Classification of Asthma:

Asthma is clinically classified according to the frequency of symptoms, forced expiratory volume in 1 second (FEV₁), and peak expiratory flow rate ²⁵. Asthma may also be classified as atopic (extrinsic) or non-atopic (intrinsic), based on whether symptoms are precipitated by allergens (atopic) or not (non-atopic) ²⁶

While asthma is classified based on severity, at the moment there is no clear method for classifying different subgroups of asthma beyond this system²⁷. Finding ways to identify subgroups that respond well to different types of treatments is a current critical goal of asthma research²⁷.

Although asthma is a chronic obstructive condition, it is not considered as a part of chronic obstructive pulmonary disease as this term refers specifically to combinations of disease that are irreversible such as bronchiectasis, chronic bronchitis, and emphysema ²⁸. Unlike these diseases, the airway obstruction in asthma is usually reversible; however, if left untreated, the chronic inflammation from asthma can lead the lungs to become irreversibly obstructed due to airway remodeling ²⁹. In contrast to emphysema, asthma affects the bronchi, not the alveoli ³⁰.

Clinical classification of severity ²⁵(Table 1)

Allergic Asthma:

Ninty Percent of all asthma sufferer have a allergic asthma. Allergic asthma is triggers by allergen-substance that causing the allergic reaction.

Asthma attack

An acute asthma exacerbation is commonly referred to as an asthma attack. The classic symptoms are shortness of breath, wheezing, and chest tightness. While these are the primary symptoms of asthma,some people present primarily with coughing, and in severe cases, air motion may be significantly impaired such that no wheezing is heard.

Exercise-induced Asthma

If you cough, wheeze or feel out of breath during or after exercise, you could be suffering from exercise-induced asthma. Obviously, your level of fitness is also a factor - a person who is unfit and runs fast for ten minutes is going to be out of breath. However, if your coughing, wheezing or panting does not make sense, this could be an indication of exercise-induced asthma.

As with other types of asthma, a person with exercise-induced asthma will experience difficulty in getting air in and out of the lungs because of inflammation of the bronchial tubes (airways) and extra mucus.

Some people only experience asthma symptoms during physical exertion. The good news is that with proper treatment, a person who suffers from exercise-induced asthma does not have to limit his/her athletic goals. With proper asthma management, one can exercise as much as desired. Mark Spitz won nine swimming gold medals during the 1972 Olympics and he suffered from exercise-induced asthma.

Exercise-induced urticaria, or anaphylaxis, is often presumed to be related to EIA, even though this condition is extremely rare and unrelated. EIA is related to histamine release ^{31,
32, 33}.Only 500-1000 cases of exercise-induced urticaria have been reported in the literature. In this condition, there is an early stage of exercise-related fatigue and itchiness, followed by early onset of urticaria and angioedema, which is initially mild ³⁴.If progression occurs, there is choking, stridor, nausea, vomiting, and even hypotension. A late stage that is marked by headache may also occur. As implied by the alternative name of anaphylaxis, EIA can be life threatening; however, this can be prevented by exercise modification or avoidance of certain conditions

Cough-Induced Asthma

Cough-induced asthma is one of the most difficult asthmas to diagnose. The doctor has to eliminate other possibilities, such as chronic bronchitis, post nasal drip due to hay fever, or sinus disease. In this case the coughing can occur alone, without other asthma-type symptoms being present. The coughing can happen at any time of day or night. If it happens at night it can disrupt sleep.

Occupational Asthma

This type of asthma is triggered by something in the patient's place of work. Factors such as chemicals, vapors, gases, smoke, dust, fumes, or other particles can trigger asthma. It can also be caused by a virus (flu), molds, animal products, pollen, humidity and temperature. Another trigger may be stress. Occupational asthma tends to occur soon after the patients starts a new job and disappears not long after leaving that job.

