First Aid procedures: asthma attack

What is it?

Asthma is caused by a swelling of the airway linings. The airways narrow, causing difficulties breathing out.

Symptoms

• Severe difficulty breathing
• Wheezing
• Distress and anxiety
• Exhaustion from effort of breathing
• Grey/blue skin
• Dry cough

First aid aims

• Ease casualty's breathing
• Get emergency help, if needed

Actions

• If this is their first attack, reassure casualty and help them to relax
• Encourage them to use their inhaler (if available)
• Ask them to breathe slowly and deeply
• Help them to sit down and relax. If indoors, open the windows to ensure a supply of fresh air.
• If the attack does not ease in a few minutes, advise them to take another dose from their inhaler.

Further action

If the attack is severe, or the casualty does not respond to medication, call 999.

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Asthma treatments

Main asthma treatments

There are two main treatments for asthma: preventers and relievers. These come in a variety of delivery devices called inhalers, which enable you to breathe the medicine in through your mouth, directly into your lungs. The addition of a spacer device increases the medication delivered to the lungs.

Asthma preventers

Preventers are designed to quell swelling and inflammation in the airways and reduce mucus. This also reduces the sensitivity of the airways and so minimises potential damage.

The protective effect is built up gradually over a period of about a fortnight. Your medication must be taken daily to maintain protection, even if you are not experiencing symptoms.

Most preventers are based on corticosteroids, usually known as steroids. These are completely different from the anabolic steroids sometimes used by bodybuilders and athletes.

Most common types of preventer are inhaled steroids. These can include beclomethasone, budesonide, fluticasone. Occasionally, if your asthma is acute and severe, you may be given a short course of steroids taken as tablets, or even an injection. There are other non-steroid preventers, usually used for children, such as sodium cromoglycate and nedocromil sodium. They are usually taken three to four times a day and are not generally as effective as steroids.

Many people worry about the side-effects of steroids. High doses taken over a long period can have significant side-effects. For this reason, doctors will be careful to prescribe the lowest possible dose needed to control your asthma.

Potential side effects of asthma preventers

The main side effects are hoarseness and an increased risk of mouth and throat infections caused by thrush, a yeast that lives normally on the body's mucous membranes.

Using the inhaler before brushing your teeth and rinsing your mouth out afterwards helps to avoid this. Using a 'spacer' makes it easier to inhale the drug, and so helps reduce the risks of steroids being absorbed into your body.

Asthma relievers

Relievers are drugs that relax and open up the airways - medically known as bronchodilators - making it easier to breath. These are prescribed for the relief of asthma symptoms during an actual asthma attack, when peak flow readings are low and before exercise or activity to reduce the risk of an attack.

Because these drugs do not reduce swelling and inflammation of airways, you may also need to take a preventer.

Some relievers alleviate symptoms almost instantly (rescue relievers). Others have a longer lasting action (long-lasting relievers). The latter may be prescribed if wheezing, breathing difficulties and coughing persist despite using a preventer and a rescue reliever - or if symptoms come on in the night - nocturnal asthma.

Common rescue relievers are salbutamol and terbutaline. Another type of reliever (most often prescribed for babies under two and for older people) is called ipratropium bromide.

Long-acting relievers include oxitropium, salmeterol, and eformoterol, all of which are inhaled. Occasionally, theophylline-based drugs are taken by mouth, so tablets may be prescribed.

Potential side effects of asthma relievers

Side effects are usually mild and pass away quickly. The main ones are a slightly increased heartbeat, and muscle trembling, especially in the hands. Some oral relievers may cause dry mouth, blurred vision, difficulties passing urine, or constipation. Theophylline-based drugs, which relax the muscles in the walls of the airways, can occasionally cause nausea, more rapid heart rate, a nettle-like rash, dizziness, nervousness, headaches, irritability or restlessness.

Always report any unusual symptoms to your doctor.

Inhaled asthma medication

Most asthma treatments are inhaled. There are several different types of inhalers, but the main ones are aerosol-based (often called puffers) and dry powder inhalers.

• Puffers - the medication is mixed into a liquid and forced under pressure into a small aerosol canister. Once activated (usually by pushing down the canister, although breath activated devices are increasingly available) the liquid evaporates, leaving the active ingredient that you inhale. A measured dose of the drug is released every time the canister is pushed down. Both relievers and preventers can be given via a puffer.
• Dry powder inhalers - the drug that comes in dry powder form is contained in a capsule. When the device is activated, the capsule breaks and the powder may be inhaled. In some inhalers the powder is contained inside a disk or compartment.
• Spacers - because it can be hard to coordinate your breathing with an inhaler, you may be prescribed a spacer. This device allows more medication to enter your lungs than would be possible using an inhaler alone. It's usually a large plastic chamber in two halves, which click together, with a mouthpiece at one end and a hole at the other end where the inhaler is attached. The drug is released into the spacer chamber from the inhaler device, and then enters your body as you breathe in through the mouthpiece.
• Nebulisers - a machine in which air or oxygen is forced through the liquid form of a drug, creating a mist, which is then inhaled through a mask or mouthpiece. It's used to administer high doses of reliever in an emergency and sometimes for children who are too young to use an inhaler.

