Asthma

What is asthma?

“Asthma" comes from the ancient Greek word meaning "panting" and, if you've experienced an asthma attack, you'll understand why. For some, an asthma attack feels as though an elephant is sitting on their chest, while for others breathing becomes so laboured that it’s like trying to suck peanut butter through a straw.

It makes your chest feel tight. However, the real problem is not that you can’t breathe in properly, but that you can’t breathe out. You’re in effect being suffocated by your own carbon dioxide-saturated breath. If you can’t breathe out, no fresh air can get in.

The reason why you struggle to breathe is because asthma affects the breathing pipes or tubes, called airways or bronchi. When you breathe in, oxygen-rich air flows through the airways into the alveoli, where the oxygen is passed from to the blood vessels, and carbon dioxide moves from the blood vessels to the alveoli. Carbon dioxide is breathed out. Asthma is a condition where the airways become narrow, restricting the amount of air that can flow from the alveoli.

Although asthma is a lung disease, and usually a long-term (chronic) disease, in which the flow of air out of the lungs is limited by obstruction, this obstruction may be reversible – unlike chronic bronchitis and emphysema – as it initially does not affect the actual anatomical structure of the airways.

Asthma often develops in childhood or during the teens. It’s the most common long-term childhood disease. People with other lung diseases, such as chronic obstructive pulmonary disease (COPD) can also develop asthma. Although it’s not clear exactly what causes asthma, it’s thought to be triggered by an allergy, or when the lungs are irritated by something in the air. Taking cough medicine won’t help relieve asthma symptoms.

Asthmatics should be able to lead completely normal lives, which means they should be able to eat, drink, play and sleep normally. If this is not the case, the diagnosis, treatment and medication should be re-evaluated.

Unfortunately, this condition often goes undiagnosed and untreated, as many people don't even know they're asthma sufferers.  And in many cases, the condition is not managed adequately by doctor and patient.

Who gets asthma? (The prevalence) 

Asthma is one of the most common respiratory diseases in the world today. The Global Initiative for Asthma (GINA) claimed in 2010 that more than 300 million people are affected by asthma worldwide.

It affects one in ten children (10%) and one in twenty adults (5%). It occurs for the first time at any age, even in adulthood, although it usually begins before the age of five.

Roughly 80% of all childhood asthma occurs before the age of five.

It’s more common in boys and is seen predominantly in children who are allergic or come from allergic families. It tends to run in families, as do related allergic conditions, such as hay fever and eczema.

Approximately 50% of childhood asthma, particularly if it’s mild, goes into remission during the teenage years, but don’t be fooled into thinking this means you have "outgrown" asthma. As many as 30% of “teenagers-in-asthma-remission” go on to re-develop asthma during adulthood. Asthma usually persists if contracted during adulthood.

Ethnic variations
For decades it was accepted that allergic diseases were infrequent amongst Africans and in people who live in rural communities. This may be because living in the country protects people from developing asthma, even if they have the genetic potential to be asthma sufferers. Recent studies have confirmed that Black Africans with asthma are much less likely to have parents or older siblings who suffer from asthma (+ve family history) than other asthma sufferers.

However, if a Black African individual DOES have a positive family history of asthma, they are much MORE likely to have asthma than Black Africans without a family history, and even people from other races WITH a family history!  In patients who have moved from rural to urban areas, either the early exposure to foreign allergens from the newly adopted Western lifestyle or the loss of protection from the rural lifestyle, contributes to a higher degree of allergic sensitisation recorded amongst African infants than in other races. These factors account for the increased number of African children who have asthma.

(Read more about the Increase in asthma among Africans.)

Exposure to urban living
Studies conducted on people living in rural areas in Transkei have shown that migration to urban and peri-urban settlements has resulted in a 20-times increased risk of developing asthma symptoms. The incidence of asthma in rural areas has also increased. 

What causes asthma?

Just what causes asthma remains something of a mystery, but it is thought to be triggered by an allergy or when the lungs are irritated by something in the air.

It's regularly confused with other bronchial infections and doesn't always "present" in a straightforward way, making diagnosis difficult. But you are more likely to develop asthma if members of your family suffer from allergies, or have asthma themselves. This strongly indicates some underlying genetic/hereditary factors (such as proneness to allergies, certain immunological reactions etc), as well as environmental factors/triggers.

It also appears to occur more regularly in people who are overweight.

The main factors involved in causing or aggravating asthma are:

1. Allergies

Asthma attacks are most commonly triggered by allergies to airborne particles or otherwise harmless stimuli like grass or tree pollens, dog and cat dander, cockroaches, dust mites, fungal spores and mildew. The house dust mite is the most common coastal and inland trigger factor amongst all races; even amongst the black population where it was previously believed to be uncommon. In Cape Town, Durban and Transkei, grass, cockroaches and cat allergies have been identified as important triggers causing asthma. On rare occasions certain foods and additives may also trigger off asthma when taken by mouth.

An allergic reaction is implicated in about 90% of childhood asthma attacks and at least 50% of adult attacks.

This allergic reaction causes the lining of the airways (bronchi) in the lungs to become inflamed and swollen and the muscles of the walls of the airways go into spasm. As the airways narrow, it makes breathing difficult. The bronchial tubes then secrete mucus, which limits the airflow even further. Once you have a tendency to suffer from asthma, any of the triggers mentioned in this section, as well as cold air and stress can trigger an attack.

