When such a difference in prevalence is revealed among those of similar racial origin, it raises the question – what is it in these different environments which leads one group of children to be more likely to develop asthma than another group? The answer could lie in the fact that higher rates of asthma are usually found with increasing urbanisation and also with an increase in a westernised style of living. We must however, be very careful not to make premature conclusions regarding the likely environmental culprits. It’s possible that along with genetic predisposition several of the following factors may be acting together:
- Increased rates of maternal smoking
- Changes in our diet (less fresh food, less oily fish, more processed/refined foods)
- Changes in our indoor environment (more closed, less well ventilated homes which may be
- associated with increased concentrations of allergens or pollutants associated with cooking)
- Changes in furnishings (which together with reductions in ventilation, expose us to potentially greater quantities of house-dust mite)
- Alterations in the type and frequency of certain infections to which we were exposed in early life (a ‘cleaner’ environment and less early life infections may allow the allergic side of our immune system to develop to a greater extent then the infective side of our defences)
- Changes in outdoor pollution exposure
Q. Will my child grow out of it?
A. Children with wheezy illnesses under the age of five may or may not have asthma but because of the difficulties of making the tests necessary to confirm asthma in the very young, all wheezy illnesses in under fives tend to be treated as if they had asthma. This means that as these children grow older many turn out not to have had asthma and they grow out of their tendency to wheeze. Older children who do have asthma find that as they grow up they may have a symptom-free period that can last for several years. Around half of these people, however, will find that their asthma returns in adulthood. If you have severe asthma as a child, it is more likely to continue or return in later life.
Q. My asthma always worsens when I get a cold – how can I prevent this?
A. A cold or a viral infection can be a trigger for many people with asthma. In fact in a National Asthma Campaign survey, The Impact of Asthma 1996, 86% of the 52,000 respondents said that colds and viral infections affected them. It’s of course almost impossible to avoid catching colds but there are certain measures that can be taken which may reduce the impact they have on your asthma.
In the first instance, ask your GP or Practice nurse to draw up a self- management plan for you which will tell you when and by how much you need to increase your use of your inhalers when you get a cold. The British Guidelines for Asthma Management states that the dose of inhaled steroids should be doubled at the first sign of a cold or virus. ‘Flu’ injections are recommended for people with severe asthma and older people.
Q. What are the side effects of inhaled steroids in children and adults?
A. The possibility of side effects from inhaled steroids is very low as the inhaled medicine is taken directly into the airways where it is needed. Very little is absorbed into the rest of the body. There is a small risk of developing a sore tongue, sore throat, hoarseness of the voice and a mouth infection called thrush. Using your inhaler before brushing your teeth and rinsing your mouth out afterwards will help you to avoid this. Using a spacer device can also reduce the possibility of thrush.
Steroid tablets may cause:
- Fattened face (moon face)
- Feeling hungry and wanting to eat more (can lead to weight gain)
- Feeling hyped up and ‘over-active with difficulty sleeping
- Feeling depressed or having sudden mood swings
- Heartburn and indigestion
- Bruising easily
- Brittle bones (osteoporosis)
- Altering diabetic control or uncovering a tendency to diabetes
- Chickenpox may be more serious
Q. Risk of cataract increases
A. It is possible that through using high dose inhaled steroids over a long period there is a slight risk that they could be absorbed and some of the above effects could be experienced. Nowadays as an alternative to high dose inhaled steroids it is often possible to achieve better control of asthma by adding a non steroid treatment (eg long acting bronchodilator such as Serevent or leukotriene modifier such as Accolate or Singulair) to a low dose of inhaled steroid, rather than just continuing to increase the inhaled steroid dose.
Your doctor will always try to keep you on the lowest dose possible of inhaled steroid to control your symptoms and in severe long-term asthma, will have weighed the risk of side effects against the benefit of controlling your asthma symptoms
Q. How do doctors know which treatments to use and when?
A. Doctor’s normally follow treatment guidelines for the management of asthma. these guidelines are formulated by the British Thoracic Society (BTS) and are regularly reviewed. These guidelines are based upon the best possible evidence obtained from research done around the world.
Q. Why should people with asthma have the ‘flu and Pneumovax jabs?
A. Having ‘flu can make asthma symptoms worse however it may not be necessary for everyone to receive the vaccination. The vaccine is recommended for older people (particularly those over 60) and people that have severe attacks or chronic and troublesome asthma. If you feel that you are at high risk from catching the flu and that your asthma would be made a lot worse then talk to your doctor or practice nurse about vaccination.
The vaccination is usually given about once a year in October or early November. It works best if you are vaccinated again each year because you might need protection against a new strain of the ‘flu virus. A smaller dose of the ‘flu vaccination is suitable for children. If the child has never had the vaccine before this will normally be repeated 4-6 weeks after the first dose.
Pneumococcal infection comes from a bacteria that can cause conditions such as pneumonia and meningitis. It affects approximately 1 in every thousand people each year. The people most at risk from pneumococcal infection are the very young (the vaccination is not suitable for children under two years of age), the very old, those with some blood disorders, people who have had their spleen removed and those with a long-term illness such as severe asthma. These people should consider having the vaccination. However you should not have the vaccine if:
- You currently have a serious infection
- You are either pregnant or breast feeding
Unlike the ‘flu vaccination, the pneumococcal is usually only given once. Side effects are rare, with occasional mild soreness where the injection is given and very rarely a mild fever.
