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Asthma

Asthmas

Asthma is a chronic inflammatory disease of the airways characterized by airway hyperresponsiveness and reversible airflow obstruction. It is caused by a combination of incompletely understood environmental and genetic interactions. Common symptoms include wheezing, coughing and dyspnea, which may vary from mild and almost undetectable to severe and unremitting. Symptoms can be prevented by avoiding triggers.


Presentation

Most of the symptoms of asthma involve the respiratory system and symptoms depend mainly on the severity of the condition. Some of the symptoms of asthma are:

Cough: The cough from asthma is so distressing that one find it difficult to sleep. It usually worsens late at night and early in the morning.

Wheezing: Wheezing manifests itself as squeaky or a whistling sound while breathing.

Chest tightness: The patient feels as if something is sitting on the chest and squeezing.

Shortness of breath: Most people find it very difficult to breathe. They feel as if they cannot breathe out.

Symptoms may vary depending on the severity of the condition and if left untreated can even turn fatal. Treatment given at the first onset of symptoms can leave the patient symptomless during the day and night.

Complications

Though not life threatening, asthmatic attacks can affect the regular activities in school and at work and may require frequent hospitalizations. Moreover, it can result in permanent narrowing of the airway. Using long term medications have their own side effects too [10]. Normal asthmatic attacks if not taken proper care can turn out to be life threatening condition called the status asthmaticus that may require hospitalization.

