Asthma is a disease of the airways in the lungs. Its symptoms are caused by inflammation, which makes the airways swollen, narrower and extra-sensitive to irritants. This leads to recurrent attacks of wheezing, breathlessness, chest tightness and coughing. Mild attacks can settle down without treatment, but treatment usually helps them resolve more quickly. Appropriate treatment can also reduce the risk of further attacks. If you experience a serious attack you should seek emergency help.

Who gets asthma?

What is asthma?

Asthma is a disease of the airways in the lungs. Its symptoms are caused by inflammation, which makes the airways swollen, narrower and extra-sensitive to irritants. This leads to recurrent attacks of wheezing, breathlessness, chest tightness and coughing. Mild attacks can settle down without treatment, but treatment usually helps them resolve more quickly. Appropriate treatment can also reduce the risk of further attacks. If you experience a serious attack you should seek emergency help.

Asthma is a long-term (chronic) disease. Your asthma does not stay the same, but changes over time, and every person with asthma has good and bad days (or longer periods of time).

Asthma is very common. Around one out of every ten people in the western world develops asthma at some stage in their life.

What is inflammation in the airways?

Inflammation is a reaction to infections and other triggers in the lining of the airways and the underlying tissue. The inflammation makes the airways become swollen, narrower and extra-sensitive.

How does inflammation of the airways affect my asthma?

Inflammation of the airways causes asthma symptoms (wheezing, breathlessness, chest tightness and coughing) by restricting or limiting the airflow to and from the lungs. It does this by causing:

• swelling of the airways, which makes them narrower
• tightening of the muscles that surround the airways (also called bronchoconstriction), which makes them even narrower
• the production of too much mucus, which can ‘plug up’ or block the airways
• longer-term damage to the walls of the airways, which prevents them from opening as widely as a normal airway.

When the airways have been inflamed for a long time, they become extra-sensitive. This means that they react faster and more strongly to various triggers, such as allergens, viruses, dust, smoke and stress.

Who gets asthma?

Asthma tends to run in families, which means that you are more likely to develop asthma if someone in your family already has it. Children with eczema or food allergy are more likely than other children to develop asthma.

Allergy to pollen, house dust mites or pets also increases your chance of developing asthma. Exposure to tobacco smoke, air pollution or other inhaled irritants can also cause asthma symptoms in those with an underlying tendency to asthma.

At what age does asthma start?

Asthma can start at any age, although about half of all people with asthma have had their first symptoms by the age of 10, and many children with asthma have had their first asthma attack before the age of 6.

What causes asthma?

The causes of asthma are not fully understood. Asthma is probably usually caused by a mixture of hereditary factors (those you are born with) and environmental factors, but how these factors work together is still largely unknown.

Allergens from house dust mites and pets are the most common causes, but many other allergens, such as pollen and moulds, can cause asthma. Some patients with asthma have no obvious allergies.

Is asthma a chronic disease?

Yes. Asthma is a chronic (long-term) disease that causes inflammation and narrowing of the airways. Some degree of inflammation is usually present, even at times when you are unaware of any symptoms.

If your asthma is untreated, you will have repeated attacks of asthma symptoms.

Mild attacks can settle down without treatment, but treatment usually helps them to resolve more quickly. Appropriate treatment can also reduce the risk of further attacks. If you experience a serious attack you should seek emergency help.

Your asthma does not stay the same, but changes over time, and every person with asthma has good and bad days (or longer periods of time). However, if asthma is properly treated, you may enjoy long periods without symptoms or attacks.

Is there a risk that my asthma will get worse with age?

Yes, that risk cannot be disregarded. Poorly treated asthma gets worse with age, and the lungs of people with untreated asthma function less well than those of non-asthmatic individuals. Modern asthma treatments have not been available for long enough for us to be certain whether or not lung function will still deteriorate in people with treated asthma as they grow older. However, most asthma doctors think that regular, preventive asthma treatment can prevent your asthma from getting worse and help to preserve your lung function.

Is it worse getting asthma when you are old?

Not necessarily, but asthma is often more severe if it starts at an older age. In addition, an older person with heart disease or other medical problems may have more difficulty in coping with an asthma attack than a younger person.

What is called ‘asthma’ in elderly people is sometimes actually chronic obstructive pulmonary disease (COPD). COPD is a collective name for chronic bronchitis and emphysema, two diseases that are commonly associated with smoking. Many of the symptoms of COPD are similar to those of asthma (e.g. breathlessness, wheezing, production of too much mucus, coughing). COPD is generally a more serious disease than asthma, because the changes in the airways are much more difficult to treat, and it usually has a worse outcome. Unfortunately, COPD can cause greater long-term disability and have a greater effect on the heart and other organ systems than asthma.

What does asthma feel like?

Asthma symptoms typically ‘come and go’. You may have trouble breathing, your chest feels tight and you can hear wheezing when you breathe or cough. These symptoms often occur during exercise or during the night.

