What are the signs, symptoms, and treatment options for asthma?

Signs and Symptoms of Asthma

Asthma presents with four cardinal symptoms—wheeze, shortness of breath, chest tightness, and cough—that characteristically vary over time, occur intermittently, worsen at night, and are provoked by specific triggers including exercise. 1

Core Symptoms

The primary symptoms of asthma include:

• Wheeze: Reported by 87.5-97% of patients, this is often the most recognizable symptom 1, 2
• Chest tightness: Experienced by 68.8-97% of patients and frequently identified as the most severe symptom in adults 1, 2
• Shortness of breath: Present in approximately 73.5% of adult patients and often rated as highly severe 1, 2
• Cough: Occurs in 81.3-88.2% of patients; when cough is the predominant symptom without wheeze, this is termed "cough variant asthma" 1, 2

Important caveat: None of these symptoms are specific to asthma alone, making the pattern of symptom presentation critical for diagnosis. 1

Characteristic Symptom Patterns

The hallmark features that distinguish asthma symptoms include:

• Variability: Symptoms fluctuate in intensity over time, with day-to-day and even hour-to-hour changes 1
• Intermittency: Symptoms come and go rather than remaining constant 1
• Nocturnal worsening: Nighttime symptoms and sleep awakenings are frequent symptom-related markers 1, 2
• Trigger-provoked: Symptoms worsen with specific exposures including exercise, allergens, viral infections, irritants, and cold air 1

Clinical Signs During Examination

During Acute Exacerbations

• Wheeze on auscultation: Typically diffuse, polyphonic, bilateral, and particularly expiratory—this is the cardinal sign and should be documented in clinical notes 1
• Reduced lung function: Decreased peak expiratory flow (PEF) or obstructive pattern on spirometry 1
• Increased work of breathing: Use of accessory respiratory muscles and tachypnea 3
• Tachycardia: Pulse >120 beats/min suggests severe airflow obstruction 4
• Difficulty speaking: Inability to speak in full sentences indicates severe obstruction 4
• Refusal to recline: Patients unable to lie flat (<30°) have severe obstruction 4
• Decreased breath sounds: Indicates severe airway narrowing 4

Between Exacerbations

Critical pitfall: Outside acute episodes, there may be no objective signs of asthma on physical examination. 1 Patients with chronic asthma may show signs of hyperinflation with or without wheeze. 1

Associated Clinical Features

Additional information supporting asthma diagnosis includes:

• Personal or family history: Asthma or other atopic conditions (eczema, allergic rhinitis) 1
• Trigger-related worsening: Symptoms after exposure to pollens, dust, animals, exercise, viral infections, chemicals, or environmental tobacco smoke 1
• Medication-induced symptoms: Worsening after aspirin/NSAIDs or beta-blockers 1

Symptom-Related Functional Impairments

Patients commonly experience:

• Sleep disturbances: Nighttime awakenings due to chest tightness, cough, shortness of breath, or wheezing 1, 2
• Activity limitations: Restrictions in day-to-day activities and exercise tolerance 1, 2
• Increased rescue medication use: Using short-acting beta-agonists more than 2 days per week indicates inadequate control 1

Markers of Severe or Poorly Controlled Asthma

Red flags requiring immediate attention include:

• Frequent exacerbations: History of hospitalizations, ED visits, ICU admissions, or intubations 4
• High rescue inhaler use: More than two canisters of albuterol per month 3
• Persistent symptoms despite treatment: Symptoms continuing on high-dose inhaled corticosteroids plus additional controllers 5
• Hypoxemia: Oxygen saturation <90% (though values >90% are reassuring, CO₂ retention may still be missed) 4

Pathophysiological Basis of Symptoms

The symptoms arise from:

• Chronic airway inflammation: Involving mast cells, eosinophils, neutrophils, T lymphocytes, and epithelial cells 3, 6
• Bronchoconstriction: Rapid airway narrowing in response to stimuli 3
• Airway hyperresponsiveness: Exaggerated bronchoconstrictor response 3
• Airway edema and remodeling: Progressive structural changes including smooth muscle hypertrophy and sub-basement fibrosis 3