Posts Tagged ‘airway inflammation’

Using inhalers
The value of using an inhaler rather than taking tablets or syrup is explained on p. 141 for steroids. The same principle applies to all drugs.
The oldest type of inhaler is the ‘puffer’ or aerosol inhaler, properly called a ‘pressurised metered-dose inhaler’ or MDI. It delivers the drug as a fine, moist, spray. In addition, there are now many devices that deliver drugs in dry-powder form.
If you or your child find the aerosol inhalers difficult, you may do better with a dry-powder inhaler. Your doctor should have several different inhalers available for you to try out, to see which one suits you best.
When you are given an inhaler you must be shown how to use it by a doctor or asthma nurse. A great many asthma patients have a ‘poor inhaler technique’, and get too little of the drug as a result. This often leads to their asthma getting out of control. The advice given here for using inhalers is no substitute for proper training, and should only be used to supplement what your doctor or asthma nurse has told you.
When using an aerosol inhaler or MDI, remember to shake the inhaler well or you will not get the right dose. Your in-breath must coincide exactly with pressing the canister down: this is the part that many people find difficult. You must breathe in slowly and deeply, otherwise you do not get much of the drug into your airways.
Many asthmatics stop inhaling the moment the
spray from the aerosol inhaler hits the back of the
throat. The spray contains a propellant, which
makes it very cold, and there is a natural reflex
response to this cold liquid which stops inhalation.
This response may be impossible to control. If so,
you need a dry-powder inhaler (see right), or a
spacer to use with your aerosol inhaler (see p. 162).
Breath-operated aerosol inhalers such as the
Autohaler can be useful for those who find ordinary
aerosol inhalers too hard to use. With these devices, you do not have to push the canister down because your in-breath triggers the release of the drug. Take care not to block the air-intake holes with your hands and don’t stop breathing when you hear the inhaler click. (If there is no click, start again and breathe in more forcefully this time.)
One hazard with aerosol inhalers is that, when almost empty, they produce no drug – just the propellant. Although they still ‘puff’ normally, they are not effective. It may be hard to tell when your inhaler is running low. Ask your doctor or asthma nurse for advice about this.
Many asthmatics find dry-powder inhalers such as the Spinhaler, Rotahaler, Diskhaler, Accuhaler, Clickhaler and Turbohaler are the easiest to use. They have no aerosol device, so none of the problems associated with the coldness of the propellant.
On the other hand, nothing pushes the drug into your mouth and lungs with a dry-powder inhaler: you have to do all the work yourself. This means you have to breathe in quite hard and fast. During a severe asthma attack you may not be able to breathe in hard enough to get a good dose of the drug. Some asthmatics have an aerosol inhaler as well, often combined with a spacer (see p. 162), for use during severe attacks.
For the parents of asthmatics, who want to keep an eye on how much of a drug is being used, most of the dry-powder inhalers allow you to do so.
Arthritis and inhalers
Those who suffer from arthritis in their hands often find inhalers difficult to use. There are several aids now available to help with this problem – ask your doctor or asthma nurse about these.
Do hold your breath
Whichever type of inhaler you use, it is important to give the drugs a chance to do their work. After inhaling, and when your lungs are full, you should hold your breath for at least ten seconds. Then breathe out, but wait at least another 30 seconds before breathing in again.
Side effects from non-drug ingredients
There are other ingredients in inhalers, besides the drug, and they occasionally cause side effects.
Aerosol inhalers are the worst offenders. They can contain up to five non-drug ingredients, such as propellants and surfactants. Some asthmatics are sensitive to one of these, and respond with coughing or bronchospasm when they inhale them.
If inhaled in large amounts, the propellants in aerosol inhalers can give a mild ‘high’, and asthmatic teenagers and their friends may - very rarely - begin abusing inhaled beta-2 relievers. Parents should be alert for the possibility of such problems, but not worry unduly.
Dry-powder inhalers do not need propellants or surfactants, so they are suitable for anyone who develops a sensitivity to these. However, they may contain lactose, or milk sugar, in addition to the drug. Enough lactose is deposited in the mouth and swallowed to provoke symptoms, such as diarrhoea and wind, in people who suffer from severe lactose intolerance (see box on p. 79). Trace amounts of milk proteins in the lactose may be a problem for people with severe milk allergy.
CFCs and inhalers
Aerosol inhalers have long contained CFCs, which are very inert gases (at ground level) and perfectly safe to inhale. Unfortunately, they cause serious damage when they reach the ozone layer high above the earth, so they are being phased out in asthma inhalers, as they are in all aerosols. Other propellants, called hydrofluoroalkanes (HFAs), are being introduced to take their place. The spray from an HFA inhaler may taste and feel different, but it should do exactly the same job as a CFC inhaler: the drug it contains remains the same. Research suggests that these new propellants are very safe, but tell your doctor if your reaction to your inhaler seems to change suddenly.
These new propellants deliver medication more efficiently into the lungs, so that usually only half the previous dose is required. Unlike CFC-type inhalers, they will deliver a constant dose until empty. In addition, they are not affected as much by below-freezing temperatures.
Inhale - then clean your teeth
Asthmatic children are more prone to dental decay than other children, and inhalers are suspected of causing the problem. No one knows, as yet, exactly which ingredient of the inhalers is the culprit - it could be a drug, or a non-drug additive such as a propellant. Alternatively, the fact that the spray from some inhalers is slightly acidic could explain this side effect. Brushing the teeth after using the inhaler, or just rinsing out the mouth with water, is recommended as a preventive measure.
Using spacers
A spacer is a large empty chamber that can be fitted to an aerosol inhaler (a puffer or MIDI). to make it more effective and easier to use. The aerosol spray goes into one end of the spacer, and the asthmatic breathes it in from the other end.
