Asma: sintomi,diagnosi e terapia
Definizione
L’asma bronchiale è una malattia che nella maggior parte dei casi è caratterizzata da infiammazione cronica delle vie aeree, a seguito di spasmi della muscolatura bronchiale. I bronchi risultano esageratamente sensibili a una serie di stimoli, ai quali reagiscono con una contrazione dei muscoli contenuti nelle loro pareti e quindi con una diminuzione del loro diametro. L’infiammazione bronchiale cronica delle vie aeree che sottende la manifestazione clinico-funzionale dell’asma è costituita da una specifica infiltrazione bronchiale di cellule infiammatorie, in particolare granulociti eosinofili, mastociti e linfociti CD4 a profilo Th2.
Sintomi
L’ asma si manifesta clinicamente con sintomi respiratori quali:
- respiro sibilante
- senso di costrizione toracica
- dispnea
- tosse non produttiva o accompagnata da espettorato bianco
- ostruzione bronchiale.
I sintomi descritti variano nel tempo per intensità e durata.
Epidemiologia
L’asma bronchiale colpisce circa 300 milioni di persone nel mondo. I dati epidemiologici basati su questionario e/o sulle prove di funzionalità respiratoria indicano che la prevalenza di asma nel mondo vari tra l’1 e il 18%. In Italia la media generale è 5% ed è leggermente più alta nei bambini e negli anziani dove tuttavia va distinta dalla BPCO (broncopneumopatia ostruttiva). L’asma bronchiale ha importanti conseguenze socio-economiche dovute alle spese sanitarie dirette e indirette per i farmaci e per il ricorso alle strutture sanitarie ma anche legate all’assenza da scuola e all’assenza di giorni lavorativi a causa dell’asma.
Fattori di rischio
La manifestazione clinica dell’asma bronchiale è il risultato dell’interazione tra fattori scatenanti ambientali e disposizione genetica dell’individuo. In alcuni casi è possibile identificare una causa esogena (più frequentemente allergeni in pazienti atopici, esposizioni professionali e farmaci), mentre in molti casi l’agente scatenante rimane non identificabile. L’asma è una patologia ad espressione clinica eterogenea. Più frequentemente l’asma compare in età pediatrica e si associa di uno stato atopico del soggetto. La comparsa della crisi dipende dall’esposizione alla sostanza nei cui confronti si è sviluppata l’allergia: si tratta di alcuni tipi di:
- polline
- forfore
- peli di animali
- muffe
- acari, vale a dire di microscopici animaletti che vivono nella polvere.
Tale manifestazione clinica dell’asma nella maggior parte dei casi ha un andamento prognostico favorevole, può regredire con l’età adulta. Si caratterizza, salvo i casi in cui la manifestazione clinica è grave sin dall’esordio, per una buona risposta al trattamento inalatorio. In altri casi, l’asma può insorgere in età adulta, ovvero oltre la seconda-terza decade di età. In questi casi, e più frequentemente nel sesso femminile, è concomitante ad una situazione di sovrappeso. Nell’età adulta l’asma può comparire in seguito a esposizione professionale o dopo infezione a carico dell’apparato respiratorio ed è caratterizzata da un andamento prognostico più sfavorevole, ovvero caratterizzato da una maggiore gravità e persistenza della sintomatologia e da una minore risposta al trattamento farmacologico.
Diagnosi
La diagnosi clinica di asma è relativamente facile, combinando i sintomi del paziente, i fattori di rischio (la familiarità asmatica, allergia e/o storia pregressa di malattie allergiche) e le alterazioni funzionali che dimostrino la presenza di ostruzione bronchiale reversibile e/o ampiamente variabile nel tempo, o in assenza di ciò, la presenza di iperreattività bronchiale. I sintomi principali dell’ asma bronchiale sono il respiro sibilante, dispnea, il senso di costrizione toracica, la tosse e l’espettorato. Il sospetto diagnostico di asma si pone quando questi sintomi sono presenti in maniera variabile. Si manifestano in particolare durante la notte, nelle prime ore del mattino e sono scatenati da stimoli quali:
- aria fredda
- attività fisica
- allergeni
- sostanze stabilizzanti.
