose, throat and upper airways will be examined for signs of asthma or allergies. Assessment of the patient’s respiratory rate and breathing pattern will be carried out in conjunction with auscultation S & S include: Wheezing (high-pitched whistling sounds when the patient exhales) Coughing, chest tightness, Shortness of breath (SOB), A runny nose, Swollen nasal passages.[5].

Diagnostic Tests[edit | edit source]

Spirometry1.jpg

The following tests are used to assess the patient’s breathing as well as to monitor the effectiveness of asthma treatment.

Lung function tests[6]

Spirometry,

Peak flow testing

Other tests:

Treatment[edit | edit source]

Kids with Asthma.jpeg

The goal of the treatment is to control the symptoms, prevent exacerbations and loss of lung function and reduce associated mortality.

  1. Drugs used for control of asthma depend on the severity of the disease. Short-acting β2-agonists can be used in patients with mild occasional symptoms. Inhaled steroids (oral steroids might be required in severe cases) and long-acting β2-agonists can be used for long-term control. Oxygen, short-acting β2-agonists, inhaled anticholinergics and systemic steroids are used in acute exacerbations.
  • Short-acting beta 2-agonists (quick acting or rescue medicine): these drugs are used best to treat sudden and severe or new asthma symptoms as they open the airways and relieve symptoms within 20 minutes and lasts four to six hours. It can also be used before physical activity about 15-20 minutes before the time to prevent exercise-induced asthma.
  • Long-acting beta 2-agonists: these drugs are not used to for a quick relief of asthma symptoms, instead they are used to control symptoms and their effect lasts 12 hours.

2, Mechanical ventilation may be necessary for severe exacerbations that do not respond to medical treatment. Non-pharmacological measures, such as smoking cessation and avoidance of occupational sensitisers, are also important.

3. Non-pharmacologic management, including asthma education on inhaler technique and self-monitoring, is vital.[7]

Prognosis[edit | edit source]

Asthma is a disease with variable progression and severity of symptoms over time. The prognosis depends on the severity of the disease and the degree of control with treatment. Some patients can be symptom-free for long periods, whereas a few patients with severe persistent asthma develop progressive loss of lung function. Death due to asthma is very rare.[1]

Even though asthma is a reversible disorder, poor lifestyle and lack of management can lead to airway remodeling that leads to chronic symptoms, which are disabling.[3]

Physiotherapy Management[edit | edit source]

Breathing relaxing.jpg

The majority of patients suffering from asthma will seek physiotherapy for dyspnea and hyperventilation [8].Physiotherapists treat asthma in a variety of ways with the aim to improve breathing technique. Physiotherapy techniques for asthma are in addition to medication and should never be used as a replacement for prescribed medication, however may reduce the dosage required.

1. Breathing Retraining Techniques [9]

Breathing techniques may have more benefit on mild – moderate asthma [10]. The aim of breathing retraining is to normalise breathing patterns by stabilising respiratory rate and increasing expiratory airflow. Instructions are given from the physiotherapist on how to complete this technique, with the following components:

  • Decreasing Breaths Taken (Reducing Respiratory Rate)
  • Taking Smaller Breaths (Reducing Tidal Volume)
  • Deep Breathing (Diaphragmatic breathing through use of abdominal muscles and lower thoracic chest movement)
  • Breathing through the Nose (Nasal Breathing)
  • Relaxation (Relaxed, controlled breathing)
  • Decreasing Air Leaving (Decreased expiratory flow through pursed lip breathing)
  • These retraining techniques help control breathing and reduce airflow turbulence, hyperinflation, variable breathing pattern and anxiety.
Buteyko.png

Buteyko Breathing Technique[11]

  • The Buteyko breathing technique is another breathing retraining technique; however, it is specific to reducing hyperinflation. It was developed based on the theory that asthmatic bronchospasm is caused by hyperventilation, leading to a low PaCO2 and therefore all asthmatic symptoms are due to this. The narrowed airways induce an “air hunger” causing a switch to mouth-breathing and an increased respiratory rate leading to hyperinflation. Buteyko believes that this hyperinflation then also contributes to bronchoconstriction. The Buteyko technique aims to reduce ventilation and subsequently lung volume, as a treatment for asthma and other respiratory diseases. A qualified practitioner is necessary to train the patient [12].
  • The Buteyko Technique[13]
    • Breathe normally through the nose for 2-3 mins
    • Breathe out normally, close nose with fingers, and hold
    • Record number of seconds
    • On first need to breathe, release nose and return to nasal breathing (Control Pause)
    • Wait 3 minutes
    • Repeat and hold breath for as long as possible (Maximum Pause)

Breathing pattern retraining and relaxed breathing techniques are two approaches to physiotherapy management of asthma. The aim of breathing pattern retraining is to develop a more efficient pattern of respiration, thereby reducing breathlessness. This is usually accomplished by slowing the breathing rate, and encouraging relaxed, ‘abdominal’ breathing (Bruton, 2006). Another potential mechanism for breathing pattern retraining is that by encouraging a longer expiratory time, the effects of any static/ dynamic hyperinflation may be reduced.