An ‘asthma attack’ is when your symptoms rapidly become more severe, usually rather suddenly. During an asthma attack, you have more trouble breathing.

You may get used to the asthma symptoms and not realise that your airflow is impaired and could be improved by treatment.

When your asthma is under good control, the airways are clear and air flows easily in and out.

What happens during an asthma attack?

When asthma is not under control, the airways become inflamed. Inflammation of the airways causes asthma symptoms (wheezing, breathlessness, chest tightness and coughing) by restricting or limiting the airflow to and from the lungs.

• The airways become red and swollen, which makes them narrower. This can often take several hours or days to develop and may take just as long to reverse after the asthma attack has passed.
• Tightening of the muscles that surround the airways (also called bronchoconstriction) makes the airways even narrower. This tightening can happen very quickly, depending on the type of trigger and underlying inflammation.
• The airways make more mucus, which can ‘plug up’ or partly block the airways.

Attacks can range from mild to severe.

What causes an asthma attack?

Some causes and triggers are common to all people with asthma, and some are more individual, especially with allergens. There are very big differences between people in how readily and how severely they react to different triggers. The severity of the symptoms can differ in the same person at different times, and the effects of treatment can also vary.

Your asthma does not stay the same, but changes over time, and every person with asthma has good days and bad days (or longer periods). However, if asthma is properly treated, there can also be long periods without symptoms or attacks.

A number of different triggers can cause asthma symptoms or start an asthma attack:

• infections, usually those caused by a virus (e.g. colds or flu)
• exercise, especially in cold weather
• emotions, such as excitement, fear or anger
• irritants, such as air pollution
• smoking – people with asthma and the parents of asthmatic children should avoid smoking
• changes in the weather (e.g. a cold spell)
• food additives, such as tartrazine (an artificial food colouring), or food allergens, such as peanuts (sensitized or allergic individuals can have a very severe allergic reaction).
• certain medications – some people may be allergic to some drugs (e.g. aspirin).

What are the signs of a severe and dangerous asthma attack?

• Symptoms that are rapidly becoming more severe and do not get better even after you take your reliever (bronchodilator) medication
• Symptoms that do not improve at all, or rapidly return after you have taken your reliever medication
• Difficulty talking because you are short of breath
• A peak flow reading below 50% of your normal value, which is not improved by the reliever medication
• A peak flow reading that – according to your Asthma Management Plan – puts you at risk of an asthma attack

Can a person die from asthma?

Unfortunately, deaths still occur in acute, severe asthma. But this is unusual and can be prevented.

Most asthma deaths occur in people who have not received enough treatment, perhaps because they did not realize or did not want to admit how serious their asthma was, or because they had not received adequate treatment guidance.

The correct use of controlling and preventive medication is the key to preventing these tragedies. People with asthma sometimes forget or choose not to take their anti-inflammatory medication, especially during periods when they are feeling well. When they start to get symptoms of asthma, they increase the dose of reliever (bronchodilator). However, this will not treat the underlying inflammation, which may lead to severe life-threatening attacks. If you have stopped taking your anti-inflammatory medication, you should re-start it at the first sign of symptoms of asthma, in addition to using a reliever.

If you are using regular inhaled corticosteroid treatment, you should not stop using this at any time unless you have discussed this with your doctor first.

Why do I lose my breath?

You lose your breath during an asthma attack because the airways become narrow, which restricts or limits the airflow to and from the lungs. The airways become restricted because:

• The lining of the airways becomes inflamed
• The production of mucus (phlegm) increases and may block the airways
• The muscles in the walls of the airways tighten

During an asthma attack, all of these things happen to different degrees.

You can also lose your breath for other reasons than asthma, for example during physical exercise, especially if you are not in good shape. If you lose your breath without typical asthma symptoms, and if your asthma medication has no effect, you should see your doctor.

How do I know if I am having an asthma attack?

During an asthma attack, you will find it harder to breathe because your airways have become narrower. Your chest feels tight, and you can hear wheezing when you breathe or cough. You may feel as if you are trying to breathe through a straw in your mouth while holding your nose.

If the peak expiratory flow rate (PEFR) value drops to half of the usual level, it’s time to seek emergency help.

Can the peak flow meter tell me if I need to see the doctor?

If you take peak flow readings regularly or know the reading you get when your asthma is well controlled then, as a general rule, if the reading falls to less than two-thirds of the usual level, it is time to be cautious and to increase the amount of medication. A reading that is less than half the usual level often indicates the need for immediate help, but this varies from person to person.

It is best if you and your doctor together set a personal peak flow reading that indicates when it is time for you to increase the dose of medication or seek acute help. This should be combined with a written treatment plan for your medications.

It is important to realize that your treatment should not be entirely determined by your peak flow readings. Whenever the usual treatment does not have the effect you wish on control of your asthma you should discuss this with your doctor, regardless of the peak flow reading.

Can asthma medication help prevent asthma symptoms?

