Asthma: Types, Causes, Symptoms, Diagnosis & Treatment 

Asthma is a disease that affects your lungs. It’s a chronic (ongoing) condition, meaning it doesn’t go away and needs ongoing medical management.

This condition can make breathing difficult and trigger coughing, a whistling sound (wheezing) when you breathe out and shortness of breath.

Asthma can’t be cured, but its symptoms can be controlled. Because asthma often changes over time, it’s important that you work with your doctor to track your signs and symptoms and adjust your treatment as needed.

Symptoms of asthma

The most common symptom of asthma is wheezing. This is a squealing or whistling sound that occurs when you breathe. Other asthma symptoms may include:

• tightness in the chest
• coughing, especially at night, when laughing, or during exercise
• shortness of breath
• difficulty talking
• anxiousness or panic
• fatigue
• chest pain
• rapid breathing
• trouble sleeping
• frequent infections

The type of asthma that you have can determine which symptoms you experience. Some people experience symptoms consistently throughout the day. Others may find that certain activities can make symptoms worse.

Not everyone with asthma will experience these particular symptoms. If you think the symptoms you’re experiencing could be a sign of a condition such as asthma, make an appointment to see your doctor.

Also, keep in mind that even if your asthma is well-managed, you may still occasionally experience a flare-up of symptoms. Flare-ups often improve with the use of quick-acting treatments, like an inhaler, but may require medical attention in severe cases. Signs of an asthma flare-up may include:

• wheezing
• coughing
• throat clearing
• difficulty sleeping
• fatigue
• chest pain or tightness

Note: If your symptoms worsen or don’t improve with the use of an inhaler, you should seek immediate medical treatment.

You should also seek treatment if you experience symptoms of an asthma emergency, including:

• severe breathing difficulty
• gasping for air
• confusion
• pale lips or fingernails
• dizziness
• difficulty walking or talking
• blue lips or fingernails

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Causes of asthma

It isn’t clear why some people get asthma and others don’t, but it’s probably due to a combination of environmental and inherited (genetic) factors.

Certain risk factors are thought to increase your chances of developing asthma. They include:

• Allergies: Having allergies can raise your risk of developing asthma.
• Genetics: If your family has a history of asthma or allergic diseases, you have a higher risk of developing the disease.
• Respiratory infections: Certain respiratory infections, such as respiratory syncytial virus (RSV), can damage young children’s developing lungs.
• Environmental factors: People can develop asthma after exposure to things that irritate the airways. These substances include allergens, toxins, fumes and second- or third-hand smoke. These can be especially harmful to infants and young children whose immune systems haven’t finished developing.
• Being a smoker.
• Having obesity or being overweight.

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What is asthma attack

When you breathe normally, muscles around your airways are relaxed, letting air move easily and quietly. During an asthma attack, three things can happen:

• Inflammation: The lining of your airways becomes swollen. Swollen airways don’t let as much air in or out of your lungs.
• Bronchospasm: The muscles around the airways constrict (tighten). When they tighten, it makes your airways narrow. Air cannot flow freely through constricted airways.
• Mucus production: During the attack, your body creates more mucus. This thick mucus clogs airways.

When your airways get tighter, you make a sound called wheezing when you breathe, a noise your airways make when you breathe out. You might also hear an asthma attack called an exacerbation or a flare-up. It’s the term for when your asthma isn’t controlled.

Types of asthma

Asthma is broken down into types based on the cause and the severity of symptoms. Healthcare providers identify asthma as:

• Intermittent: This type of asthma comes and goes so you can feel normal in between asthma flares.
• Persistent: Persistent asthma means you have symptoms much of the time. Symptoms can be mild, moderate or severe. Healthcare providers base asthma severity on how often you have symptoms. They also consider how well you can do things during an attack.
• Allergic: Some people’s allergies can cause an asthma attack. Allergens include things like molds, pollens and pet dander.
• Non-allergic: Outside factors can cause asthma to flare up. Exercise, stress, illness and weather may cause a flare.
• Adult-onset: This type of asthma starts after the age of 18.
• Pediatric asthma: Also called childhood asthma, this type of asthma often begins before the age of 5, and can occur in infants and toddlers. Children may outgrow asthma. You should make sure that you discuss it with your provider before you decide whether your child needs to have an inhaler available in case they have an asthma attack. Your child’s healthcare provider can help you understand the risks.
• Exercise-induced asthma: This type is triggered by exercise and is also called exercise-induced bronchospasm.
• Occupational asthma: This type of asthma happens primarily to people who work around irritating substances.
• Asthma-COPD overlap syndrome (ACOS): This type happens when you have both asthma and chronic obstructive pulmonary disease (COPD). Both diseases make it difficult to breathe.

Classification of asthma

According to National Asthma Education and Prevention Program (NAEPP) classification of asthma based on its severity before treatment.

Asthma is classified into four general categories:

• Intermittent. Most people have this type of asthma, which doesn’t interfere with daily activities. Symptoms are mild, lasting fewer than 2 days per week or 2 nights per month.
• Mild persistent. The symptoms occur more than twice a week but not daily and up to 4 nights per month.
• Moderate persistent. The symptoms occur daily and at least 1 night every week, but not nightly. They may limit some daily activities.
• Severe persistent. The symptoms occur several times every day and most nights. Daily activities are extremely limited.

Determining your asthma severity helps your doctor choose the best treatment. Asthma severity often changes over time, requiring treatment adjustments.

Triggers of asthma

You can have an asthma attack if you come in contact with substances that irritate you. Healthcare providers call these substances “triggers.” Knowing what triggers your asthma makes it easier to avoid asthma attacks.

For some people, a trigger can bring on an attack right away. For other people, or at other times, an attack may start hours or days later. Triggers can be different for each person. But some common triggers include:

• Air pollution: Many things outside can cause an asthma attack. Air pollution includes factory emissions, car exhaust, wildfire smoke and more.
• Dust mites: You can’t see these bugs, but they are in our homes. If you have a dust mite allergy, this can cause an asthma attack.
• Heavy exercise: For some people, exercising can cause an attack.
• Mold: Damp places can spawn mold, which can cause problems if you have asthma. You don’t even have to be allergic to mold to have an attack.
• Pests: Cockroaches, mice and other household pests can cause asthma attacks.
• Pets: Your pets can cause asthma attacks. If you’re allergic to pet dander (dried skin flakes), breathing in the dander can irritate your airways.
• Strong chemicals or smells. These things can trigger attacks in some people.
• Certain occupational exposures. You can be exposed to many things at your job, including cleaning products, dust from flour or wood, or other chemicals. These can all be triggers if you have asthma.
• Tobacco smoke: If you or someone in your home smokes, you have a higher risk of developing asthma. You should never smoke in enclosed places like the car or home, and the best solution is to quit smoking. Your provider can help.

Complications of asthma

Proper treatment makes a big difference in preventing both short-term and long-term complications caused by asthma. This complications can include:

• Sick days from work or school during asthma flare-ups
• Signs and symptoms that interfere with sleep, work and other activities
• A permanent narrowing of the tubes that carry air to and from your lungs (bronchial tubes), which affects how well you can breathe
• Side effects from long-term use of some medications used to stabilize severe asthma
• Emergency room visits and hospitalizations for severe asthma attacks

Prevention of asthma

Because researchers have yet to identify the exact cause of asthma, it’s challenging to know how to prevent the inflammatory condition.

However, more information is known about preventing asthma attacks. These strategies include:

• Taking preventive medication. Your doctor may prescribe medication for you to take on a daily basis. This medication may be used in addition to the one you use in case of an emergency.
• Avoiding triggers. Steer clear of chemicals, smells, or products that have caused breathing problems in the past.
• Reducing exposure to allergens. If you’ve identified allergens, such as dust or mold, that trigger an asthma attack, avoid them if possible.
• Getting allergy shots. Allergen immunotherapy is a type of treatment that may help alter your immune system. With routine shots, your body may become less sensitive to any triggers you encounter.