Hypoxemia
  • Although the wheezing symptoms disappeared after systemic corticosteroid therapy, the exertional dyspnea and hypoxemia did not improve.[ncbi.nlm.nih.gov]
  • Correction of the hypoxemia is one of the first priorities in setting the ventilator [ 64 ]. In non-complicated status asthmaticus, low V/Q ratio is the predominant mechanism and true shunt does not contribute significantly to the hypoxemia.[ncbi.nlm.nih.gov]
  • People who have COPD and continue to smoke, have a rapid decline in FEV1, who develop severe hypoxemia, develop right-sided heart failure and/or have poor ability to do daily functions usually have a poor prognosis.[medicinenet.com]
  • Pulse oximetry measurement is desirable in all patients with acute asthma to exclude hypoxemia.[emedicine.medscape.com]
Congestive Heart Failure
  • Then, there are other medical conditions such as chronic obstructive pulmonary disease, congestive heart failure and heart disease that can coexist with asthma and complicate diagnosis and treatment.[khn.org]
  • heart failure, cerebrovascular disease and COPD.[dx.doi.org]
  • heart failure, nonhypertensive 350,100 2 190,500 1 Cardiac dysrhythmias 278,600 5 Fracture of neck of femur (hip) 105,600 5 a Principal conditions are based on the first-listed diagnosis on the hospital discharge record and are classified using AHRQ's[hcup-us.ahrq.gov]
Noncompliance
  • A meta-analysis by DiMatteo et al [ 50 ] revealed that patients with a chronic disease and depression were three times more likely to be noncompliant with medical treatment than non-depressed patients.[doi.org]
  • In general, given patient preference for PO agents, IM agents should be reserved for known noncompliant patients.[doi.org]
  • A number of studies conducted on SCIT showed that the major cause of noncompliance was the inconvenience, related to injections and particularly to their frequency, and the cost of the treatment [ 30 ].[dx.doi.org]
Recurrent Bronchitis
  • Other nonspecific symptoms in infants or young children may be a history of recurrent bronchitis, bronchiolitis, or pneumonia; a persistent cough with colds; and/or recurrent croup or chest rattling.[emedicine.medscape.com]
  • Signs and symptoms Signs and symptoms of asthma include the following: Wheezing Coughing Shortness of breath Chest tightness/pain Other nonspecific symptoms in infants or young children may be a history of recurrent bronchitis, bronchiolitis, or pneumonia[emedicine.medscape.com]
Nocturnal Awakening
  • However, these differences were also associated with superiority with regard to some relevant clinical outcomes (e.g., number of exacerbations or nocturnal awakenings), a finding that suggests that they are clinically relevant.[dx.doi.org]
  • Only one comparison reported data on change in nocturnal awakening ( Analysis 2.11 ) and quality of life ( Analysis 2.12 ), preventing aggregation.[doi.org]
Cough
  • Symptoms include wheezing, coughing, tightness in the chest, shortness of breath, and rapid breathing. An attack may be brought on by pet hair, dust, smoke, pollen, mold, exercise, cold air, or stress.[icd9data.com]
  • Despite the patient presenting asthma characteristics (expiratory wheezing, dry cough, partial reversibility at post bronchodilator test) and asthma medication alleviating simtomathology, biological markers (eosenophil granulocytes in sputum, serum IgE[ncbi.nlm.nih.gov]
  • Gastro-oesophageal reflux can cause nocturnal cough and a postnasal drip may cause more coughing when lying down. Vocal cord dysfunction mimics steroid refractory asthma [ 9 ] .[patient.info]
  • A 72-year-old woman, known asthmatic, presented with chronic symptoms of hoarseness, dysphagia, chest heaviness, easy fatigability, cough, epigastric pain, feeling of abdominal fullness and choking with food intake and at a supine position.[ncbi.nlm.nih.gov]
Pneumonia
  • Pneumoniae infection. The authors also propose a study with the use of 2 antibiotics active against C. pneumoniae.[dx.doi.org]
  • Figures and Tables - Analysis 4.1 Comparison 4 Pneumonia, Outcome 1 Pneumonia.[doi.org]
  • Get vaccinated for influenza and pneumonia. Staying current with vaccinations can prevent flu and pneumonia from triggering asthma flare-ups. Identify and avoid asthma triggers.[mayoclinic.org]
  • […] controlled asthma can cause problems such as: feeling tired all the time underperformance at or absence from work or school stress, anxiety or depression disruption of your work and leisure because of unplanned visits to your GP or hospital lung infections (pneumonia[nhs.uk]
  • Complications There are several conditions that can complicate asthma; they include 1,6,16 : atelectasis pneumonia mucoid impaction of the airways pneumothorax pneumomediastinum and related subcutaneous emphysema eosinophilic lung disease allergic bronchopulmonary[radiopaedia.org]
Dyspnea
