Asthma

Home of Kyle J. Norton for The Better of Living & Living Health Respiratory Disease is defined as medical conditions which affect the breathing organ and tissues including Inflammatory lung disease, Obstructive lung diseases, Restrictive lung diseases, Respiratory tract infections, trachea, bronchi, bronchioles, alveoli, the nerves and  muscles breathing , etc,.
I. Asthma 
 Asthma is a chronic inflammatory disease affecting the air way of the lung with recurring symptoms, such as wheezing, chest tightness, shortness of breath, and coughing. The disease affects people of all ages, and mostly starts during childhood. In the study of 463,801 children aged 13-14 years in 155 collaborating centres in 56 countries. Children self-reported, through one-page questionnaires, symptoms of these three atopic disorders. In 99 centres in 42 countries, a video asthma questionnaire was also used for 304,796 children, found that for asthma symptoms, the highest 12-month prevalences were from centres in the UK, Australia, New Zealand, and Republic of Ireland, followed by most centres in North, Central, and South America; the lowest prevalences were from centres in several Eastern European countries, Indonesia, Greece, China, Taiwan, Uzbekistan, India, and Ethiopia(1). In the United States, approximately, asthma affects 25 million people, 7 million of them are children.

A. Symptoms
The common symptoms include
1. Coughing
In the study of Coughing  in relation to different disorders and objective variables indicative of airway inflammation, according to Department of Lung Medicine, Akademiska sjukhuset, found that there is significant positive correlation between productive coughing and asthma (adjusted odds ratios [OR] = 2.0)(2).

2. Wheezing 
Wheezing is common throughout childhood, although it decreases as children age. However, the characteristics of wheeze, its relations with asthma, and its risk factors all change with age(3).

3. Shortness of breath   
In the study of 20 individuals with asthma and 20 control subjects using an electronic diary of activities and spirometry (peak expiratory flow [PEF], FEV(1)), researchers at the Department of Psychology, Southern Methodist University, showed that people with asthma still feel more shortness of breath when being more physically active(4).

4. Chest tightness
Asthma is a chronic inflammatory disorder of the airways resulting physiologically in hyperreactivity and clinically in recurrent episodes of wheezing, chest tightness, or coughing. Airway inflammation, smooth muscle contraction, epithelial sloughing, mucous hypersecretion, bronchial hyperresponsiveness, and mucosal edema contribute to the underlying pathophysiology of asthma, according to the study by  Northwestern University Feinberg School of Medicine(5).

5. Etc.

B. Causes and triggers and Risk factors
B.1. Causes and Triggers
1. Smoking and second hand smoke
Smoking is considered as one of major cause of lung diseases, including asthma. According to the study by Texas Tech University Health Science Center, Airway mucosal permeability is increased in smokers, which could lead to increased clearance of inhaled corticosteroids from the airways. Smokers also have decreased histone deacetylase activity, which is necessary for corticosteroids to fully suppress cytokine production, and can lead to corticosteroid resistance. The study also indicated that In asthmatic patients who smoke, disease control is poorer than in asthmatic nonsmokers. Of all forms of SHS, maternal exposure seems to have the largest impact on asthma by increasing the frequency and severity of the disease and decreasing lung function. Asthmatic children exposed to multiple household smokers face an increased risk for respiratory illness-related absences from school, and these effects persist during adolescence but weaken during adulthood(6).

2. Allergies
People who are sufferred from alergies are most likely to develop asthma. The allergic march is a progression of atopic disease from eczema to asthma, and then to allergic rhinoconjunctivitis. It appears to be caused by a regional allergic response with breakdown of the local epithelial barrier that initiates systemic allergic inflammation. Genetic and environmental factors predispose to developing the allergic march, according to the study by Department of Surgery, Cape Cod Hospital, Hyannis(7). Other indicated that Allergen exposure contributes to the risk of asthma exacerbations, but other precipitating factors, such as viruses, can interact and increase the risk. According to the study by hôpitaux universitaires de Strasbourg, deteriorating asthma can be related to increased exposure to allergens, particularly allergens from house dust mite, cockroach, cat, rodent, mold or pollen. Several studies have demonstrated that sensitization to respiratory allergens and allergen exposure increases the risk of exacerbation of asthma. When asthma exacerbations are work-related, occupational allergens may be implicated(8).