Asthma as a result of (or worsened by) workplace exposures is a commonly reported occupational respiratory disease. Still most cases of occupational asthma are not reported or are not recognized as such. Estimates by the American Thoracic Society (2004) suggest that 15–23% of new-onset asthma cases in adults are work related ³⁵. In one study monitoring workplace asthma by occupation, the highest percentage of cases occurred among operators, fabricators, and laborers (32.9%), followed by managerial and professional specialists (20.2%), and in technical, sales, and administrative support jobs (19.2%). Most cases were associated with the manufacturing (41.4%) and services (34.2%) industries. ³⁶

Nocturnal asthma:

Nocturnal asthma occurs between midnight and 8 AM. It is triggered by allergens in the home such as dust and pet dander or is caused by sinus conditions. Nocturnal or nighttime asthma may occur without any daytime symptoms recognized by the patient. The patient may have wheezing or short breath when lying down and may not notice these symptoms until awoken by them in the middle of the night - usually between 2 and 4 AM.

Nocturnal asthma may occur only once in a while or frequently during the week. Nighttime symptoms may also be a common problem in those with daytime asthma as well.

Steroid-Resistant Asthma (Severe Asthma)

While the majority of patients respond to regular inhaled glucocorticoid (steroid) therapy, some are steroid resistant. Airway inflammation and immune activation play an important role in chronic asthma. Current guidelines of asthma therapy have therefore focused on the use of anti-inflammatory therapy, particularly inhaled glucocorticoids (GCs). By reducing airway inflammation and immune activation, glucocorticoids are used to treat asthma. However, patients with steroid resistant asthma have higher levels of immune activation in their airways than do patients with steroid sensitive (SS) asthma.

Furthermore, glucocorticoids do not reduce the eosinophilia (high concentration of eosinophils granulocytes in the blood) or T cell activation found in steroid resistant asthmatics. This persistent immune activation is associated with high levels of the immune system molecules IL-2 (interleukin 2), IL-4 and IL-5 in the airways of these patients.

Causes of Asthma:

Asthma is caused by environmental and genetic factors. These factors influence how severe asthma is and how well it responds to medication.

Genes

Genes linked to asthma also play roles in managing the immune system and inflammation. There have not, however, been consistent results from genetic studies across populations - so further investigations are required to figure out the complex interactions that cause asthma.

Mom and Dad may be partially to blame for asthma, since three-fifths of all asthma cases are hereditary. The Centers for Disease Control (USA) say that having a parent with asthma increases a person's risk by three to six times.

Genetics may also be interacting with environmental factors. For example, exposure to the bacterial product endotoxin and having the genetic trait CD14 (single nucleotide polymorphism (SNP) C-159T) have remained a well-replicated example of a gene-environment interaction that is associated with asthma.

Airway Hyperreactivity

Researchers are not sure why airway hyperreactivity is another risk factor for asthma, but allergens or cold air may trigger hyperreactive airways to become inflamed. Some people do not develop asthma from airway hyperreactivity, but hyperreactivity still appears to increase the risk of asthma.

Atopy

Atopy - such as eczema (atopic dermatitis), allergic rhinitis (hay fever), allergic conjunctivitis (an eye condition) - is a general class of allergic hypersensitivity that affects different parts of the body that do not come in contact with allergens. Atopy is a risk factor for developing asthma.

Some 40% to 50% of children with atopic dermatitis also develop asthma, and it is probable that children with atopic dermatitis have more severe and persistent asthma as adults.

Environmental

Allergic reactions and asthma symptoms are often the result of indoor air pollution from mold or noxious fumes from household cleaners and paints. Other indoor environmental factors associated with asthma include nitrogen oxide from gas stoves. In fact, people who cook with gas are more likely to have symptoms such as wheezing, breathlessness, asthma attacks, and hay fever.

Pollution, sulfur dioxide, nitrogen oxide, ozone, cold temperatures, and high humidity have all been shown to trigger asthma in some individuals.

During periods of heavy air pollution, there tend to be increases in asthma symptoms and hospital admissions. Smoggy conditions release the destructive ingredient known as ozone, causing coughing, shortness of breath, and even chest pain. These same conditions emit sulfur dioxide, which also results in asthma attacks by constricting airways.

