Q&A with Dr Mike Thomas of Asthma UK
Dr Mike Thomas, chief medical adviser to Asthma UK, returned to answer more of your questions about asthma symptoms and treatment.
Dr Thomas is a GP and 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.
This Q&A has been sponsored by GlaxoSmithKline
Q. Itsatiggerday: My son is two and a half, and has virally triggered asthma/viral wheeze episodes. He was hospitalised with pneumonia earlier in the winter, but apparently that might not be related to the asthma. Is there a connection?
A. Dr Mike Thomas: Viral wheeze and asthma have similar symptoms in young kids and can be difficult to tell apart until time has passed. In 'proper' asthma, the symptoms tend to be more continuous and there are often associated allergies. It tends to be persistent through childhood. Viral wheezing, however, tends to get better as children grow. These kids are often born with small air tubes, but don't have the same persistent inflammation in the lungs that children with asthma do.
Viral wheeze can often follow on after a bad chest infection as a baby, such as bronchiolitis, which can result in hospitalisation when bad. If that's what he has, the outlook is generally good in that he is likely to 'grow out of it' when he's older, eg in his teens. If he has got asthma (and sometimes only time will tell), he's less likely to grow out of it, but with proper treatment should be able to lead a full and active life, including sports etc.
Q. LittleMissGreen: My five-year-old son has asthma. He was diagnosed when he was three, although he had medication before then. When should/could he start using a peak flow meter and what does it do?
A. Dr Mike Thomas: Peak flow monitoring can be useful in asthma, and most kids can do it with training by the age of six, some older and some younger. It's particularly useful in kids (and adults) who don't notice their airways tightening up until it's too late, by which time they can be having a full asthma attack. Having a peak flow meter (plus an action plan of how to react when asthma is changing) can be helpful.
Q. trixymalixy: My son takes Clenil Modulite, two puffs a day. He also takes Salbutamol as and when required. Is the daily use of steroids likely to make him shorter in height than he potentially could have been?
A. Dr Mike Thomas: Good news on this one! There have been large studies to investigate whether inhaled steroids affect growth in kids and there is a very slight but just detectable dip in growth velocity for a few months after they are started, but this is practically balanced by better growth after this and there is trivial, if any, reduction in the final adult height, unless massive doses or long-term steroid tablets are used. However, poorly controlled asthma does stunt growth.
Q. marytuda: My son, now aged four and a half, was in hospital on a nebuliser and steroids every time he got a cold from eight months until almost two years old. I wonder if I could have avoided my son's last crisis by giving him the flu jab last autumn? It was offered us but I turned it down, given that we'd survived the last winter without anything (except Salbutamol). Do you recommend flu jabs for mild asthmatics, even under-fives?
A. Dr Mike Thomas: It's a tricky and still debated question. The jabs are offered because we know that people with asthma get flu more easily and more severely than those without (this was very clear in the swine flu epidemic), and when they have flu then this can trigger off asthma. In kids with mild asthma, it's probably not that important, but in children with more severe problems (and repeated admissions comes under that category) then there is a much stronger case for it. It's up to each family to decide, however.
Q. llynnnn: My daughter is two, and she constantly suffers with a runny nose, which started when she was tiny, and it's always the same all year round. She quite frequently has a cough and always snores at night. She has also had a hearing test and is not responding to the quieter sounds.
I've spoken to the doctor regarding this several times and he would like to try a course of inhalers as he thinks she could be asthmatic. My question is: I always think of wheezing and struggling to breath as symptoms of asthma, but my daughter has none of these, so is it possible to be asthmatic without these symptoms?
A. Dr Mike Thomas: You are right that asthma manifests with symptoms like chest tightness, breathing difficulties, wheeze and cough, and it's hard to diagnose asthma without these.
Asthma is, however, commonly linked to rhinitis, which is inflammation in the nose and sinuses, which manifests as blocked nose, runny nose, sneezing etc, and asthma and rhinitis commonly go together. The chances of getting subsequent asthma are much higher in a child with rhinitis, but it's not inevitable. Rhinitis is usually treated with steroid nose sprays and antihistamines, and asthma inhalers won't usually have much effect on the nose symptoms.
