Asthma

  • Asthma is a chronic (long-term) lung condition in which the airways are inflamed and narrowed, making it harder to breathe normally. More than 5 million people in the UK have asthma, making it the most common long-term disease affecting all age groups.

    Who gets asthma?

    Although asthma often runs in families, many people with asthma do not have relatives with the condition. Hay fever and eczema are frequently associated with asthma – either in the person with asthma or in their family. While symptoms often start in childhood, they can start at any age – even in people in their 80s.

    What happens in asthma?

    Asthma affects the bronchial tubes, the airways which carry air in and out of the lungs. Asthmatics have over-sensitive, irritable or ‘hyper reactive’ airways. When their airways are irritated, the airway lining becomes swollen, the bronchial muscles go into spasm and more mucus than usual is produced. This makes the airways narrower and so it is harder for air to get in and out of the lungs.

    Changes in asthmatic airways

    Asthma Airways Annotated

    These pages cover the main points in the British Guidelines on the Management of Asthma and give you the information you need for talking to your GP about asthma and how to manage it.

  • Asthma is not catching; it probably results from a combination of several inherited (genetic) and environmental factors. However, no-one knows for sure why some people get asthma and others do not.

    What makes asthma worse?


    Although asthma may get worse for no apparent reason, common triggers are:

    • The common cold

    • Allergies – people with asthma are commonly allergic to pollens, moulds, house dust, animal fur and certain foods.

    • Occupational (work-related) asthma – some people develop asthma as a result of exposure to a particular substance at work. This accounts for 9-15 per cent of new cases of adult asthma. Over 400 substances have been reported to cause occupational asthma; workers at risk include paint sprayers, bakers, nurses, chemical workers, animal handlers, welders, food processing workers and timber workers.

    • Exercise – can trigger asthma in some people, particularly when the exercise is undertaken in cold, dry air. With the right medication, exercise-induced asthma can be prevented or well controlled. Asthmatics should not avoid sport and exercise, as they contribute to overall good health.

    • Irritants – include tobacco smoke, fumes and pollution.

    • Weather– either cold or hot conditions can trigger asthma in some people.

    • Medicines – most medicines are safe for asthmatics. However, if you have high blood pressure or angina, some medication used to treat these conditions (such as beta-blockers) can make asthma worse. Even beta-blocker eye drops can provoke attacks. Asthmatics should also avoid aspirin and ibuprofen. Check with your doctor or pharmacist if you are not sure what to do, but don’t stop taking medication without seeking medical advice first.

    • Emotion – anger, anxiety or happiness may trigger asthma in some people.
  • People with asthma typically suffer from, at least, two of the following symptoms:

    • wheezing
    • shortness of breath
    • a tight feeling in the chest
    • coughing

    Symptoms normally come and go, often unpredictably.

    There is wide variation in the severity, frequency and duration of symptoms. One person’s experiences can be very different from another’s.

    Many people find that their symptoms are worse at night and that they are provoked by particular irritating substances or circumstances known as ‘triggers’.

  • Your GP will look for the symptoms of asthma and what triggers them. Several other illnesses can cause similar symptoms and need to be excluded. Your doctor will ask questions about your health and lifestyle and do some breathing tests to confirm if you have asthma.

    Questions the doctor might ask

    • Is there a particular pattern in your symptoms? For example, are they worse at night or in the morning?
    • Have you noticed what triggers your symptoms – for example, exercise, cold air or other triggers?
    • Are your symptoms worse after taking aspirin or beta blockers?
    • Is there a personal or family history of asthma or hay fever?
    • Do you have any known allergies?
    • Do your symptoms improve when you take time off work? This is characteristic of occupational asthma.

    Tests you might be asked to do

    Lung function tests

    Your lung function can be tested using different types of devices.

    A peak flow meter is a hand-held device, measuring the maximum speed you can blow air out of your mouth from a full breath in (this is called your ‘peak flow’). Patients with narrowed airways, as in asthma, will not be able to blow air out as fast as those with normal airways.

    Your doctor may give you a peak flow meter to take home and ask you to keep a diary of your peak flow measurements. This helps in diagnosis, particularly if you make a note of any possible triggers. If you have occupational asthma, for example, you may notice that your peak flow is better when on holiday than when at work. Your doctor may also measure your peak flow before and after you take an asthma medication; a rise in peak flow after treatment, is typical of asthma.

    A spirometer also measures obstruction of the airways by showing how fast you can blow air out. It measures FEV1 (how much air is expelled from the lung in the first second of breathing out), as well as the vital capacity, VC (the total amount of air blown out with each breath). An FEV1 of less than 80 per cent of VC suggests obstruction to airflow through narrowed airways.