3. Occupational and environmental exposures
Occupational and exposure history may increase the risk of respiratory problems. According to a report by Dr, Hoy RF., there is a case of a man, 23 years of age and previously well, presents with 2 months of cough, shortness of breath and weight loss. Occupational and exposure history identifies him as commencing work at a mushroom farm 12 months ago where he is exposed to dust from the mixing of mushroom compost. He is not required to use respiratory protection at work. His cough and chest tightness usually start in the afternoon at work and persist into the evening. Some of the effects of exposures may be immediate, whereas others such as asbestos-related lung disease may not present for many decades. Airborne contaminants may be the primary cause of respiratory disease or can exacerbate pre-existing respiratory conditions such as asthma and chronic obstructive pulmonary disease(9).

4. Obesity
Obesity is defined as a medical condition of excess body fat has accumulated overtime, while overweight is a condition of excess body weight relatively to the height. According to the Body Mass Index(BMI), a BMI between 25 to 29.9 is considered over weight, while a BMI of over 30 is an indication of obesity. According to the statistic, 68% of American population are either overweight or obese. In the study to to examine the relationship between central obesity and asthma outcomes in a group of Iranian asthma patients, researchers showed that there is a significant association of WHR-based central obesity with forced expiratory volume in 1 s (FEV(1)) (β = -9.04; p-value = .044) and forced vital capacity (FVC) (β = -10.52; p-value = .012). Logistic regression analysis showed a significant increased risk of asthma attacks in 3 months with Asian WC-based central obesity [odds ratio (OR) = 6.31, 95% confidence interval (CI): 1.16-34.41]; emergency room (ER) visits with NIH WC-based (OR = 5.15, 95% CI: 1.36-19.55) and Asian WC-based (OR = 18.72, 95% CI: 1.92-182.63) central obesity; and hospitalization in 1 year with NIH WC-based (OR = 5.28, 95% CI: 1.28-21.84) and Asian WC-based (OR = 12.39, 95% CI: 1.29-119.53) central obesity(10).
Some study suggested that asthma in the obese patient might be more responsive to leukotriene modifiers, orchestrated by leptin and/or adiponectin derived from adipose tissue, than to inhaled corticosteroids, possibly reflecting differences in the underlying airway inflammation in obese vs. non-obese asthmatics(11).

5. Exercise-Induced Asthma
Vigorous exercise can cause a narrowing of the airways in  asthma patient.There is a report of  a 44-year-old man with a history of seasonal allergic rhinitis but no asthma, who reported difficulty breathing when playing tennis and a 45-year-old woman who presented with persistent, generally well-controlled asthma, who was now experiencing bouts of coughing and wheezing during exercise. EIB is a frequently encountered problem among patients presenting to primary care specialists. Affected patients should be made aware of the importance of proactive treatment with a short-acting beta agonist before initiating any exercise(12).

6. Gastroesophageal reflux disease (GERD)
Gastroesophageal reflux disease (GERD), also known as gastro-oesophageal reflux disease (GORD), gastric reflux disease, or acid reflux disease, is defined as a chronic condition of liquid stomach acid refluxing back up from the stomach into the esophagus, causing heartburn. According to the study of “Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease.” by DeVault KR, Castell DO; American College of Gastroenterology, GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. It is considered as one the causes of asthma. There is a report of  an 11-year-old boy who was referred to a pediatric respiratory clinic for asthma that was not responsive to inhaled medications. The child presented with a one-year history of dyspnea on exertion, cough and wheeze. He also complained of chronic dyspepsia. The presence of GI symptoms, in addition to abnormalities on chest radiograph and spirometry, suggested the presence of achalasia(13).

7.  Sinusitis
Sinusitis is defined as a condition of inflammation of the paranasal sinuses of which can develop headache as a result of exposure to a cold or flu virus, or an allergic reaction to pollen, mold, dust or smoke, etc..Sinusitis affects 37 million people each year. Some researchers suggested that there is a close relationship between allergic rhinitis and asthma, food allergy, and atopic dermatitis. Rhinitis and sinusitis often coexist and are commonly referred to with the term rhinosinusitis. These conditions are also linked in the so-called atopic march, which is the sequential appearance of atopic manifestations starting with atopic dermatitis and later followed by food allergy, allergic rhinitis, and asthma(14).