Weather changes have also been known to stimulate asthma attacks. Cold air can lead to airway congestion, bronchoconstriction (airways constriction), secretions, and decreased mucociliary clearance (another type of airway inefficiency). In some populations, humidity causes breathing difficulties as well.

Many environmental risk factors have been associated with asthma development and morbidity in children. Recent studies show a relationship between exposure to air pollutants (e.g. from traffic) and childhood asthma ³⁷.This research finds that both the occurrence of the disease and exacerbation of childhood asthma are affected by outdoor air pollutants. High levels of endotoxin exposure may contribute to asthma risk ³⁸.

Obesity

Overweight adults - those with a body mass index (BMI) between 25 and 30 - are 38% more likely to have asthma compared to adults who are not overweight. Obese adults - those with a BMI of 30 or greater - have twice the risk of asthma. According to some researchers, the risk may be greater for nonallergic asthma than allergic asthma.

Pregnancy

The way you enter the world seems to impact your susceptibility to asthma. Babies born by Caesarean sections have a 20% increase in asthma prevalence compared to babies born by vaginal birth. It is possible that immune system-modifying infections from bacterial exposure during Cesarean sections are responsible for this difference.

When mothers smoke during pregnancy, their children have lower pulmonary function. This may pose additional asthma risks. Research has also shown that premature birth is a risk factor for developing asthma.

Stress

People who undergo stress have higher asthma rates. Part of this may be explained by increases in asthma-related behaviors such as smoking that are encouraged by stress. However, recent research has suggested that the immune system is modified by stress as well.

Tobacco

Tobacco smoke has been linked to a higher risk of asthma as well as a higher risk of death due to asthma, wheezing, and respiratory infections. In addition, children of mothers who smoke - and other people exposed to second-hand smoke - have a higher risk of asthma prevalence. Adolescent smoking has also been associated with increases in asthma risk.

Maternal tobacco smoking during pregnancy and after delivery is associated with a greater risk of asthma-like symptoms, wheezing, and respiratory infections during childhood.

Volatile organic compounds

Observational studies have found that indoor exposure to volatile organic compounds (VOCs) may be one of the triggers of asthma, however experimental studies have not confirmed these observations ³⁹. Even VOC exposure at low levels has been associated with an increase in the risk of pediatric asthma.

Phthalates

There is a significant association between asthma-like symptoms (wheezing) among preschool children and the concentration of DEHP (phthalates) in indoor environment. DEHP (di-ethylhexyl phthalate) is a plasticizer that is commonly used in building material. The hydrolysis product of DEHP (di-ethylhexyl phthalate) is MEHP (Mono-ethylhexyl phthalate) which mimics the prostaglandins and thromboxanes in the airway leading to symptoms related to asthma.Another mechanism that has been studied regarding phthalates causation of asthma is that high phthalates level can "modulate the murine immune response to a coallergen".

Exacerbation

Some individuals will have stable asthma for weeks or months and then suddenly develop an episode of acute asthma. Different asthmatic individuals react differently to various factors. However, most individuals can develop severe exacerbation of asthma from several triggering agents.

Socioeconomic factors

There is good research evidence of links between the prevalence of some forms of asthma and the degree of affluence in the society concerned. This could possibly be due to the 'hygiene factor', whereby lack of childhood exposure to some environmental irritants increases the sensitivity of susceptible people to develop asthma on later exposure.

Allergies

Almost all asthma sufferers have allergies. In fact, over 25% of people who have hay fever (allergic rhinitis) also develop asthma. Allergic reactions triggered by antibodies in the blood often lead to the airway inflammation that is associated with asthma.

Common sources of indoor allergens include animal proteins (mostly cat and dog allergens), dust mites, cockroaches, and fungi. It is possible that the push towards energy-efficient homes has increased exposure to these causes of asthma.

Symptoms of Asthma:

Asthma is characterized by inflammation of the bronchial tubes with increased production of sticky secretions inside the tubes. People with asthma experience symptoms when the airways tighten, inflame, or fill with mucus. Common asthma symptoms include:

· Coughing, especially at night

· Wheezing

· Shortness of breath

· Chest tightness, pain, or pressure

Still, not every person with asthma has the same symptoms in the same way. You may not have all of these symptoms, or you may have different symptoms at different times. Your asthma symptoms may also vary from one asthma attack to the next, being mild during one and severe during another.

