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Asthma

What is asthma and whom does it affect?

Asthma is a condition that affects the smaller airways of the lungs. From time to time the airways constrict in people who have asthma. The extent of the narrowing, and how long each episode lasts, can vary greatly from person to person and episode to episode.

Asthma is caused by inflammation in the airways. It is not known why the inflammation occurs. The inflammation irritates the muscles around the airways, and causes them to squeeze (constrict). This causes narrowing of the airways. It is then more difficult for air to get in and out of the lungs. This leads to wheezing and breathlessness. The inflammation also causes the lining of the airways to make extra mucus which causes cough and further obstruction to airflow.

Asthma can start at any age, but it most commonly starts in childhood. At least 1 in 10 children, and 1 in 20 adults, have asthma. Asthma also runs in some families.

What are the symptoms?

The common symptoms are cough and wheezing. You may also become breathless, and develop a feeling of chest tightness.

  • Mild Asthma
  • You tend to develop mild symptoms from time to time. For example, you may develop a mild wheeze and a cough if you have a cold or a chest infection, or during the hay fever season, or when you exercise. For most of the time you have no symptoms. A child with mild asthma may have an irritating cough each night, but is often fine during the day.

  • Moderate intensity Asthma
  • You typically have episodes of wheezing and coughing from time to time, however the time duration for which you are symptom free is less than mild asthma. Symptoms are often worse at night, or first thing in the morning. You may wake some nights coughing or with a tight chest.

  • Severe attack of asthma
  • You become very wheezy, have a tight chest, and have difficulty in breathing. You may find it difficult to talk because you are so breathless. Severe symptoms are usually superimposed on moderate symptoms.

What can make asthma symptoms worse?

Asthma symptoms may flare up from time to time. There is often no apparent reason. However, some people find that symptoms are triggered, or made worse, in certain situations.

  • Infections. Particularly colds, coughs, and chest infections.
  • Pollens and moulds. Asthma is often worse in the hay fever season.
  • Exercise. However, sport and exercise are good for you if you have asthma. If necessary, you can use an inhaler before exercise to prevent symptoms from developing. But, as a rule, exercise-induced asthma often represents undertreated asthma.
  • Certain drugs. Drugs that may cause asthma symptoms include: anti-inflammatory painkillers such as aspirin, ibuprofen, diclofenac, etc, and betablockers such as propranolol, atenolol, or timolol. This includes betablocker eye drops used to treat glaucoma.
  • Smoking and cigarette fumes. All children deserve to live in a smoke-free home. In particular, children with asthma.
  • Other fumes and chemicals. For example, fumes from paints, solvents and pollution. The increase in air pollution may be a reason why asthma is becoming more common.
  • Certain pillows and mattresses may be a trigger. It is thought that some people develop asthma symptoms from chemicals (isocyanates / methyl ethyl ketones etc) that are emitted in very low quantities from memory foam pillows and mattress toppers.
  • Emotion. Asthma is due to such things as stress, emotional upset, or laughing.
  • Allergies to animals. For example, pet cats, dogs, and horses.
  • House dust mite. This is a tiny creature which lives in mattresses and other fabrics around the home. If you are allergic to it, it may make symptoms worse. It is impossible to get rid of house dust mite completely.
  • Some foods. This is uncommon.
How is asthma diagnosed?

Sometimes symptoms are typical, and the diagnosis is easily made by a doctor. If there is doubt then two commonly used tests are called spirometry and assessment with a peak flow meter.

Spirometry

This test measures how much air you can blow out into a machine called a spirometer. Two results are important: the amount of air you can blow out in one second (called forced expiratory volume in 1 second (FEV1)) and the total amount you can blow out in one breath (called forced vital capacity (FVC)).

A value is calculated from the amount of air that you can blow out in one second divided by the total amount of air that you blow out in one breath (called FEV1/FVC ratio). A low value indicates that you have narrowed airways which are typical in asthma (but a low value can occur in other conditions too). Therefore, spirometry may be repeated after treatment. An improvement in the value after treatment to open up the airways is typical of asthma.

