Asthma is a chronic condition which causes a sudden inflammation and narrowing of airways in the lungs.

The resulting “asthma attack” causes the patient to suffer periods of wheezing, chest tightness, shortness of breath and coughing. Asthma is a truly global, non-communicable disease which afflicts people of all ages from infant to elderly adult.

Indeed, Asthma is globally ranked 16th among the leading causes of years lived with disability and 28th among the leading causes of burden of disease as measured by disability-adjusted life years. It is estimated that 300 million people have asthma worldwide and it is further estimated that by 2025 a further 100 million people will be affected. While asthma often begins in childhood it can occur at any time throughout life.

The incidence and prevalence of asthma differs by sex across the life span.

Pre-pubertal boys experience a higher incidence, prevalence and hospitalization rate than girls of the same age. This pattern however, reverses during adolescence and women suffer a higher burden of this disease at least into the fifth decade of life. The current evidence suggests that asthma is a complex multifactorial disorder and its etiology (source) is attributed to the complex interactions between the patient’s genetic susceptibility, personal (host) factors and environmental factors.

The genetic susceptibility refers to the presence or absence of certain loci on the patient’s genes. The host factors refer to such variables as obesity, nutritional factors, infections and allergic sensitization. Environmental factors refer to air pollutants, pollens, mold and other airborne allergens. The systematic epidemiological surveillance of asthma commenced during the second half of the twentieth century following the observation of a sharp increase in the prevalence of asthma in the higher income developed countries.

It is now acknowledged that the prevalence of both childhood and adult asthmas have peaked in the higher income countries but the increase in prevalence continues in the low to middle income countries. Tobacco smoking has and continues to exacerbate this global epidemic. In a survey of adults with asthma from 70 countries around the world fully one quarter of them reported to be smokers.

Even more ominous is the scientific research showing that pregnant women who smoke increase the risk of their unborn children becoming asthmatic. This strongly suggests that smoking tobacco can cause heritable modifications of the genome. Outdoor air pollution has also had a major impact on asthma for both children and adults especially in China and India.

Worldwide in 2015 an estimated 9-23 million emergency room visits by children and 5-10 million emergency room visits by adults were attributed to air pollution (1). As previously described asthma is a ubiquitous disease afflicting people of all ages around the world. The etiology is complex and appears to be a combination of genetic predisposition and environmental factors. Not surprisingly asthma manifests itself in many different forms described below.

These vary by symptoms and triggers and any given patient may be afflicted by more than one type.

Allergy-Induced Asthma- This is the most common form of asthma. People with allergic asthma are also more likely to suffer from atopic dermatitis, eczema and allergic rhinitis. These attacks are triggered when a person contacts an allergen. Allergens are substances which people are allergic to and they may gain access to the patient through inhalation, swallowing, touching or injection. Common allergens include: cockroaches, household dust mites, mold, pet dander, fungi and pollen. Once exposed the allergen causes the immune system to release antibodies called immunoglobulin E or IgE. Excess IgE causes the cellular release of a chemical called histamine which in turn leads to airway inflammation making the airways smaller and ultimately leading to an asthma attack. Allergic asthma is unique in that it triggers an immune system response unlike any other form of asthma. This sets the stage for its diagnosis which consists of an individual testing positive for an allergen and subsequently exhibiting the symptoms of asthma (2).

Exercise-Induced Bronchoconstriction (EIB)-EIB is caused by a loss of heat, water (humidity) or both from the airways during exercise when the athlete is heavily breathing in air which is drier than what is already in the body. Symptoms typically appear within several minutes of exercise and may continue for 10 to 15 minutes following the completion of the athlete’s workout. These symptoms include shortness of breath, decreased endurance, cough, upset stomach and sore throat. EIB triggers include airborne irritants related to specific sports. Some common examples are chlorine (while swimming), air pollution while running or cycling outdoors and cold, dry air while skating or playing hockey.