Q. Overthemill : My 12-year-old daughter has asthma and eczema. Both seem to be triggered by similar things, including allergens, stress and viruses. The asthma has never been adequately controlled and recently she had yet another two weeks on steroids, plus she is on maximum dose of serotide and ventolin (usually about 14 doses a day), both of which are Accuhalers plus montelukast.
During this episode, her GP referred to her condition as 'brittle asthma',which was new to me. Was he merely being metaphorical or is it something specific? She gets wheezy but mainly tight-chested, can't breathe and gets very scared. She coughs so much that she vomits, has sleepless nights and is prone to catching everything going round.
A. Dr Mike Thomas: Poor thing! She does not have well-controlled asthma despite lots of treatment, and is clearly very 'atopic' and allergic. Brittle asthma is usually applied to a situation where asthma goes from being relatively well-controlled (at least in terms of symptoms) to being really bad over a short time, eg a few hours. Sometimes peak flow monitoring can help spot early worsenings so action can be taken before a crisis occurs.
However, I think she really should see a specialist respiratory paediatrician, as I think she needs an in-depth work-up, including detailed allergy tests and a re-assessment of her medicine. There are newer asthma treatments that can be very helpful in situations like this. There are a network of 'difficult asthma' clinics, so-called 'tertiary care' centres (GP is primary care, local hospital secondary care) that specialise in this situation, and usually get results.
Q. PeanutButterCupCake: I'm in my mid-30s and have been asthmatic since childhood. I'm mainly affected if I have a cold and take 250 Seretide BD and Ventolin PRN. How do I know if I have 'grown out' of asthma? Do I just continue to take inhalers forever?
A. Dr Mike Thomas: Good question. Asthma is a variable condition and it can get better spontaneously sometimes. The only way to tell is to reduce treatment slowly. Seretide 250 is fairly weighty treatment, and shouldn't be stopped suddenly, but if control has been good for at least three months (which means no asthma attacks and very rare need for ventolin) then it's reasonable to reduce treatment, eg by going down to a lower strength seretide, and if things remain well-controlled cutting back from a 'combination inhaler' like Seretide (which has two 'controller' agents in it) to a simpler one that just has an inhaled steroid.
Sometimes it is possible to come off regular treatment altogether, but mostly a low level of 'maintenance' treatment is needed to allow a full and unimpaired life. Discuss this with your doctor?
Q. MonaLotte: I am 30 and have had asthma since I was two. I have been on Becotide with Serevent and Ventolin but have changed to Seretide and Ventolin. I am concerned about being on steroids for so long. Has there been any research into the long-term effects of steroid use in asthma?
A. Dr Mike Thomas: Yes there has, lots of it, and the results are very reassuring. At 'standard' doses on inhaled steroids (eg up to a total daily dose of 800mg of beclomethasone, the active agent in becotide, or 400mg of fluticasone, the active steroid agent in seretide) long-term side-effects are not seen.
It seems that at this dose, the steroid is not absorbed from the lungs into the circulation, so the only side effects are 'local' ones such as occasional thrush in the mouth or a hoarse voice. It's rare for higher doses to be needed, and when they are over long periods of time, a small amount of steroid absorption can sometimes occur, and if large numbers of people are followed there is a slightly higher risk of osteoporosis and cataracts. But at standard doses, the long-term safety profile is excellent.
Q. CopyAllWrite : I'm in my 40s and have had what I'd call mild asthma for 20 years. I use Becotide 100 once a day. I recently saw a specialist who carried out a spirometry test on me, which showed moderate obstructive pattern and flow volume loop indicative of airflow limitation at small airways level. It said I had a lung age of 73.
I have been shocked and quite gutted to have this on a report. The specialist didn't really explain much to me, so I would be really grateful if you would tell me how serious this is and what it means for my future.
A. Dr Mike Thomas: I can see how this must be worrying. Are you a smoker? If so, it's possible that smoking on top of asthma has resulted in scarring of the airways and fixed obstruction. However, it's also possible that you are not on enough 'preventer' treatment - Becotide 100 is low-level treatment, and if in spite of this your airways remain inflamed and constricted, these are the sort of results that could be found. If that was the case, more intensive treatment could improve your lung function and your 'lung age'.
Q. Scylla : I was diagnosed with asthma as an adult five years ago. I take Clenil 200mg twice a day, and rarely need my reliever. But my peak flow is always very low, about 250, it rarely reaches 275. Despite gym going and the occasional run, it never improves and I seem to get more out of breath than my less active friends when plodding uphill, upstairs etc. Can I stop it declining with age? I am 50 years old.
