Jon Ayres OBE

Brief Outline: Professor of Environmental & Respiratory Medicine Institute of Occupational and Environmental Medicine University of Birmingham

Background: .

A doctor explains what asthma is

Asthma is a condition in which the bronchial tubes are unduly irritable, so that if they are exposed to something like cold air or an infection they narrow down and then produce difficulty in getting air in and out and therefore breathlessness.

But they equally then will relax, either because of treatment or spontaneously and it’s that irritability due to an underlying inflammation of the airways which is what asthma is.

So are there different types of asthma?

There are many, many different types of asthma and you can classify them in all different sorts of ways and sometimes that’s helpful, sometimes it’s not. 

For instance there is one form of asthma which is due to allergy called atopic asthma. There is another form, all the rest if you like, which are not, don’t have anything to do with allergy. Equally it may have something to do with age of onset. You can have early onset asthma in childhood, you can have late onset asthma occurring in adults. It might be due to causation, such as occupation. So there are many different ways of classifying it. But at the end of the day in terms of management, there isn’t very much difference across the spectrum

So could you describe the common symptoms of asthma?

The main symptoms are wheezy breathlessness. Those are the classical symptoms of asthma and they are (usually) intermittent. You can have periods of completely being symptom free in some people, whereas others will have symptoms all the time.

Classically these symptoms will wake people from sleep and so nocturnal asthma is something which raises our concerns, because it indicates that the asthma is not being very well controlled.

The other main symptom of asthma which really wasn’t recognized until about twenty, thirty years ago is cough. And this can either be a dry cough or it can be a cough where phlegm is produced. So it’s those three symptoms, wheeze, breathlessness and cough.

A doctor explains how a person having an acute asthma attack is treated in hospital. This may include oral steroid tablets and using a nebuliser to get medication into the airways effectively. Some people may need to go to hospital.

An asthma attack is where the airways narrow rather quickly and so they have a relatively rapid onset of breathlessness and wheeze. Under those circumstances, they’ll know, the individual will know what to do themselves. But if that fails then they need to seek medical advice. Either go to their GP or if necessary go to the accident and emergency department at the nearest hospital. Treatment then is usually with what’s called a nebuliser, which is a, a mask whereby a solution of bronchodilator, which is the same stuff as we give in the blue relief inhaler as a mist and its basically given in, in large dose, so that you get a larger dose of drug, getting into the airways. And that’s very effective.

But if an individual needs nebulised therapy, then, very strong and careful consideration needs to be given to whether they need a course of oral steroids to try and cut down the inflammation, which was, which flared up, and therefore gave rise to the attack.

Now some people may be admitted to hospital. Some people may be discharged after a period of observation in, in the A & E department. It really depends upon how quickly an individual responds and so on. If they’re admitted to hospital, then in general terms they’ll be admitted for two or three days, sometimes longer. For children it’s usually 24, 48 hours tops. 

And other than nebulised treatment and possibly some oral steroids, what other treatments?

Well sometimes we will give intravenous dosing of the bronchdilator drug again. Solely because if the airways are very, very narrow, trying to get air, the stuff into the lungs by inhalation is, the problem is that the airways are narrowed. And therefore you can’t get the drugs out to the very smallest airways. That’s sometimes then you have to give the drugs intravenously, so that they just get to the lungs by another route. And of course, if you need intravenous drugs like that, then usually people are kept in hospital for longer.

And so they would stay in hospital until their condition…?

Until their condition is stabilised, peak flows have started to settle down and so on.

A doctor describes the commonest triggers for asthma.

What are the most common triggers for people with asthma?

In terms of, once you have asthma, triggering an attack of asthma then there are very common things such as viral infections. That’s probably the commonest cause of genuine worsening asthma and asthma attacks. On a more short term basis then some people find exercise, breathing cold air, those are the sorts of things that will trigger them, and then of course there are allergens which you can either experience indoors such as house dust mite, cats, or outdoor, such as grass, pollen and fungal spores.

So there’s a range of different things that can do it, both physical and in terms of allergens. But of course on top of that stress, emotion, can act as very potent triggers. On many occasions I’ve had people who will tell me that moments of high emotion, such as funerals will exacerbate an attack.

Can you tell me what, how easy it is to ascertain what the triggers are in people?

That is more difficult. Some people will say to you, this is what it is. ‘I know that if I eat peanuts that I will have an attack of asthma’. In children very often exercise is a classic, very easily recognised trigger. School teachers will say, “He’s not trying at games.” And it’s not that, it’s just they get breathless so, and viral infections clearly, you know, “I had a cold. It went to my chest. My asthma got worse.” Is something that’s fairly easy to recognise. 

More difficult are those triggers which you are more hidden, such as perhaps allergens that you’re not aware of. Or maybe even certain chemicals that you’re exposed to at work. Those sorts of things may well be much more difficult to, to understand, except with extensive investigations.

