Q&A with Dr Mike Thomas of Asthma UK

Child with inhaler and spacerDr Mike Thomas, chief medical adviser to Asthma UK, answered your questions about asthma symptoms and treatment to mark World Asthma Day. 

Dr Thomas is a GP and also Asthma UK senior research fellow at Aberdeen University, with a research programme on the diagnosis and treatment of asthma (including non-drug therapies) in everyday general practice settings.

He has published and lectured extensively on asthma and other respiratory conditions. He is chief medical officer for Asthma UK, a member of several UK governmental bodies concerned with respiratory care, a member of the UK Asthma Guidelines Group and sits on several international guideline groups.

Children and asthma | Asthma, viruses, infections and bronchiolitis | Asthma and food allergies | Exercise-induced asthma | Asthma during pregnancy | Asthma in adults | Asthma medication


Children's asthma

Q. IlovemydogandMrObama: My daughter (four) is seen every six weeks at the local children's hospital due to severe asthma. She is on Seretide 125, Singulair and Ventolin. There don't seem to be any 'triggers' for her asthma, and it seems to be an issue of controlling the symptoms. What are the percentages of children who out grow asthma?

Also, what is best practice for transporting a child with asthma to hospital? I have been told by the GP that she needs to go by ambulance if her O2 levels are 90 per cent, but I don't know what her O2 levels are!

A. DrMikeThomas: Your daughter must have genuinely severe asthma, as she needs high level of treatment to control it and still needs to go to hospital. Although it's true that many children with wheezing when they are young will grow out of it in later childhood, if her asthma is that severe, I'm afraid that it's likely that she will need more long-term treatment. Hopefully, however, her asthma will become easier to control as she grows.

The only way to check her O2 levels are to measure them, which can be done easily with a 'pulse oximeter', a simple monitor device that is clipped on to a finger or an ear lobe. It works through light beams that can assess the colour of the red blood cells (the haemoglobin goes blue when the oxygen saturation falls); it's a quick, easy and painless test. Many GPs and all hospitals will have one.

If you are ever worried about the breathing then you should always call for help, you can't be expected to assess how bad she is yourself! With her history you should always err on the side of caution. The doctor or paramedic will be able to assess the urgency of he situation with kit like the oximiter, but you really shouldn't worry at all about calling for help if she seems in trouble.

Q. ButterpieandCheese: My four-year-old seems to have mild asthma. My question is: how do you explain to a small child how to take deep breaths from the spacer? She does little gasps, and I'm sure it's not working because of that.

A. DrMikeThomas: It can be difficult! Maybe your asthma nurse could help with this. But don't worry, even repeated small breaths through a spacer can be OK. You should definitely continue with the spacer. It will get easier as she gets older if she still needs inhalers.

Q. herbietea: My 14-year-old son has moderate severe asthma and endobronchitis. He takes Singulair, Seretide 250, Ventolin, Loratidine and Azithromycin (three times a week). He has been on the Azithromycin for a year and we are hoping to stop it soon.

He has been on high doses of inhaled steroids since he was two. Every time the professor tries to reduce it, his asthma symptoms flare up and he has to use a nebulizer frequently. How likely is it that the steroids will have harmed him in some way (ie reduced his growth)? I worry about the side-effects, but accept that he has to have the meds to stay well.

A. DrMikeThomas: About one in 20 people with asthma has severe, difficult to control asthma, and unfortunately it sounds like your son is one of them. People with difficult asthma should be under a specialist team and need full assessment and careful monitoring, but if he is under a professor, that is probably already happening.

Generally, inhaled steroids don't have any long-term effect on height gain unless very high doses are used, although steroids by mouth certainly can. High doses of inhaled or oral steroids are only very occasionally needed, but there are some people (and some kids) who really do require them. They should always be used carefully under an appropriate chest specialist, and kids should have their growth and treatment needs monitored.

There are some new treatments for severe asthma, such as anti-immunoglobulin-E injection treatment, which can sometimes dramatically improve allergic asthma (thus reducing admissions and the need for steroids), but this can only be given after a full assessment by a specialist unit, and doesn't work for everyone.

Q. herbietea: Also, how likely is it that he will grow out of it?

A. DrMikeThomas: Unfortunately, not that likely, although hopefully the control and need for high dose treatment will improve as time goes on.

Q. Sirzy: My son is 17 months old and currently on 150mg twice daily of Clenil and at least 4–6 puffs of Ventolin a day. He is due back at the consultant next month who has said if he still needs Ventolin daily they will change his drugs. He mentioned Montelukast (the granuals) but I have read mixed reports on these; are they a safe option for such a young child?

A. DrMikeThomas: Montelukast (Singulair) is a safe and effective treatment used as additional treatment when asthma isn't controlled in inhaled steroids in kids. It is not a steroid and has a very good safety profile. I'd be happier with this than pushing up to high doses of inhaled steroid. Many of my patients and parents of patients have found it useful.

Q. PiaThreeTimes: My daughter (nearly three years old) has been diagnosed with asthma, although I'm not convinced by this as she doesn't seem to have much of a cough. However, she often has dry patches around her mouth. Could this be linked? She often has a snuffly sound in her nose too. She thinks she sounds like a hedgehog! Sound like asthma to you? Thanks for your time on this!

"Asthma can be difficult to diagnose and there isn't yet a simple 'yes or no' test."