Some people with asthma may go for extended periods without having any symptoms, interrupted by periodic worsening of their symptoms called asthma attacks. Others might have asthma symptoms every day. In addition, some people may only have asthma during exercise or asthma with viral infections like colds.

Mild asthma attacks are generally more common. Usually, the airways open up within a few minutes to a few hours. Severe attacks are less common but last longer and require immediate medical help. It is important to recognize and treat even mild asthma symptoms to help you prevent severe episodes and keep asthma under better control.

Early warning signs are changes that happen just before or at the very beginning of an asthma attack. These signs may start before the well-known symptoms of asthma and are the earliest signs that your asthma is worsening.

In general, these signs are not severe enough to stop you from going about your daily activities. But by recognizing these signs, you can stop an asthma attack or prevent one from getting worse. Early warning signs of asthma include:

· Frequent cough, especially at night

· Losing your breath easily or shortness of breath

· Feeling very tired or weak when exercising

· Wheezing or coughing after exercise

· Feeling tired, easily upset, grouchy, or moody

· Signs of a cold or allergies (sneezing, runny nose, cough, nasal congestion, sore throat)

· Trouble sleeping

If you have early warning signs or symptoms of asthma, you should take more asthma medication as described in your asthma action plan.

Symptoms of an Asthma Attack

An asthma attack is the episode in which bands of muscle surrounding the airways are triggered to tighten. This tightening is called bronchospasm. During the attack, the lining of the airways becomes swollen or inflamed and the cells lining the airways produce more and thicker mucus than normal.

All of these factors -- bronchospasm, inflammation, and mucus production -- cause symptoms such as difficulty breathing, wheezing, coughing, shortness of breath, and difficulty performing normal daily activities. Other symptoms of an asthma attack include:

· Severe wheezing when breathing both in and out

· Coughing that won't stop

· Very rapid breathing

· Chest pain or pressure

· Tightened neck and chest muscles, called retractions

· Difficulty talking

· Feelings of anxiety or panic

· Pale, sweaty face

· Blue lips or fingernails

· The severity of an asthma attack can escalate rapidly, so it's important to treat these asthma symptoms immediately once you recognize them.

· Without immediate treatment, such as with your asthma inhaler or bronchodilator, your breathing will become more labored. If you use a peak flow meter at this time, the reading will probably be less than 50%.

· As your lungs continue to tighten, you will be unable to use the peak flow meter at all. Gradually, your lungs will tighten so there is not enough air movement to produce wheezing. This is sometimes called the "silent chest," and it is an ominous sign. You need to be transported to a hospital immediately. Unfortunately, some people interpret the disappearance of wheezing as a sign of improvement and fail to get prompt emergency care.

· If you do not receive adequate asthma treatment, you will eventually be unable to speak and will develop a bluish coloring around your lips. This color change, known as cyanosis, means you have less and less oxygen in your blood. Without aggressive treatment for this asthma emergency, you will lose consciousness and eventually die.

· If you are experiencing an asthma attack, follow the "Red Zone" or emergency instructions in your asthma action plan immediately. These symptoms occur in life-threatening asthma attacks. You need medical attention right away.

Diagnosing of Asthma:

Asthma diagnoses are based on three core components: a medical history, a physical exam, and results from breathing tests. A primary care physician will administer tests and, if you have asthma, determine your level of asthma severity as intermittent, mild, moderate, or severe.

Medical History

A detailed family history of asthma and allergies can help your doctor make an accurate asthma diagnosis. Your own personal history of allergies is also important as many are closely linked to asthma.

Information about asthma symptoms is also useful. Be prepared to divulge when and how often they occur and what factors seem to exacerbate or worsen symptoms. Common symptoms and signs include:

Wheezing, Coughing, Breathing difficulty, Tightness in the chest, Worsening symptoms at night, Worsening symptoms due to cold air, Symptoms while exercising, Symptoms after exposure to allergens.

