• Introduction
• Who Gets Asthma?
• Asthma is an Allergic Condition, What Does This Mean?
• What Causes Asthma?
• How Does Asthma Affect Me?
• How is Asthma Treated?
• Are There Any Other Drug Treatments?
• What Are The Alternative Medical Therapies for Asthma?
• What Will Happen if I Don't Get Treatment For My Asthma?
• What Can I Do to Help Myself?
• Will I Grow Out of it?
• I Never Had Any Problems with Breathing When I Was Younger...
• Who Will See Me and Treat My Asthma?
• What is a Peak Flow Meter?
• What Should I Ask My Doctor?
• What Do My Family/Carers Need to Know?
• Can I Manage My Asthma Myself?
• When Should I Call For an Emergency Doctor?
• What Other Help and Information Can I Get?

Asthma is a condition that affects the lungs. When you take a breath in, the air travels down a series of 'tubes' or airways which get narrower and more plentiful until they branch into millions of tiny 'air sacks' known as alveoli. It is at this part of the lungs that the oxygen in the breathed-in air is taken up by the blood stream and transported around the body, and the waste gases (mainly carbon dioxide) are released from the blood into the lungs to be breathed out. This process of breathing in and out occurs almost 20,000 times a day, most of the time we are unaware of having to breathe, it just happens automatically.

In asthma, the small airways within the lungs become irritated, swollen and inflamed (much like your throat does when you get a bad cold and sore throat); this leads to the airways becoming narrowed. With narrowed airways, the flow of air in and out of the lungs is made more difficult (like blowing through a thin straw is much more difficult that blowing through a wider cardboard tube). The person with asthma becomes much more aware of having to breathe in and out and often feels breathless because of this.

Asthma is a common condition with the number of people affected gradually increasing. In the UK, about one in 25 adults and one in seven children have symptoms of asthma. About 3.4 million people have asthma in the UK¹. Boys develop asthma slightly more frequently than girls. People of afro-caribbean descent are also more likely to develop asthma².

Large worldwide studies have shown that the number of asthma sufferers in different countries varies considerably. Better off countries such as the UK, USA and Australia have higher reported rates of asthma than poorer countries³. This has led researchers to believe that certain aspects of the 'Western' lifestyle may be contributing to the increase in the number of people with asthma.

Most people with asthma are allergic to certain things in the environment. These are often referred to as 'allergic triggers' or 'allergens' as they can trigger worsening symptoms or an attack. Common allergic triggers are dust, pollen, cats and perfume sprays. Most people with asthma soon become aware of what things trigger their symptoms. When people with asthma breathe in air containing these things, their airways become more inflamed and narrow even further, sometimes leading to an 'asthma attack'.

Allergy to environmental substances is often referred to by the medical profession as 'atopy'. Most people with asthma are 'atopic', with one of the commonest triggers being dust. It is not actually the dust that causes the problem but the faeces of the tiny house dust mite that lives in the dust; these contain an irritant chemical which causes the inflammation within the airways of sensitive individuals. Another trigger that has recently been discovered is cockroach allergen. Like house dust mite allergen, it is an irritant chemical in the cockroach faeces that causes the reaction. Cockroach allergy is particularly common in overcrowded inner city areas and is one of the reasons that the number of cases of asthma in children in inner city areas is increasing⁴.

Although a lot of research has been done on the causes of asthma, it is still not completely clear why some people develop asthma and others do not. Inherited factors from your parents seem to play a large part in whether you develop asthma (genetic factors). If you have a parent with asthma, you are 2-3 times more likely to develop asthma yourself than someone whose parents do not have asthma. Early life factors (during the first 2-3 years after birth) also contribute to the likelihood of developing asthma. Babies exposed to cigarette smoke and damp conditions in the home are much more likely to develop asthma than those who live in smoke and damp free housing⁵.

What About Air Pollution?

There has been a lot of concern about current levels of air pollution over recent years. Research so far has not been able to clearly link the development of asthma with air pollution, although it is clear that those people who already have asthma have their symptoms made worse when air pollution levels are high⁶. Researchers from Birmingham have shown that living less than 500 metres from a main road makes it much more likely for young children to be admitted to hospital with asthma when compared to children who live further away from a main road⁷.