A. DrMikeThomas: Coughing can be a symptom of asthma, but isn't always, and wheeze or chest tightness is more typical. Dry patches on the skin are typical of mild eczema, and there is a definite link between asthma and eczema. Likewise, there is a strong link between asthma and rhinitis (nose and sinus inflammation), which can manifest as blocked and runny nose. So these things do make asthma more likely. However, asthma can sometimes be difficult to diagnose and there isn't yet a simple 'yes or no' test for asthma.

Q. candleshoe: My son has mild asthma, which gives him a persistent night cough but which has only twice caused an actual attack. He has been on Flixotide for two years (two puffs am and two puffs pm) and rarely needs his Salbutamol inhaler. Will he grow out of this in time? Will it stay the same/get worse? Is there anything more I can do?

A. DrMikeThomas: He might, but it can be difficult to predict. Kids with allergies, associated conditions like eczema and rhinitis, and with a family history of asthma are less likely to grow out of it. Unfortunately, there isn't a cure.

It's important that your son has regular follow-up with a good GP or asthma nurse, that his treatment is monitored and adjusted as needed, and that you have an 'asthma action plan', detailing how to react to changing asthma. Triggers should be identified and avoided where possible.

And he really shouldn't start smoking when he gets older; no kid should, but it has really bad effects on asthma.

Q. JackJacksMummy: What are the chances of further attacks in a child of six who had no previous history of asthma, but for no obvious reason had a number of severe attacks where he ended up on Amninophiline IV and in high-dependency? My son is now on an eight-week Prednisolene course, with 2x2 puffs of brown and up to 10 puffs of Salbutamol four-hourly, and hopefully now under control and displaying no signs of being asthmatic. When he finishes Prednisolene is there a chance he could go downhill again?

Also, should schools have asthma policies in place as a matter of course? Because mine does not

A. DrMikeThomas: Difficult to answer this one: hopefully he will be able to come off the steroids and control will again be good. However, he will need close monitoring, and if control worsens again, there will need a full assessment from a competent difficult asthma unit. This may be a one-off episode, but he needs close and careful monitoring, and may need additional long-term treatment if the problems persist or recur. An attack of this severity needs to be taken seriously!

"All schools need to have an asthma policy; this is something we passionately believe at Asthma UK and are lobbying hard to achieve."

I also completely agree that all schools need to have an asthma policy; this again is something we passionately believe at Asthma UK and are lobbying hard to achieve. Unfortunately, there have recently been some high-profile, terrible and tragic news stories about the failure to take asthma seriously in schools. Asthma UK is working with schools in key areas to put policies in place and improve understanding, confidence and competence in dealing with kids with asthma.

Q. MrsShiney: My daughter is 17 and is atopic and has severe asthma. She is currently on the Symbicort Smart programme, Ventolin, Montelukast, Intel inhaler, Cetirizine, tranexamic acid, Nasonex, sodium cromoglicate eye-drops, Piriton, and a few other creams and medicines for eczema and GERD. She also carries epipens and an adrenaline inhaler.

But, despite all this, she has still had ten lots of steroids in the last nine months, some with antibiotics and some without (between 20 and 70mg), and she is currently on a six-week course to try to get her off them. But she's had seven admissions in the past year, including high-dependency and numerous other A&E visits and OOHs/GP appointments. In your opinion, what would be the next stage of treatment to try to improve symptoms? 

A. DrMikeThomas: How worrying for you and for her. As with comments above, I think your daughter needs a careful assessment from a difficult asthma specialist unit. There are several possible reasons for her poor control and several possible additional treatment options, but these need to be started only after a full assessment and under close supervision. The combination of recurrent asthma attacks and bad allergies should be taken very seriously.

Q. alibobins: I have two questions: first, my older son is six and is on Seritide 125, two puffs am and pm, Montelukast, Ventolin either via neb or inhaler (depends on how bad he is, at least four times a day), Ceterizine 10ml daily and Beconase nose spray. He is still suffering and getting very wheezy at times; he has recently had a stay in hospital. We are back at the consultant in a few weeks. What could they try next?

A. DrMikeThomas: He's on high-dose treatment with normally effective medication. If he is still getting problems, then again he should be assessed in detail by a respiratory (chest) paediatrician. There are possible treatments and possible reasons why he is still suffering, and this is a situation that again demands a careful and detailed assessment.

Q. alibobins: My younger son is 16 months old and on Flixotide, Ventolin, Atrovent Montelukast and long term Clarithroymicin for a possible endobronchal infection. He also takes Omeprazole and Ranitadine for reflux. Are there any investigations I should be asking for? 

A. DrMikeThomas: Gosh, both your sons seem to have bad asthma! It sounds from what you say that he has been thoroughly assessed, and all the treatment you describe sounds appropriate and up-to-date. There is a well-recognised link between stomach acid reflux and asthma. If he is under a respiratory paediatrician, you should have a full discussion with him/her about your son's problems and the treatment options. If he hasn't seen a specialist respiratory paediatrician, then I think he should. At 16 months, there is unlikely to be additional treatment at this point, but it's a fluid situation and needs full assessment.

Q. Ladybiskybat: What are normal breathing rates for babies? My son is ten months old and seems to breathe fast more often than not. He pulls in under his ribs and his shoulders seem to pull up with each breath. He grunts sometimes, too, but doesn't flare his nostrils. He is on Clenil, Atrovent and Ventolin, and just had a three-day course of Prednisolone, and is now on Montelukast for a month.

It's hard when they say they can't diagnose asthma due to him being so young, but he hasn't been unwell enough to have got a virus for it to be viral wheezing. I think if they said it's asthma and this is what to do I would be fine. I don't want to feel like I'm panicking all of the time, but him breathing fast and coughing/choking at night worries me sick. 

