Asthma Past Present and Future
Objectives
History and Definition
Be able to give a thorough definition of asthma
Childhood Asthma
Name some clinical manifestations of asthma in children that is different than adults
Name some factors associated with childhood asthma
What happens to the lungs during an asthma attack
Describe the effects of asthma on bronchial tubes
Define Airway Remodeling
Asthma Risk Factors and Classification
List risk factors associated with asthma
Know the difference between atopic and non-atopic asthma
List some common asthma triggers
Current approaches to asthma treatment
Know the four stages of asthma as defined by the NAEPP
Name two possible irritants for asthmatics
Name two possible allergens for asthmatics
At what level of severity should asthmatics have skin tests for their allergens
Know the steps before a drug receives FDA approval
History of the Disease and a Definition
Asthma was described and treated thousands of years ago by the ancient Egyptians and Chinese. The term derives from the Greek aazein, meaning 'to pant'. (1,18) Although asthma was first described in the first century AD by the Greeks (1) Europeans didn't come to the same conclusion until 1698. That was when a Dr. John
Floyer first described asthma as a condition separate from other forms of shortness of breath. He also described how asthma was affected by seasons, temperature and treatments. He based his
observations mainly by experimenting on himself, an asthma sufferer.(2,3) Some 15 years later Bernardino Ramazzini described occupational asthma. (4 )During this time there was no major advancement in treatments were similar to what the Romans prescribed many centuries before including bleeding, and various herbal remedies. (5,6 )In 1786 William Withering wrote that "coffee made very strong" as a reliever of asthma symptoms, but it wasn't until the 1930's that xanthines would become
widespread in the treatment of asthma.(7 )
In the 19th century two instruments were invented which aided the understanding of the disease. The stethoscope was invented in 1819 and the spirometer developed some 25 years later. (8 )(9)One of the more effective treatments for asthma during this era was in prevention. Asthma patients during the 1800's to early 1900's were often directed to
health spas. Often located in areas high altitudes with dry climates, these spas could provide relief for patients. Sometimes patients would relocate to these areas if their asthma was severe enough. (1011) By today's standards treating asthma was a crude affair. For example the first version of the Merk Manual and other publications at that time
advocated smoking tobacco especially asthma cigarettes to treat asthma. (12,13)
The arrival of a new century brought about rapid developments in asthma treatments from the industrial revolution and the scientific method.
Epinephrine discovered around 1897 by John Jacob Abel. It was soon to be isolated and marketed as a cure by Jokichi Takamine. (14,15,16,17) By 1910 physicians prescribed adrenaline by injection. It was then developed into an inhaled form. In 1920 ephedrine was isolated from the herb ma
huang. (18) Interestingly enough this is the same herb used by Chinese for the treatment of asthma since at least the first century AD. (1,14) In 1938 a bulb squeezed nebulizer was popularized. (19, 20) The 1940's saw the development of isoprenaline. (21) It was synthesized as an alternative to epinephrine and its problematic side-effects. (22) Developed in the mid 1960's Salmeterol was first marketed in
1969. This came about due to a large number of deaths from isoprenaline inhalers that were being used in Britain at the time. (22) In the middle and late 1960's Scientists first
developed Intal from a Middle Eastern herbal remedy khellin. (23) In the 1990's leukotriene receptor antagonist were developed. (24)
Although the
20th century saw the development of many new drug therapies for those suffering from asthma. The treatment of asthmatics has at its core not changed in over 100 years. (14)
Basically it has been to:
- Decrease airway spasms
- Control spasms
- Remove the cause of the spasms
With all of the new respiratory drugs developed over the past 100 years anyone would think that it would have a positive effect on asthma's mortality rates and trends during the first half of the 20th
century would seem to bear this out. Deaths from asthma declined steadily for those over 34. From 1950 to about the mid 1960's deaths from asthma leveled at about 6000 per year for all ages.
(25,26 ) During the second half of the 1900s treatments for asthmatics have not proven to be successful in reducing asthma mortality or morbidity. This is
especially true during the last 30 years. From 1970 to 1997 asthma cases increased dramatically especially for children under the age of 18.(27,28,29,30)
As a response to this rise in incidences of asthma healthcare experts began to take a new look at this debilitating disease. In 1991 a group of distinguished medical professionals under the National
Heart, Lung and Blood Institute created the Expert Panel Report (EPR) 'Guidelines for the Diagnosis and Management of Asthma.' This report and two follow ups attempted to shape thought on asthma and
act as a guide for treatment. An estimated several hundred thousand copies of the first report were sent to health care providers around the country through the strong efforts of pharmaceutical companies
and professional organizations.
(31) Similar guidelines were implemented in Canada (1989)(32), Briton (1990) (33)and elsewhere.(34)
A Definition
A lasting definition of asthma has proven hard to pin down. In 1968 Andor Szventmany theorized that blockage of the Beta-2 receptors in airway smooth muscle cells caused asthma. His theory
dominated thinking toward the disease for many years. As late as 1982 an article copyrighted in 'Chest' describes asthma as 'variable and often sudden changes in airway smooth muscle tone.'
The EPR reports attempted to make major changes in the way that health care providers treat the disease. In it asthma was emphasized to be a chronic disease and the inflammatory component of it
received greater importance. Doctors were encouraged to use inhaled corticosteroids more in the treatment of persistent asthma. Asthmatics were given various treatments in a step-like approach. As flair-
ups occurred, treatment responce would increment by another step and as their symptoms came under control the treatment regiment would decrease to a lower step. Patients should monitor their condition
on a regular basis with peak flow meters. Asthma education was stressed.
(35)Results of this review can be summarized by looking at the most recent EPR's working definition:
'Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role: in particular, mast cells, eosinophils, T lymphocytes, macrophages,
neutrophils, and epithelial cells. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early
morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. The inflammation also causes an associated
increase in the existing bronchial hyperresponsiveness to a variety of stimuli. Reversibility of airflow limitation may be incomplete in some patients with asthma' (35)
Next: Read about the classifications of asthma and current treatment of the disease.
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Ruth Ann Jajosky, NIOSH
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