2. Other co-existing conditions

A viral cold or flu can aggravate asthma symptoms temporarily. This effect may last for up to six weeks after the illness. In fact, most asthma attacks in both children and adults are caused by the common cold. The virus that causes a cold is usually the trigger factor. This fact has many implications. It means that people with asthma are sensitive to colds and must get good asthma therapy to prevent the cold-causing asthma attacks. This preventative approach is extremely important in asthma management and must be stressed.

Also remember that a cold is caused by a virus and that antibiotics won't work and shouldn't be used. You don’t need an antibiotic to treat a cold or an asthma attack.

Other conditions which may aggravate asthma, include:
infection of the sinuses (sinusitis); soft, round mucous-producing tissues that project into the nasal passages (nasal polyps) and reflux (back flow) of stomach contents into the tube that leads from the throat to the stomach (gastroesophageal reflux disease). 

3. Pollution

Once you have asthma, home and workplace chemicals, tobacco smoke, car exhaust fumes and certain chemical gases can aggravate an asthma attack. Children will even be affected by passively inhaling their parents’ cigarette smoke.Parents who smokeshould be advised to stop smoking altogether. It is not enough for parents to avoid smoking in the presence of their child.

Chemicals and strong smells are transferred to children on the clothes of their parents and may trigger attacks. Smokers also have more germs carried in their throats which may affect their own children and trigger asthma attacks. Air pollutants from highly industrialised areas such as Durban, Mpumalanga and Gauteng, changing eating habits to refined foods, and using anthracite and coal as fuel have been implicated in the increased prevalence of asthma.

4. Sport and exercise

Sport and exercise, particularly in cold weather, can set off an asthma attack. However, with the correct treatment asthma can be well controlled so that asthmatics need not avoid sport or exercise. In fact about 10% of Olympic athletes have asthma.

Exercise-induced asthma is no longer regarded as a condition separate from “normal” asthma, but rather one where “normal” underlying asthma is triggered by exercise. Exercise-induced asthma refers to the trigger, not a separate condition (e.g. Pollen-induced asthma or workplace-induced asthma or smoke-induced asthma) and can be regarded as poorly controlled asthma. (Read more about Exercise-induced asthma).

5. Emotion

Emotion such as excitement, anger, fear or laughter can aggravate asthma. So-called "nerves" are not responsible for causing asthma.

6. Drugs/Medication

Certain commonly used medicines such as aspirin and other non-steroidal anti-inflammatory medication may trigger an asthma attack. Also be cautious when using "beta blocker" blood pressure tablets or eye-drops for glaucoma, as they may aggravate bronchoconstriction, and thus asthma, in adult life. 

7. Occupational hazards

Asthma in adults can often be connected to the work they do and this is referred to as occupational asthma. Working with plastic resins, wood dust, grains, insecticides, and metals can make you susceptible to developing asthma later in life. But even cleaning products and work-related chemicals, including those used in photocopiers may make you vulnerable.

By law occupation-induced asthma should be compensated. These include: organic dusts (wood, grain, grain flour, tobacco), isocyanates, formaldehyde vapour, fumes (amines), metals (platinum, nickel, cobalt, vanadium), soldering and welding fumes, epoxy resin and acrylic acid and acrylates.

What you probably don't know is that new carpeting and furnishings often release formaldehyde, a common asthma trigger. If your office (or home) is being redecorated, increase ventilation to hasten formaldehyde dissipation. Adding potted plants to your workplace can also help clear pollutants.

(Read more about pleasant and unpleasant triggers.)

What happens in the lungs? (The mechanism of asthma)

When we breathe in, air passes through the voice box and down the windpipe (trachea). The windpipe branches into the two main bronchi that take air into the two lungs. These bronchi then divide further, becoming smaller and smaller as they take air deeper into the lungs to the point where oxygen passes into the bloodstream and carbon dioxide is released and breathed out.

The walls of the bronchi can be divided into four layers:
1. The very thin smooth inner lining is called the mucosa.
2. The layer below this contains mucus-secreting glands.
3. The third layer is cartilage which acts like scaffolding, holding these tubes open.
4. The outer layer is a muscle.

Asthma is characterised by double narrowing (the “fire” and the “boa constrictor” effect) of the bronchi, caused by:

1. Swelling of the inner lining (mucosa)  -  (the “fire” effect)
2. Increased sticky mucus or secretions in the airways, produced by the mucus glands. The swelling and increased secretions are called inflammation.
3. Muscles going into spasm - (the boa constrictor effect). Spasm occurs only when there is inflammation.

When the bronchi become too narrow, or are partially obstructed due to inflammation and spasm, the typical symptoms of asthma will develop.

What are the symptoms?

Asthma symptoms vary from person to person over time. Asthma attacks can range from mild to severe and can change their severity at any given time. Symptoms vary, depending on the severity of the airway obstruction. This prevents sufficient oxygen from reaching the alveoli, which means that less can be transferred to the blood. This makes sufferers feel as though they aren’t getting enough air, so they’re forced to breathe harder and faster. Asthmatics often experience a whistling (wheezing) sound as they breathe out – this is air being forced past the obstruction.

They may also try coughing to dislodge the blockage, but this won’t help, as the bronchi themselves are constricted or their lining is thickened. There may also be thick mucus plugs that can’t be dislodged, no matter how hard you cough.

