CHAPTER – I

INTRODUCTION:

Asthma is a heterogeneous disease, usually characterized by chronic airway

inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness
of breath, chest tightness and cough that vary over time and in intensity, together with
variable expiratory airflow limitation.

Chronic respiratory diseases are among the leading causes of mortality and morbidity
worldwide, with chronic obstructive pulmonary disease (COPD) and asthma being the most
common. According to the Global burden of Disease Studies in 2015, COPD and asthma
ranked among the top 20 conditions causing disability globally and were ranked 8 th and 23rd,
respectively, as causes of disease burden when measured by disability-adjusted,life,years. [1],[2]

Bronchial asthma is the most common chronic respiratory disease, with an case
burden of approximately 358.2 million in 2015. [3] In 2015, about 0·40 million people died
from asthma, a decrease of 26·7% from 1990, and the age-standardized death rate decreased
by 58·8%. The prevalence of asthma increased by 12·6%, whereas the age-standardized
prevalence decreased by 17·7%.[3]

The set of inflammatory events in the respiratory system can lead to the severe
symptoms of an asthma attack. Worldwide, around 250,000 people die every year as a result
of asthma. Asthma attacks occur when symptoms are at their peak. They might begin
suddenly and can range from mild to severe. In some asthma attacks, swelling in the airways
can completely prevent oxygen from reaching the lungs, which also stops it entering the
bloodstream and traveling to vital organs. This type of asthma attack can be fatal and requires
urgent hospitalization. Www. medical news today.com

At the start of an asthma attack, the airways allow enough air into the lungs, but it does not
let the carbon dioxide leave the lungs at a fast enough rate. Carbon dioxide is poisonous if the
body does not expel the gas, and a prolonged asthma attack might lead to a build-up of the
gas in the lungs. This might further reduce the amount of oxygen entering the bloodstream.

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People with clear symptoms of asthma should visit a doctor. They will provide treatments
and advice on management techniques, as well as identifying potential triggers for asthma
symptoms and how to avoid them. The doctor will also prescribe medications to help reduce
the frequency of attacks asthma. Effective asthma control reduces the impact of the condition
on everyday living4.

It is a widely prevalent disease, affecting the children, young and even in adults. It is a
disease characterized by increased responsiveness of the trachea and bronchi to the various
stimuli, and is manifested by widespread narrowing of the airway passage that changes in
severity3. In recent decades there has been an increase in the burden of the disease among
both children and adults. This is mainly attributed to increasing atmospheric pollution, the
changing life-style, increasing industrialization and urbanization. The symptoms of asthma
include recurrent episodes of wheezing, chest tightness, shortness of breath and coughing. An
asthma attack is a sudden worsening of asthma symptoms caused by tightening of muscles
around the airways. During the asthma attack, the lining of the airways become swollen or
inflamed and thicker mucus-more than normal-is produced. All these factors – Inflammation,
bronchospasm, and mucus production cause symptoms of an asthma attack, such as difficulty
breathing, wheezing, coughing, shortness of breath and difficulty performing normal daily
activities. Attacks may often occur at night and may last for few minute several hours. Some
people with asthma may go for extended periods without having an asthma attack interrupted
by periodic worsening of their symptoms5.

The symptoms of asthma include recurrent episodes of wheezing, chest tightness, shortness
of breath and coughing. An asthma attack is a sudden worsening of asthma symptoms caused
by tightening of muscles around the airways.

During the asthma attack, the lining of the airways become swollen or inflamed and
thicker mucus-more than normal-is produced. All these factors – Inflammation,
bronchospasm, and mucus production cause symptoms of an asthma attack, such as difficulty
breathing, wheezing, coughing, shortness of breath and difficulty performing normal daily
activities. Attacks may often occur at night and may last for few minute several hours. Some
people with asthma may go for extended periods without having an asthma attack interrupted
by periodic worsening of their symptoms5.

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 Mild asthma attacks are generally more common and usually airways open up within
a few minutes to a few hours. Severe asthma attacks last longer and require immediate
medical treatment. People can die from severe attacks of asthma6.

