Asthma bronchiale

Bronchial asthma is the most common chronic respiratory disease worldwide. In Germany, more than 5% of the population is affected. There are different manifestations of asthma, which is associated with airway inflammation and bronchial hyperresponsiveness.

In the classical subdivision, one speaks of allergic (extrinsic) and non-allergic (intrinsic) asthma. This distinction is not always easy and there is overlap between the two forms.

Today, the distinction according to the underlying immune response has become accepted:

  • Type 2 High Asthma with allergen-specific immune response (Type 2).
  • Type-2-low asthma or non-T2 asthma without such type-2 inflammation.

Independently of the above system, other forms are named. Such as effort asthma or eosinophilic asthma.

Asthma in sports - Exercise asthma

How is bronchial asthma diagnosed?

Symptoms can be varied and are usually completely absent during the symptom-free interval. During an asthma attack, there is typically a sudden onset of coughing, shortness of breath and shortness of breath.During exhalation, a whistling sound (wheezing) can be heard.

If typical asthma symptoms are present and there is a narrowing of the airways on pulmonary function testing, asthma is confirmed when complete normalization occurs with inhalation of an asthma spray.

In most cases, the diagnosis and differentiation from other diseases is complicated by the fact that there are no symptoms or no narrowing of the airways during the medical examination.

In this situation, after irritation of the bronchial tubes by an exercise test or by inhalation of an irritant (provocation test), hypersensitivity of the bronchial tubes is typically detected. Measurement of the concentration of nitric oxide (NO) in exhaled air (FeNO measurement) also provides evidence of bronchial inflammation. The diagnosis of asthma can only be made on the basis of the overall findings and the response to therapy.

Once the diagnosis has been made, it is always necessary to check whether the underlying allergy is present and, if so, which allergy. Specific immunotherapy (SIT, formerly also called desensitization) is the only way to cure allergic asthma (more about allergies).

Inhaled medications for bronchial asthma

The target organ of asthma therapy is easily accessible with inhaled medications. The active substances applied can then exert their effect in the lower respiratory tract in a targeted manner and in higher concentration, and thus have fewer side effects in the body. The commonly used medications are:

  • Inhaled steroids (ICS): These drugs counteract the inflammation of the bronchial mucosa. This also normalizes their hypersensitivity and prevents constriction.
  • Short-acting betamimetics (SABA): The rapid onset of action via stimulation of the beta receptors in the brochial mucosa results in rapid dilation of the bronchi, although this only lasts a few hours. These drugs are used in particular in emergency treatment.
  • Long-acting betamimetics (LABA): The stimulation of the beta receptors and thus the dilation of the bronchi lasts for 12 to 24 hours. This makes these drugs useful, especially in long-term therapy.
  • Long-acting anticholinergics (LAMAs): This causes bronchial dilation by inhibiting the muscarinic receptor of the bronchial mucosa.

Asthma control

Medical checks are usually required every 3 months. The main aim here is to determine how well the asthma is controlled and how the risk of an asthma attack in the next few weeks is assessed.

The following criteria are relevant here in adults:

  • Asthma symptoms more often than 2 times per week during the day
  • Night awakening due to asthma
  • On demand medication more often than 2 times per week
  • Activity limitation due to asthma

Well controlled: no criterion met
Partially controlled: 1-2 criteria met
Uncontrolled: 3-4 criteria met

Alternatively, you can use the “Asthma control test“. The German Respiratory League also recommends some apps for the smartphone (e.g. breazy).

The risk of future deterioration can be estimated from this information, the pulmonary function test and the previous course.

For self-monitoring, it is useful to measure the peak flow at home with a small meter.

If the peak flow repeatedly drops during the protocol, this is also a sign of inadequate control. In addition, the peak-flow value during an asthma attack gives an indication of the severity of the airway constriction.

By measuring FeNO (fractional exhaled nitric oxide), the extent of airway inflammation can also be measured. If the values are low, the cortisone dose can then be reduced if necessary.

Inhale correctly

Different inhalers are used so that the active ingredient can exert its effect in the deep airways. The application of the metered dose inhaler, which is usually used as an emergency spray, is shown in the video of the German Respiratory League: (link to Video)

You can find an overview of all common inhalation systems here: Atemwegsliga

Step-by-step therapy

The goal of therapy is well-controlled asthma with no or very few symptoms.

Demand therapy can be used in all therapy stages. Short-acting betamimetics (e.g., salbutamol) or combination preparations with an anti-inflammatory component (e.g., formoterol and budesonide) are suitable for this purpose.

If asthma cannot be controlled by these alone, maintenance therapy with daily inhalation is required.

Stage 2: Inhaled steroids (ICS) low dose.

Stage 3: Inhaled steroids (ICS) low dose and combined with a long-acting betamimetic (LABA).

Stage 4: Inhaled steroids (ICS) medium dose and combined with a long-acting betamimetic (LABA). Alternatively, the dosage of stage 3 can be left if a combination drug with ICS is used as an on-demand medication.

Stage 5: Inhaled steroids (ICS) in maximum dose combined with a long-acting betamimetic (LABA) and a long-acting anticholinergic (LAMA).

Severe asthma

If sufficient control is not achieved even under level 5, further improvement can usually be achieved by adding an antibody therapy. The therapy with cortisone as tablets, which was often used in the past, can thus usually be avoided as a permanent therapy. In acute asthma attacks, cortisone in tablet form is still justified.

In severe allergic asthma to a perennial allergen, an antibody against immunoglobulin E (omalizumab) can be used.

In “eosinophilic asthma” (eosinophilic white blood cells > 300/µl), an antibody against interleukin 5/interleukin 5 receptor (mepolizumab, reslizumab or benralizuma) is used.

Another option in severe eosinophilic or uncontrolled type 2 asthma is the interleukin 4 receptor antibody dupilumab.

Behavior in case of emergency

An asthma attack is a threatening event and quickly performed self-treatment is necessary to avert harm. If the best personal peak-flow value is known, this can be used to estimate the severity of the attack.

The drugs to be used can only be listed here in general terms. The specific preparations and dosages should be determined individually during the control examination.

If you are prepared, it is easier to remain calm during an asthma attack. Calm execution of the emergency plan leads more quickly to success.

Do not delay the emergency call by calling the doctor’s office. After the alarm has been raised via 112, in Wiesbaden help is usually on the scene within 10 minutes .

Please do not contact us until you have received emergency treatment.

Emergency treatment

Danger

The peak flow meter shows values below 50% of the personal best. You are so short of breath that you can hardly speak.

Assume a breath-easing posture and use the lip brake (Video).

Take 2-4 strokes of your emergency spray and your emergency cortisone tablet. If the condition does not improve quickly, call 112.

Caution

The peak flow meter shows values between 50% and 80% of the personal best. You can still speak normally but the bronchial muscles are cramped, causing shortness of breath and wheezing.

Assume a breath-easing posture and use the lip brake (Video).

Take 2-4 strokes of your emergency spray and observe the effect over the next 10 minutes. If there is no clear improvement after 10 minutes, take another 2-4 strokes of your emergency spray and your emergency cortisone tablet. If there is no clear improvement quickly now, call the emergency doctor via 112.