  • It is characterized by spasmodic contraction of airway smooth muscle, wheezing, and dyspnea (dyspnea, paroxysmal). Asthma is a chronic disease that affects your airways. Your airways are tubes that carry air in and out of your lungs.[icd9data.com]
  • Abstract A 62-year-old man with asthma presented with a 1-month history of wheezing and exertional dyspnea. Although the wheezing symptoms disappeared after systemic corticosteroid therapy, the exertional dyspnea and hypoxemia did not improve.[ncbi.nlm.nih.gov]
  • She had used albuterol spray ten-times before admission due to accentuated dyspnea. Initial ECG revealed ST-segment elevation in leads V1-V6, I and aVL.[ncbi.nlm.nih.gov]
  • He was admitted to the hospital due to persistent wheezing and progressive dyspnea. Hyperinflation in the bilateral lungs was detected on chest x-ray, but without other significant findings. Chest computed tomography revealed a mass at the carina.[ncbi.nlm.nih.gov]
  • Both asthma and takotsubo cardiomyopathy share the same clinical presentation with dyspnea and chest tightness.[ncbi.nlm.nih.gov]
Persistent Cough
  • The complications of asthma can be severe, and may include: Death Decreased ability to exercise and take part in other activities Lack of sleep due to nighttime symptoms Permanent changes in the function of the lungs Persistent cough Trouble breathing[nlm.nih.gov]
  • It may also cause severe infections and a persistent cough. Other congenital problems may present from birth or early in infancy - eg, laryngeal or tracheal structural abnormalities, congenital heart disease .[patient.info]
Respiratory Distress
  • Neurologists encounter a diagnostic challenge if patients without a history of bronchial asthma develop neurologic features mimicking HS following acute respiratory distress.[ncbi.nlm.nih.gov]
  • Toshi complained of difficulty breathing, in the absence of wheezing or respiratory distress; peak flow recordings in the office were normal.[ncbi.nlm.nih.gov]
  • Founded in 1905 to combat TB, the ATS has grown to tackle asthma, COPD, lung cancer, sepsis, acute respiratory distress, and sleep apnea, among other diseases.[thoracic.org]
Mouth Breathing
  • breathing; and 5) increased need for conditioning the inspired air.[doi.org]
  • In allergic rhinitis, the impaired filtering and air-conditioning function of the nose, leading to mouth breathing, can result in increased exposure of the lower airways to allergens and other asthma triggers.[dx.doi.org]
Heart Disease
  • ‘It also focuses on major health issues like heart disease, asthma and diabetes.’ ‘Vaccinating children with asthma against influenza has never really caught on.’ ‘Members suffer from illnesses such as cancer, heart disease, diabetes and asthma.’[en.oxforddictionaries.com]
  • disease -- Essential hypertension -- Peripheral vascular disorders -- Thrombosis -- Ischemic heart disease : anginal syndromes -- Myocardial infarction -- Heart failure -- Cardiac arrhythmias -- Hypertensive crises -- Shock -- Sect. 4 : Pulmonary disorders[worldcat.org]
  • disease. — Fiza Pirani, ajc , "5 things moms can do to reduce child obesity risk, according to a new study," 11 July 2018 Newsletter Sign-up The company has said a major focus will be on better managing five chronic conditions: diabetes, cardiovascular[merriam-webster.com]
  • These are two keys to good asthma control and can also reduce your risk of heart disease. Getting out in the open air and knowing that you can run despite your asthma also feels good.[verywell.com]
  • In a report by Adams et al. , patients with asthma had an increased prevalence of diabetes, arthritis, heart disease, stroke, cancer and osteoporosis .[dx.doi.org]
Chest Pain
  • Abstract Precordial catch syndrome is a benign cause of chest pain in children and adolescents that remains underrecognized. Because of distinctive symptoms, precordial catch syndrome is not necessarily a diagnosis of exclusion.[ncbi.nlm.nih.gov]
  • A 72-year-old woman with asthma attack and retrosternal chest pain was presented to our emergency unit. She had used albuterol spray ten-times before admission due to accentuated dyspnea.[ncbi.nlm.nih.gov]
  • Other presenting features were chest pain, dyspnoea, cough, and particularly acute swelling of the face, neck, and upper chest. Subcutaneous emphysema was present in most patients.[ncbi.nlm.nih.gov]
  • She denied any chest pain, cough, fever, orthopnea, or leg swelling. She was afebrile and normotensive, and her physical examination was unremarkable.[ncbi.nlm.nih.gov]
  • pain Tightness in the chest The health care provider will use a stethoscope to listen to your lungs.[nlm.nih.gov]
Tachycardia
  • The tachycardia, hypertension, and neurological symptoms improved.[ncbi.nlm.nih.gov]
  • Nebulised β 2 -agonists should continue until a significant clinical response is achieved or serious side effects appear (severe tachycardia, or arrhythmias).[ncbi.nlm.nih.gov]
  • However, the wide confidence interval (including the upper limit) for some adverse events was high for tachycardia, palpitations, tremor and death, indicating uncertainty.[doi.org]