The symptoms of asthma can be very variable. Some people with asthma get very mild symptoms such as feeling slightly breathless when they exercise, when they go into dusty and smoky atmospheres or on cold 'crisp' mornings. Those people with more severe asthma get symptoms on most days and these include feeling breathless, a tight feeling in the chest and a troublesome cough, which is often worse at night-time or early in the morning. A few people are unable to work or do their normal daily activities properly because their asthma is so severe.

In 1995 and 1996 it is estimated that 18.3 million working days were lost in the UK due to asthma, costing £161 million in sickness benefit ⁸.

About one person in ten with asthma has severe symptoms that require regular monitoring and review by asthma specialists⁹.

All but the mildest cases of asthma are treated with inhalers. Inhalers are excellent devices as they get the asthma medications directly to the place where they are needed – the lungs!

People who have only occasional symptoms of breathlessness or difficulty breathing are usually given a 'reliever' inhaler. This is usually a drug called salbutamol and comes in a blue container. When salbutamol is inhaled into the lungs it works very quickly to relax the muscles in the airway walls and open them up to allow better flow of air in and out of the lungs. By widening the airway tubes the person with asthma can breathe more easily.

If you have to use your reliever inhaler more than once or twice a day your doctor will probably prescribe you a 'preventer' inhaler also, this is usually brown, red or orange in colour and works by decreasing the inflammation and irritation within the airways over a period of time. Preventer inhalers do not give immediate relief from symptoms, like relievers, but work over a period of days and weeks to control the irritation within the airways and make it less common for you to need your reliever inhaler. Preventer inhalers should be used every day, usually in the morning and the evening, even if you feel that your breathing is fine.

Using preventer inhalers in asthma is important as they keep you well by tackling the inflammation and irritation within the airways and prevent long term damage to the lungs. Reliever inhalers only treat the symptoms and do not treat airway inflammation.

What Type of Inhaler Should I Take?

There are many different inhaler devices available. The most commonly used one is the pressurized metered dose inhaler (pMDI). A small aerosol canister, which contains the drug, is pressed and delivers a 'puff' of drug, which can then be inhaled. pMDI inhalers are quite difficult to use efficiently, mainly because it is difficult to co-ordinate pressing the canister and breathing in at the appropriate time. Many people use a large volume spacing device that acts as a 'reservoir' for the expelled cloud of drug, the user can then breath it in without having to co-ordinate this process.

Breath activated inhalers are similar to pMDIs except the user does not have to press the canister to deliver the puff of drug. By breathing in through the mouthpiece of the inhaler a sensor triggers the puff at exactly the right time.

Dry powder inhalers are devices that contain the drug in powder form. The user puts the mouthpiece of the inhaler in their mouth and breathes in deeply. The powder in the inhaler is breathed into the lungs. There is some evidence that suggests these devices may be better at getting the drug into the lungs than pMDIs and also result in less side effects¹⁰.

Your doctor or the asthma nurse will be able to discuss different inhaler types with you. Together you will be able to work out which device is best suited to you and your needs.

What is a Nebuliser?

A nebuliser is a device that can deliver high doses (10-20 times the dose of reliever medication from one puff of a pMDI) of asthma medications through a face-mask or mouth piece. Nebulised reliever medications are often given to people with severe attacks of asthma who are too breathless to be able to use their reliever inhaler effectively. Liquid drug is placed in the reservoir of the nebuliser machine, when the power is switched on this liquid is converted into a fine mist that can then be breathed in. Some people with severe asthma have a nebuliser at home that they can use when their symptoms are bad. Care should be taken using a nebuliser at home as it can give a false sense of being well. If you use a nebuliser at home and you find that your symptoms are not being relieved as well as they normally are after use, then you should seek medical advice as this may mean that your asthma is not well controlled.

Most people with asthma only need nebulised treatment when they are unwell, and sometimes can use higher doses of drug using a spacer and pMDI. A study from Southampton showed that nebulised and pMDI-delivered relievers were both as effective in children with asthma attacks¹¹.

How Long Will it Take For My Preventer Inhaler to Work?

Once you start taking a preventer inhaler, it usually takes one to two weeks of taking it everyday before you start to notice an improvement in your asthma symptoms. It is important to realise that if you stop your preventer inhaler, it will also take about this long to notice that your asthma symptoms are getting worse. Commonly people stop taking their preventer inhaler because they feel so well and find that they stay well for a couple of weeks afterwards before getting worse again.

