Overview
A group of asthma outbreaks occurring during or immediately following a thunderstorm. Common symptoms include breathlessness, shortness of breath, wheezing, coughing, and chest tightness, etc. Thunderstorms lead to a sharp increase in the concentration of allergens in the air, such as pollen, fungal spores, etc., which triggers an acute asthma attack and should be controlled with medications, such as albuterol, budesonide formoterol, and loratadine.
Definition
There is no standardized definition of thunderstorm asthma, but it is usually defined as a large localized outbreak of asthma during a thunderstorm or a subsequent period of time.
Symptoms such as breathlessness, wheezing, coughing and chest tightness may occur, and can be life-threatening in severe cases.
Thunderstorms are often characterized by meteorological events such as high winds, pouring rain or hail, which can cause a significant increase in the concentration of airborne allergens such as pollen, fungal spores, grass seeds, dust, etc., thus causing many asthmatics or allergists to experience asthma attacks almost simultaneously.
Thunderstorm asthma occurs as a result of the interaction of many factors such as susceptible people and environmental factors, so it is not the presence of thunderstorms that causes the disease.
Although thunderstorm asthma is uncommon, when it occurs healthcare resources are under severe pressure and many patients may not be able to receive timely treatment. Therefore, asthma patients or their families should know the basic first aid measures and prevention methods to ensure the safety of patients’ lives [1-3].
Morbidity
Thunderstorm asthma can occur at any age, with approximately 50% occurring between the ages of 20 and 40 years.
To date, thunderstorm asthma events have been seen in several countries worldwide, mainly in Australia and the United Kingdom [1,4].
Etiology.
Because of the low incidence of thunderstorm asthma, its etiology is currently unknown and may result from a complex interaction of environmental factors and individual patient susceptibility factors.
Causes
There is a correlation between the thunderstorm environment and asthma attacks, and the bridge between the two is precisely the aeroallergens, which are mainly various types of pollens, fungal spores, grass seeds, dust, and so on.
Pollen
Pollen is the most common airborne allergen. Usually, intact pollen particles are so large in diameter that most of them are filtered by the nasal hairs inside the nose and do not reach the lower respiratory tract directly.
During thunderstorms, pollen particles will burst and break up after fully absorbing the moisture in the atmosphere, thus forming more and smaller pollen particles and returning to the ground with the sinking air currents or raindrops, and the strong winds generated by thunderstorms will spread these particles even farther, thus covering a large area of the thunderstorm area.
These pollen particles are not only more allergenic, but also more likely to enter the lower respiratory tract. Numerous pollen allergy sufferers will be exposed to high levels of pollen for a short period of time, which in turn can cause an outbreak of asthma attacks.
Fungal spores
Fungi thrive with increased humidity and are therefore also thought to be associated with thunderstorm asthma [5-6].
Other.
Grass seeds and pollen cause thunderstorm asthma for similar reasons.
Thunderstorms are often accompanied by high winds, which can increase the concentration of dust in the air, thus triggering asthma attacks.
Predisposing factors
Having any one or more of the following factors may put you at an increased risk of developing thunderstorm asthma, but not necessarily the disease.
A history of allergies to pollen, fungal spores, grass seeds, dust, etc.
A history of bronchial asthma.
Patients with allergic rhinitis, especially those suffering from moderate-to-severe allergic rhinitis.
Asthma patients who are not using therapeutic medications on a regular basis.
Being outdoors during thunderstorms.
Going outside or opening windows immediately after thunderstorms [5-7].
Pathogenesis
Asthma is a chronic respiratory disease that manifests itself as a special sensitivity of the airways to various stimuli, and this sensitivity tends to trigger reactions such as tightening of the airways, congestion, and increased secretions, which narrow the airways and cause respiratory distress.
During thunderstorms, airborne sensitizing particles penetrate deep into the human respiratory system. Some people who are sensitive to these particles may begin to experience an allergic reaction in their lungs, leading to an attack or exacerbation of asthma symptoms.