  • This may be artificially elevated by excessive use of beta 2 agonists but, nevertheless, tachycardia is a significant feature.[patient.info]
Cyanosis
  • Rescue inhalers can help you: otc inhalers Seek medical help immediately for: Fast breathing with chest retractions (skin sucks in between or around the chest plate and/or rib bones when inhaling) Cyanosis (very pale or blue coloring in the face, lips[aafa.org]
  • Extrathoracic respiratory signs should also be systematically looked for, including cyanosis, finger deformation, pulsus paradoxus, and pursed lips breathing.[erj.ersjournals.com]
  • […] pulse, and cyanosis.[medicinenet.com]
Pulsus Paradoxus
  • Severe airflow obstruction may be predicted by accessory muscle use, pulsus paradoxus, refusal to recline below 30 , a pulse 120 beats/min, and decreased breath sounds. Physicians' subjective assessments of airway obstruction are often inaccurate.[doi.org]
  • Extrathoracic respiratory signs should also be systematically looked for, including cyanosis, finger deformation, pulsus paradoxus, and pursed lips breathing.[erj.ersjournals.com]
  • Loud expiratory wheezing can be heard, and pulsus paradoxus may be present (10-20 mm Hg). Oxyhemoglobin saturation with room air is 91-95%.[emedicine.medscape.com]
  • paradoxus 25 mmHg Absence (muscle fatigue) Use of accessory muscles Evident Abdominal paradox Wheeze Present – loud 'Silent chest' Functional assessment PEF PaO 2 PaCO 2 42 mmHg SaO 2 Pulsus paradoxus can be a valuable sign of asthma severity but its[ncbi.nlm.nih.gov]
Anxiety Disorder
  • disorders -- Sleep disorders -- Schizophrenia -- Mood disorders I : major depressive disorders -- Mood disorders II : bipolar disorder -- Attention deficit hyperactivity disorder in children, adolescents, and adults -- Eating disorders -- Sect. 17 :[worldcat.org]
  • Depression and anxiety disorders are common in severe asthma and may be either a consequence of, or a contributor to, this condition 63 .[doi.org]
  • Adolescents with asthma in particular are at a greater risk of major depression, panic attacks, and anxiety disorders, which have been associated with an increased burden of asthma symptoms and inability to cope with the disease ( Richardson 2006 ).[doi.org]
  • disorders) • Chronic/recurrent respiratory infections • COPD • Hyperventilation syndrome • Glottic (vocal cord) dysfunction • Hormonal disturbances • Obesity • Smoking (tobacco addiction) Possibly increased † • Hypertension, diabetes, ischemic heart[dx.doi.org]
Insomnia
  • There were no differences in the frequency of specific adverse events including nausea and vomiting, pain, swelling, redness, insomnia, or personality changes.[ncbi.nlm.nih.gov]
  • The side effects of caffeine are similar to those of theophylline (tachycardia, palpitation, nausea and other gastrointestinal disturbances, headache, central nervous system stimulation, insomnia).[doi.org]
  • Musculoskeletal conditions, insomnia, stomach and duodenal ulcers, migraine, sinusitis, depression, cancer and atherosclerosis were significantly more prevalent when patients had a diagnosis of asthma and/or COPD compared with controls.[dx.doi.org]
Agitation
  • These properties render it particularly promising for the management of severe agitation in children admitted to the ED with acute asthma exacerbation. Copyright 2016 American College of Emergency Physicians. Published by Elsevier Inc.[ncbi.nlm.nih.gov]
  • Severe episodes In a severe episode, patients are breathless during rest, are not interested in eating, sit upright, talk in words rather than sentences, and are usually agitated.[emedicine.medscape.com]
  • Clinical and laboratory assessment Patients with acute, severe asthma appear seriously dyspneic at rest, are unable to talk with sentences or phrases, are agitated and sit upright (Table 2 ) [ 1 ].[ncbi.nlm.nih.gov]
  • After ingestion of a 'high' dose of caffeine two patients reported mild tremor ( Kivity 1990 ), three patients reported nervousness and gastrointestinal upset ( Gong 1986 ), and one patient withdrew from the study because of nervousness and agitation[doi.org]
Somnolence
  • With advanced hypercarbia, bradypnea, somnolence, and profuse diaphoresis may be present; almost no breath sounds may be heard; and the patient is willing to lie recumbent.[emedicine.medscape.com]
Dizziness
  • There were no reports of dizziness, fatigue, or any other adverse symptoms. Devi 1997 reported the following adverse effects in the treatment group: epigastric warmth (12.5%), pain (16.6%), and tingling and numbness (12.5%) at the site of infusion.[doi.org]
Grunting
  • […] child exhales • Shortness of breath or rapid breathing, which may be associated with exercise • Chest tightness (a young child may say that his chest “hurts” or “feels funny”) • Fatigue (your child may slow down or stop playing) • Problems feeding or grunting[aaaai.org]