There was a rapid increase in asthma prevalence throughout the world and the causes
of asthma are not well understood. The causes of asthma attacks however are better
understood. An asthma attack can occur when you are exposed to certain things in the
environment or environmental conditions that do not bother others who do not have asthma.
Such factors are called asthma triggers. When a person is exposed to these triggers an asthma
attack results5. The factors that can set off an asthma attack include inhaled allergens such as
dust mites, pollen, fungal spores, moulds, cats and dogs allergens, cigarette smoke7.
The factors that can set off an asthma attack include inhaled allergens such as dust
mites, pollen, fungal spores, moulds, cats and dogs allergens, cigarette smoke and passive
smoking and other factors like air pollution, exercise, strong emotions, chemical irritants and
certain drugs5.
Asthma control is achievable for nearly every patient, Dr. Elizabeth G. Nabel,
Director of the NHLBI said during a teleconference 4. Nabel stressed that with proper medical
care, healthy environments and better-informed patients, asthma can be controlled and people
can lead active lives. Avoiding triggers that induce or aggravate asthma attacks is an
important strategy to control asthma8.
Guided self-management may involve varying degrees of independence, ranging
broadly from patient-directed self-management to doctor-directed self-management. With
patient-directed self-management patients make changes in accordance with a prior written
action plan without needing to first contact their health care provider. With doctor-directed
self-management, patients still have a written action plan, but refer most major treatment
decisions to their physician at the time of a planned or unplanned consultation. The essential
components of effective guided asthma self -management education are
• Self -monitoring of symptoms and/or peak flow
•A written asthma action plan to show how to recognize and respond to worsening asthma;
and
• Regular review of asthma control, treatment and skills by a health care provider9.
Will permit most patients to achieve a good control of their disease. Yet the global burden of
asthma report documents ample evidence that, in many regions around the world, this goal is
often met10.
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 Health care providers are increasingly shifting asthma management from treating
acute attacks to achieving symptom- control to return patients to full functioning and improve
their quality of life7. The majority of deaths due to asthma in some regions of the world are
preventable11.
NEED FOR THE STUDY
The prevalence of asthma has increased several folds globally. More than 300 million people
around the world have asthma and its prevalence increased by 50% every decade. The disease
imposes a heavy burden on individuals, families and societies10.

There has been a sharp increase in the global prevalence, morbidity, mortality and
economic burden associated with asthma over the last 40 years. Worldwide approximately
180000 deaths annually are attributed to asthma. Most asthma deaths occur in those greater
than 45 years of age and are largely preventable. The financial burden on patients with
asthma in different countries ranges from $ 300 to $ 1300 per patient per year. According to
the Global Burden of Asthma Report, the majority of asthma deaths in some regions of the
world are preventable12.

The morbidity rates associated with asthma are dramatic. It affects school attendance,
occupation choice, physical activity and many other aspects of life. In India asthma
prevalence has increased from 9 percent in 1979 to 29.5 percent in 1999. It is a major health
burden in our country. It is estimated that the chronic asthma cases in India will increase from
274.4 lakhs to350.2 lakhs from 2001 to 201613. According to NFHS-2 Report the estimated
prevalence of asthma in India is 2468 for 1 lakh population. The prevalence rate was 2309
among those in the age group of 15 to 59 years. Asthma has recorded to be high in Karnataka
above national average. The prevalence of severe asthma in Bangalore has shown an increase
and reached 6.5 % during 199913.

A study conducted by Aggarwal A.N and Chaudary K to estimate the prevalence of

bronchial asthma in Indian adults in different regions of India. Data from 73605 respondents
was obtained and analyzed. Prevalence estimates of asthma in adults in the study point to a
high overall national burden of disease14.

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 A study was conducted to estimate the cost and characterize the management of
asthma attacks. The attacks were classified as mild in 43.6% of cases, moderately severe in
43.6 % and severe in 12.8%. The more severe the attack, the less preventive treatment the
patient has received previously. The mean cost of treating asthma attack was 166.7 of which
80 % were direct costs and 20 % were indirect costs15.

Asthma, a disease of attacks and remissions continues to account for substantial

morbidity and direct economic costs. Knowledge of potential environmental determinants of
asthma is important to both the patient and healthcare professional in the application of
multiple modalities of medical and interventions for management of the development, and
exacerbation of this chronic respiratory disease16.

Centers for Disease Control and Prevention (CDC) analyzed the data from the 2003
NHIS. The results of the analysis indicated that the prevalence of asthma education varied by
sex, age, group, race or ethnicity and health insurance status. The findings also suggest that a
substantial proportion of youths and adults with current asthma lack the knowledge necessary
for effective self-management and control of asthma symptoms17.

A study conducted on adult asthmatics revealed that carefully designed asthma

education programme for adults can improve patients understanding of their condition and
increase their motivation and confidence that the condition can be controlled, thereby
increasing their adherence to the treatment regimen and management of symptoms and in
turn improving control of asthma18.

Based on the above findings and the investigators personal experience with asthmatic
patients attending OPD and admitted to the hospital identified that Bronchial asthma cases
are considerably large in numbers and found that bronchial asthma patients who experienced
recurrent attacks of asthma lack the knowledge regarding the disease condition and
preventive measures, and show poor compliance to treatment. Hence the investigator felt the
need to assess their knowledge and practices regarding prevention of recurrent attacks of
asthma as well as preparing and providing the self- instructional module on prevention and
control of asthma.