INTRODUCTION

In recent decades, asthma morbidity has increased considerably in many countries, and this phenomenon is probably due to increased air pollution, the prevalence of respiratory infections, socioeconomic conditions, and lack of information about the disease, as well as emotional factors.

Asthma affects a significant portion of the population, especially children and adolescents, and has a high socioeconomic cost. Despite the frequency of this condition and the fact that it is responsible for a large number of emergency room visits, its lethality is not high. However, most deaths could be avoided if effective measures were implemented in time. Access to adequate maintenance treatments, patient education, and information about the disease would reduce hospitalizations and emergency room visits, and improve quality of life. Knowledge of the true dimensions of the disease will make it possible to establish more effective treatment plans(5).

The multicenter International Study for Asthma and Allergies in Childhood (ISAAC), conducted in 56 countries, showed a variability in the prevalence of active asthma from 1.6% to 36.8%. Brazil ranks eighth, with an average prevalence of 20% in children(7).

Asthma mortality is low, but it is increasing in several countries and regions. In developing countries, asthma mortality has been increasing over the last ten years, accounting for 5%-10% of deaths from respiratory causes, with a high proportion of deaths occurring at home.

A variety of demographic factors are associated with asthma, including age, gender, birth order and season, ethnicity, region, and country. Age is the data most strongly associated with the prevalence of asthma symptoms, which generally decline at puberty. However, there are cohort studies that observed that more than 50% of asthmatic children had asthma symptoms in adulthood(9).

The main triggers and/or aggravating factors of asthma are exercise, infection, allergens, irritants, cold air, medication, emotions, stress, food, dyes and endocrine factors(10). The specific contribution of each factor is not measurable, which does not allow us to delineate its exact role in the emergence of symptoms.

Although it is not possible to trace a homogeneous behavior for all cases, it can be said that the emotional impact of asthma generally correlates directly with the severity of the disease. And if the attacks are frequent, even if they are not so severe, there is also a clear impairment of social activities.

DIAGNOSIS

According to the III Brazilian Consensus on Asthma Management (2002), the diagnosis of asthma should be based on clinical and functional conditions and on the evaluation of the allergy.

CLINICAL DIAGNOSIS

The patient’s medical history should identify symptoms that may suggest asthma, such as wheezing and shortness of breath, assess the severity of the disease and identify precipitating factors, while also remembering the importance of family history.

FUNCTIONAL DIAGNOSIS

When the clinical findings of asthma are not typical, in cases of isolated compatible symptoms, or when the disease is of recent onset, confirmation of the diagnosis is recommended by functional methods, such as peak expiratory flow, spirometry and bronchial provocation tests.

ALLERGY DIAGNOSIS

The medical history is important for identifying probable allergens, which can be confirmed by in vitro tests , determination of blood concentration of specific immunoglobulin E (IgE) or by in vivo tests , such as skin tests.

In the past, bronchial provocation tests seemed to make it possible to discriminate between individuals with asthma and those who were clearly non-asthmatic(2). Preliminary studies on the bronchial response to nonspecific stimuli (e.g., histamine and methacholine) separated the groups based on the fact that asthmatics showed, with concentrations of these agents considered tolerable, a decrease of more than 20% in lung function, while in non-asthmatics, it was less than 20%.

In the general population, bronchial reactivity presents a continuous normal logarithmic unimodal distribution, with asthmatics being on the most reactive (or left) side of this distribution. However, there is evidence that bronchial hyperreactivity may not manifest in some individuals at times when they are undoubtedly symptomatic; or it may manifest even in the absence of symptoms, and may undergo changes over time, both in asthmatic and non-asthmatic individuals.

ASTHMA IN ADOLESCENTS

Adolescence is the transition period between childhood and adulthood characterized by the impulses of physical, mental, emotional, sexual and social development, as well as by the individual’s efforts to achieve goals related to the cultural expectations of the society in which he or she lives.

Adolescence begins with the physical changes of puberty and ends when the individual consolidates his or her growth and personality, progressively achieving economic independence, in addition to integration into his or her social group. The chronological limits of adolescence are defined by the World Health Organization (WHO) as the period between 10 and 19 years of age.