Yes. Asthma medications include very effective airway openers. Even more importantly, they include very effective preventers (inhaled steroids), which can prevent most asthma attacks when used regularly.

What causes asthma?

The causes of asthma are not fully understood. Its symptoms are caused by inflammation, which makes the airways swollen, narrower and extra-sensitive to irritants. Asthma is probably usually caused by a mixture of hereditary factors (those you are born with) and environmental factors, but how these factors work together is still largely unknown.

Allergens from house dust mites and pets are the most common causes, but many other allergens, such as pollen and moulds, can cause asthma. Some people with asthma have no obvious allergies.

What causes asthma symptoms or an asthma attack?

Some causes of symptoms (triggers) are common to all people with asthma, and some are more individual, especially allergens. There are very big differences between people in how easily and how severely they react. The severity of the symptoms or an attack can differ in the same person at different times, and treatment can also be more or less effective.

Your asthma does not stay the same, but changes over time, and every person with asthma has good days and bad days (or longer periods). However, if asthma is properly treated, there can also be long periods without symptoms or attacks.

What are asthma triggers?

Asthma triggers are factors that start asthma symptoms or an asthma attack by irritating the airways or worsening the inflammation in the airways. These triggers can provoke attacks in individuals who already have a tendency to asthma, but they are not necessarily part of the cause of that tendency. The following triggers can cause asthma symptoms or start an asthma attack:

• infections, usually those caused by a virus (e.g. colds or flu)
• allergens, most commonly from house dust mites, pets or pollen
• exercise, especially in cold weather
• emotions, such as excitement, fear or anger
• irritants, such as air pollution
• smoking – people with asthma and the parents of asthmatic children should avoid smoking
• changes in the weather (e.g. a cold spell)
• food additives, such as tartrazine (an artificial food colouring), or food allergens, such as peanuts (sensitised or allergic individuals can have a very severe allergic reaction).
• certain medications – some people may be allergic to some drugs (e.g. aspirin).

What are the main asthma triggers?

Different triggers can start an asthma attack and people differ a lot in how easily and how severely they react.

Some triggers (also called ‘inciters’) only cause tightening of the airways (bronchoconstriction) that lasts for just a short time. These triggers include:

• exercise
• cigarette smoke
• changes in air temperature
• laughing
• strong smells

Other triggers (also called ‘inducers’) also increase the underlying inflammation of the airways, and may have longer-term effects. Such triggers include:

• allergens (e.g. pets, house dust mites and pollen)
• infections (e.g. colds, flu)
• certain chemicals

What chemicals, irritants or other substances trigger asthma?

Many irritating particles or chemicals in the air can trigger an asthma attack. Examples include:

• cigarette smoke
• diesel exhaust
• perfume or other strong scents
• household sprays
• sulphur dioxide
• grain or flour dust
• sawdust

However, there are very big differences between people in how easily and how severely they react. This depends on the severity of the asthma and how well it is treated.

Can medications trigger asthma?

Only a few medications can trigger asthma. Check with your doctor or pharmacist before starting any new medicine. And if your asthma symptoms are worse after starting a new medication, you should see your doctor immediately.

The most common medicines that can trigger asthma are:

• aspirin (acetylsalicylic acid) and certain other NSAID (non-steroidal anti-inflammatory) drugs, which are used as pain relievers, and to treat arthritis and inflammatory conditions
• beta-blockers, which are used to treat high blood pressure, heart conditions, migraine or anxiety

Not all patients with asthma react to aspirin or NSAIDs, so some people with asthma can use these drugs. However, beta-blockers are likely to cause asthma symptoms in all patients with asthma and should always be avoided.

Can weather changes trigger asthma?

Yes, sudden weather changes (e.g. cold winds, humidity and storms) can trigger asthma in some people. Some of these sudden changes can cause the release of allergens, such as pollen, that can make asthma worse in people whose asthma is allergy-related. Cold air can also have a direct irritant effect on inflamed airways.

Can infections trigger asthma?

Yes, viral respiratory infections, such as colds or flu, can trigger asthma symptoms, particularly in children. Try to avoid contact with people if you know they have a respiratory infection.

Can an allergic reaction trigger asthma?

Yes. Once you are sensitised or allergic, both indoor and outdoor allergens can cause asthma symptoms and attacks, as well as other allergic symptoms such as sneezing or a runny nose. It is therefore important to consider whether your asthma is caused or worsened by allergens.

Exposure to even small amounts of airborne allergens can cause asthma symptoms. Repeated exposure may not only provoke symptoms, but may also be a cause of long-term (chronic) inflammation in the airways.

Proper advice about which allergens and environments you should avoid can only be given after talking to your doctor and often after you have been tested for allergies.

Is asthma a psychological (psychosomatic) disease?

No, asthma is not a psychological condition, it is a long-term (chronic) inflammatory disease that leads to extra-sensitive and easily irritated airways, especially when it is not properly treated.

