Health Zone

Asthma

What is asthma?
Asthma is a variable condition that affects the airways – the small tubes that carry air in and out of the lungs. People with asthma have airways that are sensitive and become inflamed.

Their airways can react badly when they have a cold or other viral infection, or when they come into contact with an asthma trigger (a trigger is something that sets off asthma symptoms – see section below)

When this happens the muscles around the walls of the airways tighten and they become narrower. The lining of the airways swell and often produce a sticky mucus. As the airways narrow, the air has to squeeze in and out, and this is what causes difficulty in breathing. Asthma symptoms can include coughing, wheezing, shortness of breath or a tight feeling in the chest.

Asthma affects over 5 million people in the UK, including one in eight school children and one in 13 adults. With the correct treatment, support and advice, most people with asthma can lead full and active lives.

What are the causes of asthma?
Asthma, like its related allergic conditions eczema and hay fever, often runs in the family and may be inherited. There are probably a number of other, environmental, factors that contribute to someone developing asthma – many aspects of modern lifestyles, such as housing and diet, might be responsible. We also know that smoking during pregnancy increases the chance of a child developing asthma. Poor air quality can make your asthma worse.

What are the things that can set off (or trigger) asthma symptoms?
A trigger is anything that irritates the airways and sets off the symptoms of asthma. Common triggers include colds or 'flu, cigarette smoke, exercise and allergies to things like pollen, furry or feathery animals or house-dust mite. Everyone with asthma is different and has different trigger factors.

Asthma symptoms include:

• shortness of breath,
• wheezing (a whistling noise in the chest),
• cough and chest tightness.

Not everybody will have all these symptoms. Young children often present only with a cough with no other symptoms hence often the asthma diagnosis is overlooked or misdiagnosed. A history of asthma, eczema or hay fever in the family may mean that your chances of developing asthma are slightly higher than those without.

If you suspect that you may have asthma, it is important to see your doctor or asthma nurse. They will discuss your medical history and your current symptoms. They may want to measure your peak flow using a peak flow meter. This measures the amount of air you can blow out of your lungs in a fraction of a second.

Each time you use the meter (usually morning and evening) the result is marked on a chart. It can help (along with keeping a record of your symptoms) to give the doctor a better picture of how well controlled your asthma is. The doctor may decide to give you your own peak flow meter and ask you to keep a diary of readings. They will be able to assess the pattern from the readings and observe the variability between the morning and evening measurements which is a good indicator of asthma control.

Most GP practices / Asthma Nurses perform spirometry testing ( blowing tests) Spirometry testing may assist in diagnosing asthma.

Is there a cure for asthma?
Currently there isn’t any cure for asthma. However, a considerable amount of research into asthma is being conducted out all around the world.

Researchers are tackling asthma from many directions: indoor and outdoor air pollution, allergies, gene therapy, cell biology and chemical structures to name but a few. The results of their work will help us understand much more about how and why this common condition develops. It might also lead to even more effective asthma treatments – and an even better quality of life for everyone who has asthma.

Current research suggests that taking certain preventative measures in the home can lessen your chances of developing asthma, or reduce your symptoms. These steps include reducing the amount of dust in your home and can be achieved using simple measures like damp dusting and opening windows.

Asthma treatments

Although there is no cure for asthma, there are many safe and effective asthma treatments available that can help to control your symptoms.

Asthma Control
The aim of your asthma treatment is to keep you free from asthma symptoms during the day and the night and to reduce the amount of time that you have to take off work. If any of the points below apply to yourself then it indicates that your asthma is not adequately controlled and you should consult your GP or asthma nurse.

Signs of poor asthma control include:-

• Night time awakenings with coughing, wheezing, shortness of breath or a chest tightness
• being short of breath on waking up in the morning
• needing more and more reliever treatment, or reliever not working very well
• being unable to continue your usual level of activity or exercise
• finding that you are too breathless to talk or eat

There are two main kinds of asthma treatment that your doctor may prescribe for you. They are called relievers and preventers

Everyone with asthma should have a reliever inhaler. Relievers are treatments taken to relieve asthma symptoms. They quickly relax the muscles surrounding the narrowed airways (within 5-10 minutes), making it easier to breathe again. Reliever inhalers are usually blue in colour and are often referred to as the “blue inhaler”.

If you need to use your reliever inhaler more than once in any day, or more than 3-4 times a week, you will need an additional preventer treatment to keep your asthma symptoms under control. This is because relievers do not reduce the inflammation and swelling in the airways there fore are not treating the underlying cause.

