Bronchial asthma

What asthma is

Asthma is a heterogeneous disease characterized by chronic airway inflammation, bronchial hyperresponsiveness (an exaggerated reaction of the bronchi to triggers that cause nothing in a healthy person) and variable airflow obstruction. In an attack, the smooth muscle of the bronchi tightens (bronchospasm), the lining swells and excess mucus is produced; air passes with difficulty, especially on breathing out, and this causes the wheeze. Unlike COPD, the narrowing in asthma is, at least at first, wholly or partly reversible, spontaneously or with treatment.

The most common phenotype is allergic asthma, linked to type 2 inflammation (eosinophils, IgE) and often to allergic rhinitis, eczema or food allergy. There are also non-allergic forms, exercise-induced asthma, occupational asthma (from workplace exposure to dusts or chemicals), asthma worsened by nonsteroidal anti-inflammatory drugs, and cough-predominant forms. Risk factors include allergies, family history, childhood exposure to tobacco smoke or pollution, overweight and premature birth.

What the symptoms are

• Wheezing when breathing (a high-pitched sound, especially on breathing out).
• Cough, often dry, worse at night or in the early morning.
• Shortness of breath and chest tightness.
• Limitation of activity because of breathing complaints.

The fundamental feature is variability: symptoms come and go and change in intensity from day to day and season to season. They are worsened by viral infections, allergens (pollen, dust, mould, animals), tobacco smoke, cold air, pollution, physical exertion, strong emotion and some drugs (aspirin and nonsteroidal anti-inflammatory drugs in some patients, non-selective beta-blockers). Not every cough or wheeze is caused by asthma: the distinction is made from the history and from functional tests.

How the diagnosis is made

The diagnosis rests on two elements: a typical history of symptoms and objective evidence of variable airflow obstruction. The doctor reviews the pattern of symptoms, exposures, allergies and personal and family history.

Spirometry (performed at the clinic) measures the amount of air forcefully exhaled in the first second (FEV₁) and its ratio to the forced vital capacity (FEV₁/FVC). Obstruction is confirmed by a reduced ratio, while the post-bronchodilator test shows reversibility: a rise in FEV₁ of at least 12% and 200 ml after a bronchodilator supports the diagnosis of asthma. As appropriate, peak expiratory flow measurements at home over a few weeks are also used to capture daily variability, along with blood tests and other tests: blood eosinophils, IgE, allergy testing, fractional exhaled nitric oxide (FeNO) where available.

A normal spirometry between episodes does not exclude asthma, because variability is precisely its hallmark; testing sometimes needs to be repeated or supplemented with provocation tests at a specialized center. A chest X-ray does not establish the diagnosis, but may be done to exclude other diseases.

How it is treated

Treatment relies on inhaled medicines, because they act directly on the bronchi at a low dose with few systemic side effects. The current principle is that in adults every patient with asthma should receive anti-inflammatory treatment, that is, an inhaled corticosteroid (ICS), according to the doctor’s regimen; relying only on a reliever inhaler without an anti-inflammatory (a short-acting beta-2 agonist, SABA) is not the recommended approach, because it relieves the symptom but does not treat the inflammation and leaves the patient exposed to severe attacks.

In practice, the preferred regimens use a combination of the inhaled corticosteroid with a fast-acting bronchodilator (formoterol) as an as-needed reliever or as both maintenance and reliever therapy in the same device. When control is inadequate, the dose is raised or other drugs are added (long-acting bronchodilators, leukotriene antagonists, tiotropium). In severe asthma not controlled by standard treatment, specialized treatments are needed, such as biological therapies (antibodies against IgE, IL-5, IL-4/13), which are provided at specialized centers. Oral corticosteroids are used as a short course in exacerbations, as directed by the doctor.

Equally important are correct inhaler technique (a common mistake is that most of the dose remains in the mouth and throat; using a spacer improves deposition), use as instructed and a written action plan for worsening: what to do according to symptoms or peak flow readings, when to raise the dose and when to seek urgent help.

When to see a pulmonologist

Seek assessment if symptoms wake you at night, limit activity, or you need the reliever inhaler more than twice a week. After an attack, a prompt check is needed even if you feel better, because the exacerbation shows that control of the disease has been inadequate. Patients with asthma should be reviewed regularly, every 6 months to a year, or sooner when the doctor considers it reasonable: the review checks inhaler technique, assesses the need to step treatment down or up and renews the action plan.

What helps in daily life

Avoid tobacco (active and passive) and exposures that trigger symptoms. Treat coexisting conditions that make control difficult: allergic rhinitis, gastroesophageal reflux, overweight and sleep apnea. Keep up suitable physical activity; with good treatment most patients can play sport. Discuss vaccination (influenza, pneumococcus, COVID-19) according to risk. Do not stop treatment because symptoms have settled and do not change doses outside the doctor’s plan. Patients with heart disease should tell their doctor about their asthma before beta-blockers are started.

Care at Tirana Polyclinic: we offer pulmonology consultation, spirometry and interpretation of tests, functional tests and imaging performed at other clinics.