Preventer Inhalers Contain Steroids, is This Safe?

Preventer inhalers are steroid-based. As mentioned already, inhalers are excellent devices as they get the drug directly to the lungs where it is needed. The dose of steroid entering your body is small – thousands of times smaller than the amount of steroids some body builders and athletes take.

A lot of people are naturally concerned about taking steroid preparations of any kind. The steroid drugs in the preventer inhalers are very good at controlling the inflammation and irritation within the airways. Taking a steroid inhaler is almost certainly less harmful to you than running the risk of not having your asthma under good control and possibly ending up in hospital with a severe attack. If your asthma is not well controlled, you may develop a severe attack that will often require your doctor to put you on steroid tablets for a week or longer. One week of a steroid tablet course is equivalent in dose to about a year's worth of a moderate dose of an inhaled steroid.

If you are concerned about the risks of steroids in preventer inhalers, you should discuss this with your doctor.

Are There Any Side Effects from Taking Inhaled Steroids?

All drug treatments have some side effects. Commonly experienced side effects from using inhaled steroids are:

• Hoarse voice
• Thrush of the mouth and throat (a fungal infection caused by candida)
• Easy skin bruising
• Possibly thinning of the bones (osteoporosis) if taken at high doses for many years
• Possibly increased risk of developing cataracts of the eye if taken at high doses for many years
• Possibly slowing of growth in children if taken at high doses

To reduce the risk of side effects, it is recommended that people using steroid inhalers should wash their mouth out with water after using the inhaler. If you are using an aerosol inhaler, a spacer device reduces the likelihood of side effects by ensuring that more of the inhaled drug reaches the lungs, where it is needed, rather than being deposited on the back of the throat where it can be swallowed and enter the general circulation to cause side effects.

Other medications may need to be added to your treatment if your symptoms are particularly bad or not responding to the usual treatments. Asthma is treated in a 'step by step' fashion, increasing the dose and type of medications used until good control of asthma symptoms has been gained. In the UK these comprise the The British Thoracic Society Guidelines, also known as the 'stepwise approach':

• Step 1

  Occasional use of short acting relief bronchodilators, (b-agonists) such as Salbutamol or Albuterol

  If relief medications are needed more than once per day to control symptoms move to Step 2.

• Step 2

  Regular inhaled preventer therapy plus as required b-agonist

  Then either - Low dose inhaled corticosteroids (Beclomethasone or Budesonide at 100-400mg / twice daily, Fluticasone 50-200mg twice daily)

  Or - Cromolins (Nedocromil Sodium or Sodium Cromoglygate 3-4 times / day)

  If asthma symptoms not controlled move to Step 3.

• Step 3

  Either - High dose inhaled corticosteroids (Beclomethasone or Budesonide 800-2000mg / day, Fluticasone 400-1000mg / day)

  Or - Add long acting bronchodilator (Salmeterol 50mg or Formoterol 12mg twice daily) to low dose inhaled steroids¹², ¹³, ¹⁴.

  Or - Add slow release xanthine (Aminophylline SR 225mg bd)

  Or - Add Leukotriene modifying agent (Montelukast 10mg nocte or Zafirlukast 20mg bd)¹⁵

• Step 4

  High dose inhaled corticosteroids plus one or more of

  • Long acting bronchodilators
  • Xanthines
  • b-agonist tablets (eg Bambuterol)¹⁶
  • Anticholinergic agents (Ipratropium bromide)
  • Cromolins

• Step 5

  All of the preceding plus corticosteroid tablets

Long acting bronchodilators are drugs similar to those found in reliever inhalers but their effects last longer so they only need to be inhaled twice a day. They can be used with preventer inhalers and their use can often lead to your doctor being able to reduce the dose of your preventer inhaler. Research has suggested that adding a long acting bronchodilator treatment to low dose inhaled steroids (see Step 3 of stepwise approach to asthma treatment) actually may result in improved asthma symptoms and improved peak flow readings rather than just increasing the dose of inhaled steroid¹⁷, ¹⁸.

Bambuterol is a long acting bronchodilator that can be taken once a day. Research has shown that it is as effective as inhaled Salmeterol taken twice a day at controlling night-time symptoms and improving peak flow readings¹⁹. Side effects are similar to that of the other long acting bronchodilators.