When using a spacer, you can breathe normally: you don’t have to take all the drug in at once. or hold your breath after you’ve inhaled. But you should try to breathe as deeply as possible, and hold your breath for up to ten seconds if you can.
Note that spacers are for use with aerosol inhalers only. Spacers allow the aerosol propellant (see p. 161) to evaporate, leaving tiny airborne droplets of the drug to be inhaled. Once the propellant has evaporated, these droplets are no longer cold, so the reflex response that stops inhalation is avoided.
During an asthma attack, spacers are immensely valuable because they allow you to get some of the drug into your airways even though you are unable to take a deep breath. There is a collapsible spacer, called the E-Z Spacer, which folds up into a plastic case small enough to be slipped into a pocket. In a severe asthma attack, having such a spacer could save your life.
In an emergency, if no spacer is available, you can improvise one (see p. 100).
Babies and small children, who cannot yet coordinate the in-breath with pushing the aerosol canister down, need spacers for everyday use. There are spacers designed for children under two years, with masks that fit over the nose and mouth.
When using a spacer, shake the inhaler and then spray it into the spacer once only. Inhale within five seconds. During an asthma attack, you can add another dose from the inhaler every ten seconds, until the attack begins to subside, but keep a count of how many puffs you use (see p. 100).
For a young child, shake the inhaler well, and fit it to the spacer. Put the mouthpiece into the child’s mouth, or put the mask on. Tell the child to breathe in and out steadily. Listen for the clicking of the valve on the spacer - this shows that it is opening and closing. When the child’s breathing is regular, puff a single dose into the spacer. The child should breathe in and out 5-8 times.
Priming a spacer
Prime a new spacer, or one that has been washed, by firing the inhaler into it about five times. Do this before you actually need to use the spacer.
The drug will coat the spacer walls, due to an electrostatic charge on the plastic. You won’t be able to see the drug as it forms a very thin coating.
When you come to use the spacer, no more of the drug will stick to the spacer walls, because they are already coated, so the full dose will be available for you or your child to inhale.
Priming new spacers is particularly important when the asthmatic is a young child, because there may be some delay between firing the inhaler and the child actually getting a proper lungful of the drug. The longer the delay, the more chance the drug has to stick to the unprimed spacer walls.
A spacer can be used on a baby while it is asleep, which may make life easier for you both. If you need to use the spacer while the baby or toddler is awake, stroke the mask against the child’s cheek first. Keep smiling and talking so that the situation doesn’t seem so frightening. If the baby does start to cry, keep the mask in place: crying will bring on a deep in-breath which is just what is needed.
For an older child, decorating the spacer with coloured stickers can make it appear less daunting. Try to make using the spacer seem like a game. If this fails, don’t get into a battle with the child – leave it a while and try again later.
Playing with the spacer when feeling well will help the child to see it as something familiar, not as a frightening piece of equipment associated with asthma attacks.
Nebulisers
A nebuliser delivers high doses of asthma drugs in an easily inhaled form. It is generally used for severe asthma only, or in an emergency to relieve asthma attacks.
A nebuliser can be attached to an oxygen cylinder, which enriches the air–drug mixture with oxygen. This is useful in severe asthma.
The only people who need to have a nebuliser at home for emergencies are those with brittle asthma, whose condition can deteriorate very suddenly and sharply.
For routine use, only a very small minority of asthmatics require a nebuliser. They include:
• Those with such severe asthma that they depend on large doses of drugs to control their symptoms
• Very small children or elderly people with severe asthma, who have difficulty using inhalers. For them, a nebuliser may be the easiest way to take their drugs.
The fact that the hospital’s nebuliser is so effective in an emergency gives it a special mystique for many people, who assume that nebulisers are a magical cure for asthma. Nebulisers are widely advertised in specialist publications for asthmatics and, while they are expensive, they can look like the answer to a prayer. Many asthmatics, or their parents, mistakenly believe that owning a nebuliser would be the answer to all their problems. In fact the nebuliser only works so well because it delivers a much higher dose of the reliever drug – a dose which also carries a higher risk of side effects. This high-dose treatment should not be used on a regular basis unless it is absolutely essential. No one should buy a nebuliser without first discussing the matter with their doctor.
Asthmatics who own a nebuliser should have detailed written instructions from a doctor about when and how to use it, and how much of the drug to put in. One hazard of owning a nebuliser is that it may give you a false sense of security during emergencies, and delay you from getting expert medical help when you need it. If the nebuliser is for emergency use you should be told the exact signs that indicate a need to use it and – no less important – the signs that show the attack is out of control and needs hospital treatment.
Take care, when using a nebuliser, not to allow the mist to escape and settle on the face or eyes. Regular exposure to steroid mist can cause cataracts in the eyes, and thinning of the skin on the face. Anti-cholinergics (see p. 156) can cause glaucoma if they come into contact with the eye. The mask must fit very tightly. As an additional precaution, place a scarf around the upper edge of the mask to cover any gaps. Wash the face after using the nebuliser for steroids.
Keep off the cough mixture
Coughing can be a useful reaction in asthma, evicting mucus from the lungs. But in some asthmatics the cough does not produce mucus and seems to be no more than a reflex reaction to the airway inflammation. This type of cough can be debilitating, but it is not a good idea to treat it with cough mixture which has no benefit and may mask the seriousness of the asthma. Tackling the airway inflammation with preventer drugs such as steroids is the best course. Simple expectorants, which loosen mucus, may be of value – ask your pharmacist about these.