Symptoms
Thunderstorm asthma symptoms are the same as regular asthma and are characterized by breathlessness, shortness of breath, wheezing, coughing and chest tightness. Asthma symptoms can flare up within minutes and may last from a few hours to a few days. Some patients may experience relief with medication or on their own.
Major Symptoms
Mild attacks
Most are characterized by episodes of coughing, mild breathlessness and chest tightness.
The cough is mostly dry, and some patients may also have colorless or white mucous sputum.
The condition is often manageable and resolves with prompt medication, or the patient may go into remission on his or her own without any treatment.
Moderate Episodes
Symptoms such as breathlessness, increased respiratory rate, and shortness of breath with slight activity.
Inability to speak continuously but can still speak in single sentences, with occasional anxiety or irritability.
Severe attack
The patient is often irritable, with obvious symptoms of breathlessness, inability to lie down, profuse sweating, and a pained expression.
During an attack, the patient can only speak simple words intermittently.
A whistle-like sound can be heard when breathing.
The “triple concave sign” is often present, which means that the skin between the ribs, on the sternum, and on the clavicle will be concave inward.
Critical Seizures
Very pronounced breathlessness and shortness of breath at rest.
There is profuse sweating and inability to speak any words.
There may be drowsiness or confusion and unresponsiveness to external stimuli [8].
Other Symptoms.
Asthma symptoms may also be accompanied by aura symptoms such as nasal congestion, sneezing, runny nose and itchy eyes.
Complications
If treatment is not timely and standardized, severe complications such as acute respiratory distress syndrome and cardiopulmonary failure can occur in thunderstorm asthma, with symptoms such as dyspnea and severe breath-holding, which can be life-threatening.
Seek medical attention
After the onset of thunderstorm asthma, the number of patients seeking medical attention will increase dramatically. Therefore, it is recommended that patients try home medication first, and then go to the hospital immediately if the symptoms do not subside or if the attack is very severe.
Where to go for medical treatment
Emergency Department
If you experience severe shortness of breath, chest tightness, difficulty breathing, or confusion during a thunderstorm, or if your asthma symptoms are not relieved by your own medication, you should go to the Emergency Department immediately.
Respiratory Medicine
If symptoms such as tolerable shortness of breath, shortness of breath, or coughing occur, or if a person has been diagnosed with asthma, it is recommended that he/she visit the Respiratory Medicine Department in a timely manner.
Preparation for medical treatment
Preparing for your visit: registration, preparation of documents, common problems
Tips for medical treatment
Patients who can walk on their own need to walk as slowly as possible to avoid aggravating respiratory problems.
Patients who are unable to walk on their own should seek medical attention as soon as possible with the help of others.
It is recommended to wear a mask and goggles to avoid further contact with allergens.
Preparation Checklist
Symptom list
Pay particular attention to the time of onset of symptoms, specific manifestations, etc.
When did the symptoms such as shortness of breath, wheezing and coughing appear?
Did you cough up phlegm? What kind of sputum?
When did the above symptoms appear and how long did they last?
Have there been any such symptoms in the past year or more?
Is there a gradual worsening of the symptoms?
Medical History Checklist
Any history of bronchial asthma?
Any history of allergies to pollen, grass seeds, fungal spores, dust, or other allergies?
Any other allergic diseases such as allergic rhinitis?
Have you received asthma-related treatment in the past, and what were the results?
Have you recently been using medications for asthma on a regular basis?
Were you outdoors during the thunderstorm?
Did you go outside or open windows immediately after the thunderstorm?
Checklist
Test results in the past 6 months, which can be brought to the doctor’s office.
Laboratory tests: blood test, C-reactive protein, specific IgE test
Imaging: Chest X-ray, Chest CT
Others: pulmonary function test, exhaled breath nitric oxide test
Medication List
Medication used in the last 3 months, if available, bring the box or package with you to the doctor’s office
Inhaled glucocorticosteroids: budesonide, fluticasone propionate, etc.
Bronchodilators: Salbutamol, Terbutaline, etc.