Mild asthmatics can hold their breath for up to twenty seconds, moderate asthmatics for fifteen seconds and severe asthmatics for up to ten seconds. The aim of this method is to increase the control pause to 60 seconds and the maximum pause to 2 minutes. It is practiced twice a day, with the practitioner there to help with breath holding and ensure safety. Its aim is to reduce minute volume through reduction of respiratory rate, and increasing carbon dioxide levels through breath holding, reducing bronchospasm caused by hyperventilation in the asthmatic patient.

2. Physical Training

  • Physical training with asthma is advised when taking the proper precautions and should not be avoided. The American College of Sports Medicine (ACSM) Guidelines provide tips and safety precautions for asthmatics to exercise safely[14].
  • Physical training should be prescribed by physiotherapists for asthmatics to increase fitness and cardiorespiratory performance, reduce symptoms such as breathlessness and improve quality of life [15]. Breathlessness, chest tightness and wheezing can occur when exercising, deterring patients from physical exertion [16]. Fear avoidance can contribute to a further deterioration of physical health and quality of life, leading to anxiety and depression. It has been shown [17] that maintaining physical training in asthmatics improves disease symptoms and quality of life, therefore making it a crucial management strategy.
  • A study protocol suggests behavior change intervention focussing on increasing participation in physical activity may exert control over asthma and quality of life[18].

3. Respiratory Muscle Training

  • Hyperinflation in asthma causes increased lung volume, leading to altered inspiratory muscle mechanics. Inspiratory muscles are shortened resulting in a sub-optimal length-tension relationship for contraction. There is a decreased capacity for tension generation when breathing, resulting in accessory muscles of inspiration being utilised [19]
  • Breathing exercises are carried out using an external device to make breathing more difficult. This helps to strengthen the inspiratory muscles, making it easier to breathe in everyday life.
    A breathing device is used which sets up a load to breathe against. During inspiration air is only released if enough effort is used to force open the valves of the device. Respiratory muscles are forced to work harder, increasing their strength, leading to diaphragmatic breathing becoming easier, reducing hyperinflation.

4. Removal of secretions

  • Percussions
  • Shaking
  • Vibrations,
  • Postural drainage and
  • Effective coughing

A randomized crossover study[20] examining the ability of physiotherapy techniques in sputum induction in children and adolescent patients with Asthma suggested that specific physiotherapy maneuvers may facilitate the collection of mucus, yielding the same amount of sputum as the gold-standard technique (hypertonic saline). The study confirms that sputum induction through physiotherapy maneuvers is safe in well-controlled asthmatic and enables physical therapists to mobilize secretions without causing bronchospasm in patients.

5. Range of motion exercises

  • Exercises for patients who need hospitalisation.

6. Education

  • About condition
  • On use of a bronchodilator and any other medication
  • How to prevent chest infection from occurring
  • Correct posture in standing and sitting which assists in the management of asthma attacks by allowing the chest to expand appropriately and the lungs to function optimally.

Evidenced-Based Physiotherapy Management[edit | edit source]

Due to the high prevalence of asthma and associated healthcare costs, it is important to identify low-cost alternatives to traditional pharmacotherapy. One of these low-cost alternatives is the use of inspiratory muscle training (IMT), which is a technique aimed at increasing the strength and endurance of the diaphragm and accessory muscles of respiration. IMT typically consists of taking voluntary inspirations against a resistive load across the entire range of vital capacity while at rest. In healthy individuals, the most notable benefits of IMT are an increase in diaphragm thickness and strength, a decrease in exertional dyspnea, and a decrease in the oxygen cost of breathing. IMT has been shown to decrease dyspnea, increase inspiratory muscle strength, and improve exercise capacity in asthmatic individuals.[21]

Also, in a systematic review done by Vera et al. (2012), it was found out that exercise can provoke asthma symptoms, such as dyspnoea, in children with asthma. Exercise-induced bronchoconstriction (EIB) is prevalent in 40–90% of children with asthma. and it was concluded physical exercise is safe and can be recommended in children with asthma. A training programme should have a minimum duration of 3 months, with at least two 60 min training sessions per week, and a training intensity set at the (personalised) ventilatory threshold.[22] Another systematic review by Cristina et al (2018) demonstrated that aerobic physical exercise may improve nocturnal asthma in children and adults by reducing the prevalence and frequency of nocturnal symptoms.[23]  A study protocol will provide the effectiveness of physiotherapy on the quality of life of children with asthma[24].