Asthma symptoms are often worse at night and in the early morning.

If you’re concerned about developing this condition, keep an eye out for the following symptoms:

Adults: 

• Coughing which often occurs more frequently at night or with activity. It can be dry or wet and is persistent.
• An asthma wheeze 
• Shortness of breath or rapid, panting breath
• Chest tightness
• Tiring quickly during exercise

Children:

• Fatigue and lack of stamina causing the child to slow down or stop play
• Coughing which often occurs more frequently at night or with activity. It can be dry or wet and is persistent.
• Complaints of chest pain
• Avoidance and a refusal to participate in active sports and games
• Asthma wheeze

Infants 

• Rapid breathing
• Grunting during feeding
• Difficulty feeding

How will you identify an asthma wheeze?

Since wheezing and coughing is very common, particularly in children younger than three years (even in those who don’t have asthma), and since all wheezing children do not suffer from asthma, it is important to distinguish between two types of wheezes:

•  The episodic/viral wheeze is triggered by a viral infection such as flu. If you only wheeze at intervals, and have no other asthma symptoms (tight chest, breathlessness etc) between these wheezing episodes, it is highly unlikely that you have asthma.
• The asthma wheeze is triggered by any of the many possible asthma and allergy triggers, ranging from allergens, chemical irritants, cigarette smoke, exercise, cold air, laughing and a cold or flu. If you have any other asthma symptoms (tight chest, breathing difficulties, etc.) between wheezes, then it is highly likely that you have asthma.

 There are usually telltale signs before a full-blown attack occurs, but these vary from person to person. Some experience an itchy chin or throat and a dry mouth. Still others may feel tired and irritable. Common warning signs include light wheezing, pain when coughing, chest tightness, shortness of breath or restlessness. As an asthmatic you need to take note of these warning signals, so that you can takes steps to help ward off a severe attack.

The second wave

After an asthma attack, you can sometimes experience a "second wave" or another attack, which is often more serious than the first. In the second wave, changes may take place in the air tubes which causes them to continue to swell, making it hard for you to breathe. This may happen without the usual tell-tale signs of an impending attack, and can last for days or even weeks after the first attack. During this time your lungs may become more sensitive to other irritants, which can trigger more attacks. Consult your doctor if your medication does not bring you any relief.

Diagnosing Asthma

Many people with asthma don't know that they have the disease. In young patients with recurrent coughing and wheezing the diagnosis of asthma is not always straightforward, and it is important to think of other causes for the symptoms. 

In the older child and in adults, where an accurate history is available and lung function tests are easy to perform, the diagnosis is less complicated. Other respiratory problems such as emphysema, bronchitis and lower respiratory infections may masquerade as asthma, as many of these illnesses share similar symptoms. The distinguishing factor between asthma and COPD is early-childhood onset in the case of asthma.

Asthma should always be considered in children with a chronic, recurrent wheeze, with or without a cough, with symptoms of breathlessness and chest tightness, which respond to an inhaled short-acting beta-blocker bronchodilator (the reliever therapy used in an acute asthma attack). In children younger than five years, symptoms are variable and non-specific and it is impossible for the doctor to measure airflow (see below) and inflammation.

Asthma should definitely be considered if you have breathing problems that come and go. Persistent cough and recurrent wheezing are also good indicators, which may suggest you are asthmatic.

For an accurate diagnosis your doctor will do a careful medical examination, take note of your medical history (Link 11: Click here to view a list of questions your doctor is likely to ask you) and conduct breathing tests which may include:

Spirometry: using an instrument that measures the air taken into and out of the lungs during normal periods, during attacks and immediately following inhalation of medications that dilate the airways.

Peak flow monitoring: (another measure of lung function) which monitors the rate of air exhaled in one breath. Peak flow decreases before an attack and as the condition becomes more serious. It's a good idea to keep a peak flow meter with you and to know your normal peak flow values.  Children may need “low-reading” peak flow meters, as adult peak flow meters may not measure accurately at low air speeds.

Other tests that may be useful, include:

Allergy skin tests

Blood tests

Exercise inhalation challenges

A chest X-ray. In asthmatics these are usually normal when there are no underlying illnesses.

Your doctor may also want to perform other tests to exclude conditions that can also cause shortness of breath or other lung problems.
 

How severe is your asthma?

Since a doctor will initiate treatment based on the severity of your asthma at diagnosis, he will assess and classify the severity of your asthma according to the latest guidelines for the management of asthma in adults and adolescents (2007), or the latest guidelines for children (2009). Asthma severity is assessed only at the first consultation to decide which initialtreatment to start, but after this the doctor will use a similar system (see below) to assess asthma control  in order to guide decisions to either maintain or adjust therapy, i.e. to step it up if necessary, or down if possible.

The assessment of severity is used as a starting point to assign a child to a particular treatment group. This assessment is performed between acute episodes in a patient who is not receiving long-term therapy.  Assessment of severity depends on the frequency of symptoms and the peak flow reading obtained (the latter in children five years and older).

Symptoms are divided into day- and night-time symptoms (essentially cough and wheeze). Asthma attacks are typically episodic. The intervals between the attacks may be days, months or even years. For severe asthmatics, however, attacks can take place on a daily basis.

Grade 1 is the mildest grade (known as mild intermittent asthma) and grade 4 the most severe. Grades 2, 3 and 4 are classified as chronic or persistent asthma. The doctor will assign you to the most severe grade in which any feature occurs.