Q. Do antibiotics help during times of bad control?
A. Antibiotics are useful in treating chest infections but they do not help with the symptoms of asthma. Indeed most infective exacerbations of asthma are due to viruses (which will not be helped by using antibiotics). If an infection makes asthma worse this usually indicates the need to increase asthma therapies rather than take antibiotics.
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Q. How do the new asthma pills work and who should try them?
A. Most asthma medications are taken by inhaler directly into the airways and this applies to both preventative medicine and reliever medicine. However two long-acting relivever medicines (theophylline and bambuterol) are available in tablet form as are two preventative medicines.
These are the steroid tablets or a new form of asthma medicine known as Leukotriene Modifiers that come in the form of a tablet and are preventer type medicines. They work by reducing the effects of a group of chemicals in your lungs called leukotrines. People with asthma produce these chemicals when coming into contact with something that triggers their asthma symptoms. The leukotriene chemicals cause asthma symptoms by:
- Causing the muscles in your airways to tighten up
- Encouraging the cells in your lungs to produce more mucus
- They also attract other inflammatory cells causing the lining of the airways to become more inflamed
The new medicines work by stopping the leukotriene chemicals being manufactured or by blocking their actions and therefore reducing the amount of inflammation in your airways. There are two types of these medicnes available in the UK: Montelukast (trade name Singulair) and Zafirlukast (trade name Accolate). Montelukast is taken once daily and may be used by adults or children over six.
For the most part these medicines will be used by people whose asthma is not adequately controlled on inhaled steroids. Presently they are given as an addition to existing asthma medication although Zafirlukast may represent an alternative therapy for some people with mild asthma. They are only available on prescription and will not be suitable for everybody with asthma. You should talk to your doctor or practice nurse about whether they are appropriate to you.
Q. Are there any complementary medicines or therapies worth trying?
A. Many people with asthma are turning to complementary medicines and therapies to help control their asthma. According to a National Asthma Campaign survey 33 per cent of adults and 26 per cent of children felt their symptoms improved either to some extent or a great extent after using a complementary technique. On the other hand, 17 per cent of adults and 16 per cent of children felt their symptoms did not improve at all.
In general, complementary medicines and therapies have not been studied as extensively as conventional medicines and without published research it is difficult to say how helpful a particular complementary medicine or therapy might be. It is important for anyone considering trying a complementary medicine or therapy to discuss it with their doctor first.
Some complementary medicines are potentially harmful for people with asthma. For instance Royal Jelly and propolis have caused serious side effects in some people with asthma and other allergies. These have included asthma attacks, breathing difficulties, anaphylactic shock and even death.
It is important to continue using treatments prescribed by a doctor unless your doctor advises you to stop or reduce your dose. It could worsen your asthma symptoms if you reduce or stop taking your regular asthma medication.
Q. How can people with asthma monitor their own condition?
A self management plan is an invaluable way of keeping asthma under control. The written action plan advises you what to do and how to alter your treatment yourself in a variety of circumstances. The plan is divided into four zones which broadly describe your asthma as: well controlled; less controlled; severe; and emergency. Your doctor or practice nurse will assist you to fill it in and show you how to use it to control your asthma. it will help you monitor your asthma and know how to alter your medication if your asthma worsens. Scientific studies have shown that that following a self management plan can reduce asthma attacks and improve your quality of life.
Some plans are based just on how you feel and others on a combination of how you feel and your peak flow readings. By taking regular peak flow readings morning and evening, before using your inhalers, you will be able to check how your asthma is doing. Peak flow meters are available on prescription from your doctor. They measure how hard you can blow air out of your lungs and the measurements show accurately how your breathing is changing.
Because you have already agreed your self management plan with your doctor or practice nurse you can increase your preventer inhaler immediately without having to make an appointment. However, it is important to keep your doctor or practice nurse informed about your symptoms, particularly if they are getting a lot worse, as your medicines may need to be changed. Your self management plan should be reviewed by your doctor or practice nurse at least twice a year.
If any further advice is needed contact the National Asthma Campaign Asthma Helpline staffed by asthma nurse specialists, open from Monday to Friday 9am to 7pm, locall rates apply. Factsheets and booklets are also available free of charge to individuals.
Author
Dr. Martyn Partridge M.D. F.R.C.P. is Consultant Respiratory Physician at Whipps Cross Hospital. He is Chief Medical Advisor to the UK National Asthma Campaign and Chairman of the Executive Committee of the British Thoracic Society.
Dr. Martyn Partridge is one of the joint co-ordinators of the British Guidelines on the Management of Asthma, and also a member of the advisory Board who produced the International Consensus Report on Asthma. He is a member of the medical aerosols sub committee of the U.N. Environment programme (looking at the effect of CFC phase out on metered dose inhalers), and a member of the Executive Committee of the NHLBI/WHO Global Initiative on Asthma (GINA). He is also a trustee of the U.K. National Asthma & Respiratory Training Centre.
