Summary
Even today, asthma remains one of the enigmas for modern medicine, as genetics and environment are involved in the pathogenesis of this chronic condition. However, the biochemical mechanism of asthma is well-researched. It is the conflict of functions when the immune system tries to battle hypersensitivity to pollutants or antigens caused by atopy or genetically or environmentally driven allergic conditions with the hyper-protection of Immunoglobulin E (IgE) antibodies. According to Sinyor and Perez (2022), “atopy or IgE antibodies attack specific antigens or pollutants, which can contribute to the disease” (para. 1). This chemical reaction causes tightening and malfunction of the respiratory system. Researchers state, “enhanced IgE response to environmental factors … have contributed to sensitize asthma exacerbating its symptoms and attributing to increased airway reactivity” (Sinyor & Perez, 2022, para. 1). Because of the chronic nature of asthma, the individual experiences its exacerbations throughout their whole life. These are diverse and include age and hormonal changes, various substances such as tobacco, new environments, irregular medication, and other illnesses.
Atopy
It is crucial to consider the phenomenon of atopy as a condition closely related to asthma. Stokes and Casale (2022), “atopy appears to result, in part, from a predisposition toward a certain response on the part of CD4+ T helper cells called a T helper type 2 (Th2) response” (para. 4). Consequently, the immune system produces an increased amount of IgE antibodies, significantly more than needed to neutralize invading allergens and pollutants. An overreaction of the body occurs and takes the form of an allergy. Drivers of atopy include irritants such as household hygiene products, allergens, and environmental agents. The presence of eczema in Nancy during her childhood indicates that she may have had atopy for a long time. This comorbidity may cause the recent re-emergence and exacerbation of her asthmatic symptoms.
Asthmatic Exacerbation in a Person’s Continuous Airway
The process of asthmatic exacerbation in the continuous airway of a person needs to be explained in more detail. According to Sinyor and Perez (2022), the asthmatic-allergic reaction can be divided into two stages. During the first one, IgE antibodies respond to triggers sensed by the body’s olfactory and taste receptors and bind to connective tissue cells and basophils in one’s respiratory system (Sinyor & Perez, 2022). Their chemical interaction with invading allergens and pollutants produces “histamine, prostaglandins, and leukotrienes” into the body (Sinyor & Perez, 2022, para. 3). Newly formed bodily fluids cause soft tissues to tighten, which creates an airflow inflammation. The presence of IgE supports this process, which prolongs and intensifies inflammation. The concentration of the bodily bio-chemicals involved increases in the pulmonary system, and bronchoconstriction and airflow obstruction happen eventually (Sinyor & Perez, 2022). This over-reaction of the immune system to external stimuli is called bronchial hyper-responsiveness.
Diagnosis
Forced expiratory volume in the first second (FEV1) is 81%, which is within the norm; however, these are post-bronchodilator numbers. Without medication, it has a value of 66%, indicative of at least moderate persistent asthma in Nancy (Fanta & Barrett, 2019). Forced vital capacity (FCV) is 88%, which is a positive and reassuring figure and a misleading one as well. Nancy takes Albuterol several times a day for about two weeks along with rescue medication, so the real numbers are 9% to 15% lower. An FVC between 70% and 80% indicates a mild to moderate persistent asthmatic condition. Therefore, FEV1/FVC with a ratio of 82% should also be reduced by about 12-15 points to get the actual value that Nancy showed during spirometry. FEV1/FVC ratio between 60% and 70% is again a sign of moderate persistent chronic asthma (Fanta & Barrett, 2019). Oxygen saturation of 93% on the radial artery confirms that the final values should be considered overly high since a pulse ox below 95% indicates a severe problem with the respiratory system.
Persistent Severe Asthma in Nancy Smith
As analyzed and noted above, Nancy Smith has signs of moderate persistent asthma at its worst. However, her actual degree of this condition is even worse, or, to put it simply, the patient has persistent severe asthma currently. There are several reasons for this, some of which are daily symptom flare-ups and nocturnal awakenings due to nighttime coughing. These also include extremely limited ability to perform basic activities manifested in severe dyspnea while walking, inability to breathe while lying down, and taking rescue medications daily. All of these are symptoms of a severe stage of chronic asthma (Fanta & Barrett, 2019). Moreover, it is also essential to consider Nancy’s health history. She was hospitalized several times and is likely to have a comorbidity atopy and, therefore, is at risk of a fatal asthma attack (Fanta & Cahill, 2022). In order to ensure her effective and safe medication, her persistent asthma should be treated as severe.
Asthma Management
Another reason for Nancy’s worsened condition may be the overuse of rescue medications. Magee and their colleagues (2018) state that frequent use of short-acting inhalers leads to paradoxical bronchoconstriction in asthmatics. It is “the unexpected constriction of smooth muscle walls of the bronchi that occurs in the setting of an expected bronchodilatory response” (Magee et al., 2018, p. 1204). Such a dangerous reaction is due to airway hyper-responsiveness driven by the inhaler excipients entering the allergic respiratory tract. Nancy should take rescue medication less frequently and avoid anticholinergic inhalers.
References
Fanta, C. H., & Barrett, N. A. (2022). An overview of asthma management. UpToDate. Web.
Fanta, C. H., & Cahill, K. N. (2022). Acute exacerbations of asthma in adults: Home and office management. UpToDate. Web.
Magee, J. S., Pittman, L. M., & Jette-Kelly, L. A. (2018). Paradoxical bronchoconstriction with short-acting beta agonist. The American Journal of Case Reports, 19, 1204–1207.
Sinyor, B., & Perez, L. C. (2022). Pathophysiology of asthma. In StatPearls [Internet]. StatPearls Publishing.
Stokes, J., & Casale, T. B. (2022). The relationship between IgE and allergic disease. UpToDate. Web.