Table 1: Classification of severity of asthma in adults and adolescents
 

 

Grading	Grade 1	Grade 2	Grade 3	Grade 4
Name	Intermittent, Mild	Chronic/persistent, Mild	Chronic/persistent, Moderate	Chronic/persistent, Severe
Daytime symptoms: any cough, tight chest and wheeze	2 times per week or less	3-4 times per week	More than 4 times per week	Continuous
Nighttime symptoms:any cough, tight chest, wheeze and night waking	Once a month or less	2-4 times per month	More than 4 times per month	Frequent
Peak flow while exhaling	80% or more of your maximum	80% or more of your maximum	Between 60 and 80% of your maximum	Less than 60% of your maximum

 

Table 2: Classification of severity of asthma in children
 

Grading	Grade 1	Grade 2	Grade 3	Grade 4
Name	Intermittent, Mild	Chronic/persistent, Mild	Chronic/persistent, Moderate	Chronic/persistent, Severe
Daytime symptoms: any cough, tight chest and wheeze	2 times per week or less	More than twice a week, but not daily	Daily	Continuous
Nighttime symptoms:any cough, tight chest, wheeze and night waking	Once a month or less	2-4 times per month	More than once per week, but not nightly	Frequent
Peak flow while exhaling	80% or more of the child’s predicted best	80% or more of the child’s predicted best	Between 60 and 80% of the child’s predicted best	Less than 60% of the child’s predicted best

   

Treatment overview

While asthma can’t be cured, it can be controlled in the vast majority of cases. It is a chronic disease and may need long-term treatment and even lifelong management. Today asthma medication is usually extremely effective. Your asthma medication, complemented by your lifestyle and the accurate early identification of asthma symptoms, will assist in optimising your asthma control. In most cases good control can be achieved and there is little reason why an asthma sufferer cannot lead a perfectly normal life.

Since asthma is actually two conditions rolled into one - inflammation and bronchoconstriction of the airways - the most effective treatment now consists of a two-pronged approach, treating both these factors simultaneously.

The objectives of asthma treatment are to help the patient to:
 

• Be free of troublesome symptoms.
• Minimize the need for reliever therapy because symptoms do not worsen.
• Avoid any further acute serious asthma attacks, and to prevent the need for hospitalization. 
• Sleep restfully.
• Improve lung function as much as possible to (near) normal lung function.
• Avoid or minimise any adverse medication-related side-effects.
• Maintain normal activity levels, including exercise. A child should be able to attend school regularly and participate   fully in all school activities, including sport.

When asthma is controlled, patients can prevent most attacks, avoid troublesome symptoms day and night, and keep physically active. If these objectives are not achieved, and you adhere 100% to your therapy, please visit your doctor to discuss more aggressive treatment, because you should be able to live a normal life.

A comprehensive  treatment plan should include the following:
 

• Timely and effective treatment of all aggravating factors such as hay fever, sinusitis, bronchitis and gastro-oesophageal reflux.
•  Reduced exposure to all possible triggers such as viral infections, flu, allergens, active and passive smoking, excluding exercise.
• Patient education – you, the patient, should be able to recognize the warning signs and an emergency in time; to adhere to the prescribed medication; to use the inhalers correctly; know how to avoid triggers and  have an action plan ready in case of an emergency.

The exact approach to the treatment of asthma in each individual depends on the severity of your asthma (grades 1 – 4) and age (the approach differs between adults/adolescents and children, and even between children older than five and those that are younger), as explained in tables 1 and 2.

Asthma treatment consists mainly of the daily, long-term treatment with an inhaled corticosteroid (often at least six months, in many cases for two years, and even lifelong if necessary), or a leukotriene inhibitor (tablets that also suppress the inflammatory reaction), plus the use of a bronchodilator, to be used when necessary (in the case of an acute attack). The long-term, daily treatment to control the continuous and underlying inflammation in the airways (the ever-smouldering fire in your airways), is referred to as controller treatment, and the use of bronchodilator treatment to relieve the bronchospasm (to unlock the tight grip, squeezing your airways like a boa constrictor squeezing his prey) as reliever therapy.

A. Control of inflammation (Controlling the “FIRE”)

In the past, doctors concentrated on the use of bronchodilators to treat only bronchoconstriction and largely ignoring the huge role of the inflamed airways. But growing recognition of the inflammatory basis for asthma has shifted the focus to long-term therapy as the first step for all patients. This treatment of inflammation is undertaken to prevent permanent damage to the airways, known as remodelling. Research has shown that in almost all cases of asthma, the sufferer shows signs of chronic inflammation of the airways. In fact, this underlying and ever-present inflammation may in general be so extensive in asthma patients, that your airways may be half-closed all the time without you realizing it. It is absolutely essential to treat this chronic inflammation with controller treatment on a daily basis.

The most important controllers are:

1. Inhaled corticosteroids.Widely used inhaled corticosteroids are beclomethasone dipropionate, budesonide, fluticasone and ciclesonide. Beclomethasone dipropionate (BDP) is available as Beclate and Qvar. Budesonide is available as Inflammide, Pulmicort andBudeflam. Fluticasone is available as Flixotide.  Ciclesonide is available as Alvesco.