It is also wise to make note of health conditions that can interfere with asthma management such as runny nose, sinus infections, acid reflux disease, psychological stress, and sleep apnea.

It is often somewhat harder to diagnose young children who may develop their first asthma symptoms before age 5. Symptoms are likely to be confused with those of other childhood conditions, but young children with wheezing episodes during colds or respiratory infections are likely to develop asthma after 6 years of age.

Physical Exam

A physical examination will generally focus on the upper respiratory tract, chest, and skin. A doctor will use a stethoscope to listen for signs of asthma in your lungs as you breathe. The high-pitched whistling sound while you exhale - or wheezing - is a key sign of both an obstructed airway and asthma.

Physicians will also check for a runny nose, swollen nasal passages, and nasal polyps. Skin will be examined for conditions such as eczema and hives, which have been linked to asthma.

Physical symptoms are not always present in asthma sufferers, and it is possible to have asthma without presenting any physical maladies during an examination.

Asthma Tests

Lung function tests, or pulmonary function tests, are the third component of an asthma diagnosis. To measure how much air you breathe in and out and how fast you can blow air out, physicians administer a spirometry test.

Spirometry is a noninvasive test that requires you to take deep breaths and forcefully exhale into a hose connected to a machine called a spirometer. The spirometer then displays two key measurements:

Forced vital capacity (FVC) - the maximum amount of air one can inhale and exhale

Forced expiratory volume (FEV-1) - the maximum amount of air exhaled in one second

The measurements are compared against standards developed for a person's age, and measurements below normal may indicate obstructed airways.

It is common for a doctor to administer a bronchodilator drug to open air passages before retesting with the spirometer. If results improve after the drug, there is a higher likelihood of receiving an asthma diagnosis.

Children younger than 5 years of age are difficult to test using spirometry, so asthma diagnoses will rely mostly on symptoms, medical histories, and other parts of the physical examination. It is common for doctors to prescribe asthma medicines for 4 to 6 weeks to see how a young child responds.

Other Tests

A "Challenge Test" (or bronchoprovocation test) is when a physician administers an airway-constricting substance (or something as simple as cold air) to deliberately trigger airway obstruction and asthma symptoms. Similarly, a challenge test for exercise-induced asthma would consist of vigorous exercise to trigger symptoms. A spirometry test is then administered, and if measurements are still normal, an asthma diagnosis is unlikely.

Physicians use allergy tests to identify substances that may be causing or worsening asthma. These tests cannot be used to diagnose asthma, but they can be used to understand the nature of asthma symptoms.

Doctors may also test for another disease with similar symptoms as asthma, such as reflux disease, heartburn, hay fever, sinusitis, sleep apnea, chronic obstructive pulmonary disease (COPD), airway tumors, airway obstruction, bronchitis, lung infection (pneumonia), blood clot in the lung (pulmonary embolism), congestive heart failure, vocal cord dysfunction, and viral lower respiratory tract infection.

Tests may be administered for these ailments such as chest x-rays, EKGs (electrocardiograms), complete blood counts, CT (computerized tomography) scans of the lungs, gastroesophageal reflux assessment, and sputum induction and examination.

A new test using exhaled nitric oxide is being evaluated since physicians are looking for a test that is more accurate than spirometry. Higher levels of nitric oxide are linked to higher degrees of asthma severity. The current drawback lies in the high cost of the test and the specialized equipment required to measure this chemical marker.

Medication of Asthma:

Medication plays a key role in gaining good control of your asthma. Asthma is a chronic (lifelong) disease that involves inflammation of the airways superimposed with recurrent episodes of decreased airflow, mucus production, and cough. Choosing the proper asthma medication is crucial in avoiding asthma attacks and living an active life.

Treatment with asthma medication focuses on:

· Taking asthma medication that controls inflammation and prevents chronic symptoms such as coughing or breathlessness at night, in the early morning, or after exertion (long-term control medications)

· Providing asthma medication to treat asthma attacks when they occur (quick-relief asthma medication)

· Avoiding asthma triggers

· Monitoring daily asthma symptoms in an asthma diary

· Monitoring peak flows with daily asthma tests

There are two general types of asthma medication which can give you long-term control or quick relief of symptoms.

