Different courses of disease

Content
Asthma
“Chronic bronchitis” (chronic obstructive Bronchitis)
Emphysema
Obstruction
“Mixed type”
How can we differentiate among the type of asthma and the types of chronic bronchitis?

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Type „Asthma“(6/2016)

Age 1 to 5:
In the first 5 years of life only different kinds of asthma (no chronic bronchitis) occur. In many children the disease starts with Neurodermitis a disease of the skin, often beginning with milk crust, followed be eczema in the bends of the joints. We also find dry and itchy skin and sometimes scales.
We might find a hay fever from the age of 3: burning and itching eyes, wet eyes, itching and wet nose, blocked nose. Often we find these symptoms depending on the release of different pollen. If we are allergic to cats these symptoms may occur too.
With some children the disease already starts within the first year of life. Others might be susceptible to infections. We might find a dry cough even if they are free of an infection. Infections might last for a longer time or even heal as expected but be followed by a spate of cough for several weeks or months. However we distinguish croup from this cough and wheezing in infections. Later we may sometimes ask the question, whether the cough was not asthma or the child was suffering from both, asthma and croup.
Age 6 to 12:
Children who were susceptible to infections in their first years of life are better now. In these years we see more often shortness of breath when playing football or doing other sports. Sometimes they suffer from asthma-attacks, sometimes only from weaker symptoms. A few children and their families and teachers try to arrange with the disease. Children affected by these symptoms do not exercise. No one is aware of the breathlessness. These children are quiet and parents like it.
Neurodermitis has disappeared but hay fever may lead to severe symptoms, cough and breathlessness. However these symptoms are seasonal.
Puberty:
2 out of 3 patients suffering from asthma now feel relieve. Cough and breathlessness now gradually subside. With the remaining symptoms one can coup better than before. However, others do not feel any symptom at all. Finally asthma has disappeared. The patient has grown out of it.
One third of the patients does not feel so well. Symptoms remain nearly to the same extent or decrease slightly.
Chronic bronchitis in childhood is the exception. I would not use this term in connection with children.
Age 15 to 35:
In these years of life severe asthma may occur, but it is rare. Most people suffering from asthma now achieve the best quality of life they will ever experience. Some people experience this period for more than ten years, some only for a brief time. The patient may frequently clear his throat, often without noticing. Parents or friends will notice it first. The ability for exertion will be sufficient to lead a normal life. Only strong exertions will cause breathlessness. This can be avoided by going by car or by lift. Quiet a few people can do sports actively.
The hay fever often subsides in these years of life too. It becomes gradually weaker over one or two decades.
Age 35 to 50:
Cough has become worse in recent years. In winter the cough used to be stronger than in summer. Between these phases there used to be times with hardly any cough. So it takes time before deciding and see the doctor. On closer examination symptoms of breathlessness have increased too. Yet they did not limit normal life. Only they felt it during exertion. Many patients have arranged with these facts.
Cause for new symptoms may be a house dust mite allergy. An other possibility is that asthma has changed into a form of nonallergic asthma or a combination of both. We often find sneezing and a running nose, in worse cases even sinusitis.
Age 50 to 90:
Cough, phlegm, shortness of breath or even breathlessness vary in their extend. Infection increase complaints. Between infections patients get better, but symptoms will increase or decrease depending on the weather and other external factors.
Becoming older extreme symptoms often disappear. Asthma attacks become less frequent. Complaints remain the same over long time. Physicians speak about a fixing of the obstruction of bronchi or transformation to COPD.
We rarely find an onset of asthma in old age. In these cases it is often severe, difficult to treat and not caused by allergies.
We find some special forms of asthma known, such as aspirin-sensitive asthma. This special form of asthma more often starts in adulthood. (Children are not treated with aspirin, but I think, that is not the only reason for this fact) The development of this form of asthma is often more severe than allergic asthma.
Recently a new type of asthma has been differentiated, asthma in overweight women. Before long we will probably be able to differentiate more than half a dozen types of asthma.

