Frequently asked questions
How is asthma diagnosed?
Asthma is diagnosed by taking a careful patient history and the results of lung function tests. Spirometery or peak flow measurements.
Spirometry
This test measures how much air you can blow out into a machine called a spirometer. Two results are important, the amount of air you can blow out in one second (called forced expiratory volume in 1 second (FEV1)) and the total amount you can blow out in one breath (called forced vital capacity (FVC)). Your age, height and sex affect your lung volume. So, your results are compared with the average predicted for your age, height and sex.
A value is calculated from the amount of air that you can blow out in one second divided by the total amount of air that you blow out in one breath (called FEV1/FVC ratio). A low value indicates that you have narrowed airways which are typical in asthma (but a low value can occur in other conditions too). Therefore, spirometry may be repeated after treatment. An improvement in the value after treatment to open up the airways is typical of asthma.
Note: spirometry may be normal in people with asthma who do not have any symptoms when the test is done. Remember, the symptoms of asthma typically come and go. Therefore, a normal result does not rule out asthma. But, if your symptoms suggest that you have asthma, ideally the test should be repeated when your symptoms are present.
Assessment with a peak flow meter
This is an alternative test. A peak flow meter is a small device that you blow into. A doctor or nurse will show you how. It measures the speed of air that you can blow out of your lungs. No matter how strong you are, if your airways are narrowed, your peak flow reading will be lower than expected for your age, size, and sex. If you have untreated asthma, then you will normally have low and variable peak flow readings. Peak flow readings in the morning are usually lower than the evening if you have asthma.
You may be asked to keep a diary of peak flow readings over two weeks or so. Typically, a person with asthma will have low and variable peak flow readings over several days. Peak flow readings improve when the narrowed airways are opened up with treatment. Regular peak flow readings can be used to help assess how well treatment is working.
(www.patient.co.uk)
It is much harder to diagnose asthma in children who cannot perform lung function tests.
‘The diagnosis of asthma in children is a clinical one. It is based on recognising a characteristic pattern of episodic symptoms in the absence of an alternative explanation’ (BTS. SIGN guidelines).
A trial of asthma treatment to see if there is any benefit may be carried out.
Clinical features that increase the probability of asthma:-
• More than one of the following symptoms –
wheeze
cough
difficulty breathing
chest tightness
– particularly if these are frequent and recurrent; are worse at night and in the early morning; occur in response to or are worse after, exercise or other triggers such as exposure to pets; cold or damp air, or with emotions or laughter; or occur apart from colds.
• Personal history of atopic disorder.
• Family history of atopic disorder and/or asthma.
• Widespread wheeze heard on auscultation (chest examination)
• History of improvement in symptoms or lung function in response to adequate therapy.
What is the difference between a blue and a brown inhaler?
A blue or reliever inhaler (Salbutamol or Terbutaline) relaxes the muscle in the airways, and makes them wider. A reliever inhaler is taken as required to ease symptoms when you are breathless, wheezy or tight chested.
A brown inhaler (Beclometasone,Budesonide, Ciclesonide, Mometasone, and Fluticasone – this is a yellow or orange coloured inhaler) is a corticosteroid inhaler which reduces the inflammation in the airways so reducing airway narrowing. A preventer inhaler needs to be taken on a regular basis, usually twice daily. It takes 7-14 days for the steroid in a preventer inhaler to build up its effect. This means it will not give any immediate relief of symptoms (like a reliever does). After a week or so of treatment with a preventer, the symptoms have often gone, or are much reduced. It can, however, take up to six weeks for maximum benefit.
Many people do not think that their brown inhaler is effective because it does not give instant relief. It is in fact a very important part of asthma management. If your asthma symptoms are well controlled with a regular preventer you may then not need to use a reliever inhaler very often, if at all, and you are far less likely to have a life threatening attack.
I have heard that steroid inhalers will impair a child’s growth.
A great deal of research has been carried out on the long-term effects for children of taking preventer medicines.
Children who have daily doses of 400 micrograms or less don't show any differences in growth. At higher doses the picture is less clear.
There is some evidence that the growth of children on high doses of preventer medicine, or short courses of steroid tablets, may be slowed down in the short-term. However, these children often have their growth spurt later and do eventually reach their predicted height.