Workup

The diagnosis of asthma is usually done by assessing the patient’s condition, by doing a complete physical examination, undertaking a thorough medical history and by doing lung function tests.

Obstruction of the airflow is assessed and proper examination is done, if the obstruction is at least partially reversible [1].

Wheezing is assessed using a stethoscope and the obstruction is considered reversible if the wheeze disappears with treatment or if the triggering factor is resolved. Various physiological tests are done to assess lung function. Some of them are:

  • Spirometry
  • Peak flow meter
  • Bronchial provocation

Apart, from these various other tests are done to exclude other possible diseases. Some of such tests are, X-ray of the chest and sinuses, testing for allergies and evaluation for gastroesophageal reflux diseases [3]. These can act as triggering factors and can worsen the asthmatic condition and hence assessment of possibilities for such worsening conditions is absolutely crucial.

Atelectasis
  • Complications There are several conditions that can complicate asthma; they include 1,6,16 : atelectasis pneumonia mucoid impaction of the airways pneumothorax pneumomediastinum and related subcutaneous emphysema eosinophilic lung disease allergic bronchopulmonary[radiopaedia.org]
  • Mucus plugging and atelectasis are not rare and usually respond to effective treatment.[ncbi.nlm.nih.gov]
  • The consequent alveolar recruitment increases functional residual capacity and counteracts the development of atelectasis ( Pavone 2013 ).[doi.org]
Right Axis Deviation
  • Electrocardiographic signs of right heart strain such as right axis deviation, clockwise rotation, and evidence of right ventricular hypertrophy may be observed in acute, severe asthma and usually resolve within hours of effective treatment [ 30 ].[ncbi.nlm.nih.gov]
Hypercapnia
  • Hypercapnia is generally well tolerated as long as PaCO 2 does not exceed 90 mmHg and acute variations in PaCO 2 are avoided.[ncbi.nlm.nih.gov]
Reversible Airway Obstruction
  • Asthma is a relatively common condition that is characterized by at least partially reversible inflammation of the airways and reversible airway obstruction due to airway hyperreactivity. It can be acute, subacute or chronic.[radiopaedia.org]
  • The patient's FEV 1 increases to almost 700 ml with inhaled albuterol, indicating that she has substantial reversible airway obstruction.[doi.org]
  • Participant characteristics Asthma was defined as reversible airways obstruction.[doi.org]
  • Asthma presents as recurrent episodes or persistent symptoms of reversible airway obstruction. It is a complex syndrome that involves bronchospasm, inflammation, secretions, and airway hyperresponsiveness ( Busse 2006 ).[doi.org]
  • Comparison of the cardiopulmonary effects of subcutaneously administered epinephrine and terbutaline in patients with reversible airway obstruction. Chest. 67 :279–286. [ PubMed ] [ Google Scholar ] Corseen G, Guitierez J, Reves JG, Huber FC.[ncbi.nlm.nih.gov]

Treatment

Treatment involves keeping the symptoms under control by using proper medications. The breathing pattern should be tracked often to assess the efficacy of the medication. In case of occasional flare-ups, inhalers such as albuterol are used for symptomatic relief. The choice of various medications used in the treatment of asthma are based on the patient’s age, symptoms, triggers and effectiveness [6]. Medications for asthma are of three categories.

Preventive, Long term medications

They reduce the inflammation of the airways leading to symptoms. Some of such medications are:

  • Inhaled corticosteroids- E.g. Fluticasone, budesonide
  • Leukotriene modifiers – e.g. Motelukast, zafirlukast
  • Long acting beta agonist – e.g. Salmeterol, Formoterol
  • Combination inhalers- e.g. Fluticasone- salmeterol, budesonide-Formoterol
  • Theophylline

Quick relief inhalers 

They open up the swollen airway and hence ease breathing. Some of such medications are:

  • Short acting beta agonists
  • Ipratropium
  • Oral and intravenous corticosteroids

Allergy medications such as antihistamines and decongestants if necessary [9].

Prognosis

Asthma is a chronic disease and prognosis usually depends on the severity of the disease. In some cases the disease can go into longer periods of remission. Generally in mild to moderate cases, the symptoms can improve over time and in some adults, they can even be disease free. Even when it comes to some severe cases, adults may find good improvement depending on the timeliness, the effectiveness of the treatment and the degree of lung obstruction.

Only in about 10% of the cases the condition is very severe and persistent and not responsive to treatment [7]. There is an irreversible decline in lung function in such patients and there are also changes in the walls of the airways which are progressive.

Smoking exacerbates the condition and declination in lung function is much faster in people with asthma than normal individuals. Death as a result of asthmatic attacks is relatively rare and can be prevented by proper medications. Though this disease condition is not that debilitating, it can turn out to be a hindrance to day-to-day activities and work if not properly controlled.

Etiology

The etiology for the occurrence of asthma has not yet been completely established. The link between the genetic and the environmental factors in the occurrence of asthma is still a subject of debate and studies are being carried on to establish the relationship of allergy to asthma. Exposure to infections and endotoxins in infancy or early childhood may act as risk factors depending on the timing of exposure.

Prenatal exposure to maternal smoking has been strongly associated with the incidence of asthma. Moreover, stress, diet, nutrition, mode of delivery and use of antibiotics are also associated with the occurrence of asthma. In later stages of life, exposure to allergens, gender, sex, family size and structure, occupational exposure to allergens are all considered to be predisposing factors to asthma.

Epidemiology

Most of the cross-sectional studies that are population based are dependent mostly on recognizing the symptoms. There is a wide variation on documentation of prevalence of asthma.