Asthma.
Tom works for the Post Office, sorting mail on a night shift. ‘After work, I come out of the sorting office - it’s about five or six in the morning, and really cold - and when I suddenly hit the cold air, I feel as if I just can’t breathe. My chest clamps up like anything, so much that it hurts. Then, when I get in the car and put the heater on, it’s fine again.’
What Tom is describing is bronchospasm, the key event in asthma – a sudden, but reversible, tightening of the bands of muscle that surround the airways. The narrowed airways stop air from leaving the lungs at the normal speed, which means the lungs are still half-full when it’s time for the next in-breath.
Taking more air into half-full lungs produces pain and tightness in the chest, as the lungs become over-inflated. (This can be alarming, because it can seem like pain from the heart, but it is just the rib joints and chest muscles hurting as they become stretched.)
Insufficient oxygen reaches the bloodstream because there is so much stale air in the lungs, so the asthmatic also feels breathless. Meanwhile, the air being forced through the narrowed airways makes a whistling sound called wheezing.
Those are the common symptoms of asthma, but there are others:
• Coughing, rather than wheezing, is the main symptom for some people (see box on p. 40).
• Sometimes there is vomiting during an asthma attack, especially in children, because the
overexpanded lungs put a great deal of pressure on the stomach.
• A few asthmatics suffer narrowing in the trachea (the upper part of the windpipe) rather than
in the airways lower down, and therefore feel as if they are being strangled.
Bronchospasm is just the endpoint of the disease process in asthma, a process which begins with inflammation of the lining of the airways. Although the airway muscles relax when an asthma attack is over, and you therefore feel much better, the underlying inflammation of the airways remains.
Airway inflammation may be caused, or partially caused, by allergy. Among asthmatic children, allergies are detected in 80-90%.
Inflammation makes the lining of the airways swell up, which itself narrows the airways a little. The inflamed airway lining often makes more mucus than usual, in an effort to protect itself (this is basically a healthy response – mucus works like a sponge mopping up irritating dust particles so that they can be ejected by coughing – but it’s excessive in asthma). This mucus can clog up the airways even more. Finally, the inflamed airways send nerve impulses direct to the airway muscles telling them to contract.
Mucus alert
Asthmatic mucus is white or clear, and sometimes frothy. Greenish or yellowish mucus suggests an infection and should be reported to your doctor.
In severe cases of asthma, a lump of mucus can completely block an airway, leading part of the lung to collapse. It is vital to clear mucus from the lungs, and a physiotherapist can help with this.
What causes asthma?
This question can be answered at three different levels:
1 What makes someone predisposed to asthma?
2 What starts asthma off – in other words, what starts the inflammation process in the airways?
3 What triggers asthma attacks (episodes of bronchospasm)?
What makes someone predisposed to asthma?
The predisposition to asthma is partly inherited (see p. and partly a matter of lifestyle: a poor
diet makes asthma more likely (see p. 206), as does too much cleanliness (see p. 21), obesity and lack of exercise.
What starts off the inflammation?
The predisposition to asthma sets the stage, but it does not, in itself, start the inflammation of the airways. That is often begun by an allergic reaction to something in the air – such as house-dust mite or pet allergens.
Alternatively, the initiating factor could be a viral infection, especially a kind known as Respiratory

Syncytial Virus or RSV – there are epidemics of RSV every two or three years. Those predisposed to

asthma may make an abnormal kind of immune response to chest infections caused by viruses, a response

that shifts the balance of the immune system towards Th2 cells (see p. 11) and allergy-type reactions.