The cromones are a group of drugs that include sodium cromoglycate and sodium nedocromil. They are taken by inhaler and work by decreasing the inflammation within the airways. These drugs are well tolerated and have no serious adverse effects, but they are less effective in treating asthma than inhaled steroids. The cromones tend to be most effective in patients with mild asthma, particularly in children. However, there is uncertainty about the degree of anti-inflammatory activity of the cromones, at least on the basis of bronchial biopsy studies. A drawback of treatment with cromones is that they have to be taken four times a day to give the best results²⁰.

The last couple of years has seen the development of a class of drug called 'leukotriene modifying agents'. These come as tablets and work to reduce the amount of a group of chemicals called leukotrienes in the lungs. Leukotrienes have been shown to be one of the chemicals responsible for the airway narrowing and irritation in asthma. Leukotriene modifying agents can be useful in keeping symptoms well controlled so as the dose of inhaled steroid can be reduced to lower levels²¹. Additionally they have been shown to be beneficial in asthma symptoms brought on by exercise²².

Theophylline is a drug that has been used for the treatment of asthma for over 50 years. Recent times has seen it fall out of favour as side effects such as nausea, vomiting and disturbances of heart rhythm are quite common. Recent research has shown that if it is tolerated it is still of value in treating asthma and gives as good improvements in peak flow measurements as increasing the dose of inhaled steroid²³.

Ipratropium bromide is a reliever drug that helps the relaxation of constricted airways. Some people with asthma find it useful but most find salbutamol is better at improving their symptoms. Side effects include dry mouth, constipation and rarely difficulty passing urine.

Steroid tablets are used to control symptoms in people with severe asthma (Step 5 of the stepwise approach to asthma treatment). Prednisolone is the most commonly used steroid tablet. It works by decreasing irritation and inflammation in the airways and by reducing the bodies reaction to trigger factors. Side effects from the prolonged use of steroid tablets can be quite severe, they include thinning of the bones (osteoporosis) and skin, weight gain (especially on the face) and diabetes. Because of these side effects doctors only use steroid tablets as a last resort in controlling asthma symptoms. Recent research has suggested that additional therapies such as methotrexate, cyclosporin A and gold can help reduce the dose of steroid tablet needed to give good asthma control in people with severe asthma.

Methotrexate is a drug that is sometimes used in the treatment of cancers. It works by dampening down the body's immune system (the complex system of blood and other cells that fight infections and keep us healthy). Although asthma is not the same as cancer, people with asthma have an over active immune reaction to allergen triggers causing inflammation and irritation within the airways. Methotrexate is sometimes used for the treatment of very severe asthma (Step 5 on the asthma treatment ladder) as a way of trying to reduce the amount of steroid tablets these people have to take. Because methotrexate affects the body's immune system people taking this drug for asthma control have to be seen in the hospital out-patient clinic regularly (usually at least once a month) and also have to have regular blood tests (once or twice a month) to check bone marrow, kidney and liver function²⁴.

Cyclosporin A is another drug that works suppresses the immune system. It is used in transplant surgery (kidney, bone marrow, liver and heart transplants) to prevent the body rejecting the transplant. Because of its effects on the immune system it has also been used in the treatment of severe asthma. Research has shown that in people with asthma who have to take daily steroid tablets cyclosporin A improves peak flow measurements and can help doctors reduce the dose of daily steroid tablets needed to keep symptoms controlled²⁵, ²⁶.

Side effects from Cyclosporin treatment include increased hair growth on the face, high blood pressure, burning sensation in hands and feet, sickness and swelling of the gums.

Gold can be used to treat severe asthma. It can be given in tablet form or as an injection and has been shown to help with reducing the steroid tablet dose of people with severe asthma²⁷. Side effects from gold treatment include mouth ulcers, skin rashes, drug treatment and lung scarring (fibrosis).

Conventional medical treatments have been shown to be very effective at controlling symptoms in the large majority of people with asthma, however there are some people who find that inhaled medicines don't work very well for them or that they just don't want to take inhalers or tablets on a long term basis. A research study from Australia showed that almost half of asthmatic families had consulted an alternative-medicine practitioner, with the most popular alternative treatments being chiropractic, homeopathy and acupuncture²⁸. There are many complimentary/alternative therapies that claim to be effective in controlling the symptoms of asthma but very few have undergone well performed research to determine whether they are of any real benefit over and above conventional medical therapy.