It is important to note that chronic untreated asthma in children will itself cause poor growth.
(Asthma UK.)
What is the difference between a round inhaler and a ‘squirty’ inhaler?
There are many different inhaler devices; both reliever and preventer medication can be given through similar types of inhaler device. It is the colour of the inhaler that will differentiate what type of medication it contains not the shape of the device itself (but always check the label). Some inhaler devices are more suitable to individuals than others, and it is the asthma advisors duty to check which device is the most appropriate.
Inhaler devices can be divided into four groups:
| Pressurised metered dose inhalers (MDIs). | The standard MDI is the most widely used. However, many people do not use it to its best effect. Common errors include: not shaking the inhaler before using it; inhaling too sharply inhaler or at the wrong time; not holding your breath long enough after breathing in the contents. |
| Breath-activated MDIs and dry powder inhalers. | These are generally much easier to use than the standard MDI as they do not require the same co-ordination. |
| Inhalers with spacer devices. | A spacer is a holding device for your medication until you breath it in so coordintion is not an issue. It is one of the best devices for getting the optimum medication into the lungs and is easy to use. Its main disadvantage is its size as it does not fit comfortably into ones pocket. It is ideal to use with a preventer inhaler as these are generally only used twice daily so do not need to be carried around and can be kept by the bedside. Using a spacer with a preventer inhaler greatly reduces any of the oral side effects, which may occur otherwise. |
| Nebulisers | These are machines that turn the liquid form of your short-acting bronchodilator medicines into a fine mist, like an aerosol; again these do not require any coordination. You breathe this in with a facemask or a mouthpiece. Nebulisers are useful for giving high doses of reliever medication during an asthma attack. They are not now generally used to treat asthma in the home, if someone’s asthma is bad enough to require high doses of a reliever medication they need to be seen as an emergency. In the past people have not got medical asthma help early enough because they were relying on this treatment to control their asthma, sometimes with fatal consequences. |
Modern spacer devices are usually just as good as nebulisers for giving large doses of inhaled drugs and do not require an electric point; they can be used outside hospitals to treat an acute asthma attack until medical help arrives. The ACT is trying to get a supply of spacers and salbutamol MDIs in every school to be used for this purpose. PLEASE LOOK AND FAMILIARISE YOURSELF WITH OUR SEPARATE LEAFLET ON HOW TO RECOGNIZE AND TREAT AN ACUTE ASTHMA ATTACK.
How often should I visit my doctor/asthma nurse?
If you are getting any asthma symptoms or need to use your reliever inhaler more than 3 times a week you should follow your asthma action plan, if you have one, or see your asthma advisor as you may need your medication adjusted. A peak flow reading is often a good guide to the severity of your asthma. If it drops below 70% of your predicted or best ever reading then you should make sure that you are seen that day, if it falls below 50% you must be seen immediately.
The government has recognised that asthma is a condition that needs regular monitoring so have made it a requirement in the Quality and Outcome Framework (QOF) that all patients on a surgery’s asthma register should be reviewed at least every 15 months. At this appointment peak flow readings, reliever usage and any asthma symptoms are checked, as the results will indicate whether treatments need to be stepped up or down. Inhaler technique is also checked (it is estimated that 80% of people using a metered dose inhaler do not use it correctly, and therefore are not getting the optimum dose of medication to their lungs). Height and weight are monitored in children. Smoking cessation advice and support is offered where required.
It is important that if you have any concerns whatsoever regarding your asthma that you discuss these with your asthma nurse/advisor.
Why am I not on the same treatment as my friend who also has asthma?
Your asthma advisor will treat you according to the asthma guidelines. These are guidelines drawn up by the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN). There are 5 steps of treatment ranging from mild to severe. These step treatments are different for children and adults. Most people are controlled in steps 1-3. Step one is for people who only get mild asthma symptoms and only need to use their reliever inhaler infrequently. If someone needs to use their reliever more than 3 times a week they are usually put on Step 2 which involves taking a regular corticosteroid inhaler (this is usually brown, orange or red colour depending on the name and strength of the medication in it). If low to medium doses of corticosteroid still do not control symptoms the next step is higher dose corticosteroids or a combined corticosteroid and long acting bronchodilator inhaler (not licensed for children under 4 years old). Sometimes a tablet called a leukotriene receptor is added in.
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