ASTHMA SIGNS AND SYMPTOMS

The classic signs and symptoms of asthma are coughing, wheezing, and dyspnea.

But asthma symptoms vary from patient to patient. Symptoms can change as a patient ages; the type of asthma symptoms a patient has, how often they occur, and how severe they are may vary over time. Some people with asthma may have extended symptom-free periods interrupted by periodic asthma episodes, while others have some symptoms every day. Sometimes symptoms might be just irritating, and at other times they may limit activities of daily living. Severe symptoms can be fatal, and it is important they be treated as soon as they occur so they do not become severe (Cleveland Clinic, 2021b).

Most children with asthma have symptoms before they turn 5. In very young children, it may be difficult for parents and clinicians to recognize that the symptoms are due to asthma. Symptoms of pediatric asthma can range from a nagging cough that lingers for days or weeks to sudden and scary breathing emergencies.

While other conditions can cause the same symptoms as asthma, the pattern of symptoms in people who have asthma usually has some of the following characteristics:

  • They come and go over time or within the same day.
  • They start or get worse with viral infections, such as a “cold.”
  • They are triggered by exercise, allergies, cold air, or hyperventilation from laughing or crying.
  • They are worse at night or in the morning.
    (NHLBI, 2020a)

Coughing

Coughing may be the only symptom of asthma, especially in cases of exercise-induced bronchoconstriction or nocturnal asthma. Usually, the cough is nonproductive and nonconvulsive. A cough that keeps coming back is a symptom of asthma. It is more likely to be asthma if the cough is accompanied by other asthma symptoms; however, not everyone with asthma coughs.

Frequent coughing, especially at night, is usually dry and nonproductive, but in some people with uncontrolled asthma, there may be thick, clear mucus. Children with nocturnal asthma tend to cough after midnight and during the early hours of the morning (Asthma UK, 2021a; Morris, 2020).

Wheezing

Wheezing is a musical, high-pitched, whistling sound caused by airflow turbulence. It is one of the most common symptoms of asthma. Wheezing is produced by air being forced through narrowed airways, and in asthma the affected airways are mainly the small bronchioles of the lungs. Asthma can occur without wheezing, however, when the obstruction predominately involves the small airways.

In the mildest form of asthma, wheezing is heard only at the end of expiration. As severity increases, the wheeze lasts throughout expiration. In a more severe asthmatic attack, wheezing is also present during inspiration. In most severe attacks, wheezing may be absent because of the severe limitation of airflow associated with airway narrowing and respiratory muscle fatigue (Morris, 2020).

Many babies and young children wheeze due to colds or viruses and do not develop asthma as they get older. The diagnosis of asthma in children usually cannot be made until they are older, by age 4 or 5 (Sawicki & Haver, 2019).

Dyspnea

Dyspnea, or shortness of breath, has many causes and is very common. The experience of dyspnea arises from interactions among multiple physiologic, psychological, social, and environmental factors. Bronchoconstriction leads to a series of sensations as the degree of constriction worsens, from chest tightness to an increased effort to breathe to a sensation of air hunger. Patients often complain of an increased effort to breathe.

Asthma is most likely the cause of dyspnea when:

  • It is accompanied by coughing and wheezing
  • Symptoms seem to be triggered by specific things (e.g., allergens, cold air, exercise)
  • The person is an adult who had asthma or asthma-like symptoms as a child
  • The person has hay fever or other allergies or family members with allergies or asthma
    (Schwartzstein, 2020; Li, 2020)

Airway Mucus Hypersecretion

Mucus is the normal secretory product of the epithelial lining and contains secreted water, sugar, proteins, lipids, minerals, and mucins. Under normal conditions, mucus protects the airways and moistens the air. Patients with severe asthma or with asthma that is not well controlled produce enough extra mucus to worsen the obstruction in their airways.

Inflammation and oxidative stress cause the inner lining of airways to swell and produce mucus. Patients with hypersecretion have more dyspnea, have poorer asthma control and quality of life, and experience more exacerbations. They are significantly older, with a longer duration of disease and more frequent severe asthma. They also have greater airflow obstruction and a higher number of emergency department visits.

The mucus produced in asthma is thicker and stickier (more viscous) than normal. Additionally, in persons with asthma the cilia (specialized cells that cleanse the airways of inhaled particles and mucus) are dysfunctional. Asthmatic mucus is more likely to remain in the airways and form plugs that make it more difficult for patients to clear their lungs by coughing (Shen et al., 2018).

Sleep Disturbances

About 75% of people with asthma are wakened by nighttime symptoms at least once a week. Around 40% of people with asthma experience nocturnal symptoms every night. Having poorly controlled severe asthma makes a person more likely to experience nocturnal symptoms.

The mechanism underlying this is not fully understood but may be related to normal circadian hormonal changes that take place in the evening. These changes may contribute to inflammation in the airways, increasing the risk of nocturnal asthma symptoms. Other mechanisms may also include obesity, GERD, and environmental triggers (Newsom, 2021).

Signs and Symptoms Unique to Children

Asthma in children is not different from asthma in adults, but children face unique challenges. Infants and young children with asthma display the following characteristics:

  • Breathlessness at rest
  • Loss of interest in feeding
  • Sitting upright
  • Talking in words, not sentences
  • Usually agitated
  • Chest retractions
  • Vomiting with cough

With imminent respiratory arrest, the child displays the symptoms mentioned above and is also drowsy and confused. Adolescents, however, may not have these symptoms until they are in frank respiratory failure (hypoxia, hypercarbia, increased work of breathing).

For children older than 2 years, asthma can cause:

  • Shortness of breath
  • Easy fatigability
  • Complaints of feeling ill
  • Poor school performance
  • Avoidance of normal activities such as playing outside or visiting friends
    (Sharma, 2021)