Although the infection is defeated by the immune system, some inflammation of the airway lining

remains.
A heavy dose of certain irritants, such as chlorine, or the substances used in spray-painting cars, can

also initiate asthma; this mainly occurs in a workplace setting, causing occupational asthma (see box

on p. 133).
What triggers asthma attacks?
Once the inflammation of the airways has begun, the airways are ‘twitchy’ –oversensitive – and the

airway muscles contract (i.e. bronchospasm occurs) at the smallest provocation. This contraction of the

muscles – an asthma attack –can be caused by irritants in the air, such as tobacco smoke, or a great

variety of other things. The possible triggers range from cold air or the scent of hyacinths, to

thunderstorms, laughter or anxiety – see p. 39 for a full list. Exposure to the allergens that started

the inflammation will also trigger an asthma attack, as will a virus (viral) infection such as a cold

or flu.
For many asthmatics, the breathing pattern is disturbed by the asthma attacks, and may remain abnormal

between attacks. Hyperventilation or ‘over-breathing’ can begin quite easily for asthmatics, and then

adds to the overall problems. It may be difficult to tell if you hyperventilate or not, because your

habitual pattern of breathing will seem normal to you, but there may be tell-tale symptoms such as

dizziness, tingling of the hands and feet, numbness and muscle cramps. For a full list of symptoms see

p. 227.
Mind power
The muscle of the airways is the kind of muscle over which we have no conscious control, like that of

the heart. It is known as involuntary muscle, whereas muscles in the arms and legs, which contract or

relax when we tell them to, are called voluntary muscles. Studies with biofeedback have shown that

asthmatics may, with training, gain some degree of control over these involuntary muscles. Experienced

yoga practitioners are able to influence certain involuntary muscles, including those in the airways.
There are also various ways in which the mind, or a person’s social and emotional situation, can make

asthma worse (see p. 234) but the damaging idea that it is an entirely ‘psychological’ disease is now

discounted.
Allergens and irritants
Understanding the difference between allergens and irritants is important for asthmatics. Allergens are

specific — either pollen is an allergen for you or it isn’t, depending on how your immune system reacts

to it. They are also a basic cause of asthma — they start it off.
Irritants, on the other hand, are non-specific: they affect every asthmatic if sufficiently

concentrated, causing bronchospasm by aggravating the airway lining. And, at the levels usually

encountered, they only cause trouble because the inflammation of the airways has already occurred.

Irritants include cigarette smoke, other smoke and some industrial fumes, ozone (see p. 130), sulphur

dioxide (given off by some foods and drinks — see box on p. 207), fly spray, air freshener and other

aerosols.
Diagnosis
There are four separate aspects to diagnosis:
1 Is this really asthma or something else entirely?
2 Is it combined with other diseases, and how are they affecting the asthma?
3 What is the basic cause of the inflammation in the airways, and can this be avoided?
4 What sort of factors trigger the asthma attacks?
You may not get this full diagnostic programme, but you can probably help in finding answers to some of

the questions.
Is this really asthma or something else entirely?
There are no tests that can diagnose asthma with complete certainty, but the average case of adult

asthma is pretty easy to spot, and the same is true for children over five. It is also true, however,

that some patients now described as asthmatic would have been given a different diagnosis (e.g. wheezy

bronchitis) thirty years ago. To some extent, this is because asthma was under-diagnosed in the past:

doctors were hesitant about giving a diagnosis of asthma, because of the supposed overtones of

psychosomatic disease. Sweeping away that stigma has been of immense value, but certain patients

(especially young children) may now get diagnosed as asthmatic without sufficient evidence. However,

there are also many instances of asthma being missed.
There are two tests that should be carried out before you are given a diagnosis of asthma:
1 Peak flow is the top speed of the outgoing air from your lungs, usually measured with a simple

portable machine called a peak-flow meter. Because of the narrowed airways, asthmatics have a lower

peak flow than normal.
2 The reversibility test depends on measuring peak flow before and after inhaling a beta-2 reliever

drug which relaxes the airway muscles (see p. 152). If the drug improves peak flow by more than 15%,

this strongly suggests asthma.
Asthma may be difficult to diagnose in certain situations:
• In babies, who often wheeze, especially when they have colds or chest infections. This

generally clears up later and does not automatically develop into asthma. There is great controversy

about whether wheezy babies should be labelled ‘asthmatic’ or not, and how bad the wheezing should be

before they are given asthma drugs. Views on this vary, so you may want to see a different doctor for a

second opinion. For older children who wheeze only when they get chest infections, most doctors feel it

is valuable to use asthma drugs – such treatment does not ‘turn wheezing into asthma’
as is sometimes claimed. (There are several things you can do to minimise the chance of early wheezing