8.  Upper Respiratory Infections
upper respiratory viral infections are strongly associated in time with hospital admissions for asthma in children and adults. Rhinoviruses were the major pathogen implicated, and the majority of viral infections and asthma admissions occurred during school attendance, according to the study by the Department of Medical Statistics and Computing, University of Southampton(15).

9. Irregular Mentruation
Irregular menstruation are associated with asthma. In the study of a total of 8588 women (response rate 77%) participated in an 8 year follow up postal questionnaire study of participants of the ECRHS stage I in Denmark, Estonia, Iceland, Norway, and Sweden. Only non-pregnant women not taking exogenous sex hormones were included in the analyses (n = 6137), showed that Irregular menstruation was associated with asthma (OR 1.54 (95% CI 1.11 to 2.13)), asthma symptoms (OR 1.47 (95% CI 1.16 to 1.86)), hay fever (OR 1.29 (95% CI 1.05 to 1.57)), and asthma preceded by hay fever (OR 1.95 (95% CI 1.30 to 2.96)) among women aged 26-42 years(16).

10. Sulphite additives
Topical, oral or parenteral exposure to sulphites (mainly from the consumption of foods and drinks that contain these additives) has been reported to induce a range of adverse clinical effects in sensitive individuals, ranging from dermatitis, urticaria, flushing, hypotension, abdominal pain and diarrhoea to life-threatening anaphylactic and asthmatic reactions(16a).

11. Cold air
Endurance athletes show an increased prevalence of airway hyperresponsiveness. In the study of a total, 64 elite athletes (32 swimmers and 32 cold-air athletes), 32 mild asthmatic subjects and 32 healthy controls underwent allergy skin prick testing, methacholine challenge and induced sputum analysis found that there is a significant airway inflammation only in competitive athletes with airway hyperresponsiveness. However, the majority of elite athletes showed evidence of bronchial epithelial damage that could possibly contribute to the development of airway hyperresponsiveness(17a).

11. Etc..

B.2. Risk factors
1. Wheezing rhinovirus illnesses
Virus-induced wheezing episodes in infancy often precede the development of asthma. Researchers at the the Department of Pediatrics, University of Wisconsin-Madison, showed that Nearly 90% (26 of 30) of children who wheezed with RV in Year 3 had asthma at 6 years of age. From birth to age 3 years, wheezing with respiratory syncytial virus (RSV) (odds ratio [OR], 2.6), rhinovirus (RV) (OR, 9.8), or both RV and RSV (OR , 10) was associated with increased asthma risk at age 6 years. In Year 1, both RV wheezing (OR, 2.8) and aeroallergen sensitization (OR, 3.6) independently increased asthma risk at age 6 years. By age 3 years, wheezing with RV (OR, 25.6) was more strongly associated with asthma at age 6 years than aeroallergen sensitization (OR, 3.4)(17).

2. Airflow obstruction
Asthma and family history of allergic rhinitis are important risk factors associated with airflow. according to the Department of Pediatrics, Lerdsin General Hospitalobstruction(18).

3. Gender
If you are women, you are at increased risk to develop asthma. According to the study by the Department of Woman and Child Health, Karolinska Institutet, in adolescence, the pattern changes and onset of wheeze is more prevalent in females than males. Asthma, after childhood, is more severe in females than in males, and is underdiagnosed and undertreated in female adolescents(19).

4. Stress
Researchers at the Departments of Family Medicine and Pediatrics, University of Pittsburgh,  suggested that stress, whether at the individual (i.e. epigenetics, perceived stress), family (i.e. prenatal maternal stress, early-life exposure, or intimate partner violence) or community (i.e. neighborhood violence; neighborhood disadvantage) level, influences asthma and asthma morbidity(20).

5. Gene
a study by National Taiwan University, showed that GSTP1, INSIG2 and IL4Ra may influence the lifetime asthma susceptibility through gene-gene interactions in schoolchildren. Home dampness combined with each one of the genes STAT6, IL13 and ADRB2 could raise the asthma risk(21). Other suggested that  rs17880588 showed a significant association with asthma in the Saudi population due to the association of  between asthma and 5 single-nucleotide polymorphisms (SNPs) in the interleukin 17 (IL17) gene. Levels of IL17A and IL17F were significantly upregulated in the asthma patients(22).