Do the treatments have side effects?
Reliever treatments are very safe and effective and have few side effects. Sometimes, high doses of reliever treatment can slightly increase your heart beat or give you mild muscle shakes. These effects are harmless and generally wear off after a short period of time.

Preventers
Preventers help to control swelling and inflammation in the airways. They also stop the airways from being so sensitive to asthma triggers. The protective effect of preventer treatments builds up over a period of time. The full effects when starting on a preventer inhaler are not achieved for several weeks so it is important to keep taking them even when you feel better.

If you take your preventer treatment regularly you will improve your long-term chances of controlling your asthma and reduce the likelihood of permanently damaging your airways.

Preventer inhalers are usually brown, red or orange

What about side effects?
Preventer treatments usually contain corticosteroids (a copy of the steroids produced naturally in our bodies) in low doses. These steroids are safe, not addictive and are completely different and not to be confused with the anabolic steroids used by body builders and athletes.

Using a preventer inhaler brings a small risk of a mouth infection called thrush and hoarseness of the voice. You can avoid this by using your inhaler before brushing your teeth and by rinsing out your mouth afterwards. Using a spacer device will also reduce the chances of these side effects. A spacer device also gives a much better delivery of the drug and delivers it to your lungs more effectively.

How do I take my treatment?
One of the most common ways of taking your asthma treatment is to use an inhaler device. Inhalers are useful because they help to get your treatment straight to the airways where it is needed. Inhalers can be in a spray form (aerosol) or dry powder form. If you use an aerosol inhaler, using a spacer device with your inhaler can also help.

Inhalers and spacers can be tricky to use at first and good technique is important in getting the most from your medication. Ask your doctor or practice nurse to check you are using your inhaler correctly the next time you see them.

Steroid tablets
Sometimes, when your asthma is first diagnosed, or if you have had a bad asthma attack, your doctor may give you a short course of a tablet form of preventer treatment (steroids). These tablets will help you to gain control of your symptoms quickly.

Add on treatments
If your asthma symptoms are not controlled by regular inhaled preventer and 'as needed' reliever, you may be prescribed an add on treatment to take in addition to your relievers and preventers.

The add on treatments currently available are:

Long Acting reliever inhalers - The effects of these inhalers are similar to the blue reliever inhalers but the effects last for approximately 12 hours so are taken morning and evening on a regular basis along with the preventer inhaler.

They help to control symptoms by relaxing the muscles of the airways to keep the airways open.

As both the long acting reliever and the preventers are both taken morning and evening they are sometimes available in a combination 2 in one inhaler for convenience.

Preventer Tablets - If your asthma symptoms are not controlled by regular inhaled preventer and 'as needed' reliever, you may be prescribed a daily preventer tablet treatment. These are not steroids and are usually taken alongside inhaled preventers to try and control symptoms if they are still present after the first lines of treatment mentioned above have been taken.

About asthma attacks
Sometimes, no matter how careful you are about taking your asthma treatment and avoiding your triggers, you may find that you have an asthma attack. Most people find that severe asthma symptoms are the result of a gradual worsening of symptoms over a few days.

If your asthma symptoms slowly get worse – don't ignore them! Quite often, using your reliever is all that is needed to get your asthma under control again. At other times, symptoms are more severe and more urgent action is needed.

Your asthma nurse or Doctor can help you devise an asthma action plan so that you know what to do in the event of a worsening of asthma and how to recognise the signs.

What to do if you have an asthma attack

1. Take your usual dose of reliever straight away, preferably using a spacer
2. Keep calm and try to relax as much as your breathing will let you. Sit down, don't lie down. Rest your hands on your knees to help support yourself. Try to slow your breathing down as this will make you less exhausted
3. Wait 5-10 minutes
4. If the symptoms disappear, you should be able to go back to whatever you were doing
5. If the reliever has no effect, call the doctor or ambulance
6. Continue to take your reliever inhaler every few minutes until help arrives preferably using a spacer. It is safe to keep taking your reliever inhaler until help arrives.

Do not be afraid of asking for help, even at night. A severe asthma attack can be life threatening and must be treated promptly.

If you are admitted to hospital or an Accident & Emergency department because of your asthma, take details of your treatment with you. You should also make an appointment with your doctor or practice nurse after you have been discharged from hospital so that you can review your asthma treatment and devise a plan if you didn’t previously have one so that you know what to do if the situation arises again.