A. DrMikeThomas: Yes, asthma and breathing difficulties in young children can be terribly worrying for parents. The pattern of breathing you describe does indeed sound like that seen in babies with obstructed airways, as occurs in asthma. However, as in some of the other posts, a very similar picture can also occur in bronchiolitis and in viral wheezing, and it genuinely can be difficult to firmly rule asthma in or out at this age.

Babies under 12 months of age can normally have fast breathing rates, up to 60 breaths/min, but grunting and recession between or under the ribs is more worrying. If you are that worried you really must get him checked out and be open with your GP about your worries.

If he is doing well overall and continuing to feed normally and put on weight, it's unlikely that he is too seriously unwell, but it's always better to share your worries with the health team, and if he is not improving on the regime you describe, you should ask for a specialist review.

Q. FannyFifer: My son has asthma; his symptoms are night-time cough, choking, breath-holding, struggling to breathe and so much fluid he sounds like he is drowning. I recently did a product test through Mumsnet for a Sharp Plasmacluster air purifier/ humidifier. Everyone on the trial saw a big improvement with their children's asthma and allergy symptoms. It has been a miracle for us and DS is no longer awake all night choking and coughing.

Would this be a product Asthma UK could look at, as the results we have had are truly amazing. Would be fantastic if more people could benefit.

A. DrMikeThomas: That's great to hear. Every child with asthma is different, and some treatments can be very effective for one person but not for another. Overall, there isn't much strong evidence for air purifiers or humidifiers in asthma, but new products and treatments are always being developed.

Promoting research has always been one of Asthma UK's priorities, and each year we have a funding round, where researchers submit potential projects to the charity and the most promising are funded. By and large, we don't 'commission' research, although give researchers guidance in what our priority areas are. Non-drug treatments for asthma are certainly of considerable interest, and Asthma UK has funded a number of such projects over recent years.

Q. HattiFattner: My son is 11, and atopic. He has been on Flixotide, Serevent and Ventolin since he was four, and now also on Neoclarityn and Nasonex in the summer/hayfever season. He is allergic to dust, pollen and cats. He is very well-controlled. However, after a two-day admission in January for an asthmatic crisis, we were advised to look into Montelukast as an alternative. Given that he is well-contolled on his current meds, so you think there is any benefit moving to a new regime?

Also, can the onset of puberty in boys make asthma worse? I have heard/read that puberty can be the turning point for 'curing' asthma, but wondered if the opposite could also be true. We seem to have had a very bad six months. He also has a bad case of 'Kevin and Perry'-itis...

A. DrMikeThomas: Although asthma can remit in adolescence, it's also a time when some run into problems, sometimes because the asthma gets more severe, and sometimes from 'Kevin'-type issues such as smoking and refusing to take preventer inhalers regularly. Re Singulair: it is a good add-on treatment for allergic asthma, but I'd think this would be 'as well as' rather than 'instead of' his other meds. It is generally safe and well tolerated, and can help the nose as well as the chest symptoms. If he is fine maybe it's not needed, but if he needs additional treatment, this would be a good option.

Q. Jux: It has been posited that today's standards of cleanliness and hygiene are contributory factors - or even causal - in the increase of incidence of asthma, particularly in children. Do you think that if we spent less time cleaning, children would develop stronger immune systems when they're young?

A. DrMikeThomas: It's a really interesting question. The reason for the increase in asthma and allergies over the last 30 years is not fully understood, but the 'hygiene hypothesis' is certainly one of the front runners and has a good theoretical basis and quite a bit of circumstantial evidence to support it.

Finding the right balance between preventing infections and preventing allergies is something that researchers are looking at right now. It may well be that we have been over-scrupulous with making everything sterile, especially for very young babies. Watch this space!

Q. onesmallkayak: My oldest daughter started Ventolin syrup at three for night-time coughing, and at age 24 is a regular user of various inhalers. She is two inches shorter than predicted.

When my second daughter, 16 years younger, started night-time coughing at three, I avoided the Ventolin route and tried massage and steamers, etc. I started her on a salt pipe at about age four and this, I believe, has made the biggest single difference.

Instead of being up through the night with her coughing she could have a last session at about 11pm and sleep through. She shows hardly any asthmatic tendencies now she is seven.

My oldest daughter, who is now a nurse, tells me that there is sound evidence that salt pipes relieve symptoms and help strengthen the air pipe such that it is less likely to collapse inwards, but this only occurs in small children; it is too late for her. However, she says, GPs are reluctant to recommend it in case parents fail to use Ventolin in a life-threatening situation. Can you please recommend a salt pipe to all the young mothers in this chat room? It is no fun growing up chronic asthmatic. If a salt pipe reduces the triggers and makes the difference, as with my second daughter, then shouldn't it be the first choice for small children?

A. DrMikeThomas: Unfortunately, the evidence for salt pipes as having a big role in routine asthma care just isn't there at the moment. As asthma is an intrinsically variable condition, it can be quite hard to be sure what has made a difference. Experimenting with complementary and alternative treatments seems fine to me, but I would advise that this is done in collaboration with your nurse and/or GP, and to continue with the usual treatment while this is done

Q. mousymouse: My son (four years old) has just been diagnosed with hayfever and allergic asthma. He now has a Ventolin inhaler and spacer to take at night. Will that be enough? Should I take him to the asthma nurse for assessment regularly? His peak flow was fine at the paed today but he coughs and wheezes during the night (very high pollen count where we are at the moment).

