Guidelines for the Diagnosis and Management of Asthma

Asthma Definition and Implications
for Treatment
Definition and Pathophysiology
Asthma is a complex disorder characterized by variable
and recurring symptoms, airflow obstruction, bronchial
hyperresponsiveness, and an underlying inflammation.
The interaction of these features determines the clinical
manifestations and severity of asthma (See figure 2,
“The Interplay and Interaction Between Airway
Inflammation and the Clinical Symptoms and
Pathophysiology of Asthma.”) and the response to
treatment. The working definition of asthma is as
follows:
Asthma is a chronic inflammatory disorder of the airways
in which many cells and cellular elements play a role: in
particular, mast cells, eosinophils, neutrophils (especially in
sudden onset, fatal exacerbations, occupational asthma,
and patients who smoke), T lymphocytes, macrophages,
and epithelial cells. In susceptible individuals, this inflammation
causes recurrent episodes of coughing (particularly
at night or early in the morning), wheezing, breathlessness,
and chest tightness. These episodes are usually associated
with widespread but variable airflow obstruction that is
often reversible either spontaneously or with treatment.
Figure 2. THE INTERPLAY AND INTERACTION BETWEEN
AIRWAY INFLAMMATION AND THE CLINICAL SYMPTOMS AND
PATHOPHYSIOLOGY OF ASTHMA
Airflow limitation is caused by a variety of changes in
the airway, all in influenced by airway inflamation:
■ Bronchoconstriction—bronchial smooth muscle
contraction that quickly narrows the airways
in response to exposure to a variety of stimuli,
including allergens or irritants.
■ Airway hyperresponsiveness—an exaggerated
bronchoconstrictor response to stimuli.
■ Airway edema—as the disease becomes more
persistent and inflammation becomes more
progressive, edema, mucus hypersecretion, and
formation of inspissated mucus plugs further
limit airflow.
Remodeling of airways may occur. Reversibility
of airflow limitation may be incomplete in some
patients. Persistent changes in airway structure
occur, including sub-basement fibrosis, mucus
hypersecretion, injury to epithelial cells, smooth
muscle hypertrophy, and angiogenesis.
Recent studies provide insights on different phenotypes
of asthma that exist. Different manifestations of
asthma may have specific and varying patterns of
inflammation (e.g., varying intensity, cellular mediator
pattern, and therapeutic response). Further studies
will determine if different treatment approaches
benefit the different patterns of inflammation.
Inflammation
Airway
Hyperresponsiveness
Airway
Obstruction
Clinical Symptoms
Asthma Definition and Implications for Treatment
9