Feeling Wheezy?
Adult-onset asthma, which can mimic other conditions, often goes undiagnosed. Fortunately, treatment can help.
If you’ve been coughing more than usual lately, you may blame it on allergy season. And that shortness of breath you feel after you hurry up the stairs? Well, you’re older now, and perhaps you haven’t been hitting the gym enough.
Another possibility, though, is adult-onset asthma.
That’s a condition that can look like a lot of other things. People often attribute its symptoms—such as chronic cough or reduced exercise tolerance—to the common cold or simply aging or being out of shape. And even doctors don’t always identify the condition right away. Says Katherine Szema, M.D., an allergist and immunologist at ENT & Allergy Associates in Shrewsbury: “Adult-onset asthma may be misdiagnosed as bronchitis, chronic obstructive pulmonary disease [COPD] or heart disease.”
Asthma causes airways to narrow and sometimes to produce extra mucus, making breathing difficult. And while it’s often thought of as a condition that affects children, “asthma affects over 25 million people, and approximately 20 million of them are adults,” says the doctor. “It can occur at any age.” And not having that diagnosis can cause problems. Though asthma is manageable with the right medications and action plans, it’s also chronic—and it’s very likely to get worse if not treated. “It you’re seeing symptoms, it’s important to seek medical care,” urges Dr. Szema.
Three kinds of asthma
No single reason explains why people develop asthma as adults. Doctors cite three categories of causes, and two of them are allergic and non-allergic. While those terms seem to cover everyone, they also mention a third group they label “occupational.”
• Allergic asthma, as the name suggests, is caused by an allergic reaction— that is, an abnormal immune response to something that is typically not harmful, such as foods, pollens or medicines. According to the American College of Allergy, Asthma and Immunology (ACAAI), sometimes asthma develops in adulthood simply because one has avoided an allergy trigger until then—for instance, one may start living in close quarters with a new type of animal or move to a place with a different type of pollen. Another possible reason is that immune responses, and therefore allergic reactions, can change with age, and one may gain a new sensitivity. Dr. Szema notes that “seasonal allergies such as pollens and mold and perennial allergies such as dust mites and pet dander are risk factors.” She adds, however, that “most cases of adult-onset asthma are due to environmental factors, viruses or other medical conditions.”
• Non-allergic asthma can be caused by a number of things. Dr. Szema cites respiratory infections such as respiratory syncytial virus (RSV) and influenza, obesity, chronic sinusitis and gastroesophageal reflux disease (GERD), which contributes to airway inflammation and therefore to symptoms, as possibilities. “Hormonal changes can also contribute to worsening symptoms, in pregnancy or menopause in particular,” says the doctor. Even stress can be a non-allergic asthma trigger.
• Occupational asthma “develops from long-term exposure to things like chemicals, fumes, dust and animal dander, typically at work,” says Dr. Szema. A wide range of people may be at risk for it—the doctor mentions “farmers, hairdressers, bakers, laboratory workers, chemical manufacturers and metal and wood workers.” Spending time around wet paint with high volatile organic compounds (VOCs) can also cause problems, as can long-term exposure to secondhand smoke from cigarettes or vapes. (Of course, smoking itself increases one’s risk of adult-onset asthma significantly, and Dr. Szema notes that there is a strong overlap between asthma and COPD, one of the most common effects of long-term tobacco use.)
There’s also what Dr. Szema identifies as “exerciseinduced bronchoconstriction” or EIB, previously known as exercise-induced asthma. “EIB occurs when the respiratory muscles constrict and decrease airflow leading to asthma symptoms,” she explains. “It is commonly caused by breathing dry, cold air. Symptoms typically occur within five to 10 minutes after the onset of exercise and may last up to one hour afterward.” While it’s no longer considered asthma because not everyone who experiences it has the chronic condition, as many as 90 percent of people with asthma also have EIB, according to the ACAAI. If it’s accompanied by a persistent cough when not exercising, it could indicate a larger problem; if it is disrupting your routine as an athlete or otherwise, it can be treated in a similar way to asthma.
When to worry
“Asthma symptoms present similarly in children and adults, and include chest tightness, wheezing, coughing—especially at night or during exercise—shortness of breath and difficulty breathing,” says Dr. Szema. “However, adult asthma is more persistent.”
Some authorities say children are more likely to have a sudden asthma attack, like the ones you see on TV shows and in movies; adults are more apt to have a stubborn symptom that lasts for weeks or months.
Adds the doctor: “Patients should seek medical care if their symptoms persist, do not improve or continue to get worse after several days.” Other flags to seek out a doctor include nighttime coughing or tightness that wakes you up, symptom flare-ups occurring more than twice per week or any sudden or severe shortness of breath.
And make no mistake—adult-onset asthma does need to be checked out. When left untreated, it can damage and scar lungs and airways (a process called “airway remodeling”) and increase one’s risk of infections such as pneumonia.
“Approximately 10 people die each day in the United States from asthma exacerbations,” says Dr. Szema. “Adults are seven times more likely to die from asthma than children, with higher death rates in females and non-Hispanic Black people. Asthma deaths are largely preventable with proper treatment and regular follow-up with your medical provider to monitor lung and inflammation.”
What to do
The good news: Treatment options are very effective and getting better every day. According to the doctor, the gold standard remains rescue inhalers. “They are filled with medicine such as albuterol or levalbuterol or albuterol/budesonide, which relax the airway and smooth muscles to lessen the constriction,” says Dr. Szema. Inhaled corticosteroids also reduce inflammation in the long term.
More recent developments include biologic medications “for patients who have poorly controlled moderate or severe asthma with frequent attacks,” says Dr. Szema. “These medications target certain cells and pathways that cause inflammation. They can be administered every two to eight weeks, depending on the medication. The recently approved depemokimab [marketed as Exdensur] is administered only twice annually.”
More recent developments include biologic medications “for patients who have poorly controlled moderate or severe asthma with frequent attacks,” says Dr. Szema. “These medications target certain cells and pathways that cause inflammation. They can be administered every two to eight weeks, depending on the medication. The recently approved depemokimab [marketed as Exdensur] is administered only twice annually.”
“There is no cure for asthma,” says Dr. Szema. “However, you can control your asthma by working with your medical provider, identifying and avoiding triggers and selecting the best medications to prevent any symptoms. It’s a manageable condition.”