Asthma is one of the main diseases of childhood and adolescence, and is the main chronic respiratory disease in adolescents. Adolescence is a time of maturation and growth, including of the respiratory system. A decline in respiratory function during this period can lead to irreversible changes in lung structure and also to a reduction in final height. In addition to the problems inherent to adolescence itself, the association of a chronic disease such as asthma can generate feelings of failure, lack of hope and anger. Self-censorship, loss of self-esteem and fear also represent an additional burden for these adolescents. The firm intention of becoming independent from the family is mixed with the aversion to being different from the other members of their group(8).

Asthma can be precipitated or aggravated by multiple factors, depending on the age group. Among adolescents, acute exacerbations can be triggered mainly by inhalable allergens (household dust mites: Dermatophagoides pteronyssinus, Dermatophagoides farinae and Blomia tropicalis ; fungi; hair; saliva and urine of domestic animals: dogs, cats and birds; remains of insects and cockroaches) and also by sudden changes in temperature. Inhalation of nonspecific irritants (strong odors, tobacco smoke, etc.) can trigger symptoms through non-immunological mechanisms, as can exercise, inhalation of cold and dry air and non-steroidal anti-inflammatory drugs (NSAIDs)(1,2).

In childhood, asthma is twice as common in boys, but this relationship changes drastically during puberty. Among adolescents, it is significantly higher in girls. There is more remission in boys and a greater number of new cases in girls(9).

Recent studies suggest that hormonal factors may be involved in this increase in the frequency of cases in girls during adolescence. It has also been described that overweight and obesity are risk factors for this increase. An increase in the incidence of asthma was observed in girls who became obese during the prepubertal period(3).

Gillaspy et al. observed, in 2002, that adolescents with a self-reported diagnosis of asthma had a higher risk of common mental disorders than those without this diagnosis(5).

Exercise-induced asthma is also common in this age group and, according to the III Brazilian Consensus on Asthma Management, 49% of asthmatics have exercise-induced asthma (EIA). The pathogenesis of EIA is associated with the flow of heat and water from the bronchial mucosa toward the lumen of the bronchus, with the aim of conditioning large volumes of air that reach the lower respiratory tract. Exercise is the only natural precipitant of asthma that can lead to tachyphylaxis. Airway obstruction begins immediately after exercise and reaches its peak between 5 and 10 minutes, followed by remission of symptoms, which are similar to those observed in attacks triggered by other stimuli. The diagnosis is made by verifying a 10% to 15% drop in forced expiratory volume in one second (FEV ₁ ) after exercise in relation to the baseline FEV ₁ , and treatment is prophylactic. It is important to reassure adolescents that exercise-induced asthma is fully compatible with their life as athletes or sportspeople, and that adequate control is all that is needed.

Nicotine is one of the most addictive substances, and most smokers begin using it during adolescence, which can have long-term health consequences. Adolescent smokers are more vulnerable to respiratory infections, asthma, oral diseases and reduced physical capacity. Passive smokers, who live with active smokers on a daily basis, have a 30% higher risk of lung cancer, a 24% higher risk of acute myocardial infarction (AMI) and a three-fold higher incidence of respiratory infections. In addition, they are susceptible to an increased incidence of atopic diseases such as asthma(4).

TREATMENT

The main goals of treatment are to maintain daily activities, including exercise, and normal lung function, and to avoid chronic symptoms and exacerbations. Frequent visits to emergency services and hospitalizations should also be avoided, in addition to minimizing the side effects of medications. During adolescence, one of the most important aspects is educating the patient and their family. Awareness of the chronic nature of the disease facilitates adherence to treatment. This education includes explanations about the correct use of medication, encouragement to practice sports, information about alternative therapies, discouraging smoking, knowledge of the main triggers and guidance on household chores. At this age group, household chores such as sweeping the house and dusting furniture usually begin. Therefore, if necessary, a rearrangement of these activities should be recommended.

ENVIRONMENTAL CONTROL

The following measures should be adopted:

• cover mattresses and pillows with dust mite-proof covers (covers must be washable); carefully vacuum the mattress, pillow, around the base of the bed and the bedroom floor weekly;
• avoid using brooms and dusters; clean all surfaces in the room weekly with a damp cloth, including the valances to which curtains are attached, the window sills and the tops of cabinets;
• Dehumidifiers help control relative humidity, but they can dry out the environment too much, causing irritating coughing fits and worsening asthma attacks; vaporizers are contraindicated in rooms of allergy sufferers as they facilitate the proliferation of fungi;
• remove feather and/or kapok pillows, wool blankets and down comforters, replacing them with synthetic fabric ones and washing them weekly;
• avoid rugs, carpets and curtains; give preference to washable floors and blinds, or materials that can be cleaned with a damp cloth;
• avoid objects that accumulate dust (stuffed animals, boxes, magazines, books, suitcases, pillows, etc.);
• avoid mold and humidity: 3% to 5% carbolic acid solution (or bleach) can be applied to moldy areas until the cause of the humidity is definitively resolved, however, these are volatile products with a strong odor that can cause irritation to the airways, therefore their application should not be done by the patient, and the house must be kept ventilated for 6 hours before residents enter;
• avoid keeping furry animals inside the home; if this is not possible, they should be bathed at least once a week, but they should not, under any circumstances, remain in the bedroom;
• avoid the use of talcum powders, perfumes, disinfectants and cleaning products with strong odors; insecticides released by heating, despite having no odor, are irritating to the respiratory mucosa;
• keep the house free of insects (especially cockroaches), avoiding the accumulation of dirt, old paper or food remains;
• prohibit active smoking inside the home and always discourage it among adolescents.

IMMUNOTHERAPY

Specific immunotherapy (SI) consists of manipulating the individual’s immune system in order to modify its response to the allergen (immunomodulation). With regard to allergic diseases, SI has been used as a therapeutic resource for controlling and reducing symptoms for approximately 90 years. Patients with mild or moderate asthma and a proven IgE mechanism who have not benefited from strict environmental control and pharmacological treatment alone are candidates for SI.

PHARMACOLOGICAL TREATMENT

The regimen described below is proposed by the III Brazilian Consensus on Asthma Management. Drugs can be classified into two categories, according to the purpose of their use:

• to improve acute symptoms (rapid onset β2-agonist, ipratropium bromide and aminophylline);
• to prevent symptoms for the maintenance phase (inhaled and systemic corticosteroids, cromones, long-acting β2-agonist and slow-release theophylline).

Treatment of mild asthma should be limited to acute exacerbations with the use of a short-acting β2 agonist via inhaler. In adolescents with exercise-induced asthma, prior use of a short-acting β2 agonist may be indicated up to 15 minutes to half an hour before exercise. The use of cromones, antileukotrienes and long-acting β2 agonists is also an option. Anti

-inflammatory agents are recommended for patients with moderate asthma. Undoubtedly, corticosteroids are the main anti-inflammatory agents and their action is observed quickly, unlike what occurs with other drugs. However, the possibility of side effects resulting from their use makes it necessary to monitor these patients more closely and frequently. In these cases, an inhaled short-acting β2 agonist can be used to relieve symptoms when necessary (maximum four times/day), or a long-acting β2 agonist.

The treatment regimen with inhaled corticosteroids (metered-dose aerosol and dry powder inhaler) should be initiated, but the patient should be reassessed in four to six weeks. If the patient improves, the long-acting β2-agonist should be discontinued, reducing the dose of the inhaled corticosteroid.

In the case of severe asthma, oral corticosteroids should be used for a short period of time. If prolonged use is necessary, an alternate-day regimen or one in which the lowest dose capable of establishing control is maintained should be preferred. Once control is achieved, the oral corticosteroid should be discontinued and the withdrawal of other medications should follow the same steps as for the treatment of moderate asthma.

The initial dose of inhaled corticosteroids to be administered ranges from 500 µg to 1,000 µg of beclomethasone dipropionate/day (or equivalent). The use of a spacer followed by oral hygiene is recommended to eliminate beclomethasone dipropionate deposited in the oropharynx.

Leukotriene antagonists have been suggested as alternative drugs for these patients because they allow for a reduction in the need for corticosteroids, or when the patient cannot use these medications for long periods.

Asthmatic adolescents, like any patient with a chronic disease, should have regular checkups to monitor the correct use of medications, as well as to assess their growth and development. Respiratory function tests are recommended. Other important topics include assessing school readiness, sociability, encouraging the practice of sports, and maintaining quality of life. Ongoing anti-smoking campaigns aimed at the patient and their family members are also welcome, and consideration should be given to the cost/benefit of pets. A global view of the patient is part of providing welcoming and efficient care, and the multidisciplinary team should be aware of all this diversity.

ACKNOWLEDGMENTS

To the entire team at the Center for Studies on Adolescent Health (NESA) for their constant collaboration.