    Other tests

    A trial of treatment – this is when you try various different medications, usually for 2-4 weeks, to see what effect they have on your symptoms and on your peak flow.

    A chest x-ray – this helps to rule out other conditions.

    Skin prick allergy testing – this help find out if there is a particular allergy that triggers your asthma.

    Blood tests – to identify any allergies which may trigger your asthma.

    Exercise test – you may be asked to walk or run on a treadmill or ride an exercise bike to see if you become wheezy and your peak flow falls.

    Challenge test – this is done in highly specialist units. You are exposed to a substance to which you may be allergic and your breathing is carefully monitored. This is occasionally done when investigating occupational asthma.

    Why you might need a second opinion

    Your GP may send you to a specialist if:

    • The diagnosis is not clear
    • Something unexpected is found
    • Tests indicate you may not have asthma
    • You might have occupational asthma
    • You are always short of breath
    • You have a wheeze all the time
    • You are suffering from chest pain
    • You have lost weight without trying to
    • Asthma treatments aren’t working and your breathlessness, wheeze or cough continues
    • You have a fever.

    Questions to ask your GP

    1. What is asthma?
    2. How can I be sure that I have asthma?
    3. What sort of tests will I have and what will they be like?
    4. Why do I need to see a specialist and how can they help?
    5. Why have I got asthma?
    6. Will my children get asthma?
    7. Are my symptoms likely to change over time?
    8. How will asthma affect my day-to-day life?
    9. Could asthma damage my lungs?
    10. Should I change my occupation?
  • Asthma cannot be cured, but with the right treatment most people can lead normal lives.

    Treatment aims to control your asthma by:

    • Getting rid of day-time and night-time symptoms
    • Removing limitations on physical activity
    • Preventing asthma getting worse and preventing asthma attacks
    • Maximising lung function
    • Minimising potential side effects.

    There are two main types of asthma medications – relievers and preventers.

    Relievers are so-called because they give rapid relief of symptoms. They are taken as and when symptoms occur. The medicine in them (usually beta 2-adrenergic agonists) relaxes the muscles in the breathing tubes and therefore opens up the airways to improve breathing.

    Preventers are so-called because they help to prevent or reduce symptoms. They work by reducing inflammation within the airways. The most commonly used preventers are corticosteroids, usually given from an inhaler. Sometimes other tablets are also prescribed to enhance the effect of the inhaler and reduce the required dose of inhaled steroids.

    Preventers only work if they are taken regularly; you must take your preventer medication as prescribed by the doctor whether or not you are experiencing symptoms – even if you feel well. Relievers are taken in addition if symptoms occur despite preventative treatment. Also, if your chest is tight, it is helpful to take a dose of the reliever medication 5-10 minutes before taking the preventer. Doing this, allows
    the airways open up and enable the preventer to penetrate further into the lungs.

    Step-wise treatment
    The British Guideline on the Management of Asthma recommend the following five step approach to treatment:

    • Step 1 is for people with mild asthma, who experience symptoms only occasionally. The only treatment needed is a short-acting reliever. If you need to use your inhaler more than twice a week, have symptoms more than twice each week, or wake in the night because of your asthma, you may need to move to step 2.
    • Step 2 is for people whose symptoms are a little worse. A preventer inhaler is used regularly as well as a reliever.
    • Steps 3 – 5 are for people whose asthma has not responded adequately to previous treatment. As you move up through steps 3 – 5, medication doses are larger and extra drugs may be added to help control symptoms. These drugs might include long-acting reliever inhalers (beta-2 agonists), tablets (steroids, theophyllines or leukotriene blockers) or possibly an intal inhaler.

    Things can change over time. If your symptoms aren’t being controlled, your doctor may decide that you need to step up treatment to the next level. If your asthma is well controlled, they will try to reduce treatment and see if your asthma can still be controlled. The aim is to find the lowest level of treatment which controls your disease. This keeps side effects of treatment to a minimum.

    Inhalers

    Most asthma medications, both relievers and preventers, are taken from a metered dose inhaler (MDI). MDIs are sometimes known as puffers and consist of a pressurised metal canister which has medication inside it - usually in liquid form. The canister is housed within a plastic case which has a mouthpiece. When the canister is pushed down, a valve delivers a measured dose of medicine in a fine mist.

    This is inhaled via the mouthpiece directly into the lungs where it is needed and also minimises side effects in other parts of the body.