6. Airway inflammation and hyperreactivity
People with Air way hyperreactivity are at increased risk to develop asthma as a result of the immune system over response to allergan. Some study suggested that epidermal growth factor receptor (EGFR) signaling, especially in the airway epithelium, plays an important role in mediating AHR and remodeling in a chronic allergic asthma model(23).

5. Atopy and viral infection
Atopy – such as eczema, allergic rhinitis, allergic conjunctivitis  and virual infection are associated with higher risk to asthma development. According to the study by The University of Western Australia, suggested that underlying this bipartite process (Viral infections occurring against a background of allergic sensitization to aeroallergens as a uniquely potent risk factor for the expression of acute severe asthma-like symptoms and for the ensuing development of asthma that can persist through childhood and into adulthood) are a series of interactions between antiviral and atopic inflammatory pathways that are mediated by local activation of myeloid cell populations in the airway mucosa and the parallel programming and recruitment of their replacements from bone marrow(24).

6. Family history
Family history of asthma in one or more first-degree relatives was consistently identified as a risk factor for asthma. But although a positive family history predicts an increased risk of asthma, it identifies a minority of children at risk. Positive family history may have utility in targeting some individual prevention efforts, but the low positive predictive value limits its value as a means to direct environmental remediation efforts, according to the study the Department of Medical History and Ethics, University of Washington(25).

7. Smoke during Pregnancy
Smoking and severe asthma exacerbations in pregnancy are risk factors for low birth weight babies.
During pregnancy, asthma exacerbations are more common and more severe in current smokers than never smokers. The risk of effects of maternal asthma on the fetus may be greater among smokers(26).

8. Low birth weight
There is a strong independent association between low birth weight and asthma. For 1988 national birth cohort, an estimated 4000 excess asthma cases were attributable to birth weight less than 2500 g(27).

C. Diagnosis and tests
If you are experience some of the above symptoms and if your doctor suspects that you have asthma, after recording your family history and completing the physical exam, the test which your doctor orders include
1. Chest X-Ray 
In the study of the medical records of 58 patients aged 18-40 with the diagnosis of mild to moderate asthmato  assess the value of the chest X-ray in helping to make the diagnosis of asthma at the primary care level, researchers at the Harvard University Health Services, showed that the number of asthmatic patients with CXR+ and SPI – (n = 23) was significantly larger than the number with CXR- and SPI+ (n = 10), which indicates that for mild asthma the chest X-ray may be more sensitive than spirometry even though not as specific(28). Other suggested that the X-ray request was an action not based on sound clinical judgement. Cost savings and a reduction in radiation exposure can be made by eliminating unnecessary chest X-ray requests(29).

2. Spirometry
Spirometry is  a lung (or pulmonary) function test to measure the lung function in studying the air volume and flow rate within the lungs. According to the study by Department of Community Medicine, University of Tromsø the ability of GPs to differentiate between asthma and COPD seems to have considerably improved during the last decade, probably due to the dissemination of spirometry and guidelines for COPD diagnosis(30).

3. Peak Flow Testing –
Peak Flow Testing is a self-assessment to evaluate lung function  The peak expiratory flow (PEF), also known as peak expiratory flow rate (PEFR)  is to measure the airway
obstruction.

4. Impulse oscillometry (IOS)
Impulse oscillometry is a noninvasive and rapid technique requiring only passive cooperation by the patient. Pressure oscillations are applied at the mouth to measure pulmonary resistance and reactance. It is employed by health care professionals to help diagnose pediatric pulmonary diseases such asthma and cystic fibrosis; assess therapeutic responses; and measure airway resistance during provocation testing(31). In the study to to evaluate whether impulse oscillometry, an easy-to-perform technique, can detect asthmatic airway obstruction stage, researchers at the Shanghai Pudong New Area People’s Hospital, found that IOS provides an accurate, reliable, and patient-friendly technique for classifying asthmatic airway obstruction(32).