Others: montelukast, loratadine, etc.
Diagnosis
Thunderstorm asthma is usually diagnosed by history and clinical manifestations, and ancillary tests such as pulmonary function and allergen testing are usually performed.
Diagnosis is based on
Medical history
The following conditions may be present, but the presence of the following conditions does not always result in an attack.
A history of bronchial asthma.
A history of allergy to pollen, grass seeds, fungal spores, dust, or other allergies.
Have a history of allergic rhinitis.
Asthma patients who have not recently used regular therapeutic medications.
Being outdoors during thunderstorms.
Being outside or opening windows immediately after a thunderstorm.
Clinical manifestations
Sudden onset of symptoms such as shortness of breath, wheezing, coughing, etc., or sudden worsening of these symptoms during or some time after a thunderstorm.
In more severe cases, obvious rales can be detected on physical examination, often accompanied by the “three concave signs”.
In very severe asthma attacks, the rales will be weakened or even disappear completely, which is a sign of critical condition and “silent lung”.
Laboratory Tests
Blood tests
Eosinophils can be measured in the peripheral blood to help determine whether the body is in an allergic state.
If eosinophils are too high in routine blood tests, it usually indicates an allergic state.
Serum immunology test
It is mainly serum specific IgE test, which is an in vitro test for allergens.
It can clarify whether the patient is in an allergic state, and guide the patient to avoid contact with allergens and carry out specific immunotherapy.
Arterial blood gas analysis
It can determine the severity of an acute asthma attack.
In severe asthma attack, the partial pressure of oxygen decreases significantly while the partial pressure of carbon dioxide increases, and the acid-base balance is disturbed.
Sputum examination
Measurement of sputum eosinophil count can help determine whether the body is in an allergic state.
Some asthma patients have more eosinophils in sputum smear under microscope. If the patient does not cough up sputum, it can be examined by inducing sputum.
Lung Function Test
Lung function test is one of the necessary tests to assess the basic function of the respiratory system. Some patients need to do bronchodilator test or bronchial provocation test on the basis of routine pulmonary function tests.
Lung function tests require close cooperation between the patient and the doctor. The patient has to follow the doctor’s instructions to breathe at different depths on the instrument, and the instrument will record the relevant parameters.
During an asthma attack, lung function may show signs of obstructive ventilatory dysfunction, such as normal or decreased forceful lung volume (FVC), decreased forceful expiratory volume in the first second (FEV1), 1-second rate (FEV1/FVC%), and peak expiratory flow (PEF).
A positive bronchial provocation test or diastolic test may also be used as an aid to diagnosis.
Exhaled breath nitric oxide test
can be used as an indicator to assess the level of airway inflammation and asthma control.
Patients may have elevated expired nitric oxide on exhaled breath nitric oxide testing.
Imaging
Chest X-ray: Early in an asthma attack, chest X-ray shows an increase in the translucency of both lungs and hyperventilation; in the remission period, there is no obvious abnormality.
Chest CT: bronchial wall thickening and mucus obstruction can be seen on chest CT in some patients [8].
Differential diagnosis
Acute cardiogenic pulmonary edema
Similarities: both present with dyspnea and shortness of breath.
Differences: acute cardiogenic pulmonary edema often has a history of hypertension and heart disease, and the onset is often after exertion and emotional stress, and lung congestion, alveolar and interstitial edema are demonstrated on X-ray chest radiographs in the acute phase. In contrast, thunderstorm asthma usually has no history of the above, the onset of the disease is related to thunderstorm weather, and pulmonary edema is usually absent on X-ray chest radiograph. On auscultation, there are multiple wet rales in both lungs. In contrast, asthma attacks are auscultated as rales in the lungs.
Bronchitis
Similarities: Both have cough and shortness of breath.
Differences: Bronchitis is characterized by a cough with yellowish-green sputum, which may be accompanied by systemic symptoms such as fever and chills, whereas thunderstorm asthma is characterized by shortness of breath and wheezing, and the onset of symptoms is clearly associated with thunderstorms.
