Asthma Part 3: Special Patient Populations

Children Below 5 Years of Age

Asthma is difficult to diagnose in children below 5 years of age. As the airways of children are naturally small, wheezing, when audible, can be confused between asthma and simple upper respiratory tract infections.

To add to the confusion, fast acting medications like Beta2 Agonists will relieve wheezing in children irrespective of whether they have asthma or not.

Your primary physician might elect to treat your child with long term medications like inhaled corticosteroids after weighing the risks vs the benefits of the drug. They will do so especially if the asthma proceeds beyond 6 years of age.

Inhaled corticosteroids are the preferred drug of choice for young children, Montelukast and Cromolyn being the other options available. Treatment is usually prescribed over a trial period between 4-6 weeks and stopped if no benefits are seen during that period of time.

Side effects of inhaled corticosteroids in very young children include slow growth across all ages. However, poorly controlled asthma also reduces a child’s growth rate. Hence, your primary physician will discuss the risks and benefits of commencing inhaled corticosteroids with you before commencing the medication.


Elderly Patients

Polypharmacy in elderly patients makes treatment in this group challenging. Commonly used drugs like Beta Blockers (for hypertension), aspirin and other NSAIDs (for analgesia) are all contraindicated in the treatment of asthma.

All elderly patients are advised to inform the doctor of all the medications currently consumed.

Side effects from asthma treatment like long time consumption of corticosteroids at high doses include development of osteoporosis and diabetes. Discuss management strategies with your primary physician before commencing these medications.


Pregnant Women

Pregnancy is complicated by asthma because the foetus requires an adequate oxygen supply above and beyond that required by the mother. Asthma also increases the risk of other complications of pregnancy, pre-eclampsia, pre-mature birth and low birth weights notwithstanding.

It is more beneficial to take asthma medicines while pregnant than to risk having an asthma attack. Discuss your Asthma Action Plan with your attending physician if you’re pregnant or planning a pregnancy. Whatever your asthma control may be, continued monitoring and control of your asthma throughout your pregnancy is essential.


Athletes and Growing Children

Physical activities can trigger asthma.

There is a range of medications that may help prevent asthma during exercise. These include:

• Short-acting Beta2-agonists - These are inhaled often before physical activity and have a duration of action up to 2-3 hours.
• Long-acting Beta2-agonists - These are inhaled and have a duration of action up to 12 hours. However, tolerance to these medications can develop and with prolonged use, the duration of action of the drug will be reduced.
• Leukotrienes -.These are often consumed orally hours before physical activity and can relieve symptoms of asthma.

It is important to slowly ease into exercise and not to over exert unnecessarily. A simple warm up prior to exercise, proper clothing and warm down post exercise will all aid in controlling asthma.

With proper control, asthmatics can participate in any physical activity or sport they wish.


Surgical Patients

Asthma is a significant risk factor for general anaesthesia. Tracheal intubation, for example, can trigger an asthmatic attack.

Patients are advised to inform the surgeon and anaesthesia team prior to surgery to pre-empt problems.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

Asthma Part 2: The Medical Consult

Asthma is diagnosed in the primary care setting by a comprehensive medical history, family history, a physical examination and lung function tests.

Your primary care physician will determine the severity of your asthma which in turn will affect the treatment you require.

Referral to a Respiratory Specialist in the following situations:

• Subspecialized tests are needed to confirm the diagnosis of asthma
• There is a history of a life threatening asthma attack
• Treatment for specific allergies 
• Polypharmacy (Multiple medications) is needed to control your asthma

Important Points To Mention During Your Medical Consult

Important points to bring up during your medical consult include:

• A Family history of asthma and allergies
• Frequency of asthmatic attacks.
• Timing of asthmatic attacks, especially if it occurs only during certain times of the year, day, or in certain places.
• Triggers of asthma specific to you
• Related conditions when experiencing an asthmatic attack, like a concurrent upper respiratory tract infection, reflux disease, stress, sleep apnoea etc

Physical Examination

Physical examination would include:

• Auscultation by your primary physician to listen for wheezing in the lungs
• Examination of the upper airways, sinuses and upper nasal passages for existing upper airway diseases
• Examination for other signs of allergic conditions eg eczema

Diagnostic Tests For Asthma

Lung Function Tests

Lung Spirometry is a type of Lung Function Test that measures the amount of air you inhale and exhale and the speed thereof.

Some respiratory specialists will use medications to “treat” existing asthma and repeat the lung function tests again to see if there is any improvement. This is usually done if chronic asthma is suspected. It is also done when the diagnosis of asthma is unclear.


Associated Tests For Asthma

Other tests performed by respiratory specialists may include:

• Allergy testing
• Perform Bronchoprovocation tests to “trigger” a controlled asthmatic attack.
• Chest X-Rays
• Electrocardiograms (ECGs) .