The 1^st line of treatment, and gold standard of controller therapy for asthma in adults and adolescents, as well as for children older than 2 years, is the long-term use of inhaled corticosteroids, with or without the use of leukotriene inhibitors (tablets or sprinkles) as add-on therapy. They have strong anti-inflammatory actions, but won’t be effective against bronchospasm, and will thus be effective against the “fire” but not the “boa constrictor”. 
If the inflammation is controlled, the risk of an acute attack diminishes, and a bronchodilator can be used only when acute attacks arise. Inhaled corticosteroids inhibit the whole inflammatory process underlying asthma by reducing the chronic swelling and redness (as part of the inflammation) in the small breathing tubes. By reducing the swelling, the airway passages are kept more "open". With the mucous membranes not inflamed, they are less sensitive to triggers, and the frequency and severity of attacks are reduced. Symptoms will decrease within one to two weeks, with maximum improvement after many weeks. However, control deteriorates within a week after stopping this therapy.
Inhaled corticosteroids are safe in daily dosages needed to control asthma in children (usually 100 – 200 microgram budesonide daily, but about 400 microgram may be needed to control exercise-induced asthma). Higher dosages may impair the child’s growth. 

2. Leukotriene modifiers/inhibitors (with active ingredient montelukast in Singulair and zafirlukast in Accolate)  Leukotriene inhibitors are the latest drugs developed to treat asthma. Leukotriene inhibitors work by blocking the action of leukotrienes, one of the many potent chemical classes which promote the damaging airway inflammation characteristic of asthma. They have anti-inflammatory effects, but not quite as strong as inhaled corticosteroids. They are mainly used as add-on therapy to inhaled corticosteroids, when single therapy with the inhaled corticosteroids is insufficient to gain symptom control. Leukotriene inhibitors may sometimes be the first choice of treatment for patients, particularly children, with mild persistent asthma, allergic rhinitis, exercise-induced asthma and  ASA (aspirin sensitive asthma).  Being a tablet or sprinkles makes it easier to administer to very young and very old patients - or to those with poor space co-ordination. They are safe for children older than 6 months. Leukotriene inhibitors may reduce the need for high doses of inhaled or oral corticosteroids.
These medication (inhaled corticosteroids with or without leukotriene inhibitors as add-ons) will put out the "fire" of inflammation in asthmatic airways. It needs to be taken on a daily basis - even if you are feeling well and your asthma is under control. People often stop taking their medication when they're feeling great, but once you start skipping doses, the "fire" is allowed to rekindle and symptoms arise.

3. Oral corticosteroids (prednisone, prednisolone, methylprednisone, methylprednisolone). When asthma is not well-controlled this is prescribed as one of the steps, with inhaled corticosteroids and/or leukotriene-inhibitors and long-acting beta-agonists, but should not be prescribed as long-term treatment, due to known and serious side-effects associated with long-term treatment. It is prescribed to knock out inflammation as quickly as possible during a period of poor control and an acute attack. Long-term use may lead to growth suppression in growing children and many other side effects.  It is usually prescribed for about ten days in adults and 5 – 7 days in children (at a dose of 1 – 2 mg/kg/day) to bring the inflammation under control. It is very BAD asthma treatment to just employ inhaled reliever therapy and use courses of oral steroids for lots of severe attacks.  If this is the treatment you are receiving, please speak to your asthma doctor or nurse about starting regular inhaled controller therapy.

4. Long-acting beta-agonists are  salmeterol (Serevent) and formoterol (Foradil, Foratec and Oxis). Salmeterol is available in normal asthma pumps as well as dry powder devices (Accuhaler).  Formoterol is available as Foradil in a pump and as Foratec and Oxis in dry powder devices known as the DP-haler and Turbuhaler respectively. This inhaler provides a sustained relief of bronchospasm, but its anti-inflammatory action is either unproven or weak. It should never, ever be used as the only asthma medication, never in children, four years old or younger and then only in combination with an inhaled corticosteroid. The bronchodilating effect will last about 12 hours.

When these medicines are used they are always used at the same time as an inhaled steroid. To make this easier, they are also available in single pumps where the steroid is already mixed in with the long-acting beta-agonist. Salmeterol is available, combined with the inhaled corticosteroid fluticasone. This combination is available in an Accuhaler (Foxair and Seretide and an MDI (Foxair, Sereflo and Seretide).

Formoterol is available in combination with the inhaled corticosteroid budesonide in the Turbuhaler device (Symbicord). Symbicord is unusual in that the long-acting beta-agonist also works very quickly as a reliever, so it can be used not only twice daily as regular maintenance therapy but also, as needed, for emergency treatment. When used in this manner, the frequency and severity of breakthrough attacks are reduced.

5. Chromolyns (nedocromil sodium and sodium chromoglycate) are non-steroid treatment to reduce inflammation. Chromolynsshould not be prescribed as the first choice of asthma control, since newer and more effective treatment options (inhaled corticosteroids, leukotriene inhibitors), are now available. It should only be used as last resort add-on therapy. If your doctor prescribes chromolyns as the first and only treatment, it may be best to seek a second opinion.

6. Sustained-release theophylline preparations. These medications have weak anti-inflammatory action, and long-term treatment is generally not recommended, due to unwanted side-effects. In fact, theophylline is regarded as outmoded treatment for asthma and should, according to the 2009 guidelines, be used if no long-acting beta-agonist inhaler or leukotriene inhibitor is available as an add-on to inhaled corticosteroids.
 

