Asthma is a chronic inflammatory disease of the airways that causes recurrent episodes of wheezing, breathlessness, chest tightness and coughing. Asthma affects people of all ages, but often starts in childhood. With proper treatment and management, most people with asthma can live a normal, active life. However, some people may experience long term effects from asthma that impact their quality of life.
Long Term Effects on the Lungs
One of the main long term effects of asthma is on the structure and function of the lungs. During asthma attacks, the airways become inflamed and constricted, which over time can lead to permanent changes. Some of the structural changes that can occur include:
- Airway remodeling – Thickening of the airway walls due to repeated injury and healing during inflammatory processes.
- Bronchiectasis – Permanent widening and scarring of the airways.
- Permanent airflow obstruction – Difficulty expelling air due to airway narrowing.
These changes decrease the ability of the airways to remain open and make breathing difficult. Ongoing airway obstruction and lung function decline can occur in people with poorly controlled asthma.
Even in those with well-controlled asthma, studies show there may be an accelerated yearly decline in lung function compared to people without asthma. For example, a 5-year study found that people with asthma had an average 33 ml per year greater decline in FEV1 (a measure of lung function) compared to those without asthma.
Effects on Quality of Life
The unpredictability of asthma symptoms and flare-ups can significantly impact a person’s quality of life long term. Frequent attacks interrupt sleep, work and recreation. Fear of sudden attacks may cause people to limit their activities.
Asthma attacks can be life-threatening and require emergency care. According to the CDC, in 2019 asthma accounted for nearly 2 million emergency department visits in the United States. People with difficult to control asthma are at higher risk of:
- Hospitalizations
- Intensive care unit admissions
- Need for intubation/mechanical ventilation
The emotional toll of living with a chronic disease like asthma is also significant. Many people report feelings of anxiety, depression, social isolation and low self-esteem related to their asthma.
Risk of Exacerbations
Even when asthma seems well-controlled, there is always a risk of exacerbations – sudden worsening of symptoms. Triggers like respiratory infections, allergens, irritants, weather changes and stress can provoke attacks. Exacerbations that require oral corticosteroid use to regain control raise the risk of future attacks.
Frequent severe exacerbations accelerate lung function decline and are associated with airway remodeling changes. Ongoing airway inflammation during severe flares may contribute to structural changes. Exacerbations account for much of the health care costs, morbidity and mortality related to asthma.
Treatment Challenges
While controller medications like inhaled corticosteroids can effectively control asthma for most people, some have difficult to treat disease. Reasons why asthma may be harder to control include:
- Underlying comorbidities like chronic sinusitis or reflux disease.
- Exposure to environmental triggers like allergens or irritants that cannot be adequately avoided.
- Severe persistent asthma phenotype.
- Issues with treatment adherence or improper inhaler technique.
People with hard to control asthma are at greater risk of attacks, lung function decline and long term consequences. Close follow up, treatment adjustments and management of comorbid conditions are important to try to gain control.
Associated Complications
Several other medical conditions are associated with asthma and can contribute to worsening severity over time. These include:
Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) causes breathing to repeatedly stop and start during sleep. It is common for people with asthma to also have OSA, especially if they are overweight. OSA worsens asthma control and outcomes. Treatment with CPAP therapy may improve asthma control.
Gastroesophageal Reflux Disease (GERD)
GERD causes acid from the stomach to back up into the esophagus and sometimes into the airways. This can trigger asthma symptoms, and asthma exacerbations can worsen GERD. Treatment with medications to reduce stomach acid may help control asthma.
Chronic Sinusitis
Many people with asthma also have chronic sinus inflammation. Post-nasal drip from sinusitis can worsen asthma. Treatment with nasal steroid sprays, saline irrigation and antibiotics if needed may improve asthma control.
Obesity
Excess weight makes asthma more difficult to control by causing mechanical changes to the lungs and chest wall, promoting inflammation, and increasing risk of OSA. Weight loss often improves asthma severity and control.
Allergic Bronchopulmonary Aspergillosis
This condition is caused by an allergic reaction to Aspergillus fungus that grows in the airways. It can lead to wheezing, airway damage and scarring over time. Treatment includes oral steroids and antifungal medications.