A. DrMikeThomas: Asthma and hayfever often go together, and asthma often gets worse in the hayfever season. Some people need extra asthma and extra hayfever treatment during the pollen season. Ventolin is fine as a sole treatment in very mild asthma, but anyone of any age who needs to use Ventolin more than three times a week should really be on a regular preventer treatment; this may only be needed during the allergy season in seasonal asthma. The peak flow can be normal during the day but low at night in some people; asthma is generally worst in the small hours of the morning (as many parents know!).

 

Asthma and viruses, infections and bronchiolitis

Q. turkeyboots: My son (18 months old) has had two bouts of bronchiolitis for which he was hospitalised. Since then he gets really wheezy and needs Ventolin and steroids when he picks up a bad cold or virus. My practice nurse tells me this means he has asthma and it will get worse. But most of the time he is fine, so should I be treating the symptoms only, or should he be taking preventive medication (nurse suggested this, but GP over-ruled her).

A. DrMikeThomas: Many children get bronchiolitis, which is a viral infection of the air tubes, when they are young, and most get wheezy during the illness. Those with the most severe bronchiolitis may need a short spell in hospital for observation and possibly for extra oxygen.

"Most kids make a full recovery from bronchiolitis, but some continue to wheeze for some time afterwards, and some may get wheezy with subsequent viral illnesses. This is known as 'recurrent viral-associated wheezing'. Kids with true asthma tend to have more persistent symptoms."

Most kids make a full recovery, but some continue to wheeze for some time afterwards, and some may get wheezy with subsequent viral illnesses. This is known as 'recurrent viral-associated wheezing', and is not uncommon after bronchiolitis. Kids with this condition are usually OK in between viral infections, whereas those with true asthma (often associated with allergies and a family history of asthma) tend to have more persistent symptoms.

However, even those with true asthma can get worse when they get a viral infection, and it can be difficult to tell between asthma and viral wheezing in young kids. Inhaled steroids are very effective for asthma but not for viral wheezing. Often it is best to delay starting regular inhaled steroids in kids of this age until the diagnosis is clearer.

Q. mumtoaandj: My 18-month-old has also had bronchiolitis at eight weeks, then two chest infections every month for six months; once we introduced the brown inhaler, he improved. However, since Christmas he has had three chest infections (all respond to Amoxycillin and steroids).

Are chest infections different from asthma? Could these be asthma attacks? At the start of each chest infection he pulls in with his breathing at his neck and under his ribs and his breathing rate increases. This then progresses and the cough and crackles begin. I never know when to ring for help - we live 30 minutes away by car from the local hospital so always sit it out (always at night). I have been told differing things about his breathing: that they are viral wheezes, bronchiolitis, allergies, chest infections, viral infections... I never know what is wrong.

A. DrMikeThomas: Difficult! See comments above about the difficulty in distinguishing between true asthma (which is generally well-controlled by inhaled steroids) and viral wheezing, which can follow bronchiolitis, but which tends to go away as kids grow into their teens.

It's pretty rare (but not unheard of) for 18-month-old kids to have recurrent bacterial chest infections needing antibiotics, but antibiotics won't help asthma attacks (which may need steroids), or bronchiolitis or viral infections. Viral infections can trigger asthma attacks, which need an increase in asthma medication rather than antibiotics.

It sounds to me that if these attacks continue, he needs a thorough assessment by a competent asthma doctor: either a GP with a particular interest and expertise in asthma, or by a chest paediatrician. There are tests for allergies and 'twitchy' or inflamed airways that can be done if appropriate. If he becomes unwell with rapid breathing and distress, you shouldn't delay in asking for help! These certainly could be asthma attacks, but there are other possibilities.

Q. Thingsfallapart: My son was hospitalised with bronchiolitis at eight weeks old. He is now seven months and has not had a single day without wheezing, sometimes finding it quite hard to breath. This has resulted in several trips to the GP and A&E.

On these occasions I am always told that it is not asthma but after-effects of the bronchiolitis (his dad has fairly bad asthma). He has been given an Atrovent inhaler; it does not seem to do much. I am worried that he seems to be getting worse and wonder should I be pushing for a referral (to whom)? Should he be being treated as if he has asthma?

A. DrMikeThomas: The number of posts on this topic is very interesting and doesn't surprise me, as it's a difficult and vexed question for professionals and experts as well as for parents. Some degree of wheeze is common after bronchiolitis, but daily symptoms are more unusual, and particularity if dad has asthma as well, I think that he does need assessment by either an asthma-focused GP or a respiratory paediatrician.

I think if I were his doctor I would strongly be tempted to try regular anti-asthma medication, either with inhaled steroids or with Montelukast, at this point. Good luck!

Q. PfftTheMagicDragon: I would ask, for a final, definitive answer regarding asthma being triggered by colds/viruses. My children both seem to have asthma that only occurs when they are ill with a cold or bronchitis, or a cough or similar. In the past, we have seen a lot of doctors and can get no definitive answer as to whether asthma can be triggered by such things. The doctor that diagnosed both of my children says yes, yet I have been almost laughed at by other doctors for asking such a thing – been told that it is silly to think that asthma is caused by a cold and that it is simply a viral wheeze (for the millionth time). Can you shed any light on this please?

A. DrMikeThomas: Most children with asthma have recognisable triggers, but these vary from person to person. However, viral 'upper respiratory tract infections' (colds, flu and flu-like illnesses) are one of the commonest triggers for asthma in all ages.