B. Control during an acute asthma attack (“controlling the SNAKE – relaxing the grip of the boa constrictor”)

Fast- and short-acting bronchodilators contain salbutamol (e.g. Ventolin, Asthavent, Venteze), fenoterol (Berotec) or terbutaline (Bricanyl), the most widely used asthma drugs. They are first-line relief therapy for most patients and for mild intermittent cases they are the only drug needed. They have a rapid onset of action, but their effects wear off over 4 to 6 hours, i.e. they are rapid but short-acting bronchodilators.

They are used to provide instantaneous relief when your chest begins to tighten at the onset of an attack. They act by relaxing the constricted smooth muscles surrounding the bronchioles, thus allowing the airways to widen. The airway passage, already very narrow due to inflamed and swollen mucous membranes, can close almost completely if the airway muscles start constricting.

The bronchodilator can relieve this muscle constriction, and thus open the airway passage again. This reduces the symptoms of breathlessness and enables sufferers to breathe more freely, but will do little to douse the underlying inflammation. They may be taken prior to exercise in patients who experience exercise-induced asthma.
 

Both controller and reliever medication are usually administered by inhalation, but some can be given orally or intravenously in the case of an emergency.

It is important to note that the use of relievers (bronchodilators) will not reduce inflammation and the use of controllers (anti-inflammatory action) will not alleviate bronchoconstriction during an acute attack.

 Notes on other medication/treatment

There are a few things about other kinds of medication you should take note of if you are an asthmatic.

Immunotherapy
Sublingual immunotherapy (SLIT) is safe and effective and recommended as additional therapy for patients older than 5 years who have been diagnosed with hay fever (allergic rhinitis) and mild to moderate asthma. It can only be done if allergy tests (skin or blood tests) show that you are sensitive to ONE allergen, rather than many.

Antihistamines can be used to alleviate allergic reactions such as hay fever, but aren’t effective in asthma treatment.

Antibiotics are seldom necessary, as viral infections are by far the most common triggers of asthma. Antibiotics are ineffective against viral infections, but effective against bacterial infections. If a patient has bronchitis due to a bacterial infection, an antibiotic to fight the bacterial infection will reduce his asthma risk because yet another asthma trigger (the bacterial infection in the lungs) will be controlled.

Sedatives (sleeping pills, tranquilisers) should be strictly avoided because they may suppress breathing and aggravate symptoms. This is especially dangerous in patients with severe asthma.

Cough mixtures to suppress your cough won’t offer any relief from a tight chest, as the cough is most often a sign of poor asthma control and a signal that (more) reliever medication is needed. Leave the cough suppressor, rather use reliever therapy.

Mucolytic drugs (which breakdown substances containing mucous to loosen the phleghm) can in fact worsen the cough.

Physical therapy/physiotherapy to loosen the mucus in the lungs, may increase the discomfort. Physiotherapy is not indicated for an asthma attack.

Breathing exercises, where the patient learn to exhale properly by using his diaphragm more effectively to empty the lungs, can sometimes help certain individuals, but is not a substitute for regular controller therapy.

Hydration with volumes of fluid for adults and older children is recommended. Dehydration may occur because of poor fluid intake, sweating, and hyperventilation. But care should also be taken not to over-hydrate the patient. It is best to provide only the normal fluid requirements for the child ifgiven intravenously.

Ionisers are ineffective.

Homoeopathic/complementary or alternative medicinesshould never be used instead of prescribed medical treatment. There is insufficient medical evidence to recommend this treatment as the sole treatment of asthma. If you do want to try homoeopathic medicines, use them in conjunction with those prescribed by your doctor.
 

How your asthma treatment will be tailored specifically for you

As soon as your doctor has confirmed a diagnosis of asthma, and excluded all other possible causes of your symptoms, he will initiate your treatment according to the severity of your asthma. There are two sets of guidelines: one for adults and adolescents, and one for children. These guidelines are constantly updated by asthma experts in South Africa. South African experts use international guidelines like the Global Initiative for Asthma (GINA, 2007) as a basis for children, and international guidelines from Europe and the USA as a basis for adults in South Africa. Although these guidelines are adapted for South African circumstances, the principles of these guidelines adhere to international guidelines.

In the international and South African guidelines, new management options had been implemented for children younger than five years, because they should not be treated exactly the same as older children. The much larger emphasis on the use of controllers as the foundation of asthma treatment and the major change in emphasis to assess asthma control are evident in the new guidelines. New treatment options such as combination treatment (an inhaled corticosteroid plus a long-acting beta agonist in one single inhaler), the use of new formulations of inhaled corticosteroids, and the use of leukotriene inhibitors and immunotherapy (to be used under your tongue) are also incorporated in the latest guidelines. These new advances in asthma management will benefit you as a patient because it is now possible to achieve good asthma control.
 

This is how your doctor will decide exactly how to manage your asthma in five main steps:
Step 1.  S/he will confirm the diagnosis of asthma(see section on diagnosis).

Step 2: S/he will identify and treat all relating conditions, aggravating factors and address the triggers.
It is important to treat (and prevent) hay fever and sinusitis, sinceabout three quarters of people with asthma also have allergies of the nose and sinuses. It is also true that if this part of the problem is out of control, so will the asthma.

Allergies will be treated by limiting exposure to the identified allergens, and to control allergy symptoms with a new generation antihistamine.