    Many people have difficulty using inhalers but your doctor or nurse will show you how to use it properly and check your technique. Poor inhaler technique can mean that your body isn’t getting the appropriate dose of the medication needed.

    Our ten tips for using an inhaler explain what you should do to make sure the medication reaches your lungs. One common mistake is not taking a slow deep breath at the same time as pressing down the canister. This means the medication ends up in your throat where it may cause irritation.

    One way to ensure you get the right technique is to practice using your inhaler in front of the mirror a few times. If you see mist coming from the top of the inhaler, from the sides of your mouth, or your nostrils, you are not inhaling the dose correctly. You can always check your technique with a practice nurse or pharmacist. If you have weak hands, you may find it easier to hold the inhaler with both hands push the canister down with both index fingers rather than one. If you are still experiencing problems, you may find the addition of a Haleraid device will help to depress the canister. You should be able to get more information from your pharmacist or practice nurse about this.

    It is important to clean your inhaler regularly otherwise it may not work properly - once a week should be enough. You should remove the metal canister and mouthpiece cap from the case of the inhaler. Wash the case and cap in warm soapy water. Rinse in warm water then leave to dry.

    The holes at the bottom of the canister can sometimes become blocked – these can be cleaned with a pin.

    Spacers

    Most inhalers are best used via a spacer – a plastic or metal chamber attached to the mouthpiece of the inhaler. After shaking the inhaler, you discharge it once into one end of the spacer and then you take between four and six normal breaths from the mouthpiece at the other end of the spacer. This process is then repeated.

    The spacer enables double the amount of medicine to reach your lungs and will also reduce the proportion which you accidentally swallow. It is particularly useful in the elderly and in children who may find it difficult to co-ordinate their breathing with the release of the medication from the inhaler.
    If you can’t easily or successfully use a MDI, there are several other types of inhaler on the market.

    Clickhalers or autohalers are occasionally useful for people who have difficulty coordinating their breathing with discharging the aerosol from the MDI. With these inhalers the discharge of areosol is triggered only by taking a breath from the inhaler.

    Dry powder devices

    In addition, it is possible to get very similar medication in the form of a dry powder from devices such as turbohalers and diskhalers. Some people find these easier to use. Talk to your doctor, practice nurse or pharmacist for advice about which one may be best for you.

    Nebulisers

    These are small, portable machines generating a mist of medicine, which you breathe in via a mouthpiece or mask. They are mainly used in emergency situations to administer large doses of reliever drugs quickly, particularly in ambulances or hospitals when someone is suffering from a severe asthma attack. Generally the same benefit can be obtained more conveniently from an MDI with spacer as with a nebuliser.

    Types of asthma medication

    Types of asthma medication

    Ten tips for using an inhaler

    1. Try to keep your back as straight as possible either by sitting up straight or standing.
    2. Lift your chin to open the airways.
    3. Take the cap from the mouthpiece and shake the inhaler
    4. If it is the first time you have used the inhaler for a while, or it is a new canister, spray into the air first to check that it works.
    5. Take a few deep breaths and then breathe out gently. If you are not using a spacer device, put the mouthpiece in your mouth, put your teeth around it and seal your lips around the mouthpiece, holding it between your lips.
    6. Start to breathe in slowly and deeply through the mouthpiece. At the same time as you begin to breathe in press down on the inhaler canister to release the medication. One press releases one puff of medication.
    7. Continue to breathe in deeply to ensure the medicine gets into your lungs.
    8. Hold your breath for 10 seconds or as long as you comfortably can, before breathing out slowly.
    9. If you have been prescribed two doses, wait for 30 seconds, shake your inhaler again and repeat the above steps.
    10. Replace the cap on the mouthpiece.

    Side-effects of treatments

    Reliever inhalers have very few side effects. However, if taken in high doses, they can produce shaking, palpitations or muscle cramp.

    Many people worry about taking steroids, but the corticosteroids used in asthma are quite different from the anabolic steroids used by some bodybuilders and athletes.

    When taken in small doses, inhaled corticosteroids have few side effects. There is a small risk of having a sore dry mouth or a husky voice from thrush. This is generally prevented by rinsing your mouth out or brushing your teeth after using your inhaler, as can using a spacer.

    Steroid tablets, particularly when taken as a long term treatment, are much more likely to cause side effects. You should discuss these in detail with your doctor. It is important to balance the relatively small risks of side effects of medication with the dangers of under-treated asthma.

    Other ways to minimise your asthma symptoms

    Things can change over time. If your symptoms aren’t being controlled, your doctor may decide you need to step up to the next level. If your asthma is well controlled, they will try and move you down a step, to see if your asthma can still be controlled using less medication. The aim is to find the lowest level of treatment that controls your disease. This keeps side effects of treatment to a minimum.