A. Dr Mike Thomas: There is great individual variability in 'personal best' peak flow, and it doesn't relate to how physically fit you are. This does, however, sound low for your age and height, and I'd suggest that you need to have more detailed lung function tests done (eg more detailed blowing tests known as spirometry) to see what your lung volumes are.
If you are or were a smoker, it may be that you have COPD (Chronic Obstructive Pulmonary Disease) rather than asthma, in which there is permanent narrowing of the airways. It's important to know whether you have COPD or asthma as the treatment is different.
Q. LIZS : How is asthma diagnosed in an adult ? Over past few years I've felt tightness in very cold conditions or associated with a bad cold/cough and a need to catch my reath. About three years ago I was prescribed an inhaler for a viral chest infection. Would this indicate asthma or are these symptoms too sporadic?
A. Dr Mike Thomas: Asthma is diagnosed by typical symptoms (which it sounds like you have - and in mild asthma the symptoms can only be noticeable when you have a bug) and by objective tests, such as variation in your peak flow rate when you are not so well.
Sometimes, people have blowing tests done at the surgery or hospital, which can be normal at times when you haven't got symptoms or been exposed to a 'trigger'. There are other tests that are sometimes needed when asthma is suspected but the blowing tests are normal (which can occur), to look for inflammation in the lungs (eg by measuring levels of a gas called nitric oxide in exhaled air, raised if the lungs show asthmatic inflammation) or by showing 'twitchiness' in the airways by a bronchial challenge test.
Q. fazsaeed: My son has been diagnosed with asthma alongside his reflux problems. He does have a frequent cough, but can asthma be diagnosed with checking peak flow first? He is on blue inhaler "when needed".
A. Dr Mike Thomas: There can be a link between asthma, cough and reflux, and sometimes if the reflux is properly treated the cough and asthma symptoms can disappear. As in the answer above, asthma diagnosis should ideally have both symptoms and demonstration of abnormal lung function.
Q. CBear6: How is asthma diagnosed in toddlers? What signs should I be looking at, and what questions should I be asking? My son is two and a half and after a few minutes of running around or when he's over-excited he begins coughing until he calms down again/rests. He doesn't wheeze, just coughs. He doesn't really cough at night but when he gets a cold or any other bug it goes straight to a cough, which seems to linger on for ages. He did have bronchiolitis as a baby. My GP keeps trying to push salbutamol inhalers at me but there haven't been any tests done and I don't want to give my son medication that he doesn't need.
A. Dr Mike Thomas: As we talked about in the children's section at the start, it can be difficult to tell between asthma and 'viral associated wheezing' in younger kids. At two and a half, he's too young to measure peak flow or spirometry, so 'pattern recognition' of symptoms is more important.
Cough can be a symptom of asthma, or viral wheezing, but in these conditions is usually with associated wheeze. It may well be that his ongoing problems are the after-effects of bronchiolitis, in which case he should grow out of it. I think it would be very reasonable to try salbutamol, although only on an 'as-needed' basis and if it doesn't help there isn't much point in pressing on. If his symptoms are bad enough, ask for a referral.
Q. lorrainelb: My daughter has had a cough since she was two weeks old. She is now three. Up until November last year it was almost constant with varying degrees of severity. She does not wheeze, but does cough when she runs. The doctors sent us away every time saying it was a viral or post-viral cough, or even croup.
After several visits to A&E when she could not stop coughing, one doctor finally prescribed Montelukast. She has not coughed since. She also now has a preventer, which I use every day. The doctors now want to take out her tonsils and adenoids. They say that they don't think it is asthma, but I am not convinced. Is there a test she can take?
A. Dr Mike Thomas: Interesting tale. Good to hear that she is better. I'm a bit confused that she is being given a 'preventer' (presumably an inhaled steroid) if they don't feel she has asthma. Tests to 'rule in' or 'rule out' asthma are very difficult at this age, unfortunately, as discussed above.
Montelukast has been shown in several studies to be helpful in post-viral syndromes, but also helps in asthma, sometimes dramatically. Tonsillectomy is done far less than it used to be these days, and is usually only recommended when there are persistent and intractable problems.