Step 3:  S/he will classify the severity of your asthma, based on the latest guidelines for adults/adolescents and for children (see section on Classification of asthma severity).
Step 4:  S/he will  initiate your treatment based on the severity of your asthma, and your age.  The section below will explain how this will be done.

For Adults and adolescents:
Table 3. Treatment according to severity in Adults and adolescents (2007 guidelines)

 

Grade of severity	1. Intermittent, Mild	2. Persistent/Chronic, Mild	3. Persistent/Chronic, moderate	4. Persistent/Chronic, severe	5. Persistent/chronic, very severe
Do you need a controller?	No	Yes. Daily. Long-term. Start with a low dose inhaled corticosteroid (ICS).(Inhaler)	Yes. Daily. Long-term. One of the following: 1. Medium to high dose ICS (inhaler) or 2. A combo: Low dose ICS + long-acting beta blocker inhaler (LABA) (probably a single inhaler) or 3. Low dose ICS + Leukotriene inhibitor (inhaler + tablet) Or 4. Low dose ICS + slow-release theophylline (only if 1st 3 options not available or not effective) (inhaler + tablet)	Yes. Daily. Long-term. One of the following:  Medium to high dose ICS (inhaler) plus one of the following: 1. + LABA (inhaler) or or  2. + Leukotriene inhibitor (tablet) [w2]  3. + LABA (inhaler) + LTRA (tablet) 4. + Slow-release theophyline (tablet). Theophyllines don’t work well.  They are really only used in the public service if other more effective medication is not available.	Yes. Daily. Long-term. Your doctor will add one of both to one of the treatment options on the left: 1. He will increase the dosage of your ICS inhaler And/or 2. Add a corticosteroid tablet.
Do you need a reliever?	Yes.  A short-acting beta agonist  inhaler when and if needed.	Yes. A short-acting beta agonist when and if needed.(inhaler)	Yes. A short-acting beta agonist inhaler when and if needed (inhaler).	Yes A short-acting beta agonist inhaler when and if needed (inhaler).
The medication at your bedside	One inhaler/pump	Two inhalers/pumps	Two inhalers/pumps or Two inhalers/pumps plus daily tablets	2 Inhalers;  or 2 inhalers plus 1 – 2 different daily tablets	2 inhalers or 2 inhalers plus 2 – 3 different daily tablets

For Children:
Children usually use the same medication as adults. The amount and type of medication will depend on the severity of the asthma. The approach to treatment in children (as in adults) is to "Hit Early, Hit Hard - then Step Down".

In mild cases (intermittent asthma, with less than two acute asthma attacks per week, See table 4 below), only a bronchodilator may be necessary, while any child with persistent asthma needs daily preventer medication to help prevent attacks by reducing the chronic inflammatory reaction in the airways.

In infants, management of asthma presents unique problems. But it is always better to treat a child as if he has asthma than not to treat him at all. If a parent is unsure whether the infant's wheezing is because of asthma, or whether he is suffering an acute attack, it is better to give him a bronchodilator than to withhold treatment, if he has been diagnosed with asthma.

Because an infant’s airways are so small, the smallest amount of mucus or tissue swelling can cause significant airway narrowing. Infants also have proportionately less smooth muscle around their airways, resulting in less support for the airway, but also less spasm of the airway. As a result, infants also respond less well to bronchodilators, which open up the airways and provide older asthmatics with quick relief. But there is no reason why a child's asthma cannot be managed and controlled to such an extent that he can live a normal life.

Parents often panic because they do not know whether their infant or toddler is really inhaling deep enough to get all the medication to his lungs. For infants and children, a spacer with a valve to ensure that no air escapes from the spacer, can be of great value.

A child often inhales in shallow and short breaths when using an inhaler, exhaling more than inhaling. As soon as your child can understand, you can teach him to relax before using his inhaler, and take long and slow breaths from the spacer, keeping his mouth on the spacer, while exhaling slowly through his nose, and then inhaling again. After four to five inhalations, chances are good that he inhaled all the medication he needs.

Table 4. Treatment according to severity in Children (2009 guidelines)

 

Grade of severity	1. Intermittent, Mild	2. Chronic, Mild	3. Chronic, moderate	4. Chronic, severe
Do you need a controller?	No	Yes. Daily. Long-term. (listed in order of preference) For all children: A low dose inhaled corticosteroid (ICS) (inhaler), or leukotriene inhibitors if ICS has failed.	Yes. Daily. Long-term (Listed in order of preference) For children 5 years or younger: 1. Medium-dose ICS (inhaler). or 2. Low-dose ICS (inhaler) + leukotriene inhibitor (tablets) For children older than 5 years: 1. Medium dose ICS (inhaler) or 2.Low-dose ICS + LABA (inhaler) or 3. Low dose ICS + leukotriene inhibitor (tablet)	Yes. Daily. Long-term (Listed in order of preference) For children 5 years or younger: Medium-dose ICS (inhaler). + leukotriene inhibitor (tablets) For children older than 5 years: 1. Medium dose ICS (inhaler) + LABA (inhaler) or 2. Medium dose ICS + leukotriene inhibitor (tablet) or 3. High dose ICS (inhaler)
Do you need a reliever? (for an acute attack, or for relieve of symptoms)	Yes. A short-acting beta blocker when your child has an asthma attack	Yes.  A short-acting beta blocker when your child has an asthma attack	Yes.  A short-acting beta blocker when your child has an asthma attack	Yes.  A short-acting beta blocker when your child has an asthma attack
The child’s medication :	One inhaler	Two inhalers, or One inhaler + daily tablets

 

Step 5: Your doctor will re-assess your condition and control of your symptoms 2 – 6 weeks after you have started treatment.