La spirometria e la misura del PEF ( il più alto flusso espiratorio ottenuto durante una manovra di espirazione forzata eseguita subito dopo un’inspirazione massimale a capacità polmonare totale), sono indispensabili per una conferma obiettiva della diagnosi e per la misurazione della gravità della malattia e della risposta alla terapia. La misurazione del VEMS (volume espiratorio massimo al primo secondo) e della CV (capacità vitale) mediante spirometria consente di evidenziare la presenza di bronco-ostruzione indicata da un indice di Tiffenau <70 (VEMS/CV<70). In presenza di ostruzione bronchiale, si deve far eseguire il test di reversibilità, che consiste nel fare inalare al paziente un broncodilatatore a breve durata d’azione, solitamente sul salbutomolo e nel ripetere la spirometria dopo 20 minuti. La bronco-ostruzione viene considerata reversibile se il VEMS ritorna entro valori normali o migliori del soggetto.
Terapia
Ogni qualvolta sono identificati i fattori scatenanti specifici, siano essi allergeni, farmaci o agenti professionali, il primo provvedimento è insegnare ai pazienti ad evitarne accuratamente l’esposizione, nei limiti del possibile. Questo vale per lo sforzo fisico, in quanto la terapia farmacologica dovrebbe essere calibrata per annullare gli effetti. Inoltre, considerati gli effetti negativi del fumo e degli inquinanti atmosferici, anche dei semplici temporali, i pazienti vanno istruiti a non fumare, non frequentare ambienti fumosi, a evitare l’esposizione a inquinanti o ad uscire in giorni con temperature particolarmente violente.
Terapia farmacologica
L’obiettivo della terapia farmacologica dell’asma è di raggiungere e mantenere il controllo clinico. I farmaci per trattare l’asma sono classificati in farmaci di controllo o di fondo e sintomatici. I farmaci di controllo vanno assunti giornalmente, allo scopo di mettere e mantenere l’arma sotto controllo clinico. Farmaci di fondo di prima scelta sono i glucocorticoidi inalatori o, nei casi molto gravi, sistemici per esempio il prednisone). I glucocorticoidi inalatori da soli o associati ai β2 –agonisti a lunga durata d’azione, sono i farmaci di fondo attualmente più efficaci e quindi di prima scelta. La terapia dell’asma è quasi esclusivamente per via inalatoria, in quanto consente il massimo beneficio con i minimii effetti collaterali, in particolare con farmaci β2 -agonisti e glucocorticoidi. I farmaci sintomatici sono quelli usati al bisogno, che quindi rimuovono l’ostruzione e l’ infiammazione bronchiale insorgenza acuta e i sintomi acuti che l’ accompagnano. Questa classe comprende i broncodilatatori β2 -agonisti a rapida azione inalatoria. I glucocorticoidi sono attualmente i farmaci antinfiammatori più efficaci nel trattamento dell’arma persistente; infatti è stato dimostrato che riducono i sintomi, migliorano la qualità di vita e la funzionalità respiratoria, diminuiscono l’iperreattività bronchiale, l’infiammazione delle vie aeree, la frequenza e la gravità delle riacutizzazioni, e quindi la mortalità per asma, pur non eliminando la malattia. In effetti, la sospensione determinai un peggioramento del controllo clinico, che sopraggiunge entro settimane-mesi nella maggior parte dei pazienti.
Spirometria
La spirometria è un esame indolore e viene eseguito con l’ausilio di uno strumento chiamato spirometro. L’indagine è molto semplice, per nulla fastidiosa e richiede la partecipazione da parte del paziente che deve eseguire delle manovre respiratorie mentre è collegato con la bocca allo spirometro. Lo spirometro misura la quantità di aria espirata e la velocità di espirazione.
Articoli correlati:
BPCO- broncopneumopatia cronica ostruttiva
Sarcoidosi: sintomi, diagnosi e cura
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