D. Complications
1. Quality of life
In a cross-sectional study explored the relationships among family ritual meaning, cohesion, conflict, and health-related quality of life (both specific to chronic health conditions and in general), and the emotional and behavioral problems reported by youths with asthma, conducted by Faculty of Psychology and Educational Sciences, University of Coimbra, showed that stronger family ritual meaning predicted a more positive family environment (i.e., higher cohesion levels and lower conflict levels), better health-related quality of life, and fewer emotional and behavior problems in youths. Furthermore, family cohesion and conflict mediated the links between family ritual meaning and health-related quality of life, and emotional and behavioral problems(34). In 2007–08, people with asthma were more likely to have taken days off work, school or study in the last 12 months due to a long term condition than people without asthma (although these days off were not necessarily due to asthma). People with asthma rate their health worse than people without the condition, according to the data ofAIHW(35).

2. Corticoid-associated complications
In the stduy to evaluate the frequency and type of side effects and complications of long-term corticosteroid therapy in the elderly, showed that infectious complications were found in 26 cases (39.3%), 11 cases (16.7%) of iatrogenic diabetes, arterial hypertension in 9 cases (13%), skeletal complications in both cases,psychiatric complications in two cases, ophthalmologic complications in one case(36). 

3. Subcutaneous and mediastinal emphysema
There is a report of a case of a 21-year-old man admitted with asthma attack complicated by subcutaneous and mediastinal emphysema. Chest tomography confirmed the mediastinal emphysema and also revealed the epidural emphysema within the vertebral canal(37).

4. Pneumomediastinum
There is a report of a 17-year-old girl with severe asthma exacerbations. On admission to the intensive care unit, she manifested expiratory dyspnea, cyanosis, and an unproductive cough. Her chest x-rays showed extensive pneumomediastinum (PM), mild subcutaneous emphysema at the right anterior triangle of the neck, and right upper-lobe atelectasis(38). 

Children with asthma are at increased risk for obstructive breathing during sleep. Adenotonsillectomy, the treatment of choice for obstructive breathing during sleep, is associated with significant postoperative respiratory morbidity. According to the study by Cincinnati Children’s Hospital, Cincinnati, in children with obstructive breathing during sleep, the presence of asthma is associated with an increased risk of respiratory complications after adenotonsillectomy(39). Other indicated that the frequency of perioperative bronchospasm and laryngospasm was surprisingly low in this cohort of persons with asthma. These complications did not lead to severe respiratory outcomes in most patients. The frequency of complications was increased in older patients and in those with active asthma(40).
5. Potentially (near) fatal asthma (PFA)
Potentially (near) fatal asthma (PFA) defines a subset of patients with asthma who are at increased risk for death from their disease. According to the study by the Northwestern University Feinberg School of Medicine, a diagnosis of PFA is made when any one of the following are present: (1) history of endotracheal intubation from asthma, (2) acute respiratory acidosis (pH respiratory failure from acute severe asthma, (3) two or more episodes of acute pneumothorax or pneumomediastinum from asthma, (4) two or more episodes of acute severe asthma despite the use of long-term oral corticosteroids and other antiasthma medications.
In the UK in 2005, over 1300 people died from asthma, and on average one person dies from asthma every seven hours.

6. Etc.

E. Misdiagnosis
According to the study by Scripps Memorial Hospital, two common reasons asthmatics fail standard therapy are incorrect diagnosis and failure to recognize underlying contributing factors(41), including

1.  Vocal cord dysfunction
Vocal cord dysfunction (VCD) is a respiratory disorder characterized by paradoxical closure of the vocal cords during the respiratory cycle leading to obstructive airway symptoms. Misdiagnosis of VCD as asthma leads to inappropriate use of systemic steroids with its adverse effects, frequent emergency department visits, hospitalization, and, rarely, intubation and tracheostomy(42). 

2. Respiratory bronchiolitis interstitial lung disease
Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD) is a type of idiopathic interstitial pneumonia (IIP) found to be associated with smokers. Many patients with interstitial lung disease have their chronic cough mistakenly attributed to that condition when, in fact, the cough is due to more common disorders such as asthma, upper airway cough syndrome (previously referred to as postnasal drip syndrome), or gastroesophageal reflux disease(43).

3. Chronic obstructive pulmonary disease (COPD)
According to the study by National Jewish Medical and Research Center, despite the availability of consensus guideline diagnostic recommendations, diagnostic confusion between COPD and asthma appears common. Increased awareness of the differences between the two conditions is needed to promote optimal patient management and treatment(44).