Although asthma is not a psychological condition, emotional stress can trigger the symptoms. For example, financial problems, not enjoying your work or worrying about your family can all help to trigger symptoms if you already have asthma.

Why is it sometimes so hard to know what triggers an asthma attack?

People with allergic asthma can often easily identify the most common trigger factor(s) for their asthma (e.g. pets or pollen). But many people with untreated or under-treated asthma have an underlying airway inflammation that they are hardly aware of. These people will react easily to many irritants, allergens and infections, and it can be difficult to identify the most important one.

If your asthma is provoked by more than one trigger at the same time, the reaction can be stronger than if you are only exposed to one trigger. For example, an airway infection may cause you to react to stimuli that you normally would not react to. This is why triggers such as physical exercise, strong smells, plants, chemicals, smoke, weather changes, anxiety, stress and some medications can sometimes cause an asthma attack and sometimes cause no symptoms.

Why does my asthma get worse when I am upset or worried about something?

Not all people with asthma feel worse when they are upset or worried. Those who do may be easily stressed, or may cry or breathe too fast (hyperventilate) easily.

Another reason that your asthma gets worse could be that you are not being treated properly for the inflammation you have in your airways.

Why do I not react when I meet my neighbour’s dog outdoors, although I react indoors?

A person with allergic asthma can be exposed to a certain amount of the allergen without reacting. In most cases, the concentration of allergens (except pollen) will be higher indoors than outdoors. You may also be exposed to higher levels of other allergens indoors, making the level of total allergens higher than what you can tolerate.

Can I really get asthma symptoms from a plastic Christmas tree?

Yes, you could if you had asthma symptoms from real Christmas trees in the past (though this is not a common allergy)! This phenomenon is called a ‘conditioned reflex’ – the same thing that causes your mouth to water when you see a picture of delicious food.

What does asthma feel like?

Asthma symptoms typically ‘come and go’. You may have trouble breathing, your chest feels tight and you can hear wheezing when you breathe or cough. These symptoms often occur during exercise or during the night.

An ‘asthma attack’ is when your symptoms rapidly become more severe, usually rather suddenly. During an asthma attack, you have more trouble breathing.

You may get used to the asthma symptoms and not realise that your airflow is impaired and could be improved by treatment.

When your asthma is under good control, the airways are clear and air flows easily in and out.

What happens during an asthma attack?

When asthma is not under control, the airways become inflamed. Inflammation of the airways causes asthma symptoms (wheezing, breathlessness, chest tightness and coughing) by restricting or limiting the airflow to and from the lungs.

• The airways become red and swollen, which makes them narrower. This can often take several hours or days to develop and may take just as long to reverse after the asthma attack has passed.
• Tightening of the muscles that surround the airways (also called bronchoconstriction) makes the airways even narrower. This tightening can happen very quickly, depending on the type of trigger and underlying inflammation.
• The airways make more mucus, which can ‘plug up’ or partly block the airways.

Attacks can range from mild to severe.

What causes an asthma attack?

Some causes and triggers are common to all people with asthma, and some are more individual, especially with allergens. There are very big differences between people in how readily and how severely they react to different triggers. The severity of the symptoms can differ in the same person at different times, and the effects of treatment can also vary.

Your asthma does not stay the same, but changes over time, and every person with asthma has good days and bad days (or longer periods). However, if asthma is properly treated, there can also be long periods without symptoms or attacks.

A number of different triggers can cause asthma symptoms or start an asthma attack:

• infections, usually those caused by a virus (e.g. colds or flu)
• exercise, especially in cold weather
• emotions, such as excitement, fear or anger
• irritants, such as air pollution
• smoking – people with asthma and the parents of asthmatic children should avoid smoking
• changes in the weather (e.g. a cold spell)
• food additives, such as tartrazine (an artificial food colouring), or food allergens, such as peanuts (sensitized or allergic individuals can have a very severe allergic reaction).
• certain medications – some people may be allergic to some drugs (e.g. aspirin).

What are the signs of a severe and dangerous asthma attack?

• Symptoms that are rapidly becoming more severe and do not get better even after you take your reliever (bronchodilator) medication
• Symptoms that do not improve at all, or rapidly return after you have taken your reliever medication
• Difficulty talking because you are short of breath
• A peak flow reading below 50% of your normal value, which is not improved by the reliever medication
• A peak flow reading that – according to your Asthma Management Plan – puts you at risk of an asthma attack

Can a person die from asthma?

Unfortunately, deaths still occur in acute, severe asthma. But this is unusual and can be prevented.

Most asthma deaths occur in people who have not received enough treatment, perhaps because they did not realize or did not want to admit how serious their asthma was, or because they had not received adequate treatment guidance.

The correct use of controlling and preventive medication is the key to preventing these tragedies. People with asthma sometimes forget or choose not to take their anti-inflammatory medication, especially during periods when they are feeling well. When they start to get symptoms of asthma, they increase the dose of reliever (bronchodilator). However, this will not treat the underlying inflammation, which may lead to severe life-threatening attacks. If you have stopped taking your anti-inflammatory medication, you should re-start it at the first sign of symptoms of asthma, in addition to using an reliever.