turning into asthma later – see pp. 244-9.)
• When the main symptom is coughing (see box on p. 40).
• When asthma occurs only at night. In some asthmatics, even intensive testing reveals no

abnormality in the airways during the day. The only way to diagnose the condition is to use a peak-flow

meter at home, morning and evening.
• When there is a sudden one-off asthma attack in response to a powerful allergen load. This

sometimes happens to hayfever sufferers at the height of the pollen season (especially during

thunderstorms). Some doctors will want to start asthma drugs immediately, but it may be better to get

the hayfever well controlled with antihistamines and see what happens. Often there are no further

asthma attacks.
Then there are conditions that can be mistaken for asthma:
• In children, an inhaled object – such as a nut or part of a toy – becoming stuck in the

airways. In babies it can also be inhalation of milk droplets; if so, the ‘asthma’ comes on mainly

after feeding.
• Post-nasal drip (see p. 29)
• Heiner’s Syndrome – (see p. 72)
• Bronchiolitis: a viral infection (generally caused by RSV –see p. 37) which affects the small

airways (the bronchioles) of babies and toddlers. Unlike asthma, it usually produces fever.
• Gastro-oesophageal reflux (GER), or the rising of acid from the stomach into the oesophagus.

(This is commonly called heartburn, after its most typical symptom, but you can suffer from GER without

having heartburn.) GER can aggravate existing asthma, and it can also be an asthma mimic. Babies,

children and adults can all suffer from this problem. There will usually be clues such as symptoms that

come on at night after a late supper, or whenever lying down.
• Hyperventilation (see p. 227) in non-asthmatics can be misdiagnosed as asthma if it causes

breathlessness.
• Aspergillosis (see box on p. 18)
• Problems with the vocal cords. Habitually contracting the vocal cords on the in-breath makes a

loud wheezing sound and can cause breathlessness. This problem can mimic asthma, but it also affects

those who really are asthmatic. The cause may be psychological.
• Low-level carbon monoxide poisoning, generally from gas fires, which can cause breathlessness

and fatigue.
• Bronchlectasis: stretching and damage to the airways caused by diseases caught in childhood,

such as pneumonia or whooping cough. This causes lifelong breathlessness.
Is it combined with other diseases, and how are they affecting the asthma?
Any allergic problems in the nose will contribute to asthmatic symptoms in the lungs, because there are

nerve-connections between the two. Long-term sinusitis can also make matters worse. Optimum treatment

for the nasal and sinus symptoms (see pp. 28-35) will help considerably with the asthma.
One unlikely source of asthmatic symptoms has only recently been recognised: allergies can develop to

the fungi causing athlete’s foot, or other diseases (see pp. 16-17).
GER (see p. 38) can contribute substantially to asthma. In some people, the reflux causes no obvious

symptoms, apart from worsening the asthma; medical tests can show that reflux is occurring. Your doctor

can advise on this, and on treatment.
For older people, especially veteran smokers, asthma may be part of a larger picture of inflammation

and damage to the air sacs of the lung (emphysema) and/or to the airways (bronchitis). This mosaic of

problems is known as chronic obstructive pulmonary disease (COPD). It may be difficult to tell if there

is asthma present, or how much it is contributing to the overall problem. Since many patients with COPD

are helped by asthma drugs, and trying out the drugs does no harm, doctors often prescribe them just to

see what happens.
What is the basic cause of airway inflammation? Skin-prick tests are usually needed here, to check for

allergic reactions. It may be difficult to get these in Britain, where there is a shortage of

allergists (see p. 89).
Simple detective work may pinpoint allergens without the need for tests. The likely suspects are all

airborne allergens – see p. 28. Remember that the reaction does not generally start as soon as exposure

to the allergen begins: there is a time-lag. So a new dog or cat, or an allergen encountered at work,

may cause no trouble for the first year or two.
Some irritants can also be a basic cause of asthma, but only if encountered in high doses, which

usually occur in the workplace. These are called asthmagens (see box on p. 133).
In all cases, removing the allergen or irritant from the airways should be a top priority. The sooner

you can end the exposure, the more likely you are to shake off the asthma, rather than have it for

ever. Once the inflammation of the airways is firmly established, it just fuels itself – so act

quickly.
In a minority of cases, food sensitivity is the initiating cause of asthma. The reaction to food is

delayed, so the link will not be obvious. Skin-prick tests for the culprit food are usually negative,

so an elimination diet (see p. 194) is needed to diagnose this problem and identify the food concerned.

