Asthma in adults presents with recurrent episodes of shortness of breath, chest tightness, wheezing, or coughing.
Examination typically demonstrates an expiratory wheeze; however, in severe asthma there is poor air entry and the chest is silent.
Treatment is stepwise, based on symptoms. Patients may need to monitor their peak expiratory flow daily and should be aware of the warning signs of a severe attack.
Some patients may develop progressive, irreversible obstructive lung disease.
Asthma is a chronic inflammatory airway disease characterized by intermittent airway obstruction and hyper-reactivity. Many cellular components are involved in the asthmatic pathway, including mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells. On insult, in susceptible people, inflammation causes increased bronchial hyper-responsiveness and recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, which are usually associated with widespread but variable airway obstruction that is reversible either spontaneously or with treatment.
History and exam
Key diagnostic factors
- recent upper respiratory tract infection
- expiratory wheezes
- nasal polyposis
- family history
- atopic history
- cigarette smoking or vaping
- respiratory viral infection early in life
- low socioeconomic status
- nasal polyposis
- gastroesophageal reflux disease (GERD)
- obstructive sleep apnea
1st investigations to order
- FEV₁/FVC ratio
- peak expiratory flow rate (PEFR)
- fractional exhaled nitric oxide (FeNO)
Investigations to consider
- bronchial challenge test
- immunoassay for allergen-specific IgE
- skin prick allergy testing
- sputum eosinophil count
initial treatment: infrequent asthma symptoms (e.g., less than twice a month) and no risk factors for exacerbations
initial treatment: asthma symptoms or need for a reliever twice a month or more (but less than 4-5 days per week)
initial treatment: troublesome asthma symptoms most days, or waking due to asthma once a week or more, especially if any risk factors exist
initial treatment: severely uncontrolled asthma or acute exacerbation
ongoing treatment: step 1 (symptoms less than twice a month and no exacerbation risk factors)
ongoing treatment: step 2 (asthma not controlled on step 1 treatment)
ongoing treatment: step 3 (asthma not controlled on step 2 treatment)
ongoing treatment: step 4 (asthma not controlled on step 3 treatment)
ongoing treatment: step 5 (asthma not controlled on step 4 treatment and patient reviewed by specialist)
- Cystic fibrosis
- Chronic rhinosinusitis
- Global strategy for asthma management and prevention
- 2020 focused updates to the asthma management guidelines
Asthma in adults: what is it?
Asthma in adults: what treatments work?More Patient leaflets
Peak flow measurement: animated demonstrationMore videos
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