If you are using regular inhaled corticosteroid treatment, you should not stop using this at any time unless you have discussed this with your doctor first.

Why do I lose my breath?

You lose your breath during an asthma attack because the airways become narrow, which restricts or limits the airflow to and from the lungs. The airways become restricted because:

• The lining of the airways becomes inflamed
• The production of mucus (phlegm) increases and may block the airways
• The muscles in the walls of the airways tighten

During an asthma attack, all of these things happen to different degrees.

You can also lose your breath for other reasons than asthma, for example during physical exercise, especially if you are not in good shape. If you lose your breath without typical asthma symptoms, and if your asthma medication has no effect, you should see your doctor.

How do I know if I am having an asthma attack?

During an asthma attack, you will find it harder to breathe because your airways have become narrower. Your chest feels tight, and you can hear wheezing when you breathe or cough. You may feel as if you are trying to breathe through a straw in your mouth while holding your nose.

If the peak expiratory flow rate(PEFR) value drops to half of the usual level, it’s time to seek emergency help.

Can the peak flow meter tell me if I need to see the doctor?

If you take peak flow readings regularly or know the reading you get when your asthma is well controlled then, as a general rule, if the reading falls to less than two-thirds of the usual level, it is time to be cautious and to increase the amount of medication. A reading that is less than half the usual level often indicates the need for immediate help, but this varies from person to person.

It is best if you and your doctor together set a personal peak flow reading that indicates when it is time for you to increase the dose of medication or seek acute help. This should be combined with a written treatment plan for your medications.

It is important to realize that your treatment should not be entirely determined by your peak flow readings. Whenever the usual treatment does not have the effect you wish on control of your asthma you should discuss this with your doctor, regardless of the peak flow reading.

Can asthma medication help prevent asthma symptoms?

Yes. Asthma medications include very effective relievers. Even more importantly, they include very effective preventers (inhaled steroids), which can prevent most asthma attacks when used regularly.

What are “preventers”?

Preventers are medicines that prevent asthma attacks from starting. The most common type of preventer medicines are anti-inflammatory medicines.

Anti-inflammatory medicines work by reducing the inflammation in the airways that occurs in asthma. The most effective and most commonly used anti-inflammatory medicines are inhaled corticosteroids, such as budesonide, beclomethasone and fluticasone. These medicines help to prevent periods of greater severity of asthma if you take them regularly as instructed by your doctor (usually once or twice every day), and they may relieve you of your symptoms completely for most of the time. If your doctor gives you an inhaled corticosteroid you must take it regularly, even if you are not wheezing.

If the inflammation is not controlled, the airways become swollen, narrower and extra-sensitive. Some degree of inflammation is usually present in your lungs, even when you are unaware of symptoms, and worsening of the inflammation may lead you to feel an attack coming on.

What are “relievers”?

Relievers – or airway openers – are medicines that provide rapid relief from an asthma attack by quickly opening up the narrowed airways (dilating the bronchi). They do this by relaxing the muscles surrounding the airways, and are known to doctors and other health professionals as bronchodilators or ß2-agonists.

There are two types of airway openers – short-acting bronchodilators and long-acting bronchodilators. The most widely used short- and quick-acting airway opener is salbutamol (also known as albuterol) and terbutaline.

What are “controllers”?

Controllers, which are also known as long-acting airway openers, are medicines that help to prevent attacks progressing by opening up the narrowed airways. They do this by relaxing the muscles surrounding the airways. Most airway openers only have a short-term effect and should not be used regularly as controllers. Long-acting airway openers, including eformoterol and salmeterol, are effective as controllers when they are used regularly with an inhaled corticosteroid. However, they should not be used regularly on their own as they do not treat the underlying inflammation and their effect on the symptoms of asthma could even hide the fact that it is getting worse.

Salmeterol is a long-acting airway opener that has a slower action, so it is used for longer-term control, but not for the quick relief of symptoms. Eformoterol is a long-acting airway opener that is also quick-acting, so it can be used both for rapid relief of symptoms and for longer-term control.

What are combination medications?

Combination medications contain a preventer and a controller in the same inhaler. This type of inhaler opens up the airways (preventing the feeling of chest tightening and the worsening of an attack) and also reduces the underlying inflammation that causes asthma. As a result, combination inhalers may provide better control of asthma symptoms and reduce the number of inhalers you have to use.

With conventional combination inhalers, you take the same amount of medication all the time. But because every person with asthma has good days and bad days, this means that sometimes you will take a bit more of the medication than you really need, and at other times you might not be getting enough and you may have to use doses from a second inhaler containing a short-acting reliever.

What effects do anti-inflammatory medications have?