Asthma In Young Children

Many children develop asthmatic symptoms before 5 years of age and it is difficult to diagnose asthma in young children because the symptoms often present together with many other childhood diseases.

Reason is because children have small airways to begin with. Any respiratory condition with mucus production, for example, will further narrow their airways causing wheezing to be audible, thereby mimicking asthma. As the child grows older, the airways enlarge, and wheezing no longer becomes audible.

However, asthma should be suspected if:

• One or both parents have asthma
• Other allergic conditions eg eczema is present
• A history of pollen allergy or hay fever is present
• Wheezing is audible even when the child is healthy

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

Asthma Part 1: An Overview

Asthma is a chronic lung disease that causes inflammation and narrowing of the airways in the lungs. Recurring periods of wheezing, chest tightness, shortness of breath, and coughing are all hallmarks of asthma.

Asthma affects people of all ages, but most often starts during childhood.


Overview

Asthmatics have inflamed airways in their lungs. Inflamed airways are narrowed and very sensitive, thereby reacting very stronging to inhaled allergens.

When the airways react, the muscles around them tighten, narrowing the airways causing reduced airflow into the lungs. The swelling can and will progress, farther narrowing the airways. Associated with this process is the increased production of mucus, a thick, sticky fluid that farther narrows the already narrowed airways.

These reactions result in the symptoms of asthma - Wheezing, chest tightness, shortness of breath, and coughing.

Asthmatic symptoms are often mild and spontaneously resolve or are easily treated with minimal treatment. However, in some cases, it can progress and become worse, resulting in what is commonly known as an asthmatic attack.

Hence, treating symptoms of asthma early is paramount. By the time an asthmatic attack ensues, emergency care is required and if left untreated, asthma can be fatal.

There is no cure for asthma. However, with proper and thorough ongoing treatment, asthma can be managed and sufferers of asthma can and will continue to lead normal and active lives.


Populations At Risk

Most often, asthma starts during childhood but it can affect all ages.

Young children who frequently suffer from respiratory infections are at highest risk of developing asthma. Other risk factors influencing the development of asthma include being atopic (having multiple allergies), eczema, or, as mentioned above, having parents who are also asthmatic.

Boys have a higher risk of developing asthma compared to girls. However, once adulthood is reached, there are more female asthmatics compared to their male counterparts. As a sum total, most people with asthma have allergies.

Another significant population with asthma are industrial workers who come into contact with chemical irritants or industrial pollutants in their workplace. This population develops occupational asthma, a contentious disease label.


Causes of Asthma

A multitude of causes for asthma have been documented so far. These include :

• Genetic causes, especially atopic individuals or asthmatic parents
• Childhood Respiratory Infections
• A multitude of airborne allergens have been implicated

Signs and Symptoms of Asthma

Common signs and symptoms of asthma include:

• Coughing 
• Wheezing.
• Chest tightness  
• Shortness of breath.

Coughing caused by Asthma is often worse at night, disrupting sleep. Wheezing is a squeaky, whooshy sound that is audible with each breath. Chest tightness and shortness of breath can and is often confused with cardiac causes and can result in undue stress to the patient.

Having one or more of the above symptoms do not automatically diagnose asthma. Proper lung function tests, history taking and a physical examination by a health profession is the only way of confirming asthma.

The type and severity of symptoms of asthma suffered by the patients though determines the management of the disease. Because symptoms vary over time, asthmatics need to be aware of their own symptoms and fluctuations thereof, and seek treatment early because while mild symptoms can be simply annoying, severe symptoms can seriously limit daily routines and exercise, and very severe symptoms can potentially cause death if untreated.

Treatment is now available to prevent the onset of asthma in known asthmatics.


Triggers Of Asthma

These include:

• Allergens - dust, animal fur, cockroaches, mold, and pollens from trees, grasses, and flowers etc.
• Chemical Irritants - cigarette smoke, air pollution, chemicals, workplace dust, sprays etc.
• Medicines - NSAIDs (eg aspirin) and B-Blockers (eg Atenolol).
• Upper respiratory infections
• Physical activity - exercise can trigger asthma.

This list is not exhaustive. Each asthmatic is unique and it is best if you seek advice from your health professional.


Prevention Of Asthma

Asthma can’t be cured. But you can prevent it. Following these simple steps will go a long way in managing asthma.

• Educate yourself about asthma. Empower yourself. 
• Have an Asthma Action Plan and follow through with it. 
• Follow your physician’s medicine regime
• Identify the triggers that cause your asthma and avoid them
• Document progression of your asthma
• Regular visits to your treating physician

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.