So yes, if you have asthma and you get a cold, it's quite likely that your asthma will get worse, and it could trigger a full-blown asthma attack. On the other hand, not all children (especially very young ones) who wheeze with viral illnesses have full-blown asthma. It can be difficult to separate out, especially in young children and babies.

"Most babies who wheeze with colds do not go on to get full-on allergic asthma, although some will."

Most babies who wheeze with colds do not go on to get full-on allergic asthma, although some will. It can be hard, even for experts, to firmly diagnose asthma in young children; a personal history of atopy (allergies, hay fever, eczema etc) and/or a strong family history of asthma (particularly maternal asthma) make persistent asthma more likely.

So sorry I can't give you a definitive answer! Sometimes it only becomes clear in retrospect. If your children are well between viruses, I wouldn't be in any great hurry to diagnose asthma or to recommend regular inhaled steroids, although having a 'reliever' inhaler like Ventolin or Atrovent to use when they are wheezy would probably help both.

 

Asthma and food allergies

Q. ppeatfruit: My husband and son both had asthma that was cured by giving up dairy products and using the Buteyko breathing system. Could most asthmatics respond in the same way?

A. DrMikeThomas: Dairy product allergy and intolerance is actually relatively rare as an asthma trigger, although some people do have it. More commonly, the allergic trigger is an 'aeroallergen', ie something in the air: eg house-dust mite, cat or dog danger, pollen, grass or fungal spores. By and large, I've been disappointed at the results of dietary changes to control asthma, although a healthy diet high in vitamins and antioxidants is undoubtedly good – fresh fruit, veg, etc.

"Dairy product allergy and intolerance is actually relatively rare as an asthma trigger."

I'm personally very interested in the role of breathing techniques to control asthma: it's what my PhD was about and I've published a number of papers on this, with a large ongoing government-funded study at the moment. In my research, we use a respiratory physiotherapist teaching breathing exercises, but there are many similarities between what they teach and what a Butekyo practitioner teaches.

My observations make me pretty sure that most people with poorly controlled asthma can be helped by breathing exercises, which can reduce symptoms, improve confidence and quality of life, and may reduce the need for 'rescue' inhalers like Ventolin.

However, I don't believe that they are a cure for asthma, and most people will continue to need preventer inhalers. I'm sure the Butekyo method can help some people, although I'd advise a certain amount of scepticism about some of the claims they make about curing asthma. I hope that when we finish our research programme, we will be able to make a case for the NHS to fund this sort of treatment widely, and have it as a more routine part of controlling asthma.

Q. nottirednow: I would like you to say something about the role of allergy in asthma, desensitisation and about alternative therapies such as the medinose-type devices.

A. DrMikeThomas: Everyone with asthma is different, but allergic asthma is very common. Not everyone with asthma has allergies, but 50 per cent or more do have allergic triggers. Standard asthma treatment decreases the likelihood of an allergic asthma attack, but some people still have to be very careful, eg about exposure to pets, dust or certain foods.

Desensitisation is possible, but is most effective when there is a single allergic trigger, and in people with multiple triggers is much less successful. It's possible to confirm sensitisation by skin prick tests or blood tests, although not all GPs will have access to such tests. It's essential that they are done before desensitisation is attempted.

In the past, desensitisation was done by regular courses of injections of small amounts of the substance causing the allergy. This went out of favour about 25 year ago, as there were a number of deaths resulting from anaphylaxis (major allergic reactions), so injection desensitisation is now only done in specialist hospital units with full resuscitation facilities.

"There are now a number of new 'sublingual' desensitisation programmes and products being developed. The first is for pollen, and we will soon have a house-dust mite preparation as well."

However, there are now a number of new 'sublingual' (under the tongue) desensitisation programmes and products being developed. The first is for pollen, and we will soon have a house-dust mite preparation as well. They are mainly being used for people with rhinitis (nasal allergies) at the moment, but we hope that after proper trials showing they are safe and effective, that they will be helpful in allergic asthma. Watch this space!

 

Exercise-induced asthma

Q. stealthsquiggle: My son (eight) has what seems to me to be mild exercise-induced asthma. He gets very short of breath during competitive sport and struggles to keep up despite doing so much sport that he should be very fit. The symptoms sounded very familiar to me (as a mild asthmatic myself) and the GP agreed, so he now has a Salbutamol inhaler to take before games. So my question is: what are the chances of him growing out of it, or of it getting worse? My husband is very keen for our son to be able to dive when he gets older (and our son is very keen too), and current guidelines say that he wouldn't be able to if on any steroids.

A. DrMikeThomas: This does sound suspiciously like exercise-induced asthma. It should be possible to confirm by doing peak flow readings before and after exercise. It's quite possible that he will grow out of it but only time will tell. Asthma is quite common in elite athletes, although with treatment it should be possible to fully control and should not affect performance.

Many top-achieving athletes have asthma: Paula Radcliffe, David Beckham and the swimmer Rebecca Adlington. There are various treatments that are particularly effective for exercise-induced asthma, not only inhaled steroids. There are, as you say, issues with diving and asthma, but with mild asthma it's not usually a big problem.

Q. nottirednow: I have a child with anaphylactic reactions to nut. We have a family history of severe asthma. Last winter they came in one day from a long walk and started wheezing. Our GP did one test, giving them Salbuamol from an inhaler, and said they weren't asthmatic. I'm concerned about exercise-induced asthma, as they have complained of shortness of breath after exercise. Should I ask for further tests?