Treatment
Treatment objective: timely relief of symptoms, restoration of normal breathing, and prevention of serious complications.
Treatment principle: timely application of drugs to relieve and control symptoms, along with general treatment. Patients with a history of asthma and their families should master the use of asthma emergency medications in order to get effective treatment in the first time.
General treatment
Avoid continued exposure to allergens
Avoid going outside after a thunderstorm. Keep windows and doors closed and avoid opening windows for a short period of time after a thunderstorm. Wear a good mask and goggles if you go out for medical treatment.
Oxygen
Oxygen therapy should be given to correct the hypoxemia caused by asthma symptoms.
Psychological intervention
During the stabilization period, patients can perform some relaxation exercises, such as deep breathing and yoga, which can help improve asthma control and reduce asthma attacks.
Attention to rest
Avoid excessive exercise during an attack and choose a resting position that allows for clear breathing.
Medication
Emergency medications
短效β2受体激动剂
The medication of choice for relieving acute symptoms of mild to moderate asthma provides rapid relief of bronchospasm. This medication can be used as a first aid after the onset of asthma symptoms and usually works within minutes and remains effective for several hours.
Commonly used drugs include albuterol and terbutaline.
These medications are not routine medications and should be used as needed in accordance with the doctor’s prescription or the drug’s instructions, and should not be used in a long-term, single-use, or overdose manner.
If the symptoms continue to be unrelieved or tend to worsen after self-medication, one should go to the hospital immediately for systematic treatment.
长效β2受体激动剂+吸入性糖皮质激素
With anti-inflammatory and asthma-relieving effects, it can be used for daily maintenance treatment or to relieve discomfort when symptoms worsen, but is not preferred as an emergency drug.
Commonly used drugs include budesonide formoterol and beclomethasone formoterol.
Antihistamines
Commonly used drugs include loratadine, ebastine, terfenadine, etc..
They can relieve the symptoms caused by allergy.
Conventional medications
The following drugs are commonly used in the routine treatment of asthma, patients should strictly follow the doctor’s instructions to use drugs, do not stop the drug, change the drug or change the dosage, so as not to cause poor control of asthma, recurrent attacks.
Inhaled glucocorticosteroids
Inhaled glucocorticosteroids have local anti-inflammatory effect, the drug acts directly on the respiratory tract, the required dose is small, and the systemic adverse effects are less, often used in combination with long-acting β2 agonists.
Commonly used drugs include budesonide, fluticasone propionate and so on.
Long-term use of the drug is prone to cause hoarseness, pharyngeal discomfort and candida infection and other adverse reactions.
Care should be taken to rinse the mouth with water after inhalation of this drug.
Oral glucocorticosteroids
For chronic severe persistent asthma that cannot be controlled by inhaled glucocorticosteroids, small doses of oral hormone maintenance therapy can be attached.
Commonly used drugs include prednisone and prednisolone.
Long-term oral application of glucocorticoids may cause osteoporosis, hypertension, diabetes mellitus, obesity and so on.
长效β2受体激动剂
It has the effect of diastolic bronchial smooth muscle, and its effect can be maintained for more than 12 hours.
Commonly used drugs include salmeterol and formoterol, which can be administered via aerosol, dry powder, and other devices.
Leukotriene receptor antagonists
One of the long-term controller medications that can be applied alone in addition to inhaled glucocorticoids, and can be used as an alternative therapeutic medication for mild asthma and as a combination medication for moderate to severe asthma.
Commonly used drugs include montelukast sodium and zalustat.
Be aware of adverse reactions with psychiatric symptoms, such as anxiety, insomnia, and obsessive-compulsive symptoms, when using such medications.
Theophyllines
Can act directly on bronchial smooth muscle, with the effect of diastolic bronchial smooth muscle.
Commonly used drugs include aminophylline, doxophylline, dihydroxypropyl theophylline and so on.
Mainly have nausea, vomiting, arrhythmia, hypotension and other adverse effects.
