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Asthma

Brief Overview: Asthma is a chronic inflammatory disease of the airways characterized by reversible airflow obstruction and bronchial hyperresponsiveness. Patients experience episodic symptoms such as wheezing, shortness of breath, chest tightness, and cough, which may vary in frequency and severity over time.
Asthma management focuses on long-term control of airway inflammation, prevention of exacerbations, and prompt treatment of acute symptoms. With appropriate treatment and education, most patients can achieve good symptom control and maintain normal daily activities.

Prevalence: According to UpToDate, “the prevalence of asthma in adults age 65 years and older is estimated at 4 to 8 percent.”

Etiology: The exact etiology is unknown. Many factors have been linked to an increased risk for asthma, though.

Risk Factors:

  • Tobacco use
  • Family history of asthma
  • Atopy
  • Allergic rhinitis, eczema, food allergies
  • Occupational, residential, and ambient air exposures
  • Postmenopausal hormone replacement therapy
  • Obesity
  • Chronic stress

Commonly Associated Conditions:

  • Allergic rhinitis and chronic sinusitis
  • GERD
  • Obstructive sleep apnea
  • Anxiety and depression
  • Obesity
  • Vocal cord dysfunction (can mimic asthma)

Common Medications:

  • Relievers (rescue medications)
    • Inhaled short-acting beta2-agonists (SABAs) – albuterol, levalbuterol
    • Oral corticosteroids may be prescribed in some cases
    • Short-acting anticholinergics – ipratropium bromide
  • Controllers
    • Inhaled corticosteroids (ICS) – budesonide, fluticasone, beclomethasone, mometasone
    • Biologics - omalizumab, mepolizumab, benralizumab, dupilumab, tezepelumab
    • Leukotriene receptor antagonists – montelukast
    • Inhaled mast cell stabilizers – cromolyn
    • Inhaled long-acting beta-adrenergics (formoterol) with ICS. ICS/LABA combinations: budesonide–formoterol, fluticasone–salmeterol, fluticasone–vilanterol
    • Long-acting muscarinic antagonists (LAMAS) - anticholinergics – tiotropium
    • Allergy shots
    • Antihistamines – cetirizine, loratadine, fexofenadine

Common Labs, Imaging, and Tests:

  • Pulmonary function testing, including spirometry with bronchodilator reversibility and methacholine challenge testing
  • Chest x-ray
  • Skin or serologic allergy tests in select patients

Common Symptoms:

  • Wheezing, cough, chest tightness
  • Dyspnea
  • Symptoms triggered by exercise, allergens, cold air, or respiratory infections
  • Variable symptom-free intervals between flares

Common Treatments:

  • Medication (see above)
  • Asthma Action Plan
  • Allergen/trigger avoidance and mitigation
  • Smoking cessation
  • Vaccination as recommended by healthcare provider
  • Management of comorbid conditions (allergic rhinitis, GERD, obesity)
  • Asthma education including inhaler technique education and spacer use
  • Bronchial thermoplasty may be indicated for some

Physical Findings:

  • May be normal between episodes
  • Pale edematous nasal mucosa, nasal polyps
  • During symptoms/exacerbation: wheeze, prolonged expiratory phase, tachypnea, accessory muscle use
  • Severe signs: difficulty speaking full sentences, drowsiness/confusion, “silent chest,” cyanosis (emergency)

Potential Complications and Contraindications:

  • Potential complications:
    • Acute asthma exacerbations requiring urgent or emergency care
    • Decreased quality of life and activity limitation
    • Airway remodeling with chronic poor control
    • Medication side effects (oral thrush with ICS, tachycardia with SABAs)
  • Contraindications / cautions:
    • LABA therapy should not be used without ICS
    • Over-reliance on rescue inhalers indicates poor control
    • Sedatives and beta-blockers may worsen symptoms in some patients
    • According to UpToDate, “Theophyllineis not suggested for treatment of asthma in most older adults due to variable metabolism and multiple medication interactions.”

General Health and Lifestyle Guidance:

  • Encourage controller/maintenance adherence even when feeling well
  • Rinse mouth after ICS use; use spacer when indicated
  • Track symptoms + triggers; consider a peak flow diary if recommended by your healthcare provider
  • Reduce irritants: smoke/vape, strong fragrances, cleaning aerosols; manage indoor allergens
  • Exercise is encouraged (if approved by your healthcare provider) — use pre-exercise strategies if exercise-induced symptoms
  • Know red flags: increasing reliever/rescue inhaler use, nighttime symptoms, reduced activity tolerance
  • Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  

Suggested Questions to Ask Patients:

  1. What symptoms are you having (wheeze/SOB/cough/tightness), and how often (day vs night)?
  2. How often are you using your rescue inhaler per day/week?
  3. Any recent triggers: cold/flu, smoke exposure, new pets, cleaning chemicals, exercise, weather changes?
  4. Any recent ED/urgent care visits, oral steroid bursts, missed work/school?
  5. What inhalers do you have at home (names/colors), and how are you using them?
  6. Do you use a spacer? Can you walk me through your inhaler technique?
  7. Any comorbid symptoms: nasal allergies, reflux/heartburn, snoring/daytime sleepiness, anxiety?
  8. Safety check: Are you having trouble speaking, bluish lips, severe breathlessness, or no relief after rescue meds?
    1. If an emergency is present, call 911 for the patient per emergency protocols.

Suggested Talking Points:

  • Asthma is inflammation + tightening of the airways. Controllers prevent flare-ups; relievers treat breakthrough symptoms.
  • Needing your rescue inhaler more often is a sign you should ask your healthcare provider to consider adjusting the long-term plan.
  • Using an ICS-containing approach helps reduce the risk of severe attacks.
  • Technique matters—a small change in inhaler use can make a big difference.
  • If you have severe shortness of breath, trouble talking, bluish color, or symptoms not improving after rescue medication, that’s an emergency—seek care right away.
  • Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.