Suggestions for active people to relieve their symptoms of EIB include

• Warm up with gentle exercise for about 15 minutes before you start more intense physical activity.
• Cover your mouth and nose with a scarf or a face mask when you exercise in the cold weather. • Try to breathe through your nose while you are exercising since this helps to warm and humidify the air going to your lungs. (3).

It is important to recognize that this type of asthma can be controlled with the proper medications and training techniques. Many elite and world class athletes have EIB- including Olympic medal winners in sports such as cross-country skiing, figure skating and ice hockey.

People who are overweight or even obese should not be discouraged by EIB to exercise. Fat cells can “sit on the lungs” and prevent them from growing. Furthermore, research suggests that over time regular exercise has been shown to reduce the symptoms of EIB (4).

Cough-Variant Asthma-This is a difficult to diagnose form of asthma which presents itself as a dry (no phlegm or mucus) cough often in the absence of other typical symptoms of asthma such as wheezing or shortness of breath. If the patient suffers from this type of cough for a period of eight or more weeks, it is considered chronic and two tests can be performed to determine if the cough is asthma. The first is a methacholine test in which the patient is administered increasing doses of the drug methacholine to inhale. The doctor then tests the patient’s lung function. If the cough is indeed caused by asthma the methacholine will trigger wheezing during inhalation. Non asthmatics have little or no reaction to this drug. The second diagnostic test is the administration of certain asthma medications. If the cough improves then it is assumed to be asthma (5).

The diagnosis of this form of asthma and the implementation of the appropriate medicine/s is important since people with this form of asthma are more susceptible to pneumonia, collapsed lung, lung failure and fractured rib.

Occupational Asthma-Asthma which first manifests upon starting a new job or asthma which seems to subside when away from work as on weekends, vacations etc. would suggest occupational asthma. More than 250 manufacturing substances have been identified as antagonizing or triggering asthma. These include, but are not limited to, paints, cleaning products, dust from mites, wood, grain and flour, latex gloves molds and fungi. The proper course of action is to see a doctor to determine if it is indeed asthma and then modify the work environment to minimize or eliminate the offending substance (4).

Nocturnal asthma- In a series of surveys of asthmatic patients from different countries throughout the world a staggering 47-75% reported nocturnal asthmatic symptoms. This has been shown to negatively affect mental performance especially in children. This can also lead to psychological problems and impaired function in school (4).

One reason for the decline in lung function at night is the body’s circadian rhythm. This causes hormone production to ebb and flow. During the late night/early morning hours the levels of the hormones which protect against asthma symptoms are at their lowest. Triggers that may make nocturnal asthmatic symptoms worse include infections such as cold or flu, dust or other allergens and acid reflux.

According to the National Sleep Foundation, people who have nocturnal asthma tend to have more severe asthma. Perhaps fortunately the most common cause of nocturnal asthma is the inadequate treatment of the patient’s asthma. The patient and doctor need to reexamine the medical regimen and make any necessary adjustments to allow for asthma free nights. Use of a humidifier in the bedroom is a common panacea as is the occasional use of a continuous positive airway pressure (CPAP) machine (6). Nonallergic asthma- Any form of asthma that is not triggered by allergies is termed “nonallergic asthma” and while its symptoms are identical to those of allergic asthma the triggers are different and these include infections, exercise (see EIB above), stress and changing weather conditions (4).

Severe asthma- When people suffer asthma symptoms more than twice per week their asthma is referred to as “persistent”. Persistent asthma is further categorized as mild, intermediate or severe. The symptoms of severe asthma are similar to those of mild asthma however they are more frequent, more severe and require more medications to keep under control (4).

Since asthma is a widespread disease with varying causes and triggers as well as degrees of severity in both children and adults it follows that there is a wide range of medications used to treat this disease. These medications are divided into 4 categories. Long term asthma control medications- These medications are taken regularly to control chronic symptoms and prevent asthma attacks. They include: Inhaled corticosteroids- These are anti-inflammatory drugs and the most effective in long term control of asthma. They reduce swelling and tightening in the airways.

