Reactive airway disease 

There can be some misunderstanding as to what reactive airway disease is and is often used interchangeably with asthma, but this is not always accurate. This article will explain what reactive airway disease is. This article will first define reactive airway disease, then go into more detail about the diagnosis, treatment, management and prevention of the conditions of this disease. 

Reactive airway disease is a label that medical professionals give to patients with symptoms similar to asthma before they are given a formal diagnosis. It includes symptoms of wheezing, coughing, shortness of breath and sputum production. The term is most often given to children where there is some caution to diagnose asthma at a young age.   

The types of reactive airway disease will be explored, followed by its causes, diagnosis, treatment, management and prevention. The focus will predominantly be, but not exclusively, on asthma, as it is the most common cause of reactive airway disease. 

Types of reactive airway diseases 

Asthma

As discussed, asthma is the most common type of reactive airway disease. It is described by NICE as a chronic respiratory condition associated with airway inflammation and hyper-responsiveness. The condition is typically characterised by the symptoms of reactive airway disease described above. Symptoms can be triggered by environmental factors and require treatments with inhaled or oral medication. An exacerbation requires urgent medical treatment and can be life-threatening.¹  

Bronchospasm 

Bronchospasm is the process by which the airways are narrowed following inflammation in asthma, caused by the tightening of muscles lining the airways. Bronchospasm can be caused by asthma, as well as, respiratory infections, COPD, allergies, exercise, smoking, cold temperatures and general anaesthesia. 

Causes and risk factors 

Genetic predisposition

Asthma is caused by a combination of genetic and environmental factors. The likelihood of developing asthma is higher if a first-degree relative has the condition.² If asthma develops before the age of 12, it is more likely to have a genetic predisposition.³

Environmental factors 

Susceptibility to asthma can be caused by an individual's biological, physical and psychological environment. Studies have shown that asthma triggers include allergens, biological matter and pollutants including mice, cockroaches, pets, dust mites and mould amongst others.⁴

Respiratory infections 

Respiratory infections such as pneumonia and bronchitis can trigger asthma, due to causing inflammation within the airways. Asthma involves inflammation of the airways, so any additional inflammation will exacerbate the condition.  People with asthma are at a higher risk of developing serious chest infections.⁵

Diagnosis

History and examination

Asthma is diagnosed based on clinical evaluation, as there isn't a single test that can definitively confirm the condition. However, medical professionals have many tools to support a diagnosis: 

The first step in diagnosing reactive airway disease is for medical professionals to take a thorough history and clinical examination. A patient with suspected reactive airway disease will be asked about their symptoms such as wheezing, coughing, breathlessness and chest tightness. The symptoms will come in episodes, and will commonly be worse in the night or early morning (known as ‘diurnal’). Symptoms can be triggered by various things depending on age. In children, they can be brought on by emotion or exercise.  Whereas in adults, symptoms can be brought on by certain medications including beta-blockers and non-steroidal anti-inflammatory drugs (NSAIDs). Adult patients will also be asked if symptoms are worse at work, pointing to occupational asthma. The medical history will also cover questions about any personal or family history of eczema, allergic rhinitis or food allergies. These are called atopic illnesses and can increase the risk of developing cancer. 

The examination focuses on the respiratory system. The patient may have a wheeze, which is a whistling sound heard during breathing when a medical professional examines their chest. A peak flow meter is used to measure the ability of the lungs to push out air, a low reading could be a sign of reactive airway diseases. Certain findings such as low oxygen, high respiratory rate or an inability to complete sentences may result in hospital admission. On the other hand, the examination may be completely normal at the time of assessment, but a reactive airway could still be suspected based on patient history. 

Special tests

Fractional exhaled nitric oxide testing, also known as FeNO testing, can be used to support an asthma diagnosis in adults. A spirometry test can be used to distinguish asthma and reactive airway diseases from other respiratory illnesses such as chronic obstructive airway disease (also known as COPD). A very useful tool to support a diagnosis of asthma is to see how someone responds to an inhaler to help with restricted airways, termed bronchodilator reversibility.    