· Anti-inflammatory drugs. This is the most important type of therapy for most people with asthma because these asthma medications prevent asthma attacks on an ongoing basis. Steroids, also called "corticosteroids," are an important type of anti-inflammatory medication for people suffering from asthma. These asthma medications reduce swelling and mucus production in the airways. As a result, airways are less sensitive and less likely to react to triggers.

· Bronchodilators. These asthma medications relieve the symptoms of asthma by relaxing the muscle bands that tighten around the airways. This action rapidly opens the airways, letting more air come in and out of the lungs. As a result, breathing improves. Bronchodilators also help clear mucus from the lungs. As the airways open, the mucus moves more freely and can be coughed out more easily.

These asthma medications can be administered in different ways. Successful treatment should allow you to live an active and normal life. If your asthma symptoms are not in good control, you should contact your doctor for advice and look at a different asthma medication that may work best for you.

NOTE: A newer asthma medication, called Xolair, works by inhibiting the allergic reaction that often causes constriction of the airways. It works by blocking proteins in the immune system from becoming activated, an underlying cause of allergic asthma symptoms.

Long-Term Control Asthma Medications

Doctors and asthma specialists recognize that asthma has two main components: airway inflammation and acute bronchoconstriction (constriction of the airways). Research has shown that reducing and preventing further inflammation is the key to preventing asthma attacks, hospitalizations, and death from asthma.

Long-term control asthma medications are taken daily over an extended period of time to achieve and maintain control of persistent asthma (asthma that causes symptoms more than twice a week and frequent attacks that affect activity).

The most effective long-term control asthma medications are those that stop airway inflammation (anti-inflammatory drugs), but there are others that are often used along with anti-inflammatory drugs to enhance their effect.

Long-term control asthma medications include:

· Corticosteroids (The inhaled form is the anti-inflammatory drug of choice for persistent asthma.)

· Mast cell stabilizers (anti-inflammatory drugs)

· Long acting beta-agonists (bronchodilators often used along with an anti-inflammatory drug)

· Theophylline (a bronchodilator used along with an anti-inflammatory drug to prevent nighttime symptoms)

· Leukotriene modifiers (an alternative to steroids and mast cell stabilizers)

· Xolair (an injectable asthma medication used when inhaled steroids for asthma failed to control asthma symptoms in people with moderate to severe asthma who also have allergies)