4. Psychogenic cough
Psychogenic cough and its relationship to asthma and other asthma-like illnesses is complex since distinct maladies with similar features may coexist individually or in combination in any given patient. While chronic cough may occur as a sole presenting manifestation of bronchial asthma in all age groups, recent findings suggest that most children with persistent cough without other respiratory symptoms do not have asthma, according to the study by Ohio University(45).

5. Tracheobronchomalacia
There is a report of 62-year-old woman, diagnosed as bronchial asthma 3 years previously, was admitted due to acute severe dyspnea. Physical examination revealed saddle nose, flare/swelling of the ear auricles, and stridor. Computed tomography demonstrated thickening of tracheal/bronchial walls and stenosis of the lumen that deteriorated on expiration, suggesting tracheobronchomalacia(46).

6. Tracheal schwannoma
There is a report of a case of  tracheal schwannoma in a female patient who presented with breathlessness and wheeze, and she was being treated for asthma(47).

7. Exercise-induced bronchoconstriction
A high proportion of English professional soccer players medicated for asthma/EIB (a third with reliever therapy only) do not present reversible airway obstruction or airway hyperresponsiveness to indirect stimuli, according to the study by University of Northumbria(48).

8. Etc.

E. Preventions
E.1. The do and do not’s list to prevent asthma and asthma attack
1. Breast feeding
Breast feeding is considered to have a protective effect against asthma in children and prolonged breastfeeding was shown to reduce the risk of allergic and respiratory diseases, according to the study by the Dept. of Medical Statistics & Epidemiology, Hamad Medical Corporation, exclusive breast-feeding prevents development of allergic diseases in children. The main factors associated with breastfeeding for allergic diseases were being the first baby, maternal history of asthma, and parental history of allergic rhinitis. The study findings opens a big avenue for interventional role of breastfeeding(49). But longer duration of breastfeeding and later introduction of solid foods did not prevent the onset of asthma, eczema or atopy by age 5 years(50).

2. Lose weight if you are Obese
Asthma is more prevalent in obese compared with normal weight subjects. According to study,
asthma in the obese patient might be more responsive to leukotriene modifiers, orchestrated by leptin and/or adiponectin derived from adipose tissue, than to inhaled corticosteroids, possibly reflecting differences in the underlying airway inflammation in obese vs. non-obese asthmatics.In conclusion, overweight and obesity is associated with poorer asthma control and, very importantly, overall poorer response to asthma therapy compared with normal weight individuals(51).

3.  Prevention of occupational asthma
Prevention of occupational asthma related to a work-sensitizing agent ideally would be achieved by avoidance of exposures that cause immunologic sensitization and subsequent asthma.
Education measures for workers to understand the meaning of work-related respiratory symptoms and appropriate workplace safety measures have not been formally evaluated but may also be expected to enhance protective measures and lead to earlier diagnosis, according to the study by Toronto Western Hospital(52).

4. Quit smoking and avoid second smoke
As smoking is considered as one of the major cause of asthma and second hand smoke can cause asthma to children and adult if exposing to a prolonged period of time.

5. Enhancing your immune system to prevent viral infection causes of asthma

6. Avoid asthma triggering allergens if you are diagnosed with allergens cause of asthma

7. Traditional Mediterranean diet
In a cross-sectional survey of 690 children aged 7-18 years in rural Crete, whose parents completed a questionnaire on their child’s respiratory and allergic symptoms and a 58-item food frequency questionnaire,researchers at the University of Crete found that a beneficial effect of commonly consumed fruits, vegetables and nuts, and of a high adherence to a traditional Mediterranean diet during childhood on symptoms of asthma and rhinitis. Diet may explain the relative lack of allergic symptoms in this population(53).

8. Etc.

E.2. Antioxidants and Phytochemicals to prevent asthma
1. Selenium
Although levels of Se intake have been hypothesized to play an important role in the pathogenesis of asthma. However, significant associations between Se status and prevalence or severity of asthma have not been consistently demonstrated in human studies, mouse models of asthma have provided more definitive results suggesting that the benefits of Se supplementation may depend on an individual’s initial Se status(54). But other suggested that Se intake and allergic airway inflammation are not related in a simple dose-response manner(55).