Useful Links for more information about asthma

www.asthma.org.uk
www.Asthma-Help.co.uk
www.bbc.co.uk/health/asthma/

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COPD

What is COPD? (Chronic Obstructive Pulmonary Disease)
COPD (Chronic Obstructive Pulmonary Disease) is a general term which includes the conditions chronic bronchitis and emphysema.

• Chronic means that it is persistent and long term.
• Bronchitis is inflammation of the bronchi (the airways of the lungs).
• Emphysema is damage to the smaller airways and air sacs (alveoli) of the lungs.
• Pulmonary means 'affecting the lungs'.

Chronic bronchitis or emphysema can cause obstruction (narrowing) of the airways. Chronic bronchitis and emphysema commonly occur together. The term COPD is used to describe airways which are narrowed due to chronic bronchitis, emphysema, or both.

How common is COPD?
COPD is common in the UK. It usually affects people over the age of 40. A flare-up (exacerbation) of COPD is one of the commonest reasons for admission to hospital.

What causes COPD?
Smoking is the most common cause of COPD.

The lining of the airways become damaged and inflammed with smoking. Environmental pollution and exposure to polluted conditions through occupation may play a part, or make the disease worse. However, people who have never smoked rarely develop COPD.

Symptoms of COPD

• Cough is usually the first symptom to develop. It is productive with phlegm (sputum). It tends to be sporadic at first, and then gradually becomes more persistent (chronic). People often think that their “Smokers Cough” is part and parcel of being a smoker but when symptoms of breathlessness occur is when concerns usually begin.
• Breathlessness ('short of breath') and wheeze may occur only when you exert yourself at first, going up stairs and hills. These symptoms tend to become gradually worse over the years if you continue to smoke. Difficulty with breathing may eventually become quite distressing.
• Sputum. The damaged airways make considerably more mucus than normal. This forms sputum (phlegm). Patients with chronic bronchitis tend to cough up a lot of sputum each day which normally would be white in colour.
• Chest infections are more common if you have COPD. Wheezing with cough and breathlessness may become worse than usual if you have a chest infection. Sputum usually turns yellow or green during a chest infection.

What's the difference between COPD and asthma?
Asthma and COPD cause similar symptoms. However, they are different diseases.

• In COPD there is permanent damage to the airways. The narrowed airways are 'fixed', and so symptoms are chronic (persistent) and tend not to vary much from one week to the next and do not vary between different seasons. Treatments that are taken to 'open up the airways' have a more limited effect.
• In asthma there is inflammation in the airways which causes muscles in the airways to constrict. This causes the airways to narrow. The symptoms tend to be much more variable than with COPD and may vary from one week to the next and may be worse at different times of year.
• Asthma can be triggered by various stimulants eg- exposure to allergens such as pollen dust animal dander or may be triggered by exercise/weather conditions etc Treatment to reduce inflammation and to 'open up the airways' usually works well.

A person with asthma who is also a persistent smoker may go on to develop COPD. Both asthma and COPD are common, and some people have both conditions.

What tests may be necessary?
Spirometry is often performed to confirm the diagnosis. This test measures how much air you blow into a machine. A low value indicates that you have narrowed airways. The test may be repeated after you take an inhaler which 'opens up the airways'. If there is a significant improvement in the result after taking the inhaler indicates that asthma is causing some or all of the symptoms. COPD is likely if there is little or no improvement after taking the inhaler.

What is the progression and outlook of COPD?
Symptoms usually begin in people aged over 40 who have smoked for 20 years or more. A 'smokers cough' tends to develop at first. Once symptoms start, if you continue to smoke, there is usually a gradual decline over several years to increasing breathlessness. Chest infections tend to become more frequent as time goes by. A flare-up of symptoms (exacerbation) occurs from time to time, typically during a chest infection.

As the disease becomes more severe, insufficient oxygen may get into the lungs through the narrowed airways. A reduced amount of oxygen then passes into the bloodstream. This can cause heart failure as the heart needs a good oxygen supply.

At least 25,000 people die each year in the UK from severe COPD. Many of these people have several years of ill health and poor quality of life before they die. Chronic ill health and death due to COPD is preventable in most cases (see below).

What can you do to help?
Stop smoking. This is the most important factor that can make a difference. Especially if you stop smoking at an early stage after developing the condition.