Table 2: brief review of antiasthmatic plants

Plants	Family	Chemical constituents	Mechanism of action
Achillea mellifolium	Asteraceae (compositae)	Alkaloids	Inhibits action of histamine, acetylcholine and 5-HT
Achyranthes aspera	Amaranthaceae	Saponin C , Saponin D	Mast cell stabilizer
Acorus calamus	Araceae	Asarone	Inhibits action of histamine, acetylcholine and 5-HT
Adhatoda vasica	Acanthaceae	Alkaloids	1. Bronchodilator 2. Anti-anaphylactic
Aegle marmelos	Rutaceae	Alkaloid-aegeline	Antihistaminic
Albizzia lebbeck	Leguminosae	Alkaloids, tannins, flavonoids,	1. Bronchodilator 2. Mast cell stabilizer
Allium cepa	Liliaceae	Quercetin	1. Mast cell stabilizer 2. Lipoxygenase inhibitor 3. PAF inhibitor 4. COX inhibitor
Ammi visnaga	Umbelliferae	Khellin	Bronchodilator
Artemisia vulgaris	Asteraceae	Artemisin	-----
Asystasia gangetica	Acanthaceae	Triterpenoids, saponins, Steroidal aglycone	1. Bronchodilator 2. Anti-inflammatory
Balanites roxburghii	Simarubaceae	Alkaloids	1. Bronchodilator 2. Mast cell stabilizer
Boswellia serrata	Burseraceae	Boswellin, Boswellic acid	Inhibits leukotriene biosynthesis
Cassia sophera	Caesalpiniaceae	Flavonoids, glycosides	1. Bronchodilator 2. Antihistaminic 3. Antiallergic 4.anti-inflammatory
Cedrus deodara	Pinaceae	Himacholol	Mast cell stabilizer
Centipeda minima	Compositae	Pseudoguainolide, sesquiterpene, lactone, flavonoids	Antiallergic
Clerodendron phlomidis	Verbenaceae	Flavonoids, terpenoids, steroids	1. Antihistaminic 2. Mast cell stabilizer
Curculigo orchioides	amarylliaceae	Triterpenoids sapogenins and saponin glycosides	1. Antihistaminic 2. Anti-inflammatory
Curcuma longa	Zingiberaceae	Curcuminoids	Inhibits histamine release
Ephedra gerardiana	Ephedraceae	Ephedrine	Bronchodilator
Eucalyptus globules	Myrtaceae	Volatile oil	Anti-inflammatory
Glycyrrhiza glabra	Leguminosae	Glycyrrhizinic acid	1.Antihistaminic 2.Antiallergic
Hedychium spicatum	Zingiberaceae	Sitosterol, Volatile oil	Anti inflammatory
Inula racemosa	Asteraceae	Inulin, sesquiterpene lactone- alantolactone	Antihistaminic
Lipidum sativum	Cruciferae	Alkaloids, Flavonoids	Bronchodilator
Moringa oleifera	Morangaceae	Tannins, steroids, triterpenoids, flavonoids, alkaloids, saponins	Antihistaminic
Myrica sapida	Myricaceae	Glycosides	Mast cell stabilizer
Nigella sativa	Ranunculaceae	Volatile oil, fatty acid	Bronchodilator
Ocimum sanctum	Labiateae	Ursolic acid	Mast cell stabilizer
Passiflora incarnata	Passifloraceae	Benzoflavone	Bronchodilator
Picorrhiza kurroa	Scrophulareaceae	Picorrhizin	Antihistaminic
Solanum xanhocarpum	Solanaceae	Phyto-sterol, alkaloids, flavonoooids, Steroids	1. Antihistaminic 2. Mast cell stabilizer
Tamarindus indica	Caesalpiniaceae	Flavone, Glycosides	1.Brochodialator 2. Antihistaminic 3. Anti-inflammatory
Terminalia belerica	Combrataceae	Beta sitosterol, Gallic acid, ellagic acid, glycoside	Mast cell stabilizer
Tinospora cordifolia	Mensipermaceae	Alkaloids	1. Antihistaminic 2. Mast cell stabilizer

Quick-Relief Asthma Medications

These asthma medications are used to provide prompt relief of asthma attack symptoms (cough, chest tightness, and wheezing -- all signs of airway bronchoconstriction).

The asthma drugs include:

· Short acting beta-agonists (bronchodilators that are the drug of choice to relieve asthma attacks and prevent exercise-induced asthma symptoms)

· Anticholinergics (bronchodilators used in addition to short-acting beta-agonists when needed or as an alternative to these drugs when needed)

· Systemic corticosteroids (an anti-inflammatory drug used in an emergency to get rapid control of the disease while initiating other treatments and to speed recovery)

Inhalers, Nebulizers, and Pills as Asthma Medicine

Asthma medicines can be either inhaled, using a metered dose inhaler, dry powder inhaler, or a nebulizer, or taken orally, either in pill or liquid form. A newer type asthma medication called Xolair is given by injection just under the skin.

Some asthma medicines can be taken together. There are some inhalers that contain a combination of two different medications. These devices allow both medications to be delivered from one device, shortening treatment times and decreasing the number of inhalers needed to treat asthma symptoms.

Theophylline for Asthma

Theophylline is another type of bronchodilator that is used to control symptoms of asthma, but it is not delivered in an asthma inhaler. Theophylline is sold under the brand names Uniphyl, Theo-Dur, Slo-Bid, and Theo-24 and is available as an oral (pill and liquid) or intravenous (through the vein) drug. Theophylline is long-acting and prevents asthma attacks. Theophylline is used to treat difficult-to-control or severe asthma and must be taken daily.