Buteyko Breathing Technique

This is a therapy that uses methods to control overbreathing (hyperventilation) and improve symptoms of asthma. Buteyko practitioners believe that asthma is caused by hyperventilation which results in decreased levels of the waste gas carbon dioxide within the lungs. The technique trains people to control their breathing patterns and hold there breath for longer and longer periods of time.

A research study done in Australia with 39 people with asthma showed that using the Buteyko Breathing Technique for three months enabled a clear reduction in the use of reliever and preventer medications and a reduction in hyperventilation²⁹.

Homeopathy

Homeopathy is based on the belief that people with particular signs and symptoms of illness can be cured if given a drug that produces the same effects in healthy individuals and that remedies retain their effect if they are repeatedly diluted and shaken between each dilution. Homeopathic remedies in asthma are very dilute solutions of things that cause asthma. A recent review of all of the well conducted research work on homeopathy has shown that homeopathic remedies for a variety of illnesses and ailments produces clear improvements in general well-being, this is particularly the case for allergies such as hay fever and asthma³⁰.

Acupuncture

Acupuncture is a treatment that started in China several thousand years ago. Acupuncture needles stimulate the nerves in skin and muscle, and it is claimed can produce a variety of effects including increases in the body's release of natural painkillers, endorphins.

Research into the use of acupuncture in asthma has not given any clear results. One study showed that of 23 people with asthma given acupuncture there was no improvement in peak flow but there was a clear improvement in general well-being and a reduction in the use of reliever medication³¹. In another study of 25 people with asthma there was no improvement seen symptoms, use of medications or lung function³².

The Cochrane Collaboration, an independent research organisation, has recently conducted a review of all of the published research on acupuncture in asthma and stated that at present there is not enough evidence to indicate that short term (1-12 weeks) acupuncture treatment has a significant effect on asthma and further well conducted research is needed³³.

Chiropractic

Chiropractic is the manipulation of the spine. It can be used in relieving back pain, however some chiropractic practitioners believe that it can be useful in the treatment of asthma by correcting out of line bones in the back (vertebrae) and improving the nerve and muscle function of the chest and improving breathing. A research study from the USA and Canada on 91 children with asthma who either had chiropractic for 4 months or 'dummy' (placebo) chiropractic (manipulation of the spine that was not done by a chiropractor). There were no differences in peak flow, reliever or preventer medication use or symptoms in the two groups³⁴.

Alexander Technique

The Alexander technique was originally developed by an Australian, FM Alexander, in the early years of the 20th Century. The Alexander Technique is a type of physical therapy involving movements aimed to correct posture and bring the body into natural alignment. The purpose of the Alexander technique is to help the body to function efficiently. The Alexander Technique has to be taught and requires practice, it does not involve physical exercise and many Alexander Technique practitioners prefer to use the term 'breathing education'. A research study looking at the effect of the Alexander Technique on healthy people without asthma showed a 9% improvement in peak flow after 20 weekly sessions³⁵.

Immunotherapy

Strictly speaking immunotherapy is not an alternative medical therapy. Immunotherapy is popular in the USA and also some parts of Europe and is used to treat a variety of allergies. Injections of allergen solution are given every two to three weeks. The strength (concentration) of allergen solution is increased on each visit with the aim of making the person less sensitive to the allergens in the solution and so making their allergy better.

A review of 20 research trials of using immunotherapy in asthma showed clear improvements in asthma symptoms and reduction in the use of reliever inhalers. However, a study of immunotherapy in children in the USA did not show any significant improvement in these areas³⁶, ³⁷. It is therefore not clear what role immunotherapy has in the treatment of asthma at the present time but it may be of benefit to some people.

Many people with mild asthma remain well with little or no treatment. However if you find that you are getting asthma symptoms most days then you run the risk of getting very unwell and possibly needing hospital admission. Every year there are still a few people who die from severe asthma attacks. This is, however, fortunately rare.

Why don't you try this asthma severity questionnaire and calculator to assess the severity of your symptoms:

• Are you troubled by shortness of breath when hurrying on level ground or walking up a slight hill? If yes...

• Do you feel short of breath walking with other people of your own age on level ground? If yes...

• Do you have to stop for breath when walking at your own pace on level ground?

