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A common problem:
Asthma is one of the most common lung problems in Australia, and
affects as many as 1 in 5 children and 1 in 10 adults. Although it is common, asthma causes
variable symptoms in different individuals. There is no cure for asthma. Asthma can,
however, be controlled with long term treatment.
First, a brief anatomy lesson:
to understand lung disease it is important to remember that
normal lungs are like two big sponges hanging within the rib cage. Into these sponges, like
the roots of a tree, the small airways divide – carrying the air that we breathe to the furthest
reaches of that sponge. The tiny little sacks of air that make up the sponge are called
alveoli. The small airways are called bronchi or bronchioles. Blood circulates in tiny vessels
in the walls of the alveoli, extracting oxygen from the air (and releasing the toxic carbon
dioxide, one of our body’s waste products, to be breathed out). The lungs are lined by a
slimy membrane called ‘pleura’. Pleura also lines the inside of the chest wall, and these two
surfaces are continually rubbing against each other as we breathe.
An airway problem:
Asthma is a problem of the airways. People with asthma have the
unhelpful capacity to develop inflammation
within their airways in response to a certain
stimulus. While in children this inflammation is characterized by features of allergic
inflammation, other types of inflammation can lead to the same end result clinically. The
hallmarks of inflammation in the human body, as anybody who has ever been bitten by an
insect will know, are swelling, redness and oozing of fluid – if the inflammation gets
particularly bad. Everybody with asthma gets inflammation in the airways. Because the
airways are tubed lined by ‘mucosa’ (sort of like the inside of your cheek) the swelling is
always inwards, narrowing the tube and making it harder to move air through. In addition to
inflammation, people with asthma develop hyperresponsiveness
of the muscles that
surround the airways. This airway ‘twitchiness’ results in a tendency for muscle spasm, with
resultant rapid narrowing of the airways; an asthma ‘attack’.
People with asthma have symptoms that vary, reflecting variability in airway
inflammation. On a good day most people with asthma will have lungs that work almost
normally, and no symptoms (and the goal of management is to have as many good days as
It is about here that the similarities between people with asthma end.
Symptoms of asthma are very often – almost always – ‘triggered’ by an exposure
to something which is breathed in. Mostly this will be an allergy (for example to dust or
dust-mite, tree or grass pollens, animal fur or skin (cats, horses)). Viruses are also common
triggers for asthma. Many asthmatics only suffer symptoms with exercise. Perfumes,
sprays and industrial chemicals can be a trigger. Sometimes there is no clear trigger factor.
The means by which trigger factors cause the end result of inflammation in the airways are
complicated and even now poorly understood. Individual people with asthma will vary a
great deal in terms of what triggers asthma.
Here, too, there is individual variation. Many people with asthma will
experience shortness of breath, chest tightness and wheeze when they are suffering an
asthma ‘attack’. Some people, however, will only cough. (Nocturnal or early morning cough
Since there is considerable variability in the presentation of asthma, particularly
with adults, it is important to be confident of the diagnosis prior to treatment. In some people
this is reasonably easy. When an experienced doctor hears wheeze in the chest of a person
who is very short of breath and when that shortness of breath responds to asthma treatment,
the diagnosis is not usually in question). Often the diagnosis is not clear, but in most people
with untreated asthma the diagnosis can be confirmed by a simple test called spirometry.
involves blowing as hard as possible into a tube attached to a computer, which
measures the volume of air you move and how quickly it comes out. This test is always
performed several times for accuracy, and then done again after you have been given
If it is done well and in the appropriate clinical context, most people with asthma will be
diagnosed by this test. If this test doesn’t confirm the diagnosis the a test called
In this test spirometry is performed after small doses of an airway
irritant. The irritant will provoke minor airway inflammation in people with asthma, leading to
a measurable deterioration in lung function due to hyperresponsiveness of the airway
smooth muscle. Newer tests, such as measuring exhaled nitric oxide on a single breath, will
provide us with easier ways to confirm the diagnosis of asthma and may be readily available
Management of asthma:
managing asthma always requires a high level of awareness of
when things are going badly. For most people with asthma this is reasonably easy.