Anticholinergic drugs
Anticholinergic drugs have some bronchodilatory effect, but weaker than β2 agonists, and slower onset of action.
Commonly used drugs include ipratropium bromide and tiotropium bromide.
Adverse effects mainly include dry mouth, bitter taste sensation, and occasionally dry cough and laryngeal discomfort [8-9].
Prognosis.
Through timely and standardized treatment, most thunderstorm asthma symptoms can be effectively controlled.
Cure
The severity of asthma symptoms due to thunderstorm asthma varies, and the specific cure varies according to individual differences. Generally, with prompt and effective treatment, people with thunderstorm asthma can get significant relief from their symptoms without permanent lung damage.
Delayed treatment in patients may lead to worsening of asthma symptoms and may even be life-threatening.
The prognosis is relatively poor if the patient has a history of severe allergies and asthma.
Hazards
Thunderstorm asthma attacks may affect sleep, study and work. Patients need to standardize their medication and take precautions when thunderstorms are approaching, all of which may affect their quality of life.
Thunderstorm asthma may induce severe asthma symptoms, which may be life-threatening due to untimely treatment or complications such as acute respiratory distress syndrome and cardiopulmonary failure.
The occurrence of thunderstorm asthma may lead to a surge in emergency room visits, increasing the burden on the healthcare system, and some patients may not receive timely treatment.
Daily
Thunderstorm asthma should be prevented on a daily basis by minimizing exposure to aeroallergens and using prophylactic medications as prescribed by a physician if necessary.
Daily Management
Dietary management
Patients should adopt healthy eating habits and ensure balanced nutrition.
Try to avoid foods that may trigger allergic reactions, such as seafood and milk.
It is recommended to limit foods that are too spicy and oily to reduce the risk of asthma attacks.
Life Management
Maintain good living habits and regular routine.
Avoid contact with various substances that may trigger allergic reactions, such as pollen, grass seeds, dust and dust mites.
When thunderstorms are approaching, take appropriate precautions and avoid going out as much as possible to minimize the possibility of inhaling pollen, grass seeds and fungal spores.
During the stabilization period, patients can take appropriate physical exercise, such as walking and swimming, to improve lung function and immunity.
Psychological support
Asthma attacks may bring psychological pressure to patients. Patients are advised to communicate with friends or family members and maintain a positive attitude towards life.
Prevention
The cause and pathogenesis of thunderstorm asthma are still unclear, so it is not possible to completely prevent the disease, but some measures can be taken to reduce the likelihood of attacks, as follows.
People with a history of asthma or allergies should avoid or minimize going out after thunderstorms and close windows and doors to avoid inhalation of allergens. Do not go out or open windows immediately after a thunderstorm either, when the concentration of allergenic particles is still high.
During the peak of allergenic pollen, it is recommended to change outer clothes, dust with a wet towel, wash face, hands and bath promptly after returning to the living room from outdoor. At bedtime, it is recommended to put the outerwear you wore outside in a room other than your bedroom.
Those who are allergic to pollen can use some software or small programs for pollen monitoring data to know the recent environmental pollen concentration.
Allergic individuals can take anti-allergy medications (e.g., loratadine, etc.) well in advance of the thunderstorm season to alleviate any allergic reactions that may be caused.
For people with diagnosed asthma, it is recommended to have emergency medication (e.g. albuterol) with them. Preventive medications (e.g., inhaled glucocorticosteroids) can be applied in advance before thunderstorms occur, which can effectively prevent the occurrence of thunderstorm asthma. At the same time, patients should strictly follow the doctor’s instructions for daily medication, thus reducing the risk of recurrent asthma attacks or acute exacerbations.
Since patients with allergic rhinitis are also at risk for thunderstorm asthma, it is recommended that patients use regular prophylactic treatment with nasal glucocorticoids (e.g. budesonide nasal spray) from a few weeks before the start of the spring weather with high pollen concentration and thunderstorm season.
Maintain a good diet and moderate exercise to enhance body resistance [6,10].