Your doctor can help you put an asthma action plan in place so that you know which treatments to use and when.

In addition to using maintenance medications, you can take steps each day to help make yourself healthier and reduce your risk for asthma attacks. These include:

• Quitting smoking, if you smoke. Irritants such as cigarette smoke can trigger asthma and increase your risk for COPD.
• Eating a healthier diet. Eating a healthy, balanced diet can help improve your overall health.
• Exercising regularly. Activity can trigger an asthma attack, but regular exercise may actually help reduce the risk of breathing problems. 
• Managing stress. Stress can be a trigger for asthma symptoms. Stress can also make stopping an asthma attack more difficult.
• Maintaining a moderate weight. Asthma tends to be worse in people with overweight and obesity. Losing weight is healthy for your heart, your joints, and your lungs.

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Diagnosis of asthma

Your doctor will perform a physical exam to rule out other possible conditions, such as a respiratory infection or chronic obstructive pulmonary disease (COPD). Your doctor will also ask you questions about your signs and symptoms and about any other health problems.

You may be given lung function tests to determine how much air moves in and out as you breathe. These tests may include:

• Spirometry. This test estimates the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath and how fast you can breathe out.
• Peak flow. A peak flow meter is a simple device that measures how hard you can breathe out. Lower than usual peak flow readings are a sign that your lungs may not be working as well and that your asthma may be getting worse. Your doctor will give you instructions on how to track and deal with low peak flow readings.

Lung function tests often are done before and after taking a medication to open your airways called a bronchodilator, such as albuterol. If your lung function improves with use of a bronchodilator, it’s likely you have asthma. Other tests to diagnose asthma include:

• Allergy testing. Allergy tests can be performed by a skin test or blood test. They tell you if you’re allergic to pets, dust, mold or pollen. If allergy triggers are identified, your doctor may recommend allergy shots.
• Methacholine challenge. Methacholine is a known asthma trigger. When inhaled, it will cause your airways to narrow slightly. If you react to the methacholine, you likely have asthma. This test may be used even if your initial lung function test is normal.
• Imaging tests. A chest X-ray can help identify any structural abnormalities or diseases (such as infection) that can cause or aggravate breathing problems.
• Nitric oxide test. This test measures the amount of the gas nitric oxide in your breath. When your airways are inflamed — a sign of asthma — you may have higher than normal nitric oxide levels. This test isn’t widely available.
• Provocative testing for exercise and cold-induced asthma. In these tests, your doctor measures your airway obstruction before and after you perform vigorous physical activity or take several breaths of cold air.
• Sputum eosinophils. This test looks for certain white blood cells (eosinophils) in the mixture of saliva and mucus (sputum) you discharge during coughing. Eosinophils are present when symptoms develop and become visible when stained with a rose-colored dye.

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Treatment of asthma

The goal of asthma treatment is to control symptoms, which means:

• Have no (or minimal) asthma symptoms.
• Can do the things you want to do at work and home.
• Sleep without asthma interrupting your rest.
• Rarely need to use your reliever medicine (rescue inhaler).

Your treatment plan may also involve learning your triggers, monitoring your symptoms carefully, and taking steps to avoid flare-ups.

Medications used for asthma

The right medications for you depend on a number of things like your age, symptoms, asthma triggers and what works best to keep your asthma under control.

Preventive, long-term control medications reduce the swelling (inflammation) in your airways that leads to symptoms. Quick-relief inhalers (bronchodilators) quickly open swollen airways that are limiting breathing. In some cases, allergy medications are necessary.