Those most likely to benefit are brittle asthmatics (those most severely affected) – as many as 60%

have a food sensitivity. There are various other clues that food could be a factor (see p. 69).
When asthma begins in adulthood, there may be no clear initiating cause – it is just a question of

long-term damage and irritation to the airways. But there can be allergens playing a part, so it is

worth investigating this possibility.
What sort of factors trigger the asthma attacks?
Most asthmatics will recognise one or more of these as triggers:
• cold or dry air
• strong smells including perfume and fragrant flowers
• irritants in the air (such as cigarette smoke and other indoor pollutants, traffic fumes,

industrial pollutants); indoor pollution is often the worst, especially if you have a gas cooker

without adequate ventilation, so there is a lot you can do to improve the air you breathe (see pp.

128-30)
• sulphur dioxide given off by preservatives used in some food and drink (see box on p. 207)
• weather conditions, particularly thunderstorms
• laughing, sighing, yawning, coughing or any other altered breathing pattern
• stress or anxiety
• strong emotions such as fear, anger or excitement
• situations or people that evoke unpleasant memories –including traumatic childhood memories;

sometimes psychotherapy is needed to sort out such problems (see p. 233)
• exercise (because breathing hard dries out the airways)
• the allergens responsible for the asthma, e.g. cat allergen
• colds, flu and chest infections.
Recording your symptoms day-by-day should help to identify the triggers that are most powerful for you.

Generally speaking, such triggers should be avoided, but this is not the case for exercise which does

much more good than harm, in the long run – without exercise, your asthma will get far worse (see p.

41).
Take care with aspirin
Aspirin sensitivity can develop unexpectedly in asthmatics, especially those with allergic rhinitis

and/or nasal polyps (see box on p. 28). It can produce a severe, even fatal, asthma attack in someone

who has previously been able to take aspirin (see p. 151).
Treatment
The first and most important aspect of asthma is environmental control – to try to minimise contact

with allergens and irritants. If you are asthmatic and you smoke, you must stop, because this will only

make matters worse by stoking up the inflammation. Any other smokers in the family should accept that

from now on this is an outdoor activity.
One of the aims of good asthma treatment is to calm the airways down, so that they are less sensitive

and ‘twitchy’. This means tackling the inflammation. You can do this with preventer drugs such as

steroids or cromoglycate (see p. 157), or with the new anti - leu kotriene drugs (see p. 159), or you

can simply remove the basic cause of the trouble, if it is a domestic allergen source, such as a cat, a

dog or house-dust mites.
Treating associated diseases such as sinusitis, hayfever, perennial allergic rhinifis, gastroesophageal

reflux (GER – see p. 38) and athlete’s foot (where this is adding to the symptoms – see p. 16) can also

help in reducing the airway inflammation. Eating a better diet may make a further contribution to

calming the airways down (see p. 206).
The second strand of treatment is to deal with bronchospasm (contraction of the airway muscles) when it

occurs. This is done with reliever drugs such as Ventolin and Atrovent (see p. 152). Note that these

only relieve the symptoms of an asthma attack, and do not address the underlying problem of

inflammation. What is more, if used too frequently (more than once a day) they may increase the risk of

a fatal or near-fatal asthma attack (see p. 153).
At one time, reliever drugs were the mainstay of asthma treatment, and were perceived as entirely safe,

while preventer drugs such as steroids were only given to those with severe asthma. All this has

changed, and most asthmatics, other than those with very infrequent attacks, are now given a

pre-venter. If your drug regime has not been reviewed for some time, make an appointment with your

doctor and check that you are getting the best of the modern treatments.
Drug treatment of asthma is not something you can just hand over to the doctor – it requires a lot of

personal decision - making. If you usually get worse when you have a cold, for example, you need to
Just a cough?
For some, coughing is the main symptom of asthma. Known as cough-variant asthma, this is not always

diagnosed correctly, especially in children. For children with recurrent coughing (two or more episodes

per year of coughing without a cold) it may be a long time before the doctor considers asthma. But

other doctors may diagnose a coughing child as `asthmatic’ all too readily, without doing enough tests.

The important point is that asthma involves episodes of bronchospasm – contraction of the airway

muscles. Without this it is not asthma. Bronchospasm can be detected by medical tests such as peak-flow

readings. Wheezing is one possible symptom of bronchospasm, but coughing is another.
If there is only coughing as a symptom, and never any wheezing, this is probably not asthma. Among

children with this pattern of symptoms, allergies are unlikely to be involved. The cause of such

coughing may be:
• in children, the effects of parental smoking
• in those with perennial allergic rhinitis (see pp. 28-9) mucus from the nose running into the

lungs. This is called post-nasal drip and produces a persistent cough.
• in the middle-aged, eosinophilic bronchitis. This is caused by an influx of eosinophils (see p.