• How many times a day do you need to take your reliever (blue) inhaler? Do you find that going into dusty and smoky atmospheres makes you cough and feel breathless?

• Do you wake at night coughing or short of breath?

• Does your chest feel tight first thing in the morning or in cold weather?

• Have you had to have a course of steroid tablets in the last year?

• Have you been in hospital because of your asthma in the last year?

• Have you ever been admitted to the intensive care unit of a hospital because of your asthma?

Each of these questions are scored and asthma severity graded³⁸, ³⁹, ⁴⁰ .

There are many things you can do that may improve your asthma. The first, and probably most important is if you are a smoker to try and give this up. Cigarette smoke irritates the airways within the lungs and makes it much less likely that the drug therapy for your asthma will work effectively.

There is debate about whether allergen avoidance is helpful in improving asthma symptoms⁴¹, ⁴² but it is probably useful to make sure that your house or flat is cleaned regularly. If possible get someone else to clean it for you so you don't get exposed to lots of dust during the cleaning process. Use a damp cloth when cleaning as this prevents dust clouds. Vacuum all of the carpets and beds once a week. House dust mites love mattresses and pillows, if these are old it may be worth considering buying new ones. If at all possible get pillows that have synthetic or man made filling, not feathers or down as some people are allergic to these. Special covers for mattresses, duvets and pillows are available that can reduce your exposure to dust and the house dust mite whilst sleeping in your bed.

Give your house or flat a good airing at least once a week. Open all of the windows and renew the air. Modern houses with double glazing trap many allergens and pollutants inside. Do not leave food out as this can encourage cockroaches.

Painful as it may seem, if you are allergic to your cat or any other pet it may be necessary to find them another home if your asthma symptoms are to improve. You will need to speak to your doctor or the asthma nurse at the hospital about this (see below). If you are unable to avoid having a pet in the house make sure they aren't allowed into the bedroom.

If your child has asthma putting all soft and furry toys into the freezer for about an hour once a month kills off the house dust mites and reduces your child's exposure to high levels of this trigger factor for their asthma.

Some children find that their asthma symptoms get better as they get older. They find that they don't need to take their preventer inhalers anymore and only get wheezy and tight chested when they get a severe cold or 'flu like illness.

At the present time there is no way of predicting which children will get better as they get older. We do not recommend stopping your or your child's preventer inhaler without first consulting your doctor.

... But have developed them now, why is this? Some people develop asthma in later life (40 years old and above) and this is commonly referred to by doctors as late onset asthma. The reason for this still remains unclear. Often no significant trigger factors can be found and it can be difficult to treat effectively. Late onset asthma affects women more than men.

Most cases of asthma are treated by family doctors (general practitioners), only those with more severe asthma or in whom the diagnosis is uncertain are seen in hospital. If your family doctor wants you to be seen in hospital by a specialist (consultant) he will either phone or write a letter so as an appointment can be made for you. You should receive an appointment in the post telling you at which hospital and when your appointment is, this can take a few weeks.

When you are seen in the hospital clinic there will probably be a few things that need doing when you arrive before you get to see the specialist. Usually a nurse will weigh you and may arrange for you to have a chest X-ray. You may see the consultant or possibly one of his understudies, the registrar. The doctor will ask you questions about your illness and then will probably want to examine you and in particular listen to your chest.

The doctor will probably want you to do some blowing tests whilst in the clinic room. He will ask you to blow into a special device called a peak flow meter, which measures how much and how fast you can blow out. He may also arrange for you to have some blood tests and may book an appointment to see the respiratory nurse (the specialist nurse who deals with asthma and other lung conditions).

A peak flow meter is a small hand held device that you blow into. It measures how fast you can blow out. The reading gives a good indication of how inflamed and narrowed your airways are. What your peak flow reading should be depends on how old and how tall you are.

Measuring your peak flow daily can give you advance warning of when your asthma is getting worse as it tends to fall a day or two before you start to notice that your asthma symptoms are worse. Knowing your best peak flow reading (when you are well) is important because when it drops you can make decisions about what extra treatment you need to prevent a mild attack turning into a severe attack (see below Can I Manage My Asthma Myself?)

To use a peak flow meter properly take as deep a breath in as you possibly can. Put your lips around the mouthpiece and blow out as fast as you can. The blowing out does not have to be for a long time but needs to be fast and quick.