Asthma is caused by inflammation of the airways, which makes them become red, swollen, narrower and extra-sensitive to irritants. Anti-inflammatory medicines (preventers) relieve this inflammation, so that the swelling goes down and further swelling is prevented, the narrowing due to muscle tightening is reduced, and the airways become less sensitive to asthma triggers.

Anti-inflammatory medications are very effective and can control asthma in most people. The most effective anti-inflammatory medicines are the inhaled corticosteroids, such as budesonide, beclomethasone and fluticasone.

What effects do airway opener medications have?

Airway openers work by opening up the narrowed airways. They do this by relaxing the muscles surrounding the airways. This makes it easier to get air in and out of the lungs. Most airway openers work quickly and can be used to treat an asthma attack. They are sometimes called relievers or ‘rescue’ bronchodilators.

What are corticosteroids?

Corticosteroids, are anti-inflammatory medicines. They are used to relieve and prevent inflammation of the airways, which is the cause of asthma. In asthma, corticosteroids are usually inhaled and referred to as inhaled corticosteroids or inhaled steroids. The most effective and commonly used are budesonide, beclomethasone and fluticasone.

Why are corticosteroid medications inhaled?

In asthma, corticosteroids are usually inhaled so that the medicine goes straight to the lining of the airways affected by inflammation. This also greatly reduces the risk of any possible harmful effects on the rest of the body. The small amount of medicine that goes into the bloodstream is rapidly removed from the body, so that normally there are none of the side effects that may occur with other types of steroid treatment.

When and why are corticosteroid tablets or injections used?

Corticosteroid tablets (usually prednisolone or prednisone) or injections can be helpful to treat a severe attack of asthma when inhaled corticosteroids have not had enough effect or are not available.

Treatment with corticosteroid tablets or injections for short periods has few side effects. High doses can, however, temporarily affect your mood, either positively or negatively. Long-term treatment with corticosteroid tablets or injections can cause side effects, including osteoporosis, thinning of the skin, weight gain, high blood pressure and high blood-sugar levels. These risks are avoided if you switch back to inhaled corticosteroids as soon as possible (in consultation with your doctor) and avoid the long-term use of corticosteroid tablets or injections.

What is the difference between a corticosteroid and an anabolic steroid?

Both corticosteroids and anabolic steroids are sometimes just called ‘steroids’. However, corticosteroids are very different from anabolic steroids. Corticosteroids reduce the swelling in the airways that make breathing difficult and also reduce the amount of mucus produced in the lungs. Anabolic steroids have an effect similar to that of the male hormone testosterone, and are used illegally by some athletes to increase muscle mass, strength and endurance. Corticosteroids do not have these effects.

What are inhaled non-steroidal anti-inflammatory medications?

Inhaled non-steroidal anti-inflammatory medications, such as the cromones (sodium cromoglycate and nedocromil), have weaker anti-inflammatory effects than corticosteroids. If your doctor gives you an inhaled non-steroidal anti-inflammatory medication, you must take it regularly, even if you are not wheezing – in the same way as you should take an inhaled corticosteroid. If you are being treated with one of these medications, you will need to take a reliever from another inhaler to treat any asthma attacks.

Is there an effective alternative to using inhaled corticosteroids?

There are no alternative treatments that control asthma as effectively as inhaled corticosteroids. Inhaled non-steroidal anti-inflammatory medications, such the cromones, are not as effective and do not usually relieve the inflammation completely.

Anti-leukotrienes are tablets that are taken by mouth and are helpful to some people with asthma. Often they are not as effective an alternative to inhaled corticosteroids for the long-term control of asthma and the prevention of attacks, but some patients benefit from their use.

Antihistamine tablets are not helpful in the treatment of asthma. However, patients who also have hay fever may find that their asthma improves when the hay fever is successfully controlled, and antihistamines may be successfully used to treat hay fever.

Some airway openers, such as theophylline, can be taken by mouth in ‘long-acting’ preparations. To select the safe and effective dose for an individual patient, and thus achieve the best effect, blood levels of the drug may need to be measured and the dose adjusted. In general, long-acting airway openers are not an alternative to inhaled corticosteroids, because these medications do not fully relieve the underlying inflammation of asthma. The inflammation tends to become worse over time, causing more frequent asthma attacks and more severe symptoms. Although some patients find that their asthma can be satisfactorily controlled by the regular use of theophylline tablets or capsules, these treatments have been largely replaced by inhaled medications. If you have been using theophylline for some time, you may want to discuss today’s alternative treatments with your doctor.

What are anti-leukotrienes?

Anti-leukotrienes are a relatively new type of medication for asthma that are taken as tablets once or twice a day. They work by relieving the part of the airway inflammation caused by chemical substances called leukotrienes, but do not reduce it completely. They may also help to protect against asthma attacks. Often they are not an effective alternative to inhaled corticosteroids for the long-term control of asthma and the prevention of attacks, but some patients benefit from their use.

Do I still need my inhaled corticosteroid if I feel OK?

