Asthma
Long-term management of airway inflammation and narrowing that causes wheezing, cough and breathing difficulty
What is asthma?
Asthma is a long-term inflammation of the airways that makes them twitchy. In an airway that is already inflamed, the muscle in the wall tightens, the lining swells and mucus is produced, and the tube narrows. The narrowing comes and goes, and it opens up again with treatment, and that variability is what distinguishes asthma from the other causes of breathlessness.
The inflammation is there between attacks, even on days when you feel completely well. That is the single most useful fact about the condition, because it explains why a preventer inhaler is taken every day and a reliever inhaler is taken only when needed.
Triggers differ from person to person and are worth identifying. House dust mite, cockroach, pollens, moulds and animal dander are the common allergic ones in Indian homes. Tobacco smoke, incense, mosquito coils, cooking smoke, outdoor air pollution, cold air, exercise, viral colds, strong emotion and certain painkillers set off attacks without any allergy being involved. A family history of asthma, eczema or allergic rhinitis makes it more likely, and childhood asthma and adult asthma are the same disease behaving differently at different ages.
What you might notice
- A wheeze or whistle in the chest
- A cough that has lasted more than three weeks
- Getting out of breath on stairs
How it is diagnosed
Your doctor listens carefully to the story before listening to your chest, because the pattern is where the diagnosis lives. They are asking whether the trouble is worse at night and in the early hours, whether it flares with colds, exercise, dust or a particular season, whether it comes and goes completely between episodes, and what happens when you stop and rest.
They examine the chest for the sound of narrowed airways, which is often absent on a good day and does not exclude anything. They also look in your nose and at your skin, since allergic rhinitis and eczema travel with asthma and treating the nose improves the chest.
The confirmation comes from measuring the airflow. You blow hard into a device, the reading is taken, a reliever is given, and the measurement is repeated to see whether the narrowing opens up. Where the picture is unclear you may be asked to record a home reading twice daily for two weeks, because a swing between morning and evening readings is itself diagnostic. Your doctor is also ruling out the conditions that mimic asthma, and in India that includes tuberculosis.
Recovery
Asthma is controlled and not cured, so the useful measure is how long before you are living normally. Reliever inhalers open the airway within minutes. A preventer inhaler works on the inflammation and takes two to four weeks to show its effect, with the full benefit at about six weeks, so do not judge it in the first fortnight.
Your doctor will review you at four to eight weeks and ask four questions: daytime symptoms more than twice a week, any night waking, any limitation of activity, and reliever use more than twice a week. Answering no to all four is control, and the treatment steps down after a stable stretch of about three months.
After an attack, expect several days of tiredness and a cough, and up to two to six weeks before your readings return to your own baseline. A short course of tablets is usually taken for five days. Ask someone to watch you use your inhaler at the review, since incorrect technique is the commonest reason treatment appears to fail, and a spacer fixes most of it.
If it is left untreated
Uncontrolled asthma is dangerous in two separate ways. In the short term, an attack can become severe, and deaths from asthma occur overwhelmingly in people whose day-to-day control was poor and who relied on a reliever inhaler alone. Needing your reliever more than twice a week is a warning that the inflammation is untreated, and getting through more than one canister a month is a strong one.
In the long term, airways that are inflamed for years remodel. The walls thicken and the narrowing stops opening up fully with treatment, so a proportion of lung function is permanently lost. In children, poorly controlled asthma also costs school days and can affect growth through repeated courses of tablets.
Go to hospital the same day if you are too breathless to complete a sentence, if the reliever is not lasting four hours, if your lips or fingertips look blue, or if a child is quiet, drowsy or using the muscles of their neck to breathe. Ask your doctor to write you an action plan that says exactly what to do as symptoms escalate, and keep it where your family can find it.
Questions about asthma
Are steroid inhalers safe to use for years?
Yes, at the doses used for asthma. The dose delivered by an inhaler is a tiny fraction of what steroid tablets deliver, and it is put directly into the airway instead of circulating around the body, so the side effects people associate with steroids are not the ones you should expect. The common local effects are hoarseness and oral thrush, and both are largely prevented by using a spacer and rinsing your mouth after each dose. Children on inhaled steroids should have their height measured at reviews. Weigh this against the alternative: uncontrolled inflammation permanently narrows airways, and relying on a reliever alone is what makes attacks dangerous.
Will my child grow out of asthma?
Many children improve substantially through the teenage years, and a good number have no symptoms as young adults. The tendency does not disappear altogether and can return in adult life, often triggered by a chest infection, a change of workplace or pregnancy. Children whose asthma is mild, who have no allergies and no family history do best. What you can influence is the control in the meantime, since poorly controlled asthma in childhood costs school days and can leave a degree of permanent narrowing. Keep the preventer going as prescribed even through good stretches, and ask for the treatment to be stepped down at review once control has been stable for about three months.
Can I exercise or play sport?
Yes, and you should. Well controlled asthma is compatible with sport at every level, including competitive athletics, and regular exercise improves fitness and breathlessness. If exercise consistently sets off symptoms, that is a sign the underlying inflammation is not adequately treated, and the answer is usually to review the preventer and the inhaler technique instead of giving up the activity. Practical measures help: use your reliever about fifteen minutes before starting if your doctor has advised it, warm up properly for ten minutes, avoid exercising outdoors in cold air or heavy pollution, and breathe through your nose where you can. Raise it at your next review.
Other pulmonology treatments
Treatment and monitoring of chronic obstructive lung disease to reduce symptoms and improve daily function
Day CareDiagnosis and treatment of repeated interruptions in breathing during sleep
Day CareTalk to a care coordinator about asthma
Leave a number and a care coordinator calls you back with what the treatment involves and which hospital it would be at. They book a consult only if you want one