Brittle asthma explained

Prevention:Allergen avoidance and self-management approach

Brittle asthma is a type of asthma distinguishable from other forms by recurrent, severe attacks.[1] [2] [3] There are two subtypes divided by symptoms: Type 1 and Type 2,[4] depending on the stability of the patient's maximum speed of expiration, or peak expiratory flow rate (PEFR). Type 1 is characterized by a maintained wide PEF variability despite considerable medical therapy including a dose of inhaled steroids, and Type 2 is characterized by sudden acute attacks occurring in less than three hours without an obvious trigger on a background of well controlled asthma.[5]

Brittle asthma is one of the "unstable" subtypes of "difficult asthma", a term used to characterize the less than 5% of asthma cases that do not respond to maximal inhaled treatment, including high doses of corticosteroids combined with additional therapies such as long-acting beta-2 agonists.[6] [7]

Diagnosis

Types

The 2005 Oxford Textbook of Medicine distinguishes type 1 brittle asthma by "persistent daily chaotic variability in peak flow (usually greater than 40 per cent diurnal variation in PEFR more than 50 per cent of the time)", while type 2 is identified by "sporadic sudden falls in PEFR against a background of usually well-controlled asthma with normal or near normal lung function".[8] In both types, patients are subject to recurrent, severe attacks. The cardinal symptoms of an asthma attack are shortness of breath (dyspnea), wheezing, and chest tightness.[9] Individuals with type 1 suffer chronic attacks in spite of ongoing medical therapy, while those with type 2 experience sudden, acute and even potentially life-threatening attacks even though otherwise their asthma seems well managed.[10]

When first defined by Margaret Turner-Warwick in 1977, the term brittle asthma was used specifically to describe type 1, but as studies into the phenotype were conducted the second type was also distinguished.[11]

Treatment

In addition to any issues of treatment compliance, and maximised corticosteroids (inhaled or oral) and beta agonist, brittle asthma treatment also involves for type 1 additional subcutaneous injections of beta2 agonist and inhalation of long acting beta-adrenoceptor agonist,[12] whilst type 2 needs allergen avoidance and self-management approaches.[13] Since catastrophic attacks are unpredictable in type 2, patients may display identification of the issue, such as a MedicAlert bracelet, and carry an epinephrine autoinjector.[8]

Epidemiology

The condition is rare. 1999's Difficult Asthma estimates a prevalence of approximately 0.05% brittle asthma sufferers among the asthmatic population.[14] Though found in all ages, it is most commonly found in individuals between the ages of 18 and 55; it is present in both sexes, though type 1 has been diagnosed in three times as many women as men.[14] Hospitalization is more frequent for type 1 than type 2.[14]

Notes and References

  1. Book: Holgate . Stephen T. . Homer A. Boushey . Leonardo M. Fabbri . Difficult asthma . Informa Health Care . 1999 . 1-85317-556-0 . 291.
  2. Gupta D, Ayres JG . Brittle asthma: a separate clinical phenotype of asthma? . Indian J Chest Dis Allied Sci . 43 . 1 . 33–8 . 2001 . 11370504 .
  3. Ayres JG, Jyothish D, Ninan T . Brittle asthma . Paediatr Respir Rev . 5 . 1 . 40–4 . March 2004 . 15222953 . 10.1016/j.prrv.2003.09.003 .
  4. Ayres JG, Miles JF, Barnes PJ . Brittle asthma . Thorax . 53 . 4 . 315–21 . April 1998 . 9741378 . 1745199 . 10.1136/thx.53.4.315.
  5. Brittle asthma. 10.1136/thx.53.4.315. 1998. Ayres. J. G.. Miles. J. F.. Barnes. P. J.. Thorax. 53. 4. 315–321. 9741378. 1745199.
  6. Book: Warrell, David A. . Oxford textbook of medicine: Sections 18-33 . 3 . Oxford Medical Publications . 4th . Oxford University Press . 2005 . 0-19-856978-5 . 1346.
  7. Ogorodova LM, Selivanova PA, Gereng EA, Bogomiakov VS, Volkova LI, Pleshko RI . [Pathomorphological characteristics of unstable bronchial asthma (brittle phenotype)] . ru . Ter. Arkh. . 80 . 3 . 39–43 . 2008 . 18441682 .
  8. Warrell, 1347.
  9. Book: Saunders . Asthma . Mason: Murray & Nadel's Textbook of Respiratory Medicine . Homer A. Boushey Jr., M.D. . David B. Corry, M.D. . John V. Fahy, M.D. . Esteban G. Burchard, M.D. . Prescott G. Woodruff, M.D. . etal . 4th . Elsevier . 2005.
  10. Holgate et al., 292.
  11. Book: Waldron, Jill . Asthma Care in the Community . Wiley-Interscience . 2007 . 978-0-470-03000-4 . 122.
  12. Graziani E, Petroianni A, Terzano C . Brittle asthma . Eur Rev Med Pharmacol Sci . 8 . 4 . 135–8 . 2004 . 15636398 .
  13. Toungoussova O, Foschino Barbaro MP, Esposito LM . Brittle asthma . Monaldi Arch Chest Dis . 67 . 2 . 102–5 . June 2007 . 17695694 . 10.4081/monaldi.2007.497. etal. free . 11383/8808 . free .
  14. Holgate et al., 293.