    As well as using your medication you may want to consider the following ways of controlling your asthma.

    Avoiding triggers - the most important thing is to avoid, if possible, anything which provokes your asthma - in particular animals, pollens and certain foods. Asthma provoked by food allergy is not very common. However, those with allergies to foods like nuts and seafood must be extremely careful to avoid them as reactions can be severe.

    Smoking should be avoided by those with asthma and around asthma sufferers as it makes symptoms worse. In addition, there is evidence that smoking while pregnant may result in an asthmatic child.

    Diet - there is some evidence that eating foods containing flavenoids (e.g. apples) may improve asthma symptoms and that eating apples and fish while pregnant may have a small protective effect against asthma. If you have been diagnosed as clinically obese, losing weight should help to improve your asthma.

    Breathing exercises and physical exercise may also be helpful, but please consult your doctor for advice.

    Immunotherapy - asthmatics who have a severe allergy to specific items such as grass pollen or dust mites may want to talk to their doctor about subcutaneous immunotherapy. The aim of this treatment is to reduce allergic reactions to a specific agent by giving a course of gradually increasing amounts of that agent. This is given in injections under the skin. Immunotherapy is usually carried out in specialist centresand may be particularly useful in those allergic to bee-sting.

     

  • People who are experiencing very severe asthma symptoms are said to be having an ‘asthma attack’ or an ‘acute asthma exacerbation’. You might be having an asthma attack if you have any of the following problems:

    • Your symptoms are getting worse and worse
    • Your usual reliever is not working
    • Your peak flow reading has dropped suddenly
    • You are very breathless (unable to complete a sentence in one breath)
    • Your breathing is rapid
    • Your pulse is racing
    • You feel exhausted and confused

    Triggers of asthma attacks include chest infections and the common cold.

    What to do

    Most asthma attacks can be managed by taking action quickly. First, use your reliever – this will always work better with a spacer in an acute attack because it is too difficult to coordinate the inhaler when you are breathless and breathing fast. You can take more doses of the reliever if your breathing does not improve.

    Asthma attacks can become life threatening. If your condition deteriorates very quickly and is not responding to your reliever, then emergency treatment is vital.

    • Refer to your management plan.
    • Seek urgent treatment from your doctor or the Accident and Emergency (Casualty) Department of your local hospital. Do not hesitate to dial 999.
    • Keep using your reliever inhaler, with your spacer if you have one, until help arrives.

    How to prevent attacks

    • Make sure you have an up-to-date personal asthma action plan and follow it at all times. See your doctor if it isn’t working properly.
    • Take preventers, even when feeling well. Many asthma deaths are caused by under treatment, particularly under-use of steroids.
    • Make sure you know when and how to increase your treatment levels if your asthma isn’t under control.
    • Get to know your triggers.
    • Make sure you know when and how to increase your treatment levels if your asthma isn’t under control.
    • Never ignore worsening symptoms – the symptoms of a severe asthma attack can take 6 to 48 hours to become serious and can even become life threatening. Waking at night with asthma is an important warning sign.
    • Discuss with your doctor whether you need to keep emergency treatments at home.
  • There are some things you can do to help take control of your asthma, and continue to lead an active life.

    Personal asthma action plans

    A personal action plan is a written summary of how to manage your own asthma. You should meet once a year with your GP or nurse to review the plan. The plan should include:

    • Which medicines you take, how much you take and when you take them.
    • How to tell if your asthma is getting better or worse
    • Actions you should take if your asthma changes – for example when to seek emergency help or when and how to increase the dose of your inhaled steroids
    • What your normal peak flow is, how to find out if it is low and what to do if it is low. It is important to stick to your action plan at all times. See your doctor or nurse if your plan isn’t keeping your asthma under control.

    How do you know when your asthma is controlled?

    Severity of symptoms and your peak flow indicates asthma control. Check and record your peak flow and ask yourself these questions every week or month and compare the answers to the months before, looking for any change:

    • Have you had difficulty sleeping because of your asthma symptoms (including a cough)?
    • Have you had your usual asthma symptoms during the day (a cough, wheezing, chest tightness or breathlessness)?
    • Has your asthma interfered with your usual activities?
    • How often do you need to use your reliever inhaler?

    Another way to know if your asthma is under control is to monitor your peak flow - try and record this every day.