Q. Sirzy: My son is two and asthmatic (on 400mg Clenil and Singulair as well as Ventolin), and we have established that one of his triggers is dust. Other than regular cleaning of his bedroom, no teddies allowed, and so on, are there any good ways to reduce dust levels especially in bedrooms?
A. Dr Mike Thomas: It can be a lot of hard work to reduce house dust mite levels, and the results are variable, but can be very helpful for some. You could think of taking up the carpets and reducing fabrics in the bedroom. There are 'allergy-friendly' special mattress and pillow covers than can cut the levels in the air. Asthma UK has useful information on its website and a 'kite-marking' system for allergy friendly products if you are interested in taking it further.
Q. HattiFattner : The asthma clinic nurse suggested we look at fabric conditioner as a potential irritant. Having switched from a "heavenly" to a "pure" variety, I find my son much improved. Have you heard much about the heavily scented conditioners triggering asthma attacks?
A. Dr Mike Thomas: Yes. People with asthma often report that certain scents and perfumes and certain perfumed products act as triggers. These probably act as irritants to an already inflamed and vulnerable airway in the same way as secondhand cigarette smoke does.
Q. libelulle: My three-year-old daughter has had asthma symptoms since having bronchiolitis at nine months old. She was on daily Clenil and needing regular Ventolin during coughs and colds, with several hospital admissions to her name. She has also had countless chest infections, for which she is under the chest consultant.
Last winter she was taking preventative Azythromycin thrice weekly. Since she had her tonsils and adenoids out (suggested because of sleep apnoea and chest infections), her asthma seems completely resolved. She is off all her meds, including Clenil, and doesn't wheeze at all during viral infections, has masses of energy and is able to run distances for the first time in her life.
I'm delighted, but perplexed, since no-one mentioned dodgy tonsils/adenoids as a cause of asthma. Is it just coincidence that she seems to have outgrown it just at the time her tonsils came out? And if not, why were tonsils/adenoids never mentioned to us before as a factor in her severe viral wheeze?
A. Dr Mike Thomas: Enlarged tonsils and adenoids are not thought to be a cause of asthma, although if they are large enough they can lead to sleep apnoea, in which the airways can almost completely block off when the muscles in the throat relax in sleep. I hope her chest symptoms continue to be better.
Q. misscph1973: Do you have any information on the link between asthma and nutrition? Both of my children have mild asthma. Although they have no allergies we try to avoid dairy products. They also get a strong vitamin D tablet every day from October to April as my daughter tested low (should be over 75, was 68) vitamin D.
Since these changes, last summer was their first summer without asthma inhalers, but as soon as the cold and especially damp weather starts, they cough when they get a virus, so back on inhalers on asthma nurse's recommendation.
A. Dr Mike Thomas: Asthma is commonly associated with allergies, but these are far more often due to 'aeroallergens', ie small particles in the air, such as house dust mite, cat or dog dander, pollens or moulds, and food allergies are rarely the trigger for asthma.
In those who do have food allergies, however, they can be very important and serious. For instance, in susceptible people nut allergy can cause life-threatening anaphylaxis and severe asthma. These allergies can be tested for by either blood tests or skin prick tests, and it's possible to ask your doctor for such tests. Generally, cows milk allergy is not a common trigger for asthma. We do know that a healthy diet rich in antioxidants - particularly with unprocessed foods and fresh fruit and veg - is good for lung health and can protect against asthma.
Q. Januarysnowdrop: Do you have any views on Buteyko breathing techniques? It completely sorted out my asthma, which was terrible after my daughter was born, and I've always wondered why it's not better known about. It always strikes me that it would save the NHS ridiculous sums of money if Buteyko lessons worked even for only a small percentage of asthma sufferers. I only needed about five lessons to get the hang of it. Was I just lucky in that it worked for me?
A. Dr Mike Thomas: Breathing exercises of various types, including physiotherapist-taught programmes, yoga breathing techniques and Butekyo have all been shown to help improve symptoms, improve quality of life and reduce reliance on 'rescue' medication for asthma.
This is one of my own personal research interests, and we are just starting a new government-funded research study on physio-taught breathing training as a treatment for asthma. I hope that if this study confirms what we think, then these exercises will be available generally through the NHS. My research indicates that most people who continue to get asthma symptoms despite standard treatment stand to benefit from these techniques, but that they are not a 'cure' for asthma but should be used as well as inhalers.