Side effects of theophylline include:

· Nausea and/or vomiting, Diarrhea, Stomachache, Headache, Rapid or irregular heartbeat, Muscle cramps, Jittery or nervous feeling, Hyperactivity.

These side effects of theophylline may also be a sign of having taken too much medication. Your doctor will check your blood levels of the medication to make sure you are receiving the proper amount.

Always tell your doctors if you take theophylline for asthma because certain medications, such as antibiotics containing erythromycin, seizure medicine, and ulcer medicine can interfere with the way theophylline works. Also, make sure your doctor knows about any other medical conditions you may have, since some diseases and illnesses can change how your body responds to theophylline.

And keep in mind that not only is smoking and exposure to cigarette smoke especially dangerous for those with asthma, but smoking can also interfere with how your body responds to theophylline. Therefore, it is best to avoid smoke when possible.

Herbal drugs for Asthma:

Though the large numbers of drugs are available for the treatment of asthma, the relief offered by them is mainly symptomatic and short lived. Moreover the side effects of these drugs are also quite disturbing. Recently there has been a shift in universal trend from synthetic to herbal medicine, which we can say ‘Return to Nature’. Medicinal plants have been known for millennia and are highly esteemed all over the world as a rich source of therapeutic agents for the prevention of diseases and ailments 40. A large number of medicinal plants have been used traditionally for the treatment of asthma and have been scientifically proven to have antiasthmatic properties. Important medicinal plants having anti-asthmatic potential are Achyranthes aspera, ⁴¹ Allium cepa, ^41,
42 Adhatoda vasica,^{43, 44} Albizzia lebbeck, ^45,
46 Achillea mellifolium,⁴⁷ Asystasia gangetica,⁴⁸ Acorus calamus, Ammi visnaga, Boswellia serrata,⁴⁹ Balanites roxburghii,⁵⁰ Cedrus deodara,⁵¹ Curculigo orchioides,⁵² Clerodendron phlomidis,⁵³ Curcuma longa,⁵⁴ Cassia sophera,⁵⁵ Centipeda minima,⁵⁶ Ephedra gerardiana,⁵⁷ Eucalyptus globules,⁵⁸ Aegle marmelos,⁵⁹ Hedychium spicatum,^{60, 61} Glycyrrhiza glabra,^62,63 Inula racemosa,⁶⁴ , Moringa oleifera,⁶⁵ Myrica sapida,⁶⁶ Nigella sativa, Ocimum sanctum, Picorrhiza kurroa,⁶⁷ Lipidum sativum,⁶⁸ Passiflora incarnata,⁶⁹ Solanum xanhocarpum,^{70, 71} Terminalia belerica,⁷² Tinospora cordifolia,⁷³ Tamarandus indica ⁷⁴. Table 2 gives a brief review of the antiasthmatic plant with their chemical constituent and probable Mechanism of action.

CONCLUSION:

Many synthetic drugs are used to treat asthma, but they are not completely safe for long term use. Nature has bestowed our country with an enormous wealth of medicinal plants; therefore India has often been referred to as the Medicinal Garden of the world. Scientifically explored exhaustive reports published in Indian and international journals suggest the importance of herbal medicine in the treatment of asthma is indisputable.

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Received on 18.06.2012

Modified on 08.07.2012

Accepted on 14.07.2012

Research J. Pharmacology and Pharmacodynamics. 4(5): September –October, 2012, 328-338

Severity in patients ≥ 12 years of age ^[15]	Symptom frequency	Night time symptoms	%FEV₁ of predicted	FEV₁ Variability	Use of short-acting beta₂ agonist for symptom control (not for prevention of EIB)
Intermittent	≤2 per week	≤2 per month	≥80%	<20%	≤2 days per week
Mild persistent	>2 per week but not daily	3–4 per month	≥80%	20–30%	>2 days/week but not daily
Moderate persistent	Daily	>1 per week but not nightly	60–80%	>30%	Daily
Severe persistent	Throughout the day	Frequent (often 7×/week)	<60%	>30%	Several times per day