Typ “Chronic bronchitis” (chronic obstructive bronchitis)(8/2015)
Age 1 – 20:
In these years the genetic disposition of chronic bronchitis nearly never leads to symptoms of a chronic bronchitis. However, in exceptional cases we find such symptoms. In most of these cases these symptoms are caused by a malformation of the lungs at birth, Bronchiectasia, Cystic fibrosis, foreign bodies in the bronchi or similar things.
Age 20 – 30:
In young adults we often do not find any symptoms either.
Age 30 – 50:
In these years we often find the first symptoms like feeling a lump in one’s throat. It feels like phlegm or like a foreign body in one’s throat. Patients often clear their throats and this without any obvious reason. Complaints are more severe after infections and in winter than in summer. Consequently at the beginning we usually find periods without symptoms. That’s why meanwhile the patient assumes to be recovered. In the following years winter starts earlier and ends later, summer becomes shorter and some years later symptoms remain throughout the year. Symptoms further are strongest in winter and weaker in summer.
Frequently the bronchi are easily irritated by foam, dust and humid air, either warm or cold. Even exposure to smoke often irritates airway that’s why it is avoided.
If we are exposed to such external factors, symptoms often increase fast and after the end of the irritation decrease slowly.
Many people suffering from chronic bronchitis become susceptible to infections. Others hardly get any infection. During infections cough and phlegm frequently get worse. Unfortunately symptoms may remain worse after the recovering compared to the time before infection.
Age 50 – 90:
Not all, but most people suffering from chronic bronchitis develop shortness of breath sooner or later. At first it is felt during extreme exertion. Later on it limits exertion sooner and sooner. Finally breathlessness occurs at night and even when just sitting in a chair. In these cases we can rarely achieve a higher capacity of exertion.
Today’s medicine is rarely able to prevent this development. The tendency to become worse nevertheless can be often avoided by consequent treatment. Therefore it is worth starting treatment rather earlier than later although a full recovery cannot be achieved. Lifespan may be shorter but not necessarily. More important is the reduction of quality of life for our patients. The focus of treatment is not necessarily on extending life but increasing the quality of life.
You might have heard the term “Blue bloater”. It belongs to this type of chronic bronchitis. These people tend to be overweight. When suffering from an advanced stage of the disease and having low oxygen in their blood their body does not feel it strongly. Their lung responds to the more difficult breathing with reduction of breathing to avoid fatigue.

Typ “Emphysema” (9/2015)
Age 1 – 20:
In childhood and adolescence these people feel quite good health in spite of their genetic disposition. There might be some young people different from average because they can not perform as well as others in sports. They do not complain of shortness of breath. They can often not clearly say why they are not so good at sports. And because many of these people feel embarrassed with their poor achievement, nobody speaks about it.
Age 20 – 30:
Many do not feel anything wrong even now. Some people start coughing a little bit. They feel a scratching in their throat. Rarely some phlegm appears. Mainly they suffer from a simple dry cough they can not get rid of.
Some patients are seen first by the doctor because of a spontaneously Pneumothorax (a leakage in the skin of the lung, so the lung collapses). Other symptoms at this age are often absent.
Age 30 – 50:
The dry cough slowly increases but it does not hurt. These patients rarely suffer from infections. After such a rare infection their condition often is not as good as before. Dominant there is a slow decrease of physical strength because of the shortness of breath.
Age 50 – 90:
The dry nervous cough becomes more or less persistent. Physical capacity meanwhile decreases step by step caused by shortness of breath and later breathlessness. The physical strength rarely oscillates. The limit of the capacity for exertion remains low no matter what happens.
We find a reduction of blood oxygen. Our body tries to compensate this by breathing deeper and faster but the ability for compensation is limited. Persons concerned often loose weight and rarely can gain some grams of weight. “Pink puffers” belong to this type of patients. Medication betters this disease only to a small extent. Medication widening bronchi affords a little relief. Later on they may need therapy with oxygen.
If there are bigger air cysts in the lung, surgical resection of them or of a part of the lung may be helpful. In special cases the use of valves or wire may be useful.
It is important for the prognosis to avoid infections.
Also known is one type of emphysema, which is caused by a lack or decreased amount of one enzyme (Alpha-1-antitrypsin or Alpha-1-proteaseinhibitor). The disease is called Alpha-1-antitrypsin-deficiency-emphysema. In special cases substitution of the enzyme may slow down the progress of the illness.