Other Health Professional Management[edit | edit source]

Asthma patients will be involved with a multidisciplinary team to manage their condition. Other health professionals treating the patient include:

  1. Doctor
    • Initial diagnosis and treatment.
  2. Consultant
    • Specialised in asthma, to help with reducing symptoms and recognising triggers.
  3. Specialised Nurse
    • To provide help, education, medication advice and general information.
  4. Pharmacist
    • Medication distribution.
  5. Dietitian
    • Advice on proper to diet to not induce symptoms.
  6. Health Psychologist
    • To help with anxiety/depression associated with symptoms

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Radiopedia Asthma Available from:https://radiopaedia.org/articles/asthma-1 (accessed 25.5.2021)
  2. ↑ 2.0 2.1 WHO Asthma Available from: https://www.who.int/news-room/fact-sheets/detail/asthma(accessed 25.5.2021)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Hashmi MF, Tariq M, Cataletto ME, Hoover EL. Asthma 2020.Available from:https://www.ncbi.nlm.nih.gov/books/NBK430901/ (accessed 25.5.2021)
  4. ↑ National heart, lung and blood institute. Asthma 2014. available from http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/diagnosis
  5. ↑ Mayo Clinic. Asthma: steps in testing and diagnosis. available from http://www.mayoclinic.org/diseases-conditions/asthma/in-depth/asthma/art-20045198
  6. ↑ Web MD. Diagnosing Asthma. Available from http://www.webmd.com/asthma/guide/diagnosing-asthma?page=4
  7. ↑ Anil Nanda, Alan P. Baptist, Rohit Divekar, Neil Parikh, Joram S. Seggev, Joseph S. Yusin & Sharmilee M. Nyenhuis. Asthma in the older adult, Journal of Asthma (2019); DOI: 10.1080/02770903.2019.1565828
  8. ↑ Thomas M, Bruton A. Breathing exercises for asthma. Breathe 2014;10(4):312-322. (level of evidence 3a)
  9. ↑ Bott J, British Thoracic Society Physiotherapy Guideline Development Group. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. BMJ Publ. Group; 2009. (level of evidence 5)
  10. ↑ Lord of Physiotherapy. Postural Drainage. Available from: http://www.youtube.com/watch?v=TPZsP1ujg0U[last accessed 08/02/13] (level of evidence 5)
  11. ↑ Cowie RL, Conley DP, Underwood MF, Reader PG. A randomised controlled trial of the Buteyko technique as an adjunct to conventional management of asthma. Respir Med 2008;102(5):726-732. (level of evidence 1b)
  12. ↑ Hough A. Physiotherapy in Respiratory and Cardiac Care: An Evidence-Based Approach. Nelson Thornes; 2013. (level of evidence 5)
  13. ↑ http://www.buteyko.co.uk/ (level of evidence 5)
  14. ↑ https://www.acsm.org/docs/current-comments/allergiesandasthmatemp.pdf (level of evidence 5)
  15. ↑ Bott J, British Thoracic Society Physiotherapy Guideline Development Group. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. BMJ Publ. Group; 2009. (level of evidence 5)
  16. ↑ Turner S, Eastwood P, Cook A, Jenkins S. Improvements in symptoms and quality of life following exercise training in older adults with moderate/severe persistent asthma. Respiration 2011;81(4):302-310. (level of evidence 1b)
  17. ↑ Fanelli A, Cabral ALB, Neder JA, Martins MA, Carvalho CRF. Exercise training on disease control and quality of life in asthmatic children. Med Sci Sports Exerc 2007;39(9):1474. (level of evidence 1b)
  18. ↑ Freitas PD, Xavier RF, Passos NF, Carvalho-Pinto RM, Cukier A, Martins MA, Cavalheri V, Hill K, Stelmach R, Carvalho CR. Effects of a behaviour change intervention aimed at increasing physical activity on clinical control of adults with asthma: study protocol for a randomised controlled trial. BMC Sports Science, Medicine and Rehabilitation. 2019 Dec;11(1):1-9.
  19. ↑ Silva IS, Fregonezi GA, Dias FA, Ribeiro CT, Guerra RO, Ferreira GM. Inspiratory muscle training for asthma. The Cochrane Library 2013. (level of evidence 1a)
  20. ↑ Felicio-Júnior EL, Barnabé V, de Almeida FM, Avona MD, de Genaro IS, Kurdejak A, Eller MC, Verganid KP, Rodrigues JC, Tibério ID, Martins MD. Randomized trial of physiotherapy and hypertonic saline techniques for sputum induction in asthmatic children and adolescents. Clinics. 2020;75.
  21. ↑ Ren-Jay Shei, Hunter L. R. Paris, Daniel P. Wilhite, Robert F. Chapman & Timothy D. Mickleborough. The role of inspiratory muscle training in the management of asthma and exercise-induced bronchoconstriction. The Physician and Sportsmedicine (2016); 44:4,327-334,
  22. ↑ Wanrooij VH, Willeboordse M, Dompeling E, Kim D van de Kant. Exercise training in children with asthma: a systematic review. Br J Sports Med 2014;48:1024-1031
  23. ↑ Cristina de Oliveira Francisco, Swati Anil, W. Darlene Reid, Azadeh Y. Effects of physical exercise training on nocturnal symptoms in asthma: Systematic review. PLoS One. 2018; 13(10): e0204953
  24. ↑ Zhang W, Liu L, Yang W, Liu H. Effectiveness of physiotherapy on quality of life in children with asthma: Study protocol for a systematic review and meta-analysis. Medicine. 2019 Jun;98(26).
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