Any damage already done to your airways cannot be reversed, but stopping smoking prevents the disease from getting much worse. It is never too late to stop at any stage of the disease. Even if you have fairly advanced COPD, you are likely to benefit and prevent further worsening of the condition.

If you have a cough it may seem worse for a while after you have given up and this is quite hard for people to understand. It will usually ease within a few weeks.

It is important at this time to resist temptation to want to smoke to help the cough.

See a practice nurse or doctor if you have difficulty in stopping smoking. Help is available. For example, stop smoking clinics, nicotine replacement therapy (nicotine gum patches etc), or a tablet treatment may help you give up.

How is COPD Treated?
Stop smoking
This is the most important treatment.

Bronchodilator inhalers-Reliever inhalers
An inhaler with a bronchodilator medicine is often prescribed. They work by relaxing the muscles in the airways to open up them up as wide as possible. They include:

• beta agonist inhalers. For example, salbutamol and terbutaline which are short acting relievers lasting approximately 6 hours. There are also long acting inhalers such as salmeterol and formoterol which have a 12 hourly action and are taken twice daily.
• anticholinergic inhalers. For example, oxitropium and ipratropium. Again there are long and short acting ones. Tiotropium is a relatively newly available long acting inhaler the effect lasting approximately 24 hours.
• Combination Inhalers. There are also inhalers which contain both of the above inhaler types which can complement each other when taken together as they work on the airways in different ways.
  Inhalers work well for some people, but not so well in others. Some people with mild or intermittent symptoms only need an inhaler 'as required' for when breathlessness or wheeze occur. Some people need to use inhalers regularly. The different types of inhalers work in different ways. A combination of two different inhalers may help some people.

Bronchodilator tablets
These contain medicines that 'open the airways'. Side effects are quite common and inhalers are usually better. However, some people find inhalers difficult to use, and tablets are an alternative or may be an add on treatment if symptoms are not adeqautely controlled.

Steroid inhalers
Some people with COPD are prescribed a steroid inhaler in addition to a bronchodilator inhaler. Steroids reduce inflammation of the airways. There are several different steroids inhalers. People with COPD who also have some asthma benefit most from a steroid inhaler.

If you do not have any 'asthma tendency', the role of steroid inhalers is controversial. Some studies suggest that they may help. For example, one large study showed that there was a slower decline in health, and less flare-ups of symptoms in people with moderate or severe COPD who took a regular steroid inhaler.

Steroid tablets
A short course of steroid tablets is sometimes prescribed if you have a bad flare-up of wheeze and breathlessness (often during a chest infection). They help by reducing the extra inflammation in the airways caused by infections. Taking steroid tablets long term is not advised due to the serious side effects which can develop.

Mucolytic medicines
A mucolytic medicine makes the sputum less thick and easier to cough up. This may also have a knock-on effect of making it less easy for bacteria (bugs) to infect the mucus and cause chest infections. The number of flare-ups of symptoms (exacerbations) tends to be less in people who take a mucolytic. It needs to be taken regularly, and is most likely to help if you have moderate or severe COPD and have frequent or bad flare-ups.

Antibiotics
A short course is often prescribed if you have a chest infection.

Oxygen
This may help some people with severe symptoms. It does not help in all cases. A specialist usually does some breathing tests to assess whether oxygen will help. If found to help, oxygen needs to be taken for at least 15 hours a day to be of benefit.

Surgery
This is an option in a very small number of cases. For example, removing a section of lung that has become useless may improve symptoms. Lung transplantation is being studied, but is not a realistic option in most cases.

What can be done to help?

• Get immunised. Two immunisations are advised.
  FLU JAB yearly 'flu jab' each autumn protects against possible chest damage from influenza.
  PNEUMONIA JAB Immunisation against pneumococcus (a bacteria that can cause serious chest infections). This is a 'one off' injection and not yearly like the 'flu jab'.
• Keep fit. Studies have shown that people with COPD who exercise regularly tend to improve their breathing, ease symptoms, and have a better quality of life. Any regular exercise is good. A daily walk is a good start if you are not used to exercise.
• Lose weight if you are overweight. Carrying extra weight can make breathlessness worse.
  
  Remember
• COPD is usually caused by smoking.
• Symptoms usually worsen with continued smoking.
• Symptoms are unlikely to get much worse if you stop smoking.
• Treatment with inhalers often eases symptoms, but no treatment can reverse the damage to the airways.
• A flare-up of symptoms, often during a chest infection, may be helped by a short course of steroid tablets and/or antibiotics.

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