    Top tips for control

    • Make sure you fully understand your personal action plan
    • Follow the plan and seek advice if it isn’t working
    • Review your action plan, symptoms and inhaler technique once a year with your GP or nurse, or more often if your symptoms are hard to control
    • Make sure you know what medicines to take and when to take them
    • Know your triggers
    • Make sure you know what to do if your asthma symptoms change and when to seek emergency help
    • Use your preventer medications regularly, as prescribed, even when you feel well
    • Check your peak flow and compare with your normal values
    • Eat healthily, take regular exercise and get enough sleep to keep fitness levels up.

    Taking contol of occupational asthma

    See your GP

    If your GP thinks you may have occupational asthma they should refer you to a specialist, who will ask you to use a peak-flow meter regularly, both when at work and when not. The specialist may also arrange for some tests in the specialist centre, when breathing tests are monitored while you reproduce the activity which is thought to be the cause of the asthma. For example you may be asked to monitor your breathing test before and after using a soldering iron.

    Try to avoid the substance that’s caused your asthma

    Completely avoiding the substance that triggers your asthma boosts your chances of recovery, especially if done within twelve months of your first symptoms.

    Keep your employer informed of what’s happening

    Ask your employer whether it’s possible to improve conditions at work, so that you are no longer exposed to the substance that has caused your asthma.

    Seek financial help

    You may be entitled to Industrial Injuries Disablement Benefit. Your local Benefits Office will have more information. You can also call our helpline on 03000 030 555.

    List of questions to ask your GP

    1. How often do I need to see my doctor or nurse? When should I seek their help?
    2. What are my medicines and how do they work?
    3. Why are preventers needed every day, even when I’m feeling well? Is it bad for me if I only use my reliever?
    4. Why do I sometimes have symptoms even though I am taking the medicine?
    5. How can I tell when I need more or less medicine?
    6. How do I know which inhaler is best for me, and whether I’m using it properly?
    7. How do I clean my spacer?
    8. What are the benefits and risks of each treatment? Are steroids dangerous?
    9. When should I see a specialist?
    10. What are the dangers of under-treating asthma?
    11. Is asthma ever dangerous? How can I tell when to seek emergency help?
    12. Can pets affect my asthma?
    13. Why is important to use a spacer with my inhaler?
    14. Wouldn’t a nebuliser be more useful?
    15. I don’t have a personal asthma plan, how do I get one?
       

    Pregnancy

    Pregnancy can affect your asthma. Asthma gets worse in about a third of pregnant women, improves in another third and stays the same in the final third. It is difficult to predict which women will fall into which category, though each successive pregnancy may well affect asthma symptoms in a similar way.

    Your GP should:

    • Offer advice on the importance and safety of asthma medication during pregnancy. If asthma is well controlled, there is little or no increased risk of complications to mother or baby.
    • Monitor you closely throughout pregnancy so that any change in symptoms can be matched with a change in treatment.
    • If you smoke, advise you about the risks involved for yourself and your baby and help you to stop.
    • Ensure your obstetrician and respiratory consultant talk to each other about your health.

    Use of medicines in pregnancy, labour and breastfeeding

    In pregnancy

    Most women should be able to use their asthma medications as normal during pregnancy. ‘In general, the medicines used to treat asthma are safe in pregnancy,’ states the British Thoracic Society Guideline.

    However, the small number of pregnant women who are taking theophylline tablets (used occasionally in severe asthma) should have blood levels checked. Also it is best not to start taking leukotriene receptor antagonist tablets for the first time during pregnancy. Steroid inhalers are safe if used normally, and there is no evidence that steroid tablets harm babies.

    The British Guidelines state: ‘The risk of harm to the unborn baby from severe or chronically under-treated asthma outweighs any small risk from the medications used to control asthma’.

    During labour

    All forms of pain relief known for labour are safe for asthmatics and mothers should continue their usual medication.

    Acute asthma attacks are rare in labour. A caesarean section may be offered to a pregnant woman with acute severe asthma. It is better to have a spinal, or epidural, than a general anaesthetic.

    Breastfeeding reduces the risk of your child becoming asthmatic. Nursing mothers can use their asthma medications as normal.


    Questions to ask your GP during pregnancy

    1.  How will pregnancy affect my asthma?
    2. Will you monitor my asthma during pregnancy?
    3. What complications may occur if I do, or don't, take my medication?
    4. How will my baby get enough oxygen if I am short of breath?
    5. What kind of labour should I plan to have?
    6. How might asthma, and my asthma medications, affect my labour?
    7. How would a general anaesthetic or an epidural affect things?
    8. I want to breast feed my baby. Is my asthma medication safe?
    9. Will my baby have asthma because I do?