Most people with poorly controlled asthma do not have severe disease. They have treatable asthma being undermined by two fixable problems: incorrect inhaler technique and over reliance on the reliever inhaler.
Well controlled asthma should mean almost no symptoms and no restriction on activity.
What Good Control Looks Like
Many patients accept a level of symptoms that is not necessary, having adjusted their lives around it.
Well controlled asthma means: daytime symptoms no more than twice a week, no night waking due to asthma, reliever inhaler needed no more than twice a week, and no limitation on activity including exercise.
If you wake at night with cough or wheeze, avoid exercise because of your chest, or use your reliever most days, your asthma is not controlled and your treatment needs reviewing.
The reliever usage figure is the most useful single measure. Getting through more than one reliever inhaler in three months indicates poor control and increased risk of a serious attack.
The Two Inhalers and Their Different Jobs
Confusion between these is at the heart of most poor control.
Reliever, usually blue, relaxes the airway muscle within minutes. It treats symptoms and does nothing for the underlying inflammation. Using it more does not improve the disease.
Preventer, containing an inhaled steroid, reduces the airway inflammation that causes the narrowing. It must be taken every day, including on days when you feel completely well, and takes weeks to reach full effect.
Patients frequently stop the preventer when they feel well, which is precisely when it is working. Symptoms then return, the reliever is used more, and the cycle continues.
Current guidance increasingly favours combination inhalers containing both, used as maintenance and as reliever, which avoids this problem structurally.
Inhaler Technique Is Usually Wrong
Studies consistently find that a large proportion of patients use their inhaler incorrectly, delivering the drug to the mouth and throat rather than the lungs.
For a metered dose inhaler: shake it, breathe out fully away from the device, place the mouthpiece between the teeth and seal the lips, begin a slow deep breath in and press the canister at the same time, continue breathing in slowly, then hold your breath for ten seconds.
Common errors: pressing before starting to breathe in, breathing in too fast, not holding the breath, not shaking the device, and firing multiple puffs at once.
Use a spacer. A spacer device dramatically improves drug delivery with a metered dose inhaler and reduces throat side effects. It is inexpensive and consistently under used.
Rinse your mouth after using a steroid inhaler to prevent oral thrush and hoarseness.
Identifying Your Triggers
Triggers vary between individuals, and identifying yours allows targeted avoidance.
- House dust mites, the dominant allergen in humid Chennai
- Pollen and mould spores
- Pet dander
- Cockroach allergen
- Tobacco smoke, including passive exposure
- Air pollution and traffic fumes
- Cold air and sudden weather change
- Exercise, particularly in cold or dry air
- Viral infections, the commonest trigger for attacks
- Anti inflammatory painkillers in some people
- Strong perfumes, incense and cooking fumes
- Stress and strong emotion
Aspirin sensitive asthma is worth knowing about. Some patients with asthma, nasal polyps and aspirin sensitivity have severe reactions to anti inflammatory painkillers, and this combination should be identified.
Asthma Attacks: Recognising Severity
Knowing when an attack has become dangerous is essential.
Mild to moderate: increased wheeze and cough, reliever helping, able to speak in full sentences.
Severe, needing urgent care: unable to complete sentences in one breath, reliever not helping or wearing off within an hour, peak flow well below your best, breathing very fast, unable to walk across a room.
Life threatening, needing emergency care immediately: exhaustion, confusion or drowsiness, blue lips or fingers, a silent chest with no wheeze because too little air is moving, and a slowing heart rate.
A silent chest is dangerously reassuring to the untrained ear. The absence of wheeze in someone struggling to breathe is a very bad sign, not a good one. Our respiratory emergency service treats these urgently.
What to Do During an Attack
Have a plan agreed in advance, because decisions are harder during an attack.
- Sit upright, do not lie down
- Take your reliever, one puff at a time through a spacer, up to ten puffs, taking slow breaths between
- Try to keep breathing calm and slow
- If there is no improvement after ten puffs, or symptoms worsen, get emergency help
- You can repeat the reliever while waiting for help
- Take oral steroids if you have them as part of a written action plan
Ask your doctor for a written asthma action plan stating what to do at each level of symptoms and when to seek help. Patients with a written plan have fewer emergency admissions.
Conditions That Undermine Control
Asthma that will not settle despite good treatment often has an untreated coexisting condition.
- Allergic rhinitis: treating the nose improves the chest, since the airway is continuous
- Reflux: acid reaching the airway causes cough and worsens asthma
- Obesity: worsens asthma control and reduces treatment response
- Obstructive sleep apnoea
- Anxiety, which can both mimic and worsen asthma
- Continued smoking or household smoke exposure
- Beta blockers, which can worsen asthma and need review
Allergic rhinitis is the most common and most treatable of these. Our ENT department and pulmonology department often manage these together.
Living Well With Asthma
Well controlled asthma should not restrict your life.
- Exercise is encouraged. Use your reliever fifteen minutes before if exercise triggers symptoms, warm up properly, and consider indoor activity on high pollution days
- Get an annual influenza vaccine, and pneumococcal vaccination
- Attend an annual asthma review even when well, including technique check and treatment step down if appropriate
- Address dust mite exposure at home, particularly in the bedroom
- Keep a spare reliever at work and when travelling
- Carry your inhalers in hand luggage when flying
- Tell your doctor if you are pregnant, since asthma control matters and most treatments are safe
Asthma treatment during pregnancy should generally continue. Uncontrolled asthma poses more risk to the pregnancy than the medications do.
If you use your reliever more than twice a week, your asthma is not controlled and it can be. Ask someone to watch your inhaler technique, use a spacer, take the preventer every day including good days, and get a written action plan.
Our pulmonology department at T. Nagar assesses asthma control and inhaler technique.
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