Documented evidence suggests low prevalence rate of asthma in Asian countries like China and India. There is only a 2-4% of prevalence in these countries when compared to developed countries such as the United Kingdom, Canada, Australia and New Zealand, the prevalence of this disease is documented to be 15-20%.

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of asthma is a complex phenomena and the attack may be spontaneous or it may be triggered. Either way, the attack progresses as follows.

  • Initially there is an activation of the inflammatory cells resulting in the release of inflammatory mediators from the epithelial cells, macrophages and the bronchial mast cells.
  • There is an increased responsiveness in the airway smooth muscles as a result of alterations in the neural control of the muscle tone and disturbance in the epithelial integrity.
  • This results in clinical manifestations such as dyspnea and wheezing.

The various factors that contribute for the clinical manifestations are, bronchospasms, edema and inflammation of the mucosa, thick mucus that contributes to airway obstruction, hyperinflation, impaired gas exchange and increased work on breathing [4]. If the initial attack is not taken good care the condition may exacerbate into a more acute and severe form called the status asthmaticus which may require hospitalization.

Prevention

Asthmatic attacks can be prevented by reducing the exposure to the triggers. For this the first step is to identify the triggers. Some of such triggers include air pollution, allergies, sinusitis, cold air, flu virus, smoke and fragrances. Maintaining a diary of conditions that can trigger an asthmatic attack can be helpful in managing the symptoms.

An IgE testing can also be done to identify substances that can sensitize and induce an asthmatic attack. For some people exercise may induce an asthmatic attack and such people should consult their physician before undergoing an exercise regimen [2].

Smoking can worsen the asthmatic attack and hence smoking in any form such as smoking tobacco, fireworks, incense and candles should be avoided.

If cold and flu can induce an asthmatic attack, avoiding situations that can cause a cold or flu such as a crowded place or exposure to cold air must be avoided to reduce the incidence of asthmatic attacks [5].

Summary

Asthma is a chronic inflammatory disease found worldwide. This disease affects the airways and is characterized by a reversible bronchospasm and airflow obstruction. It has been estimated that 24 million people are affected by this disease and being a common childhood disease, more than 7 million children are found to be victims of this disease.

The occurrence of asthma has increased over the recent years especially after the 1970s. Asthma has also been found to be a cause for around 250,000 deaths. The etiology for the occurrence of asthma is a bit complex and involves a combination of genetic and environmental factors.

Patient Information

Asthma is a chronic illness that can be managed successfully with proper medications. Though an asthmatic attack turning to become fatal is rare, it can be debilitating at times affecting day-to-day life. Hence it is necessary to keep note on the triggering factors by maintaining a diary and avoiding them [8]. Usage of proper medications prescribed by the physician are mandatory to avoid future asthmatic attacks and avoiding flare ups.

References

Article

1. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. Nov 2007;120(5 Suppl):S94-138.

2. National Heart, Lung, and Blood Institute. Global Strategy for Asthma Management and Prevention. NIH Publication; 2008.

3. Harding SM, Guzzo MR, Richter JE. The prevalence of gastroesophageal reflux in asthma patients without reflux symptoms. Am J Respir Crit Care Med. Jul 2000;162(1):34-9.

4. Randolph C. Exercise-induced asthma: update on pathophysiology, clinical diagnosis, and treatment. Curr Probl Pediatr. Feb 1997;27(2):53-77

5. Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M, et al. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J. Jan 2008;31(1):143-78.

6. Management of Asthma Working Group. VA/DoD clinical practice guideline for management of asthma in children and adults. Washington (DC): Department of Veteran Affairs, Department of Defense; 2009

7. Moorman JE, Rudd RA, Johnson CA, King M, Minor P, Bailey C, et al. National surveillance for asthma--United States, 1980-2004. MMWR Surveill Summ. Oct 19 2007;56(8):1-54.

8. Kotses H, Bernstein IL, Bernstein DI, Reynolds RV, Korbee L, Wigal JK, et al. A self-management program for adult asthma. Part I: Development and evaluation. J Allergy Clin Immunol. Feb 1995;95(2):529-40.

9. From the Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2010. Available at http://www.ginasthma.org.

10. Sears MR. Consequences of long-term inflammation. The natural history of asthma. Clin Chest Med. Jun 2000;21(2):315-29.

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Last updated: 2017-08-09 18:21