Specific considerations with children

Children under the age of 5 may have difficulties in describing their symptoms or taking part in the tests described above. In this case, they may not be given an official diagnosis of asthma but may be labelled only with reactive airway disease if it is suspected. Often the tests are repeated after the age of 5 to give a more definitive diagnosis, or the symptoms may have resolved. 

Differential diagnosis of symptoms of reactive airway disease 

A medical professional will need to consider other possibilities when someone has symptoms of reactive airway disease. Although rare, it is important to rule out more serious conditions such as lung cancer, pulmonary embolism or cystic fibrosis.⁶ 

Management and treatment 

When looking at the management of reactive airway disease, it is important to consider what is classed as ‘control’ of the disease. In general, the aim would be to have no symptoms in the day or night, no limitation of daily activities and no exacerbations (or asthma attacks). If this is achieved, it could be said that there is complete control of the reactive airway disease. However, this is not the same as ‘cured’. Reactive airway disease is often a lifelong condition and requires long-term management.

To manage their condition, patients will usually have their baseline asthma status recorded using a validated tool such as the Asthma Control Questionnaire. This can be used to see how unwell patients are during an exacerbation. Patients will also be encouraged to formulate an asthma action plan. Parents will need to engage with this when the patient is a child.

Patients will need to be up to date with all immunisations and will be advised to avoid any known triggers. If they smoke, they will be advised to stop and offer support with this. They will be screened for depression and anxiety, which is not uncommon in those suffering from any chronic illness.  

Inhaled medication, in the form of handheld inhalers, is the mainstay of medical treatment of reactive airway disease. An inhaler may be needed to keep symptoms at bay and to keep the peak flow at a normal level. A reliever inhaler, commonly known as Salbutamol or Ventolin will be prescribed for use as needed. If this is needed more than 3 times per week, a steroid inhaler is prescribed as a preventer. This is to be used every day, to prevent asthma symptoms starting in the first place. Occasionally, reliever and preventer medication is combined and given in one single inhaler. 

At review, patients will be checked to see if they are using the medication properly. If they are and symptoms are still present, other medications such as leukotriene receptor antagonists or long-acting beta-agonists may be used. Referral to a respiratory specialist is needed in some cases.   

If you are given a diagnosis of asthma or reactive airway disease, you should be followed up every year if you remain stable. This is often carried out by a specialist asthma nurse in primary care. Those with poor lung function, or who have had an asthma attack in the past year, should be followed up more frequently. The severity of symptoms and inhaler technique will be checked at review. The Asthma Control Questionnaire can be used to compare current symptoms with baseline.⁷

Complications and prognosis

Anyone diagnosed with asthma or reactive airway disease is at risk of an exacerbation. These can range from mild to life-threatening or even ‘near-fatal’. The first sign will be a worsening of asthma symptoms including wheezing, shortness of breath and cough. Signs of a very severe exacerbation include agitation and behaviour change, cyanosis (blue-tinged lips), and obvious difficulty in breathing. Those who are very unwell may not appear distressed, as they have become exhausted. A mild or moderate exacerbation can be treated by a GP with steroid tablets or a nebulizer. Anything more severe will require oxygen and hospital treatment.⁸

Reactive airway disease, particularly when a diagnosis of asthma has been given, is a chronic illness and a patient may live with it their whole life. Patients can suffer from anxiety and depression when they have a chronic illness. Many patients with severe asthma may have difficulties maintaining jobs and can have difficulties in friend and family relationships Furthermore, those with frequent exacerbations requiring oral steroid treatment are at risk of side effects from these drugs including osteoporosis and diabetes.⁹ 

Summary 

Reactive airway disease is a label given to patients with a specific set of symptoms which are often then diagnosed as asthma. There is no one test to give a definitive diagnosis, however, medical professionals have a multitude of ways to determine the likelihood of asthma based on clinical assessment and special tests. Both reactive airway disease and asthma are managed mainly with inhaled medications, and during an exacerbation, patients can require oral treatment, nebulizers or hospital admission. If asthma is diagnosed, it is considered a chronic condition and could be with the patient for life. Medication is not always required, however in severe asthma patients can suffer from side effects, especially if oral steroids are used.