Yes. Asthma is a long-term (chronic) disease that causes inflammation and narrowing of the airways. Your asthma does not stay the same, but changes over time, and some degree of inflammation is usually present, even when you are unaware of any symptoms.

People with asthma sometimes forget or choose not to take their anti-inflammatory medication, especially during periods when they are feeling well. When they start to get symptoms of asthma, they increase the dose of reliever (bronchodilator). However, this will not treat the underlying inflammation. At the first sign of symptoms of asthma, you should re-start your anti-inflammatory medication if you have stopped it, in addition to using a reliever.

You should not stop regular use of your inhaled corticosteroid at any time unless you have discussed this with your doctor first.

Inhaled corticosteroids are recommended for treating asthma because they are anti-inflammatory. Aspirin is also anti-inflammatory, but is not recommended for people with asthma. Why?

Corticosteroids and aspirin are both anti-inflammatory, but work in very different ways and relieve different types of inflammation. Aspirin has no effect on the inflammation of the airways that occurs in asthma. More seriously, in some patients with asthma, aspirin may provoke severe attacks of asthma. Any patient who is known to have such ‘aspirin sensitivity’ should avoid the use of aspirin at all times. Even in other patients, aspirin has no beneficial effects on asthma.

What anti-inflammatory medication can I take for a strained muscle, aching joints, severe back pain or rheumatism, for example?

If you have asthma and have used aspirin or a similar medicine (often called non-steroidal anti-inflammatory drugs or NSAIDs) without any worsening of your asthma, you can continue to use it. If, however, you have had asthma symptoms after using aspirin or an NSAID, you should avoid these drugs and use paracetamol or another medicine instead. You should discuss appropriate alternatives with your doctor if necessary.

What is hyposensitisation (vaccination)?

‘Hyposensitisation’ is often referred to as ‘allergy vaccination’. It usually involves having a series of injections of the allergen or allergens that are known to cause your asthma. The dose of the injections is gradually increased, with the aim that the body will learn to handle these allergens better and no longer develop asthma on exposure to them.

Hyposensitisation is sometimes suitable for the treatment of asthma provoked by pollen, some animals or dust mites. It is most likely to be successful if your asthma is caused by only one or a few allergens. If your asthma reacts to many different things, it will not usually get better with this treatment.

Hyposensitisation has been used for more than 80 years and is still the only treatment that can potentially reduce your reaction to a specific allergen. The method works for asthma that has been provoked by pollen, furry animals and dust mites, but not for mould. However, there is a risk of serious reactions to the injections, so they should only be given by a specialist, and usually only in a hospital clinic. The risks of these injections limit their availability in some countries, and the treatment is also relatively expensive.

I'm troubled by my asthma when outdoors in cold weather. What can I do?

First of all, be sure that you are using an effective anti-inflammatory treatment. If cold air causes asthma symptoms, inhaled corticosteroids are probably needed. If you are already taking them, ask your doctor whether you should increase the dose or take additional treatment. A long-acting bronchodilator, such as eformoterol, may be considered.

A face mask may also help by heating and moisturising the inhaled air, because cold air dries and irritates the mucus membranes in the airways, especially in people with asthma. Your doctor or pharmacist will be able to advise you.

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Breathing exercises for asthma

Can my asthma be cured?

No, there is not yet a total cure for asthma.

The causes of asthma are not fully understood. Sometimes children with asthma can grow out of their symptoms, or after many years of regular treatment with anti-inflammatory asthma medication, the disease may seem to disappear. However, asthma may recur again later in life in both these groups of patients.

Asthma does not stay the same, but changes over time, and every person with asthma has good days and bad days. It is tempting to think that your asthma has been cured if you have not had symptoms for a long time, but you will usually still have a tendency to asthma if you are exposed to the appropriate triggers in the future.

Allergy treatment using hyposensitisation (often called allergy vaccination) can very occasionally achieve a near-cure of asthma in someone with specific reactions to known allergens, but this approach is not helpful for most people.

Is there a risk that my asthma will get worse with age?

Yes, that risk cannot be disregarded. Poorly treated asthma gets worse with age, and the lungs of people with untreated asthma function less well than those of non-asthmatic individuals. Modern asthma treatments have not been available for long enough for us to be certain whether or not lung function will still deteriorate more rapidly in patients with treated asthma as they grow older. However, most asthma doctors think that regular, preventive asthma treatment can prevent your asthma from getting worse and help to preserve your lung function.

Can I outgrow my asthma?

Whether you can outgrow your asthma depends on how old you were when it started and how severe it was at the time. Around half the children with mild asthma will have no symptoms by the time they reach their mid-teens. Asthma does, however, often recur in adulthood. Children with more severe asthma are less likely to be free of symptoms when they get older.

Asthma that develops in adulthood can be associated with long-term exposure to specific triggers, such as chemicals or pollution, and can sometimes be greatly improved if the triggers are avoided.

Most asthma can be well controlled with appropriate medication, but as an adult you are unlikely to outgrow it completely.