Type “Obstruction”(9/2015)
Age 1 – 20:
Inspite of the genetic disposition there are often no symptoms at this age.
Age 20 – 30:
Even in their twenties many people concerned do not feel anything.
Age 30 – 50:
Bit by bit people concerned start coughing dryly a little bit. They feel a scratching in their throat. Once in a while a small mucous lump is coughed up. Mainly a mild to moderate cough occurs which is not possible to get rid of.
These patients do not suffer from many infections. However, if they do suffer from such a rare infection their condition often remains worse. But they rarely feel it themselves. In the results of their lung function test we see it often more clearly. Dominant we find a slow decrease in the capacity for exertion due to the increase of breathlessness. Patients cope with the reduced abilities by driving by car or taking the lift or jogging or going more slowly, even often take a break. They do not realize this limitation or they forget about it. Nevertheless, the results of the lung function test at the pneumologist are alarmingly poor.
Unless an infection of the airways is worsening the disease the condition may remain stable for a long time. External influences rarely do impair the function of these lungs. The limitation remains nearly stable for a long time and only decreases a little.
Age 50 – 90:
Sooner or later a condition is reached when only one staircase can be climbed without taking a break or the distance which the patient can walk straight on without break decreases beneath 100 m. In an appropriate environment (car and lift etc.) even now people remain independently. In this way the limitations may rarely be felt by the patient. Like in the type “Emphysema” later on we find low levels of oxygen in the blood. Quite often patients die from other diseases. The pulmonary disease only decreased their quality of life and patients themselves rarely did realize this fact.

Type “Mixed type”
Among pulmonary diseases we mentioned there are several mixed forms. That’s why not each patient can be put in one of these four categories.
As consequence we find terms like “asthmatic bronchitis” or “chronic bronchitis with emphysema”. The four types of obstructive lung diseases are nowadays defined by measured results. But the diseases are much more substantial than can ever be expressed by measured results. It is like a puzzle to be solved by the pneumologist.

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How can we differentiate among the type of asthma and the types of chronic bronchitis? (10/2015)
As shown in the chapter “developments of diseases” we may find different characteristic histories of asthma and such of chronic bronchitis in the course of a patient life. However, we often find mixed types which can not be clearly distinguished. In consequence we find many individual histories.
Typically asthma is a disease of young people which often starts already in childhood. Chronic bronchitis is rarely found before the age of thirty. Often it occurs in the second half of life.
In two out of three cases asthma is caused by allergies, whereas chronic bronchitis is not connected with allergies.
Asthma often shows a wide range of symptoms, from days without attacks from asthma to severe fits of cough. Chronic bronchitis shows a long and over the years slow increase of complaints, at the beginning still with periods free from symptoms. During infections the condition becomes worse. After recovery the feeling sometimes remains worse.
In childhood many people suffering from asthma are very susceptible to infections. Probably this susceptibility to infections is often not caused by a deficiency in the immune system but by the inflammation of the mucoid layer in the bronchi. This mucoid layer nearly always suffers from a kind of eczema. However, we can not see it from outside. If we saw this mucoid skin, we would always be seeing the GP and he would always prescribe a cortisone-medication against inflammation. If this assumption were right, the immune system of asthmatics would be better trained than that of healthy people because it wards off more infections. The inflamed mucoid skin in the bronchi is the problem. It is not able to defend the microorganisms. However, with each breath we breathe in bacteria and viruses.
A good asthma-therapie can often be recognized when the susceptibility to infections disappears. However, treatment has to be continued for a long period of time. In the years spend at school susceptibility to infections mostly disappears spontaneously. Asthma now is transformed in another phase.
People suffering from chronic bronchitis may suffer from a susceptibility to infections too (in each type but most frequently in the type “chronic bronchitis”). In these cases the susceptibility is more difficult to be treated. It takes more medication and more time for each infection than in asthma. More rarely the condition before the infection can be achieved again. Treatment is more difficult than in asthma. However, some people suffering from a type of chronic bronchitis do not suffer from many infections.