Assessment with a peak flow meter

This is an alternative test. A peak flow meter is a small device that you blow into. A doctor or nurse will show you how. It measures the speed of air that you can blow out of your lungs. No matter how strong you are, if your airways are narrowed, your peak flow reading will be lower than expected for your age, size, and sex. Peak flow readings improve when the narrowed airways are opened up with treatment. Regular peak flow readings can be used to help assess how well treatment is working.

What are the treatments for asthma?

For most people with asthma, the symptoms can be prevented most of the time with treatment. So, you are able to get on with normal life, school, work, sport, etc.

Inhalers

Most people with asthma are treated with inhalers. Inhalers deliver a small dose of drug directly to the airways. The dose is enough to treat the airways. However, the amount of drug that gets into the rest of your body is small so side-effects are unlikely, or minor. A doctor or nurse will advise on the different types.

Drugs delivered by inhalers can be grouped into relievers, preventers and long-acting bronchodilators:

  1. A reliever inhaler is taken as required to ease symptoms immediately. The drug in a reliever inhaler relaxes the muscle in the airways. This makes the airways open wider, and symptoms usually quickly ease. For example, salbutamol and terbutaline. These come in various brands made by different companies. If you need a reliever inhaler three times a week or more to ease symptoms, a preventer inhaler is usually advised.
  2. A preventer inhaler is taken every day to prevent symptoms from developing. The drug commonly used in preventer inhalers is a steroid. Steroids work by reducing the inflammation in the airways. It takes 7-14 days for the steroid in a preventer inhaler to build up its effect. Therefore, it will not give any immediate relief of symptoms. It can take up to six weeks for maximum benefit. You should then continue with the preventer inhaler every day even when your symptoms have gone - to prevent symptoms from coming back.
  3. A long acting bronchodilator may be advised in addition to a preventer inhaler. One may be needed if symptoms are not fully controlled by the preventer inhaler alone. The drugs in these inhalers work in a similar way to reliever inhalers, but work for up to 12 hours after taking each dose. They include salmeterol and formoterol.
Spacer devices:

Spacer devices are used with some types of inhaler. They are commonly used by children, but many adults also use them. A spacer is like a small plastic chamber that attaches to the inhaler. It holds the drug like a reservoir when the inhaler is pressed. A valve at the mouth end ensures that the drug is kept within the spacer until you breathe in. When you breathe out, the valve closes. So, you don't need to have good co-ordination to inhale the drug if you use a spacer device.

Tablets to open up the airways

Steroid tablets

A short course of steroid tablets (such as prednisolone) is sometimes needed to ease a severe or prolonged attack of asthma. Steroid tablets are good at reducing the inflammation in the airways. For example, a severe attack may occur if you have a cold or chest infection.

Omalizumab

Omalizumab is a drug that is only used in a small number of people who have severe persistent allergic asthma that has not been controlled by other treatments. It is given by injection. It works by interfering with the immune system to reduce inflammation in the airways which is present in asthma.

Deriphyllin

This works by improving the contractility of the respiratory muscles and causes the small airways to open up.

A typical treatment plan.Supposing the patient is a moderate intensity asthmatic:

  • A preventer inhaler (usually a steroid inhaler), taken each morning and at bedtime. This usually prevents symptoms throughout the day and night.
  • A reliever inhaler may be needed now and then if breakthrough symptoms occur.
  • If exercise or sport causes symptoms, then a dose of a reliever inhaler just before the exercise usually prevents symptoms.
  • Some people may need to add in a long-acting bronchodilator, or tablets, if symptoms are not controlled with the above.
Does asthma go away?

About half of the children who develop asthma grow out of it by the time they are adults. For many adults, asthma is variable with some good spells and some spells that are not so good. Some people are worse in the winter months, and some worse in the hay fever season. Although not curable, asthma is treatable.

Important general points about asthma

  • See a doctor urgently if you develop severe symptoms that are not eased by a reliever inhaler. In particular, if you have difficulty talking due to shortness of breath. You may need emergency treatment with high-dose reliever drugs and other treatments, sometimes in hospital. A severe asthma attack can be life-threatening.
  • You should have an influenza immunisation every autumn (the flu jab) if you need continuous or repeated use of high-dose inhaled steroids and/or take steroid tablets and/or have had an episode of asthma which needed hospital admission.

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