Leukotriene modifiers- Leukotrienes are chemicals released by the immune system during inflammation and can cause or worsen asthma symptoms. These medications block the effects of leukotrienes. Long-acting beta agonists (LABAs)- These bronchodilator medications open airways and reduce swelling for at least 12 hours. They are used on a regular schedule to control asthma and prevent nighttime symptoms. These medications are only used in combination with a corticosteroid described above in what is known as a combination inhaler.

Theophylline- This drug is a bronchodilator taken daily as a pill to treat mild asthma. Theophylline relaxes airways and decreases the lung’s response to irritants. Potential side effects of this drug include insomnia and gastric reflux. Quick relief medications-These are often called rescue medications. They relax the airway muscles thereby opening the lungs. They can ease worsening symptoms and stop an attack altogether. They begin working within minutes and are effective for four to six hours. These medicines are not for daily use. They can be used before exercise to prevent an attack.

Albuterol and Levalbuterol- bronchodilators administered by inhalers.

Ipratropium- A nasal spray which acts as a short acting bronchodilator. Oral corticosteroids- These may be taken to treat severe asthma attacks. They should not be taken for long periods of time since chronic use can lead to osteoporosis, muscle weakness and high blood pressure. Medications for asthma triggered by allergies- These medications focus on treating allergic triggers and thus preventing the resulting asthma symptoms. Allergy shots- These are a form of immunotherapy in which the patient is first given a skin test to determine which allergens trigger asthma symptoms.

Next is the injection of small doses of those allergens. Initially this is performed once a week for several months then once per month for three to five years. Over time the patient should lose their sensitivity to the allergen/s. Allergy Medications- These include oral and nasal spray antihistamines and decongestants, as well as corticosteroid nasal sprays. These medications are available over the counter and with a prescription. Corticosteroid nasal spray reduces inflammation without serious side effects.

All these medicines are safe to use for long periods of time. Biologics- A relatively new class of medicines which act upon the immune system. Drugs such as Omalizumab (Xolair) are used to treat asthma triggered by airborne allergens. Allergies are suffered by people because their immune systems produce allergy-causing antibodies to attack substances that would otherwise cause no harm. Omalizumab blocks the action of these antibodies thereby reducing the immune system reaction that can cause allergic and asthma symptoms. This drug is administered by injection every two to four weeks. It is not for children under 12. A more recent class of biologic drugs has been developed to target specific substances secreted by certain immune system cells. In some patients, certain white blood cells known as eosinophils build up in number and under allergic or inflammatory stimuli produce substances called cytokines which cause inflammation.

These newer biologics target both the eosinophils and the cytokines which they produce. These biologics are usually taken together with other medications to treat patients with more severe forms of asthma (7).

The alcohol which people consume is more accurately known as ethanol or ethyl alcohol. Its chemical formula is CH3CH2OH. It is metabolized in the body in a two- step process. Ethanol is first oxidized to a substance known as acetaldehyde by an enzyme known as alcohol dehydrogenase. Acetaldehyde is then acted upon by an enzyme known as acetaldehyde dehydrogenase 2 (ALDH2) to form acetic acid which is then excreted from the body in the urine. At least half of all Asians, and some American Indians, Eskimos and Mexicans have a genetic deficiency of acetaldehyde dehydrogenase which results in a dangerous buildup of acetaldehyde following consumption of alcohol. The result in these populations is alcohol induced asthma (ALA).

Acetaldehyde causes mast cells and basophils to release histamine which in turn causes bronchoconstriction, nausea and tachycardia. In international surveys of asthmatics as many as 40% report the triggering of asthma symptoms following alcoholic drink consumption and 30-35% reported that alcoholic consumption worsened their asthma. Alcohol increases the total serum IgE levels which as previously described, leads to cellular release of histamine which can trigger an asthma attack. In addition to alcohol and its metabolite acetaldehyde triggering asthmatic symptoms, the threat of alcoholic consumption triggering asthmatic symptoms gets more complex since the alcohol in alcoholic drinks is formed as a result of the biochemically complex organic process known as fermentation.