19) into the airway lining, causing inflammation. Allergies do not seem to play a part (it is no more

common in atopics than anyone else) and the airway muscles do not contract abnormally. Treatment is

with inhaled steroids.
• in atopics (those prone to allergies), a condition sometimes called atopic cough. It involves

eosinophils congregating in the trachea (windpipe) and bronchi, but not in the lower airways. There is

inflammation but no airway narrowing. Very little is known about this disease at present; it may or may

not involve allergies. Again, inhaled steroids are effective.
• for a few people, habitual coughing. This is usually an expression of some underlying emotional

difficulty and responds to psychological treatments. The cough often has a honking or barking sound.
Any of these can be misdiagnosed as asthma. For patients with eosinophilic bronchitis or atopic cough,

this is no tragedy as they will probably get the right treatment (inhaled steroids) anyway. But if more

exact diagnostic criteria are being used (e.g. a reversibility test – see p. 38) such patients will not

be classed as asthmatic – this is more of a problem because they may not get appropriate treatment.
increase your dose of preventer as soon as a cold appears, to stop airway inflammation before it

starts. You also need to know when an asthma attack is serious enough to warrant calling an ambulance.

A management plan, worked out with your doctor, is a useful aid (see p. 96). Using a peak-flow meter,

night and morning, to monitor your asthma will also be valuable (see p. 97).
The third strand of asthma treatment is to deal with associated problems:
• Panicky reactions during asthma attacks –which make matters infinitely worse – can be dealt

with by meditation, yoga, relaxation techniques or martial arts training (see p. 222).
• Hyperventilation, which plays a much larger role in asthma than previously suspected, can be

tackled by a variety of methods (see p. 228).
• The distortions of the rib-cage that develop in severe asthma can be treated with osteopathy.
• Losing weight, if you are very heavy, will help ease the burden on your breathing.
Exercise and asthma
Exercise-induced asthma is best tackled, paradoxically, by taking exercise. As your fitness improves,

you don’t pant so hard when exercising, so your airways dry out much less. Countless asthmatics will

tell you that once you overcome the first hurdle – of wheezing the minute you start to exercise –

things get a great deal easier. You will need reliever drugs, and possibly extra preventer, to help you

over this hurdle, but it’s worth it. Warming up with a few sharp sprints, separated by a rest period,

will also help. (If you get an asthma attack while exercising, however, you should always stop –

carrying on regardless can be fatal – literally. Always have your reliever inhaler with you when you

exercise and use it if you get an attack.)
Swimming is an excellent starting point for unfit asthmatics, because the moist air prevents the

airways from drying out. Swim outdoors if you can, since chlorine can be an irritant.
Once you are fitter, regular strenuous exercise makes the breathing muscles stronger, which is of great

benefit – this can also be achieved with special exercises (see p. 231).
Don’t underestimate asthma
Asthma can be fatal, so never take it too lightly. If you often wake up in the night with asthma, you

cannot keep up with most other people your age, or are frequently breathless when climbing stairs or

walking uphill, then your asthma is not under control. The same is true if you need your reliever

inhaler more than once a day, or frequently need steroid tablets. Review your treatment with your

doctor because you probably need more preventive treatment such as inhaled steroids (see p. 157) or

anti-leukotriene drugs (see p. 149).
Recognising an asthma attack and knowing when to call for help, or go to the hospital, is also crucial

(see p. 100). Remember that fatal asthma attacks often come on very quickly – half those who die do so

within two hours of the attack starting, and a quarter die within 30 minutes. Those who die are

generally people who have neglected their preventer medication, or have been exposed to very high

levels of allergens.
There is a major organisation involved in asthma prevention, by the name of Asthma UK. They work together with people with asthma, health professionals and researchers, to develop and share expertise to help people increase their understanding of asthma, and asthma prevention, allowing them to voice their concerns to the people who matter and reduce the effect of it on their lives. They are the only charity dedicated to asthma prevention by improving the health and well-being of people with asthma and are funded by voluntary donations, indeed they are responsible for nearly £3m of asthma research each year for the cause of asthma prevention.

A form of asthma prevention can be in the improvements in environmental quality to benefit everyone in the school building because pollutants have a universally negative effect. For example, for the benefit of the students, schools should undertake extensive building repairs, painting, cleaning, and extermination during long vacations. They should replace plastic furniture and carpeting, which often emit pollutants in the form of noxious gases. For further asthma prevention, they should limit use of cleaning supplies and equipment that emit toxic fumes and strong odours which again are pollutants, and require good ventilation when they are used. They should have the entire building (particularly the heating and ventilation system) cleaned regularly to eliminate dust mites, mildew, animal dander, feathers, cockroaches, and other possible asthma and allergy triggers, and make sure that leaks of water and plaster dust are stopped and quickly cleaned up. Additionally the can help in asthma prevention by regularly monitoring the air quality of schools, especially those in sealed buildings and try to increase the ventilation so that pollutants can escape. All this can help with asthma prevention. So whilst schools may not be able to eliminate other pollutants, such as chalk dust, they can, as an act of asthma prevention, find out which of them are triggers for particular students and try to limit the student’s exposure to them. Further, sensitive scheduling can keep students with specific sensitivities away from certain art supplies and animals, which may enhance the education of some students but sicken students with asthma.