Is asthma a life-long disease?

Asthma is a long-term (chronic) disease, and the tendency to develop asthma symptoms is probably life-long. In some children, symptoms only appear intermittently. Also, some children with mild asthma will have no symptoms by the time they reach their mid-teens.

Is it worse getting asthma when you are old?

Not necessarily, but asthma is often more severe if it starts at an older age. In addition, an older person with heart disease or other medical problems may have more difficulty in dealing with an asthma attack than a younger person.

What is called ‘asthma’ in elderly people is sometimes actually chronic obstructive pulmonary disease (COPD). This is a different disease from asthma, and occurs mainly in cigarette smokers. COPD is generally a more serious disease than asthma, because the changes in the airways are much more difficult to treat, and it usually has a worse outcome.

Can tiredness and forgetfulness be caused by my asthma medication?

No, but if you are not sleeping well because you have poorly treated asthma, you can become tired and forgetful.

Theophylline and related medications can also adversely affect your sleep and may therefore make you feel tired indirectly. If you suspect something like this, discuss it with the doctor who treats your asthma.

Some antihistamines can make you feel drowsy. If you use these medications for hay fever or other allergies and feel tired, you should talk to your doctor about possible alternative medications. If you are allergic to pollen, it is also possible that this causes you to feel tired during the pollen season.

Do inhaled corticosteroids cause any long-term side effects?

As with most medications, inhaled corticosteroids may have side effects in some people.

The most common side effect is a fungal infection in the mouth (oral candidiasis). This is easily treated, and can be prevented by rinsing the mouth after inhalation or sometimes by changing your inhalation technique. Inhaled corticosteroids do not cause fungal (or other) infections in the lungs.

Some people find that their voices become husky after using an inhaled corticosteroid. This usually passes when the dose is lowered, but the hoarseness can sometimes prevent further treatment.

Side effects of inhaled corticosteroids elsewhere in the body are very rare, in contrast to the known risks of corticosteroid tablets that are swallowed. Occasionally bruising can occur. There is no evidence that the most commonly prescribed doses of inhaled corticosteroids can lead to osteoporosis or to cataracts in the eyes, for example – although these are recognised complications of corticosteroid tablets.

Inhaled corticosteroids are a very effective way of treating asthma, and in most people the benefit of this effective treatment is much greater than any risk of side-effects. You should discuss any worries you may have about this with your doctor.

Is it good for me to always use inhaled corticosteroids?

If you have been prescribed them to help control your asthma, then – yes. These anti-inflammatory medications are currently the most effective treatment for asthma, because they treat the causes of asthma instead of just relieving the symptoms. With long-term treatment, the mucus membranes lining the airways return to normal without harmful effects on the lungs.

Early treatment with inhaled corticosteroids seems to help prevent asthma from getting worse. This may make it less likely that you will have severe attacks and the treatment these require.

Can I become addicted to the corticosteroids in asthma medications?

No.

Why can I use inhaled corticosteroids for many years, but corticosteroid on my skin for only a short time?

The skin and the blood vessels just below the surface of the skin are very sensitive to the effects of corticosteroids. If you apply a corticosteroid cream to the same area of skin for a long time, the skin and the walls of the blood vessels become fragile and break easily, which makes bruising common. Because of this, doctors and scientists have looked very carefully to see whether this could happen in the airways of people treated with inhaled corticosteroids over a long period of time. However, no signs of damage to the airways have been seen and it seems that the lining of the airways reacts to inhaled corticosteroids in a different way from the skin.

Do I need to rinse out my mouth after using an inhaled corticosteroid?

There is a slight risk of fungal infection in the mouth when using inhaled corticosteroids. Although this affects very few people, it does not hurt to rinse out your mouth after inhaling a corticosteroid, whenever convenient (e.g. at home in the morning or evening). If you are out during the day and it is inconvenient to rinse, this is not a problem, as the risk is very small.

If I can't remember whether I actually took my daily maintenance dose of inhaled corticosteriod, is it better to risk taking a double dose or none at all?

There is no risk in taking a double dose on a single occasion, but try not to make a habit of this! Inhaled corticosteroids are best taken regularly as instructed by your doctor.

What can I do to prevent osteoporosis?

There is no evidence that inhaled corticosteroids in commonly prescribed doses can cause osteoporosis, but it is reasonable for all patients with asthma (especially older women) to take steps to avoid this, as it is a recognized consequence of increasing age and physical inactivity (and of corticosteroid tablets used in the long-term).

Physical activity will help your skeleton grow stronger and is probably the most important factor in preventing osteoporosis. Inactivity, for example due to very poor lung function or fear of getting an asthma attack, makes osteoporosis worse. Effective asthma treatment that makes it possible to lead an active life is therefore very important. Calcium supplements for middle-aged and older women who are unlikely to get sufficient calcium in their ordinary food may also reduce the risk of osteoporosis, and specific treatments are available for those at special risk. Research in this field will probably lead to further developments in the future.