2.  Vitamin C and E
Free radical scavenger vitamin C and E intake are associated with the reduced risk of asthma. In a
of 452 children aged 3-6 years whom parents completed a questionnaire on the children’s and parents’ lifestyle and demographics, showed that children with high intakes of vitamins C and E may be associated with a reduced prevalence of asthma(56).

3. Vitamin D
Vitamin D (VD) inhibits the genesis of both Th1- and Th2-cell mediated diseases. The pleiotropic character VD-induced effects are due to the altered transcription of hundreds of genes. VD supplementation in most related studies reduced the prevalence of asthma(57).

4. Vitamin A and carotenoids and lycopene
Low serum levels of dietary antioxidants are associated with allergic diseases including asthma. In the study of 433 asthmatic schoolchildren and 537 healthy control subjects, between 6 and 18 years of age, conducted by the College of Science, King Saud University, showed that reduction of vitamin A in asthmatic children may have etiological implications for the disease(58). Other suggested that dietary supplementation or adequate intake of lycopene and vitamin A rich foods may be beneficial in asthmatic subjects(59).

5. Epigallocatechin gallate (EGCG)
Epigallocatechin gallate (EGCG) is one of component of catechin found abundantly in green tea. Purified EGCG included in vitro also suppressed IgE production, but at lower levels, compared with control. This study demonstrates that GTE and its major catechin, EGCG, have immunoregulatory effects on human IgE responses, according to the study by Royal Aberdeen Children’s Hospital Department of Child Health, University of Aberdeen(60).

6. Carotenoids
Carotenoids are fat soluble organic pigments of plants such as algae, some bacteria, and fungus. It generally cannot be manufactured by animals but have to acquired plants. Researchers at the University of Newcastle, New South Wales, showed that modifying the dietary intake of carotenoids alters clinical asthma outcomes. Improvements were evident only after increased fruit and vegetable intake, which suggests that whole-food interventions are most effective(61).

E.3. Foods to prevent asthma
1. Apple
Diet high in fruits and vegetables may decrease the risk of chronic diseases. In the study of Apple phytochemicals and their health benefits, found that apples have been found to have very strong antioxidant activity, inhibit cancer cell proliferation, decrease lipid oxidation, and lower cholesterol. Apples contain a variety of phytochemicals, including quercetin, catechin, phloridzin and chlorogenic acid, all of which are strong antioxidants. The phytochemical composition of apples varies greatly between different varieties of apples, and there are also small changes in phytochemicals during the maturation and ripening of the fruit(62).

2. Artichoke and Strawberries
Gallic acid (Strawberries) and caffeic acids (Artichoke) are reported to modulate allergic reactions via unknown mode(s) of action. In the stufy to evaluate whether both phenolic acids share a common mode of action with the two asthma drugs, suggest that certain anti-inflammatory phytochemicals including gallic acid and wedelolactone may modulate inflammatory allergic action via their agonism at GPR35. GPR35 may represent a target for the treatment of allergic disorders including asthma(63).

3. Flax and Sunflower seeds
Omega 3 fatty acid is types of phytochemical found abundantly in flax and sunflower seeds
In the study  to assess the relation between observed levels of omega-3 fatty acids in plasma and symptoms of asthma and atopy in children at 18 months of age, showed that omega-3 fatty acid levels were expressed in quintiles of exposure ‘as treated’ without reference to treatment group allocation. Wheeze ever, doctor visits for wheeze, bronchodilator use and nocturnal coughing were significantly reduced in children in the higher exposure quintiles. Serum IgE was reduced in the highest quintile but not significantly so. There was no difference in diagnosed asthma or atopy between the exposure quintiles. Although wheeze at this age may not be a good indicator of asthma in later childhood, it is encouraging that some symptoms have been reduced in children with high omega-3 fatty acid concentrations in plasma(64).

4. Tomato
Lycopene, a phytochemical found abundantly in tomato. In the study to investigate the effects of lycopene, on allergic inflammation, in a mouse model of AAD. BALB/c mice receiving lycopene supplement or control were intraperitoneally sensitised and intranasally challenged with ovalbumin (OVA) to induce AAD, found that supplementation with lycopene reduces allergic inflammation both in the lungs and systemically, by decreasing Th2 cytokine responses. Thus, lycopene supplementation may have a protective effect against asthma(65).