Adults
After re-assessment he will classify your asthma (at this assessment and every following assessment) as either “controlled”, “partly controlled” or “uncontrolled” (see table 5).

Table 5. Classification of control in Adults

 

Characteristics/symptoms	Controlled (all of the below)	Partly controlled (if any one of the features below is present in any week)	Uncontrolled (If more than 3 features of Partly controlled asthma are present in any week)
Daytime symptoms (wheezing, cough, difficult breathing)	2 or less per week	More than twice per week	More than twice per week
Nocturnal symptoms or waking at night	None	Any	Any
Need for reliever therapy	2 or less in any week	More than twice in any week	More than twice in any week
Lung function (with peak flow meter) as % of predicted or personal best	Normal	Less than 80%	Less than 80%

Based on this classification, S/he will either step up or step down your treatment (from your initial treatment – see table 3) to achieve total control (no acute attacks at all, no need for reliever therapy due to worsened symptoms) as soon as possible. Before stepping up therapy, your doctor must make sure that you are taking your medication regularly and not forgetting any doses, and that you know how to use your medications and pumps.

You should bring your medication with to the doctor and show him / her how you use it so that s/he can help you with your technique.  Spacers with your pumps (or a dry powder inhaler) are necessary in people of any age who are having very poor control.

If your asthma remains anything but well-controlled despite checking your using the medicine, your technique and stepping up therapy, S/he should refer you to a specialist physician/pulmonologist. You definitely need the help of a specialist physician or pulmonologist if you have initially been diagnosed with moderate persistent asthma (grade 3) and total control has not been achieved with initial treatment. 
If total control is achieved and maintained for at least 3 months, therapy will be stepped down.

In Children:
After re-assessment, the doctor will classify your child’s asthma (at this assessment and every following assessment) as either controlled, partly controlled or uncontrolled (see table 5).
Table 6. Classification of asthma control in children

 

Characteristics/symptoms	Controlled (all of the below)	Partly controlled (if any one of the features below is present in any week)	Uncontrolled (If more than 3 features of Partly controlled asthma are present in any week)
Daytime symptoms (wheezing, cough, difficult breathing)	Less than twice per week	More than twice per week	More than twice per week
Nocturnal symptoms or waking at night	None	Any	Any
Need for reliever therapy or rescue treatment	2 or less in any week	More than twice in any week	More than twice in any week
Lung function (with peak flow meter) as % of predicted or personal best	Normal	Less than 80%	Less than 80%
Acute attacks/exacerbations	None	1 or more per year	1 in any week

Based on this classification, he will either step up or step down your child’s treatment (from your initial treatment – see table 4) to achieve fully controlled asthma (no acute attacks at all, no need for relievers due to worsening of symptoms) as soon as possible.

Before stepping up therapy, your doctor must make sure that your child is taking your medication regularly and not forgetting any doses, and that you know how to use your medications and pumps.  You should bring your medication with to the doctor and show him / her how you use it so that s/he can help you with your technique. Spacers are necessary in all children to help them take their pumps effectively. Your child may do better with a mouthpiece or a mask. Ask your doctor which is best.

An acute asthma attack in any week makes that an uncontrolled asthma week. There should not be even one uncontrolled asthma week in your child’s life. 

Every time you child suffers an acute attack/exacerbation, you should inform your child’s doctor, because any acute attack in any week should prompt immediate review of his/her treatment to ensure adequate control. An acute attack means that your child’s treatment is inadequate. 

If your child’s asthma remains anything but well-controlled despite stepping up therapy, he will/should refer you to a paediatrician, pulmonologist or allergist.

If total control is achieved and maintained for at least 3 months, therapy should be stepped down.

Asthma should be managed on a daily basis.

When should you be referred to a specialist?

Adults should be referred to a specialist and special care taken:
 

• When asthma is poorly controlled despite intensive treatment.
• When the asthma patient suffers from other medical conditions such as a peptic ulcer, heart failure or hypertension, or if the patient is pregnant. Poor asthma control is much more dangerous to the mother and the unborn baby than the possible side-effects of any asthma medication.
• When the patient suffers from occupational asthma.
• When the patient is frequently absent from work.
• When the patient needs immunotherapy.

Note that elderly asthma patients should rather not use theophyllines and oral corticosteroids due to possible adverse effects, that asthma patients with heart problems and hypertension should rather not use beta agonists because it may affect their heart and blood pressure, that diabetics should rather not use oral corticosteroids, and that asthma patients with pulmonary tuberculosis should not take isoniazid (a TB medication) while using inhaled or oral corticosteroids.

Children should be referred to a specialist and special care taken:

• When asthma is poorly controlled despite treatment, or has shown no or merely slight improvement in control over the past year.
• When a child regularly requires oral corticosteroids.
• When a child has had one or more life-threatening episode.
• When the child is frequently absent from school.
• When the child needs immunotherapy.

Reviewed and updated May 2011 by Dr Mike Levin, pediatrician, Red Cross Children's Hospital, Cape Town. 
 

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