Sensitivity to particular cereal components of beer such as barley, malt, rice and corn have been described as have allergic sensitivities to brewer’s yeast. Wine is the most common reported alcoholic drink in triggering asthmatic symptoms. Fermentation by-products in wine include biogenic amines believed to be the result of malolactic fermentation by lactic acid bacteria. Red wines generally contain higher levels these amines than white wine due to the greater importance of malolactic fermentation in red wines.

Of the biogenic amines, two in particular provide the greatest threat. Histamine is a potent mediator of various allergic responses including asthmatic. Tyramine along with histamine has been shown to play an important role in the triggering of headaches, especially migraines. People being treated with monoamine oxidase inhibitors (MAO) are particularly at risk. Tyramine is also able to induce dangerous spikes in blood pressure. Sulphite additives are added at various stages of the wine-making process. They are first added to sterilize barrels and/or tanks before fermentation takes place. Additionally, they are added to the grape must and wine at various stages of fermentation to prevent the growth of undesired species of yeast and bacteria that can cause spoilage. Finally, they are present in the final bottling of wine to prevent oxidation and help to maintain the desirable sensory characteristics of the wine (8,9).

People with asthma are twice as likely as those without asthma to develop gastroesophageal reflux disease (GERD). In fact, research has confirmed that more than 75% of adults (drinking age) with asthma also have GERD. Consumption of certain alcoholic beverages such as distilled spirits either straight up or “on the rocks” can trigger a GERD episode which in turn can trigger asthmatic symptoms. The acid reflux triggers a protective nerve reflex which causes the airways to tighten in order to prevent the stomach acid from entering the lungs. This tightening can cause an asthma attack (10).

Aspirin exacerbated respiratory disease (AERD) clinically is characterized by asthma, recurrent nasal polyposis, and hypersensitivity to COX-1 inhibitors (aspirin, ibuprofen). While this asthma subtype only accounts for 5-10% of adults with asthma, it represents a disproportionately high proportion of severe asthma cases. In a study published by the American Academy of Allergy, Asthma&Immunology, fully 83% of patients with AERD developed alcohol induced respiratory reactions.

The severity of these alcohol induced respiratory reactions closely correlated with the patient’s sensitivity to aspirin. One consistent finding in patients with AERD is the elevation of cysteinyl leukotrienes (LT) in the blood stream.

These cysteinyl LTs are powerful bronchoconstrictors and are the main effectors of aspirin induced reactions as well as alcohol induced reactions since alcohol consumption causes elevation of cysteinyl LTs. Asthma is a complex disease with varying stimuli or triggers.

It is important to get an accurate diagnosis as well as an effective treatment regimen. Consumption of alcohol should be done very carefully.

References :

1. Dharmage, Shyamali C., Perret, Jennifer L., Custovic, Adnan Epidemiology of Asthma in Children and Adults. Frontiers in Pediatrics vol 7 Article 246 18 June 2019. Doi: 10.3389/fped.2019.00246.
3. bronchoconstriction-eib 
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8. Vally H, Thompson PJ. Allergic and Asthmatic Reactions to Alcoholic Drinks. Addict Biol. 2003;8:3-11. DOI: 10.1080/1355621031000069828
9. Linneberg A, Berg ND, Gonzalez-Quintela A, et al. Prevalence of Self Reported Hypersensitivity Symptoms Following Intake of Alcoholic Drinks. Clin Exp Allergy. 2008;38:145-151.
11. Cardet, Juan Carlos et al.; Alcohol Induced Respiratory Symptoms Are Common in Patients With Aspirin Exacerbated Respiratory Disease. J Allergy Clin Immunol Pract 2 (2) 208-213 (2014).