Q. MumsNuttter: I'm really interested in the connection between a UK senior research fellow and GlaxoSmithKline. Does this mean you only test its drugs? I know its business is selling drugs, however does it not become a vested interest for GSK to have you researching for them? Are you paid by the company?
A. Dr Mike Thomas: My research is mostly funded by government funding streams, but some of my research has been funded by different pharmaceutical companies, and I've received payment for advisory work.
As an academic and a member of various government advisory bodies and committees, like all my academic peers I'm required to submit 'conflict of interest' statements and to have full transparancy about all my contacts with pharma.
I don't have any shares or financial stake in any pharmaceutical company. GSK funded the development of the 'MyAsthma' app and asked me and some academic colleagues to advise on the format and content that would help people most. I think the app is free of any bias towards any particular medication or any company's product - we refer to medication by classes and not by product, and it's aimed to be helpful to anyone with asthma and not just people using particular inhalers.
Q. MGMidget : I have heard of salt therapy (ie inhaling salt in a salt cave for example) having a healing effect on the lungs and treating conditions such as asthma. Do you think this works and if so, can the healing be permanent (eg if lungs were damaged) or is it a treatment that you need to keep up continuously and if so how often is it needed?
A. Dr Mike Thomas: The evidence isn't great at the moment for salt, although some people think it has helped them.
Q. aristocat: Please may I ask what makes another illness so dangerous when the patient has asthma anyway? Is it the combination of drugs needed? My mum was an asthmatic and had an awful case of shingles, which made her very poorly. I always thought asthma was hereditary, is this correct?
A. Dr Mike Thomas: We think asthma is caused by a mixture of genetic background and environmental factors, ie things you are exposed to in life. Shingles isn't generally thought to be a trigger for asthma, although everyone is different. People with asthma are more susceptible to some infections, eg flu. Some illnesses are known to make asthma worse, such as hay fever, sinusitis, anxiety or depression and reflux.
Q. PenguinArmy: Can you prevent an attack? I had asthma as a child, but it went away and then gradually returned once I went to university. I can recognise the symptoms of when I'm going to have an attack, sometimes several hours before, but I was wondering if there is a way to tackle these signs and stop it in its tracks. These questions seem to highlight how many people aren't involved in discussion about their asthma with healthcare professionals and what it all really means.
A. Dr Mike Thomas: We think most asthma attacks (and most asthma deaths) are preventable with better treatment and by having a personal asthma action plan that tells you what to do as your asthma worsens, to try to take action to prevent the worsening resulting in a full-blown asthma attack.
As most people with asthma recognise, there are 'triggers' that can precipitate an asthma attack, which vary between individuals. These can include allergies (eg pets, pollen), irritants (eg smoke and perfume), exercise or virus infections.
I quite agree about the communication issue - I view my job as an asthma clinician as providing my patients with the understanding and tools to be able to make their own well-informed decisions about how they want to treat their asthma. We know that when a good discussion has occurred and the patient and the clinician have agreed a suitable 'action plan', then outcomes are better.
Q. Londonista: My son is 14 months and was first hospitalised for difficulty breathing (70 breaths per minute = hysterical mother banging on the doors of the A&E). I cannot accurately describe how horrifying it is to see your child struggle to breathe. My question therefore is this: are there guidelines for how physicians should communicate and educate parents of young asthma sufferers to help them cope? We have found this varies greatly. Who's job is it to keep us calm and informed?
Do you have any top tips for getting a one year old to sit quietly while you administer a puffer with a spacer. We find the 'half-nelson' is the only way - I guess if he screams he is only going to suck down more of the medicine.
A. Dr Mike Thomas: Yes I do know how frightening this situation can be as a parent, my own daughter was admitted aged one with severe viral wheezing, and it's very hard to watch. It's always best to call for professional help when a baby is having any difficult breathing, and modern medicine has very efficient non-invasive ways of monitoring whether enough oxygen is getting from the lungs to the blood, such as 'pulse oximetry'.
A good doctor or nurse should always be aware of the parents as well as the child, and provide full and updated information on how things are going. As in most facets of life, the ideal isn't always met. We do recognise the importance of communication and partnership between patients, parent and professionals.
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