Bronchiectasis
As mentioned earlier, permanent airway widening (bronchiectasis) can occur from repeated asthma exacerbations. Bronchiectasis further impairs mucus clearance which can worsen asthma control and accelerate lung function decline.
Progression in Severity
For reasons not entirely understood, some people with asthma experience progression in disease severity over time. In severe persistent asthma, symptoms continue to worsen over years despite treatment with high dose controller medications.
Factors associated with greater risk of developing severe asthma include:
- Adult-onset asthma
- Low initial lung function
- Exposures like smoking and air pollution
- Comorbidities like sinusitis and GERD
Severe asthma occurs more frequently in women and those with family history of asthma. More research is needed to understand what drives disease progression so interventions can be developed.
Prevention
While no cure for asthma exists, measures can be taken to prevent long term consequences:
- Avoid triggers – Minimize exposure to allergens, irritants like smoke, and respiratory infections as much as possible.
- Control airway inflammation – Take controller medications like inhaled corticosteroids regularly to reduce inflammation even when symptoms are mild.
- Get recommended vaccinations – Get an annual flu shot and any recommended pneumonia, pertussis or COVID-19 vaccinations.
- Use spacer devices – Use a holding chamber spacer with inhalers to ensure medication reaches the airways properly.
- Maintain a healthy weight – Carrying excess weight worsens asthma severity. Aim for a BMI in the normal range.
- Exercise regularly – Staying active improves cardiovascular fitness and quality of life. Prevent exercise induced bronchospasm by using a rescue inhaler before activity.
- Manage reflux, sinusitis – Treating these associated conditions can improve asthma control.
- No smoking – Don’t smoke or avoid secondhand smoke. Smoking damages lungs and worsens asthma.
With proper control measures and working closely with your healthcare provider, it is possible to manage asthma well and prevent progression or long term consequences.
Treatment Options
A number of treatment options exist for managing asthma long term:
Controller Medications
Inhaled corticosteroids are the cornerstone treatment for persistent asthma. These powerful anti-inflammatory drugs are taken daily to control inflammation and prevent symptoms. Long-acting beta agonists, leukotriene modifiers and biologic therapies are add-on options for more severe disease.
Bronchial Thermoplasty
This procedure uses heat energy to reduce airway smooth muscle mass. Clinical trials show it reduces exacerbations and improves asthma control in people with severe persistent asthma.
Pulmonary Rehabilitation
Supervised exercise training programs can help improve physical fitness and quality of life in people with compromised lung function.
Allergen Immunotherapy
Allergy shots or sublingual tablets expose people to gradually increasing doses of an allergen to desensitize the immune system. This can be effective for some people with allergy-triggered asthma.
Monitoring Your Condition
It is important to monitor your asthma regularly with your healthcare provider to assess control and look for signs of progression. Monitoring may include:
- Symptom review – Tracking symptoms in a diary can help identify triggers and control issues.
- Lung function tests – Spirometry measures airway obstruction and monitors function over time.
- FeNO testing – Measures fractional exhaled nitric oxide levels which are elevated with airway inflammation.
- Allergy testing – Skin or blood tests help identify allergy triggers that may worsen asthma.
Reporting any increase in symptoms, medication use, or decreased tolerance to physical activity can prompt medication adjustments or further evaluation if needed.
The Bottom Line
While asthma is typically thought of as a disease that comes and goes with symptom flares, its impact over decades can be more far-reaching. Airway remodeling from chronic inflammation can impair lung function over time. Frequent exacerbations also accelerate lung function decline and worsen quality of life.
However, asthma progression and its long term consequences are not inevitable. Taking a proactive approach to treatment and avoiding triggers can enable most people with asthma to live active, healthy lives. Close monitoring and follow up care are key to identifying and addressing disease progression quickly.
New biologic therapies offer hope for better control for more difficult to treat asthma. With a combination of proper medications, lifestyle modification, treatment of comorbid conditions and ongoing communication with your healthcare team, it is possible to effectively manage your asthma and minimize negative long term effects.