A. DrMikeThomas: Yes you should! It's a good story for exercise-induced asthma. It's not possible to exclude asthma from a single test like that. If I were your GP, I'd start by giving you a peak flow meter to measure your blowing at home, and ask you to compile a peak flow diary for a few weeks.
I'd also want an 'exercise test' – measuring lung function before and after a session of fairly strenuous exercise. I often send kids off to the local park for 20 minutes of running and then repeat the blowing tests. Asthma is more common in people with allergies. I hope that your child has got proper treatment for nut allergy as well! If they have had an anaphylactic reaction, then probably you should have an epi-pen of adrenaline, plus training on how and when to use it. 

  

Asthma during pregnancy

Q. Guacamole: I am asthmatic, I have been since I was about seven years old. I am currently on Seretide 250 and Ventolin. When I became pregnant I stopped Seretide (personal choice, GP told me I could continue with it) and strangely even without Seretide I didn't need my Ventolin once; it was as if pregnancy cured my asthma. Three weeks after giving birth I had a severe asthma attack and now require my Seretide and Ventolin again. Why was I totally symptomless while pregnant?

"There are hormonal effects on asthma, which vary from person to person. Extensive research has shown that asthma inhalers are safe in pregnancy."

A. DrMikeThomas: The effects of pregnancy on asthma are very varied; some people find that it gets better but some that it gets worse. There are hormonal effects on asthma, which vary from person to person. Everyone with asthma is different. However, extensive research has shown that asthma inhalers are safe in pregnancy, and don't need to be stopped if they are still needed. Asthma should always be monitored carefully during pregnancy.

Q. JemimaMop: I am asthmatic, and have had a bad few years with it which seemed to be triggered by being pregnant with my third child. I have been hospitalised several times with pneumonia. It seems (fingers crossed) to be under control now with the help of Singulair, Phyllocontin, Symbicort and Salbutamol.

I think a lot of the problem was stress, which in turn gets worse as not being able to breathe makes you more stressed! Lots of other things trigger it (hayfever, certain foods etc) but the reaction is always worse if I am stressed. As I say, things are a lot better than they were, although it has taken five years to get to this point. My question is: what is the best way to make sure that this good stretch continues and I don't go back to how things were when I was being hospitalised two–three times a year?

A. DrMikeThomas: Asthma can get better or get worse during pregnancy, so if you do get pregnant again, you should have regular asthma checks. It's good that your control is so much better, and you are on a good combination of treatment.

"There is no doubt that stress is a common trigger for asthma. Slow, steady deep breathing through the nose can help both stress and asthma."

I'd advise you to have regular asthma checks with your GP and/or nurse, and to have a 'personal asthma action plan' (if you don't have one, there is information about this on the Asthma UK website at www.asthma.org.uk).

I'm interested to hear that you have identified stress as a trigger; this is one of my interest areas, and there is no doubt that stress is a common trigger for asthma. I'm interested in breathing exercises, involving slow, steady deep breathing through the nose, which can help both stress and asthma.

 

Asthma in adults

Q. NettoSuperstar: I currently take Seretide, Ventolin, Saline nebs (also have Ventolin nebs if needed), Singulair, Mucodyne and Azithromycin. I'm waiting to hear back from my consultant as he's going to the professor with my case to see if there's anything else they can do to help, as my asthma is getting worse, not better. Is there anything else you can suggest that may help, whether that be a medical treatment to ask about, or diet, just general tips on living a normal life?

A. DrMikeThomas: It does indeed sound like you are another person with severe, 'difficult to control' asthma, and that despite plenty of treatment, your control is poor. I think you need a full assessment in a 'difficult asthma' clinic. This may mean you being referred to a regional centre, as these clinics aren't available in every hospital.

"There are some newer treatments for asthma, such as anti-IgE treatment, that can help some people."

There are some newer treatments for asthma, such as anti-IgE treatment, that can help some people. Identifying whether or not you are such a person, and finding what treatment would help you, would need a full assessment. Everyone with asthma is different, and we are moving to a model of targeted, personalised treatment for asthma, particularly for more severe and difficult asthma. In more general terms, having a good understanding of your asthma, knowing what triggers your asthma and having a personalised asthma action plan are very important.

Q. FudgeGirl: I've used Ventolin and Becotide/Clenil inhalers since I was about seven, usually a couple of times a day when wheezy. For the past two months, I've suddenly stopped needed them almost totally. I've used my blue inhaler probably five times in that time. Despite the hayfever season now being upon us, my asthma seems to have all but disappeared.

My triggers are dust, dogs, cats, grass (what the doctor described as 'level four allergies' after blood tests), and sometimes exercising, laughing too much and perfumes would set me off. If I was poorly with a cold, I'd be using my inhalers a lot. Would be really grateful for any insight into why this has happened. I'm not complaining, just curious! Nothing else has changed in my life/diet. I'm 30 years old.

A. DrMikeThomas: You are lucky! Asthma is a variable condition that can spontaneously get milder to the point that it practically disappears, but unfortunately the opposite can also happen. I don't think anyone can adequately explain this at the moment, but it's certainly commonly seen. There is always the possibility that it could come back, but let's hope not!

Q. Dalrymps: I only started suffering from asthma when I was about 15 (triggered by kittens). I am now 30, is it possible for asthma to improve or even disappear with age? 

A. DrMikeThomas: Yes, asthma can indeed spontaneously go into remission. Generally, the longer it goes on, the less likely this is to happen however.