A doctor explains how anxiety can exacerbate the onset of an asthma attack.

There is absolutely no doubt that anxiety acts as a potent trigger for asthma. Managing it is very difficult. Because it lies as much in the management of the anxiety as in the management of the asthma. 

Some people of course get very frightened when they have an asthma attack, and that’s not surprising. It’s a very frightening thing to happen. And of course, therefore, when they feel they’re on the verge of another attack, panic may set in, and that may in fact exacerbate the likelihood of getting an attack. There are a number of different options to do it, people have tried yoga and things like that. As far as I’m concerned I’m all for people trying these things if they feel it works for them. The scientific evidence to support that is virtually absent, but it’s, any way in which anxiety can be managed better is likely in those individuals to improve their asthma control. There are a number of different options to do it, people have tried yoga and things like that. As far as I’m concerned I’m all for people trying these things if they feel it works for them. The scientific evidence to support that is virtually absent, but it’s, any way in which anxiety can be managed better is likely in those individuals to improve their asthma control.

A doctor talks about some of the possible side effects from using inhaled steroid medication, but says that the benefits outweigh the risks.

There are side effects. The blue inhalers can cause people to have a little bit of the shakes if they use too much of them. They can feel their hearts racing a bit. These are not dangerous. It’s just a physiological response to the drug. And it tends to settle down in time. 

As far as inhaled steroids are concerned there is some evidence that, that very high doses over long periods of time, it can cause problems with contributing, particularly in older people, contributing to osteoporosis (decalcification of the bones), but that’s a very much less an effect. More common is a dry mouth. Occasionally thrush in the mouth. The, the fungal infection in the mouth can occur in about 2 or 3 per cent of people. But those are the, the symptoms you get from inhaled steroids.

I’ve had some people who’ve I’ve spoken to who have talked about things like skin thinning. Is that something that you’re familiar with?

Yes. In older people with high dose inhaled steroids you can get, not so much thinning but easy bruising and so you get these rather purplish patches on the, on the skin and when they fade then the skin does look a bit thinner, where that has been.

Clearly any side effect of any treatment needs to be made clear to the patient what they are. From my point of view the benefits of inhaled steroids are so strong, it was the most dramatic arrival on the scene in the late 1960s when inhaled steroids first arrived. It transformed the life of many people with asthma. They’d never had anything like it. It is a tremendously effective treatment. It controls symptoms. It reduces asthma attacks. And when you balance that against some of the long term side effects then I think, yes, you need to understand what those benefits are, but the benefits in my view, way outweigh the risks.

A doctor explains how ‘Putting people in charge of their own asthma is absolutely fundamental, because it empowers them to take control of their own asthma.’

Self-management is a fundamental, intrinsic part of asthma. Most of the, asthma is very, very common. We know that it affects probably something like 6 or 7% of the population in the UK and many more children. Self management is absolutely key. People need to know when to increase their treatment, to help them through periods of worsening symptoms. How they deal with acute attacks. And this is why we provide people very often with management plans or action plans, which can be written down, which may be driven by symptoms, changes in symptoms, if they increase by a certain amount, increase your therapy by a certain amount. Or driven by changes in those peak flow readings I mentioned earlier, where if peak flows drop to a certain level then this should be the first step that you should do, may be double your inhaled steroids. If despite that it then drops even further, then go along and see your GP or if you are more severe and you have these to hand, start a course of oral steroids. 

And, putting people in charge of their own asthma is very, it’s absolutely fundamental to my view, because it empowers them to take control of their own asthma. 

What are the common problems that people find in self managing their own condition?

I think part of it is a fear about whether they’re doing the right thing. I think the second thing is that there are some people who are perhaps slavishly adherent to the, to the guidelines. And I think, but in general terms, I think the one thing that people find more of an issue with self management plans is he sheer phaff of it. Yes, but having said that there, for many, many people self management plans work beautifully. For some it’s just not the thing. And you just have to try and work it out and work in collaboration between the doctor and the patient as to how best their asthma is to be managed. And in the majority of people self management works very well.

A doctor describes how irritants in the workplace can cause asthma.

Occupational asthma is one of the clear identifiable causes of asthma which we can do something about. Probably one to 2,000 people a year in the UK have developed asthma from an exposure that happens at work. The two commonest groups of workers who suffer in this regard, are paint sprayers, so people who paint car bodies and things like that. And that’s due to the hardener in the paints. And those involved in the baking or catering industries, where they’re sensitised either to flour, or to the enzymes they use to, to make bread rise. And those are the two commonest causes worldwide of occupational asthma. However there are probably over 300 different causes of occupational asthma. Some of them relatively esoteric, some of them relatively common. Chemicals, apart from the paint hardeners. Organic molecules such as for instance people who work in fish processing or prawn processing characteristically develop occupational asthma.