As an asthma prevention in Scandinavia, cross-country skiers sometimes wear breathing masks which store the heat and moisture from the air they breathe out and then return it to the air they breathe in. This is helpful in avoiding exercise-induced asthma. Good control of your asthma, whether by breathing in a ‘preventer’ treatment or by avoiding causes of asthma such as house dust mites and pets can have a tremendously helpful effect on exercise-induced asthma. Reliever inhalers can be tremendously helpful in asthma prevention if you use them just before you exercise. This applies especially to the so-called ‘beta-2 stimulants’ such as salbutamol (albuterol) or terbutaline. The benefit should last for hours. Long-acting reliever inhalers are also very helpful; they just work for longer. If you are a competitive athlete or sportsman, you may be concerned about disqualification because you use drugs. The good news is that all the ordinary asthma medicines, used in the medically recommended way and dosage, are acceptable to sporting bodies provided you use them correctly for asthma. The wise thing is to check with your sports authority or sports doctor. Asthma prevention is good asthma management!
There are oral asthma medications that an individual can take to control their asthma, inhaled at the onset of an asthma attack. People with asthma can carry a peak flow meter; a hand-held tool for measuring their air flow to determine whether an attack is imminent, thus requiring their asthma medications. With help from medical providers and age-appropriate printed materials, children can learn to monitor their asthma and self-medicate with their asthma medications. Taking such control of their asthma medications not only decreases its symptoms, but also promotes the children’s feelings of self-confidence, with the management of their asthma and its medications.

There are dozens of asthma medications available in the UK; the most frequently prescribed of these medications being: Ventolin; Bricanyl; Becodite; Pulmicort; Intal and Tilade. The first 2 asthma medications are essentially relievers, whilst the others are preventers. The preventer drugs are taken by an inhaled route and must be taken regularly to gain maximum effect. They belong to either the steroid or anti-inflammatory groups of asthma medications. The reliever drugs do not need to be taken as often; indeed there is evidence to support that these medications are more effective when they are taken only occasionally. Naturally there will be a concern about side effects, but in the main, asthma medications are safe and free from problems.

One such treatment which can have side effects is a steroid called prednisolone; which is taken by tablet form. These asthma medications dampen down and reduces inflammation, swelling and phlegm. There is a soluble form of these medications called Prednesol, which is useful for children and people who struggle to swallow tablets. If used in short courses there should be no risks at all; it is only when these asthma medications are prescribed over a period of years that certain side effects can occur. These include skin changes, thinning of the bones, increased blood pressure, indigestion, ulcers and the development of diabetes. Once again the emphasis is on serious long term prescriptions of these asthma medications and a brief course has no history of causing any of the above side effects.

Asthma is not an allergy as such, but there are asthma triggers, which can be caused by an allergic reaction to any number of incidents. If you have asthma, your air passages are irritable. This means things which are harmless to other people may be asthma triggers to an asthma sufferer. Various asthma triggers include: (i) Emotional stress - people with asthma often say their asthma gets worse if they are upset. (ii) Cold air - if you move from warm indoor air to cold air outdoors it can affect the air passeges. (iii) Pollution, in particular tobacco smoke - e.g. in a pub, can be one of the more common asthma triggers. (iv) Grass pollen - particularly when exposed to a recently mown lawn. (v) House dust mites - often attracted by central heating. (vii) Pet fur - especially during the malting season can affect the air passeges. (viii) Exercise - can provoke narrowing of the air passages. (ix) Infections of the lining of the breathing passages - e.g. colds and ‘flu. (x) Some drugs - especially medicines called beta blockers used for high blood pressure or heart disease have been known to be asthma triggers. (xi) Indigestion - also called gastro-oesophageal reflux, with stomach acid coming up into your gullet. (xii) Laughing - so don’t laugh! (Only joking, but it can happen). All the above reflect the irritability of the air passages in asthma, even if some of them do so in somewhat different ways, they all can be asthma triggers.

There have been significant changes in air quality over the past few decades. Pollution, from the burning of coal, which resulted in emissions of sulphur dioxide and particulate matter has decreased considerably; however, the frequency of peaks of traffic related pollution and the geographical extent of it have probably increased. Episodes of pollution from secondary pollutants, notably ozone, produced by photochemical oxidation, have also increased and this is one of the chief asthma triggers. Moreover, there have also been changes in people’s diet, lifestyle, and in homes and other indoor environments. For example, homes have tended to become warmer and, in this and other ways, much more appealing to cohabitation by dust mites, a real enemy of asthma sufferers. All these can act as asthma triggers. Cinemas and theatres can also surprisingly act as asthma triggers for some people. Research carried out recently found low levels of bacteria and moulds on carpets and seats, but high concentrations of cat allergens; presumably brought in on the clothes of members of the audience. Maybe get a DVD next time!