5. Peaches, organic orange juice
Peach contains high amount of vitamin C which may be used to prevent and treat asthma.
In this double blind clinical trial study to evaluated 60 patients with chronic stable asthma. The patients were divided into two groups (A and B) including 30 patients in each group. group A received 1000 mg vitamin C daily and group B received placebo, found that The mean (±SD) leukocyte vitamin C level in group A at the baseline and after one month treatment with 1000 mg/day vitamin C, were 0.0903 (±0.0787) µg/108 leukocytes and 0.1400 (±0.0953) µg/108 leukocytes respectively (P<0.05). The mean (±SD) leukocyte vitamin C level in group B at the baseline and after one month administration of placebo, were 0.0867 (±0.0629) µg/108 leukocytes and 0.0805(±0.0736) µg/108 leukocytes respectively. The leukocyte vitamin C level in group A was higher than those of group B after one month treatment with vitamin C and placebo and the difference was statistically significant (P<0.05)(66)

6. Etc.

F. Treatments
F.1. In conventional medicine perspective
According to the guide line of Asthma society of Canada, Most people with asthma take two kinds of medication.
F.1.1. Controllers
Controllers are medication with an aim to prevent the inflammation of the airway. There are advised that patients aho are taking the cotrollers shoud continue to take them even without sympyoms to prevent recurence.
1. Corticosteroids
Corticosteroids  are most frequent used sontrollers in preventing inflammaory airways in asthma patients.
a. Inhaled corticosteroids
According to the study by University of Nevada School of Medicine, in the review of review is to compare and contrast the newer inhaled corticosteroid (ICS) ciclesonide with older ICSs, showed that once-daily administration of ICSs is generally not as effective as twice-daily. Continuous administration of ICSs does not change the natural history of asthma in either children or adults. Long-term administration of medium dose ICSs does not increase the risk of cataracts or osteopenia in children and young adults(67). Others in the study of  Dry powder inhaler (DPI) devices
 to assess the proportion of patients with asthma or chronic obstructive pulmonary disease (COPD) with significant bronchoobstruction who do not have inspiratory flows necessary for the adequate use of dry powder inhaler (DPI) devices Diskus and Turbuhaler. showed that significant proportion of patients with asthma or COPD with significant bronchoobstruction do not exhibit satisfactory inspiratory flows for the use of dry powder inhaler (DPI) devices (Diskus
b. Oral or intravenous corticosteroids
In the study of 47 patients, 30 females, 17 male, 24 received oral prednisolone and 23 received IV hydrocortisone. At baseline the oral and IV groups were similar (mean, SD) in age (38.3, 12.8 vs 37.3, 12.9, P=0.80) and initial percent predicted (PP) PEF (61, 16.7 vs 69, 13.0, P=0.11). After 72 h both groups had similar improvements in PEF (27%, 26 vs 27%, 19, P=0.96), researchers at the Department of Respiratory and Sleep Disorders Medicine, Western Hospital, found that Corticosteroids administered orally and IV had similar efficacy in the treatment of adults hospitalised with acute asthma(69).

c. Side effects
a.1. psychiatric side effects include mania, depression and mood disturbances within the first two weeks of corticosteroid therapy(70).
2. Short side effects include cutaneous effects, electrolyte abnormalities, hypertension, hyperglycemia, pancreatitis, hematologic, immunologic, and neuropsychologic effects. and Long-term corticosteroid use may be associated with more serious sequel, including osteoporosis, aseptic joint necrosis, adrenal insufficiency, gastrointestinal, hepatic, and ophthalmologic effects, hyperlipidemia, growth suppression, and possible congenital malformations(71).

2. Cromolyn sodium and nedocromil
a. The medication are used tr block part of the asthma immune response causes of airway inflammation.
Some researchers found that the asthma drugs cromolyn disodium and nedocromil sodium are potent G-protein-coupled receptor 35 (GPR35) agonists. In the study by Amgen San Francisco, South San Francisco,  unlike zaprinast, a potent phosphodiesterase 5 (PDE5) inhibitor, cromolyn disodium and nedocromil sodium lack inhibitory activity towards PDE5. These findings suggest that GPR35 may play an important role in mast cell biology and be a potential target for the treatment of asthma(72).

b. Side effects are not limit to

http://medicaladvisorjournals.blogspot.com