If you develop occupational asthma, this is a compensatible disease. You can get compensation from the government, and, but the most important thing is to try and remove the individual from the cause. Now that’s easier said than done. If you’re a baker, you can’t really, for instance, say, you have to change your job and become a, you can, but that’s a big decision to make. 

Another approach, of course, is to say well can we find something else that would do instead of the agent that causes the problem. For instance, there was, there is a cause of occupational asthma, due to something that’s found in the flux in solder. So solderers get it. And they found, and once you found, once we had established what it was in that solder flux, it could be removed. The flux still worked and so you were able to remove that opportunity for individuals to get occupational asthma. But if you’re a baker you can’t remove flour. It just isn’t an option, you know, then no job.

So, then you’re into the possibilities of using what’s called respiratory protective equipment or RPE, which is a mask, to try and reduce your inhaled, your inhaled exposures. Some people find that perfectly acceptable. Others find it almost impossible in the context of their job. And very often people with occupational asthma have to change their job. Which is a major upheaval.

So in general occupational is a well recognised, but not as well as it should be, cause of asthma. And if anybody who develops asthma during working years for the first time, one in ten of those individuals it will be due to their work.

A doctor explains why it’s important to take exercise if you can, and to know your limits. Using a reliever inhaler before participating in sport or exercise can reduce or eliminate symptoms.

If somebody knows that exercise will make their asthma worse, there’s some advantage in taking a relief inhaler ten to fifteen minutes before hand. Get your retaliation in first if you like. And, and that will enable them to, to undertake some level of exercise. 

Swimming is regarded as an acceptable form of exercise for asthma because people are breathing humidified air. And while there is some issues about whether chlorine will exacerbate some people, in general terms the humidified air is, is a help for asthmatics. Breathing dry air often triggers them. 

So its understanding what makes, what is right for them and then either avoiding them or developing strategies for managing them. It’s very individual. 

It’s a difficult one, because for those who’ve got bad asthma exercise is impossible. They have to walk slowly. They find what you and I would regard as relatively mild exertion as impossible. At the milder end of the spectrum if you like, where people may well find that on their good days they can run miles, and on their bad days, they find that after, you know, walking half a mile, they’re breathless. Then that’s just a matter of understanding taking, you know, preparatory doses of inhaler. People generally know when their asthma’s not quite right. They talk about it in those terms, rather than being able to define it more clearly. And understanding what needs to be done to avoid those situations or at least deal with them, is very individual.

A doctor talks about the importance of knowing what foods trigger your asthma, and says that being overweight puts more strain on the lungs making it more difficult to breathe easily.

As far as diet is concerned there are some people who are allergic to certain foods. And sometimes that’s difficult to work out, sometimes it’s very obvious to work out. Once they are identified, then avoiding those foods is important. Wheat and dairy products of course, are difficult to avoid. And you have to find non dairy or non wheat substitutes. But those are available. 

As far as drinks are concerned, then there are some people who find that alcohol will exacerbate their asthma. It’s relatively common. It’s probably about one in five adult asthmatics will report that some form of alcohol at some stage will make their asthma worse. Worst is red wines followed by whisky. And sometimes beers as well. With beers very often you need two or three pints to really get it going, but so moderation in all things. But it is relatively common.

If you know about it then you know how to deal with it. And there are some people who will only respond adversely to a certain drink and therefore they avoid red wines for instance. 

Being overweight adds to the amount of bulk that you have to move around and therefore the load that you put on your lungs. And under those circumstances, yes, being overweight will appear to make asthma worse. What it’s just doing is that the asthmatic lungs are finding it harder to deal with, the extra weight and therefore it gives the impression that its making the asthma worse. It’s not making the asthma worse, it’s just that asthmatic lungs find it harder work.

One of the problems of course, is people at the severe end of the spectrum who’ve had multiple courses of oral steroids for instance, the side effect of which is putting on weight, that becomes a real difficulty and in those individuals again then we’re back into the story of exercise and all the rest of it. So that’s a more difficult area.

A doctor explains why asthma sufferers shouldn’t smoke if at all possible. It’s not easy, but there are programmes to help you quit.

It’s a sad fact that about 15-20% of people with asthma smoke. And, there is absolutely no doubt that smoking is bad for asthma. It’s a double insult. The increased risk of developing COPD, increased risk of recurrent infections, apart from all the other health effects of smoking. And smoking is bad for asthma.

Would your advice, what would your advice be, to stop smoking?

Absolutely. 

… if you’re diagnosed with asthma?

Absolutely. Stopping smoking is mandatory in my view in asthma. Easier said than done, but of course there are lots of smoking cessation clinics now in both primary and secondary care, and we’re getting better at being able to provide the sort of support that people need to get off what in many cases of course is an addiction. But cigarette smoking is an absolute no, no, in asthma.