Q. QuelleLeJeff: As a lifetime sufferer, I have experienced bad periods of illness which have included prolonged hospital stays, and less bad times where I have maintained some small semblance of control over the illness.

As I am getting older I have been trying very hard to stick to taking my preventer spray and am currently on 2x100 Beclomestastone diapriopionate (I always knew it as Becotide) puffs twice daily and I have been impressed with the reduction in my Ventolin intake.

However, despite using mouthwash/rinsing my mouth after use/brushing my teeth etc after use, I am suffering terribly from a sore mouth, cracking of the tongue and numbness of the tip of my tongue. I appreciate that the Becotide is helping my lungs but am very worried about the effects it appears to be having on my mouth and am also distressed at the amount of pain I am in. Are there any other steps I can take to reduce the negative effects of the steroid spray which won't compromise the positive effects?

A. DrMikeThomas: Unfortunately, although inhaled steroids are so very effective in controlling asthma (as you have found), sore mouths and mouth thrush (a fungal infection) are possible side-effects. This results from the fact that some of the inhaled dose gets left in the mouth as you inhale, and causes these effects.

It can be reduced by rinsing your mouth after using the inhaler (eg use it before you brush your teeth, morning and night). It can also be greatly reduced by using a spacer device (the plastic cones that the inhalers plug into), which stops the 'jet' of spray impacting on the back of your mouth and only allows the smaller particles through, which mostly get to the lungs where they are wanted.

If this doesn't work, your doctor could change you to a different inhaled steroid; there is one (called Ciclesonide) that is inhaled in an inactive form, and only becomes converted into the active form in the lungs. Mouth side-effects (and hoarseness, another side-effect that bothers some people, especially singers) are very uncommon with this inhaler.

Q. chickchickchicken: I have rheumatoid arthritis and asthma. The rheumatology consultant said I can no longer take anti-inflammatories due to having a few severe asthma attacks. This has a huge impact on my mobility. I can no longer take morphine or Tramadol because I have low blood pressure and been admitted with it dangerously low. My question is: what painkillers are safe to take when you have asthma? Are there any anti-inflammatory drugs I could take? Diclofenac was the one which triggered severe asthma attacks. Are there any others?

I am 42. I take Serevent, Qvar and Ventolin to control asthma. I have tried various inhalers over the years but became allergic to them. My asthma nurse says this is the last combination I can try. Is this correct?

I spent time in hospital on a steroid drip for arthritis and my asthma was better for about three weeks. It was lovely! Why is there such a restriction on steroid drips? I accept side-effects but at least quality of life was so much improved. 

A. DrMikeThomas: Diclofenac is a member of a class of medicines called non-steroidal anti-inflammatory drugs (NSAIDs) that includes ibuprofen and aspirin. Unfortunately, some people with asthma (between one in 10 and one in 20) get wheezing with all the drugs of this class, so any of the alternatives is likely to do the same.

"This is known as 'aspirin-sensitive asthma' or 'salicylate-sensitive asthma' and is often associated with bad rhinitis."

This is known as 'aspirin-sensitive asthma' or 'salicylate-sensitive asthma' and is often associated with bad rhinitis (nasal allergies) and even nasal polyps. There are other types of painkillers that don't share this property, but often they aren't as good as NSAIDs in rheumatoid arthritis, so you have a problem.

I can think of two possibilities: first, discuss other painkillers (although the BP problem may not allow many of these) with your rheumatologist. There is a class of drugs called 'coxibs' (eg Arcoxia) which are related to NSAIDs but rarely cause wheezing (although like all medicines do have other potential side-effects) – it's worth discussing. Second, ask for a referral to an allergy centre for consideration of desensitisation to NSAIDs. I know there are several allergists offering this treatment in the UK, but they are hard to track down/

It's very unusual to become allergic to asthma medications, and I find it hard to believe that there are not options you haven't tried yet! Maybe you need to discuss this with your GP.

Steroids by mouth, drip or injection are very effective for both asthma and rheumatoid, but unfortunately do have significant side-effects that accumulate the more you use them. These include osteoporosis, diabetes, weight gain and high blood pressure, so sometimes the cure is worse than the disease. Generally, we try to avoid the use of 'systemic' steroids (ie anything other than by the inhaled route, which largely avoids these problems in asthma), although are occasionally forced down this route.

Q. lifeistooshort: I had pneumonia last year when pregnant with my son and seem to have repeated chest infections ever since. I also have had several times a feeling that my lungs are burning. I have always felt that I can't breathe properly. I am allergic to cats, dogs and have hayfever. My doctor has put me on brown and blue inhalers for the past month, and it has made a difference, but I do have to use the blue inhaler at least two or three times a day.

My question is: twice in the past three weeks I have felt so bad when waking up that I had to go back to bed. The first time was the morning after strenuous exercise. My muscles (in legs and arms) felt very weak and shaky. I only had a little wheeze and cough for about ten minutes when I woke up, but I felt as if I had loads of fluid/phlegm and it feels worse when lying down. Generally, I do not cough or wheeze. I went to my doctor yesterday who did a peak flow and said it was fine. From the symptoms summarised above, could this be asthma? Or is it something completely unrelated?

A. DrMikeThomas: Your symptoms certainly could be due to asthma, and the fact that you improved on the brown inhaler is a strong pointer in that direction. However, if you still need to use the blue inhaler every day, you almost certainly need to be on stronger regular 'preventer' treatment.

There are other possible lung conditions that can cause symptoms like this, for example a condition called 'bronchiectasis', but asthma does sound very possible. I think you need to discuss this further with your doctor, and either he needs to try different treatments or refer you on. Don't put up with feeling like this!