Symptoms of a cough or shortness of breath are usually readily identifiable. However, for
some people with asthma it can be difficult to sense when things are starting to get bad. In
those people it can be very helpful to have a means at home of monitoring their asthma.
Peak flow measurements provide a helpful means of doing this in some situations.
Peak flow monitoring;
a peak flow monitor is a simple device (generally a tube with a
spring loaded guage) into which a person blows once, very hard. It measures the highest
flow rate of air from the lungs on a single breath, the ‘Peak Expiratory Flow ‘ (PEF). The
PEF does tend to fall in severe asthma. It is not a very sensitive tool for the diagnosis of
asthma, but if an individual knows what their usual best peak flow is then peak flow
monitoring can be a very helpful way of monitoring their asthma at home. It is especially
useful in people who have trouble perceiving the symptoms of their asthma.
Treatment of asthma;
most effective treatment of asthma is with medications that are
inhaled. In general terms these are regarded as either ‘relievers’ or ‘ preventers’.
the principal reliever medications are salbutamol, terbutaline and
ipratroprium. The last of these has little role in asthma but is used in COPD management.
The major effect of these medications is to relax the muscle around the small airways in the
lungs, thereby allowing temporary dilatation of the airways and relief of symptoms of an
asthma attack. Most people with asthma are best off using salbutamol puffers through a
spacer, although some will use nebulisers. When using a spacer it is very important that the
right technique is used, and also that an adequate dose of medication is administered.
these include inhaled corticosteroids (fluticasone, budesonide,
beclomethasone, ciclesonide) and long-acting beta agonists (which act in a similar way to
salbutamol, but have a longer duration of effect) called salmeterol or eformoterol. Flixotide /
salmeterol and Budesonide/eformoterol are now available in combination in the one inhaler
Goal of treatment;
the goal of treatment of asthma is to completely suppress airway
inflammation and hyperresponsiveness thereby controlling symptoms, with the regular use of
‘preventer’ medications. This limits the need for reliever medications. Preventer
medications are generally used twice a day. There is evidence in people with moderate
asthma that Budesonide / eformoterol in combination (Symbicort TM) can be used as both a
this steroid medication is a very potent suppressor of all inflammation and
effectively treats asthma. Prednisolone has, however, many side effects. These include:
changes to the distribution of body hair
disturbances to the body’s biochemistry
psychological side effects – often mania but sometimes depression.
Prednisolone in high dose is toxic. Prednisolone in high dose is toxic. Do I need to say it
again? Prednisolone also makes most people with asthma feel pretty good pretty quickly
when things are bad. It should be used only when things are bad, as part of an action plan
for severe asthma, and should only be used for short periods of time.
Montelukast is a daily tablet that blocks one of the pathways that can
lead to airway inflammation. It is effective in some people, and has a particular role in
children. Omaluzimab is a medication given by injection. It modifies the body’s immune
system in an anti-allergic manner but is very expensive and suitable only for a small number
in some people it can be very helpful to define precisely the presence of any
allergies to inhaled substances. Sometimes these can be targeted effectively by
desensitization, although that approach, which is often helpful in allergic rhinitis / hay fever is
very much less successful in control of asthma. Often avoidance (such as minimizing dust in
the home or removing a pet from the environment) can make a great deal of difference.
Allergy can be defined on blood testing, but skin prick testing is the most precise way to
most people with asthma will require continued use of medication. There should
be no other restriction on activity in most people with asthma. Cigarette smoking is
particularly hazardous to the health of people with asthma. It is important for everybody with
asthma to have a relationship with a doctor who know them and their asthma well, and is
able to help manage and monitor the asthma over years.
When things go wrong;
some people with asthma will experience episodic sudden and
extreme worsening of their symptoms. It is very important to work out with your doctor how
to firstly prevent that happening, and secondly what to do if that does happen to you. The
plan for what to do in these circumstances is often called an ‘action plan’.
stay at your best possible level of function
work out an action plan with your doctor
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