Long-term asthma control medications, generally taken daily, are the cornerstone of asthma treatment. These medications keep asthma under control on a day-to-day basis and make it less likely you’ll have an asthma attack. Types of long-term control medications include:

• Inhaled corticosteroids. These medications include fluticasone propionate (Flovent HFA, Flovent Diskus, Xhance), budesonide (Pulmicort Flexhaler, Pulmicort Respules, Rhinocort), ciclesonide (Alvesco), beclomethasone (Qvar Redihaler), mometasone (Asmanex HFA, Asmanex Twisthaler) and fluticasone furoate (Arnuity Ellipta).You may need to use these medications for several days to weeks before they reach their maximum benefit. Unlike oral corticosteroids, inhaled corticosteroids have a relatively low risk of serious side effects.
• Combination inhalers. These medications such as fluticasone-salmeterol (Advair HFA, Airduo Digihaler, others), budesonide-formoterol (Symbicort), formoterol-mometasone (Dulera) and fluticasone furoate-vilanterol (Breo Ellipta) contain a long-acting beta agonist along with a corticosteroid.
• Theophylline. Theophylline (Theo-24, Elixophyllin, Theochron) is a daily pill that helps keep the airways open by relaxing the muscles around the airways. It’s not used as often as other asthma medications and requires regular blood tests.
• Leukotriene modifiers. These oral medications including montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo) help relieve asthma symptoms.Montelukast has been linked to psychological reactions, such as agitation, aggression, hallucinations, depression and suicidal thinking. Seek medical advice right away if you experience any of these reactions.

Quick-relief (rescue) medications are used as needed for rapid, short-term symptom relief during an asthma attack. They may also be used before exercise if your doctor recommends it. Types of quick-relief medications include:

• Oral and intravenous corticosteroids. These medications which include prednisone (Prednisone Intensol, Rayos) and methylprednisolone (Medrol, Depo-Medrol, Solu-Medrol) relieve airway inflammation caused by severe asthma. They can cause serious side effects when used long term, so these drugs are used only on a short-term basis to treat severe asthma symptoms.
• Short-acting beta agonists. These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others) and levalbuterol (Xopenex, Xopenex HFA). Short-acting beta agonists can be taken using a portable, hand-held inhaler or a nebulizer, a machine that converts asthma medications to a fine mist. They’re inhaled through a face mask or mouthpiece.
• Anticholinergic agents. Like other bronchodilators, ipratropium (Atrovent HFA) and tiotropium (Spiriva, Spiriva Respimat) act quickly to immediately relax your airways, making it easier to breathe. They’re mostly used for emphysema and chronic bronchitis, but can be used to treat asthma.

If you have an asthma flare-up, a quick-relief inhaler can ease your symptoms right away. But you shouldn’t need to use your quick-relief inhaler very often if your long-term control medications are working properly.

Keep a record of how many puffs you use each week. If you need to use your quick-relief inhaler more often than your doctor recommends, see your doctor. You probably need to adjust your long-term control medication.

Allergy medications may help if your asthma is triggered or worsened by allergies. These include:

• Allergy shots (immunotherapy). Over time, allergy shots gradually reduce your immune system reaction to specific allergens. You generally receive shots once a week for a few months, then once a month for a period of three to five years.
• Biologics. These medications which include omalizumab (Xolair), mepolizumab (Nucala), dupilumab (Dupixent), reslizumab (Cinqair) and benralizumab (Fasenra) are specifically for people who have severe asthma.

Bronchial thermoplasty. This treatment is used for severe asthma that doesn’t improve with inhaled corticosteroids or other long-term asthma medications. It isn’t widely available nor right for everyone.

During bronchial thermoplasty, your doctor heats the insides of the airways in the lungs with an electrode. The heat reduces the smooth muscle inside the airways. This limits the ability of the airways to tighten, making breathing easier and possibly reducing asthma attacks. The therapy is generally done over three outpatient visits.

Your treatment should be flexible and based on changes in your symptoms. Your doctor should ask about your symptoms at each visit. Based on your signs and symptoms, your doctor can adjust your treatment accordingly. For example, if your asthma is well controlled, your doctor may prescribe less medication. If your asthma isn’t well controlled or is getting worse, your doctor may increase your medication and recommend more-frequent visits.

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