Going to see a doctor can often be quite stressful. Many people find that when they get out of the clinic room they can't remember many things that were talked about and often have forgotten to ask certain questions that they wanted to. It may be worth writing down the questions that you want to ask on a piece of paper beforehand with the most important questions at the top to act as a reminder for you.

Here is a list of some questions you may want to ask the doctor who sees you about your asthma (some of them may not be relevant to you):

• Are you a specialist in chest diseases?
• Have I got asthma?
• What treatment should I take?
• How long will I need to be on treatment for?
• How long will it take for the treatment to work?
• What side effects do the treatments have?
• How can I check that my asthma is under control?
• Will my breathing get worse?
• If my breathing gets worse when should I call a doctor?
• If I do need to contact a doctor who should I call?
• Should I have allergy tests?
• Is there anything I can do to make my symptoms better?
• Is there anything I should not do?
• Is it possible that my breathing problems are due to my smoking in the past?
• Will I be able to use alternative/complimentary therapies as well?

Many people live with asthma everyday. As already discussed, how asthma affects your life depends on how severely it affects you. Your family, close friends, and possibly carers, need to know that you have asthma, that probably means that you will have to tell them. They need to know that there will be days when your asthma is well controlled and days when it is less well controlled. They will need to be taught, along with you to recognise the signs that your asthma is getting worse and what to do if this happens.

Shared decision making between doctors, nurses and people with asthma is important. About three quarters of asthma admissions to hospital could be avoided if there was clear communication between medical staff and people with asthma. Most people with asthma get a gradual deterioration in their symptoms over a few days or even weeks, and it is at this stage that it is important to know exactly what to do and when to get help.

Many doctor's practices and hospital asthma clinics run 'guided self management' plans for people with asthma. In order to be able to take part in asthma self management plans it is important that you can recognise the warning signs of worsening asthma (an asthma exacerbation), these include:

• Increased breathlessness
• Increased wheeze, cough and phlegm (mucous) production
• Symptoms of asthma at night-time
• Increased use of reliever inhalers
• Increased symptoms of asthma when exerting yourself

A key part of an asthma self management plan is recording your peak flow every day, preferably both in the morning and evening. You should also know what your best peak flow measurement is when you are well because this is the base-line value that is used to work out how bad your asthma is at a given time.

Below is an example of a personal asthma self management plan based on peak flow measurements⁴³.

Asthma under control Peak Flow greater than 85% of personal best value
No extra treatment needed.

Asthma getting worse Peak flow between 70% and 85% of personal best
Double the dose of inhaled steroids (eg If you normally take two puffs of Becloforte twice a day increase this to four puffs twice a day.

Asthma severe Peak flow between 50% and 70% of personal best
Start course of steroid tablets and contact your doctor.

Asthma emergency Peak flow less than 50% of personal best
Go to hospital accident and emergency department immediately.

If you feel that your asthma is significantly worse than normal you should seek medical help. Certainly if you are having difficulty sleeping at night because you are coughing or feeling breathless or if you are having difficulty doing everyday tasks that you normally wouldn't have any problems with. If you are having difficulty speaking in full sentences due to feeling breathless then you should definitely go straight to casualty.

There are a number of patient and carer support organisations that specialise in asthma and other breathing conditions. Below is a list of organisations and contact details.

National Asthma Campaign
Providence House
Providence Place
London
N1 0NT
Tel 020 7226 2260
Fax 020 7704 0740
Asthma Helpline 0845-7010203
Website The National Asthma Campaign

British Lung Foundation
78 Hatton Garden
London
EC1N 8LD
Tel 020 7831 5831
Fax 020 7831 5832
Website British Lung Foundation

European Federation of Asthma and Allergy Associations
EFA Central Office
Kyviksvägen 71
S-42931 Kullavik
Sweden
Tel +46 319 30536
Fax +46 319 30557
Website EFAnet

British Thoracic Society
6th Floor
North Wing
New Garden House
78 Hatton Garden
London EC1N 8LD
Website British Thoracic Society

British Allergy Foundation
Deepdene House
30 Bellegrove Road
Welling
Kent
DA16 3PY
Tel 0208 303 8525
Fax 0208 181 303 8792
Website British Allergy Foundation

Healthline provides a very comprehensive overview of COPD as a critical starting point for individuals and/or their loved ones.
For more information, visit their website Healthline