Q. mousymouse: My allergic asthma as a child was left untreated, as my mother doesn't believe in conventional medicine and 'treated' me with homeopathy instead. My asthma has now changed from asthmatic to chronic. Could there be a connection?

A. DrMikeThomas: Well, that is a possibility. Untreated asthma can in time result in 'airways remodelling', permanent structural changes in the airways, so we do generally recommend regular anti-inflammatory treatment in children with persistent asthma.

Q. FartingFran: I am asthmatic but I only have symptoms when I am exposed to allergens. The problem is that my job involves unavoidable exposure to them! I manage with daily antihistamines and occasional Salbutamol. I have been given Beclamethasone but don't use it as although my peak flow is generally a bit low, I don't feel that my symptoms are frequently severe, and if they are I can get by with extra Salbutamol.

Often the symptoms are at their worst at night after daytime exposure so I guess it is reactively managed. Is long-term exposure to allergens likely to cause me chronic respiratory problems or can I continue to be as cavalier about managing it? I have asked GPs in the past and never been given a definitive answer.

A. DrMikeThomas: I'm a bit worried by your story! It sounds to me like you are developing 'occupational asthma', ie allergic asthma caused by ongoing work exposure to high levels of something you are allergic to. If this is the case, your symptoms are likely to get worse and worse if something isn't done. If the exposure is removed or attenuated soon enough, the asthma can go completely, but if not, after a certain time it can become fixed, and sometimes severe.

I'd recommend seeing an expert in occupational asthma. With regards to Ventolin: if you need to use it more than a few times each week, you should really be on a 'preventer' such as Beclomethasone. However, I think you need to get assessed soon for possible occupational asthma.

Q. notremotelyintofootie: I developed asthma when I was 18 following a pretty bad case of bronchitis. I am now 37 and have to take Seretide twice a day and Flixotide 50 twice a day (upped to Flixotide 250 when I have chest infections). Every winter I end up with chest infections after a cold, and this winter I had four courses of antibiotics along with Prednisoline to resolve an infection that was hanging around for two months! What can I do to try to avoid this, and am I ever likely to be able to come off my inhalers?

A. DrMikeThomas: You are on high levels of treatment and yet still getting regular winter infections. Something isn't right! I think you need a through assessment by a competent chest doctor and wonder if you perhaps don't have some other complicating lung condition, eg bronchiectasis.

 

Asthma medication and prescription charges

Q. MadHairbaaadonroyalweddingDay: Do you think people with chronic chest conditions should get free prescriptions? People with some other chronic conditions get them, and rightly so, but there are many, myself included, who would die without medication, so rely on it, but still have to pay. Any chance of this ever changing?

A. DrMikeThomas: Couldn't agree more! We are really trying at Asthma UK to get this changed; it seems wrong to me, especially as if you live in Wales, Scotland or Northern Ireland, you don't have to pay. The financial situation is challenging at the moment, however, so as a first step we want to see the government reduce the cost of pre-payment certificates, which let you pay a certain amount upfront to limit your prescription costs for that quarter of that year. They are available from some pharmacies and by post or phone.

Q. MadHairbaaadonroyalweddingDay: What do you think can be done to change perceptions of lung disease when it comes to DLA for example, or ESA? Because it is often a fluctuating condition, many people do not receive such benefits and then struggle greatly because they are still unable to work due to the fluctuations and exhaustion this causes. With the new ATOS reviews for those already on DLA, do you worry that asthmatics and sufferers of other lung diseases will lose benefits and enter into vicious circles of further illness from stress and loss of income?

A. DrMikeThomas: We at Asthma UK completely agree with this as well. Asthma can be a very disabling condition for some people, and the perception that it is a mild and minor condition is common but very mistaken. The economic climate is tough, but why should people who have asthma through no fault of their own be penalised?

Q. NettoSuperstar: I agree with MadHair; I am employed but haven't worked since February due to severe asthma, and had over six months off with it last year, and am terrified I won't get ESA or DLA. It's a very real illness, but as you say, many people think it's not that serious, when it almost killed me twice last year – I had to be ventilated at one point.

I'm at the point now where I struggle to go out by myself, and usually get a friend or, at the very least, my nine-year-old to come with me. She also does lots round the house that I no longer can.

ADrMikeThomas: It's very unfair and wrong that people in authority (and sometimes in the medical profession) don't realise how much asthma can affect people's lives. There is often a complacency about asthma – 'it's only a bit of asthma' – that is wrong in so many ways. From what you say, it would be very wrong for your application to be rejected, but if it were, I'd advise you to appeal. It sometimes seems to me these days that the 'default position' is to say no, and only to really look at people's circumstances when they appeal.

Q. herbietea: Do you think there is ever going to be a time when asthmatics get their medication for free in England, like diabetics do?

"It's very arbitrary and illogical that some people with long-term conditions eg diabetes and thyroid problems, don't have to pay for essential medicines, whereas people with asthma do have to pay."

A. DrMikeThomas: We really hope so and are actively campaigning on this issue at Asthma UK as part of a coalition of leading health charities. We agree that it's very unfair that people with asthma should have to pay for essential medicines needed to keep them healthy, and it's very arbitrary and illogical that some people with some long-term conditions (eg diabetes or thyroid problems) don't have to pay, whereas others, like those with asthma, do have to pay prescription charges for their essential medication. 

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Last updated: 24-Sep-2013 at 3:15 PM