Other asthma medication

There are a number of medicines that are taken in pill form, including eukotriene receptor antagonists, theophyllines and steroids . Your doctor will be able to advise you when and why these may be necessary for you.

If your asthma is really bad, your doctor may also prescribe a short course of steroid tables to calm down your inflamed airways.

New anti-inflammatory tablet-form medication for asthma includes the leukotriene receptor antagonists. These are particularly useful for brittle asthma and those with aspirin-sensitive asthma.

Omalizumab is a new injection treatment for asthma that works by dampening down the allergic reaction in those with severe persistent allergic asthma.

Dealing with an asthma attack

• Remove yourself from any conditions or situations that trigger your asthma. Treatment is not as effective in the presence of a trigger.
• Take a couple of puffs of your reliever (usually the blue inhaler) , using a spacer if you have one. Stay calm and relaxed and breathe slowly to reduce fatigue.
• Rest sitting up. It's harder to breathe lying down. Loosen any tight clothing. Rest your hands on your knees to help support your back.
• If you have no immediate improvement, take another puff of your reliever inhaler every minute for 5 minutes or until symptoms improve.
• Wait five to ten minutes to see if the attack eases. Measure your peak flow to see if your reading is improving. If it does, you can resume what you were doing. If the reliever has not taken effect within 15 minutes, call your doctor or call an ambulance on 999. Carry on using the reliever every minute until help arrives.

Never put off seeking medical help because of fear of making a fuss or being a nuisance.

Hospital treatment for asthma

If you need hospital treatment, take your medication (and your asthma management plan, if you have one) with you. The doctor will need to know what steroids you have taken, whether you used a nebuliser and if you are taking the drug theophylline.

On arrival, the doctor will examine you and check your pulse, oxygen saturation blood pressure and peak flow, and listen to your chest. You may also have a test to check blood levels of oxygen and carbon dioxide.

Treatment will usually begin with a nebuliser to improve your peak flow reading. If you have to be admitted, a chest x-ray may be done to check for damage to your lungs. On the ward, you'll probably have nebulised bronchodilator treatment and steroid injections. Oxygen may be needed and, in severe cases, artificial ventilation.

Helping someone having an asthma attack

If you're with someone who is having an asthma attack, try to stay calm. Make sure they take their reliever medicine. Listen to them, reassure them and encourage them to breathe slowly and deeply. If the person has a peak flow meter use this to monitor their condition.

Don't try to lie them down as this constricts the breathing passages. If the reliever has no effect after five -ten minutes, or if the peak flow meter falls to less than 50 per cent of the expected reading, you should call a doctor or ambulance immediately. You should also do this if the person becomes distressed or unable to speak properly.

Call for medical help immediately if the person's:

• Symptoms worsen even after taking medication.
• Peak flow number decreases or doesn't improve after treatment.
• Breathing becomes increasingly difficult and the chest and neck are depressed with each breath.
• Having difficulty walking or talking and has to stop what they're doing.
• Lips, tongue or fingernails take on a blue or grey tinge.

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Asthma triggers

Identifying asthma triggers

Trigger factors, such as allergens and activities, can bring on asthma symptoms. Some triggers involve specific irritants, such as cigarette smoke, certain foods or chemicals, while others are non-specific, such as cold air, exercise and emotions.

Often more than one trigger is involved. For example, if you're sensitive to certain foods, these can make your bronchi more sensitive, if you then breathe in cigarette smoke it can trigger an attack.

A good way to identify your triggers is to keep a diary and write down any symptoms (such as cough, wheeze, difficulty breathing, peak flow readings) together with any potential triggers you've been exposed to (such as traffic fumes, a change in the weather, a cold or cough).

Show these notes to your doctor or practice nurse. You may also wish to ask your doctor about allergy testing as it may be useful.

Knowing how to avoid your triggers can help you to reduce the likelihood and intensity of an attack. If your asthma is caused by an allergy, you may be able to find out what you're allergic to by having special tests such as skin prick testing to common allergens, and then taking practical steps to avoid the allergen.

Remember, never stop taking your preventer medication, even when your symptoms are stable.

Airborne irritants

Any substances you breathe in can become an allergen. These might include:

• Traffic fumes
• Smoke from cigarettes, bonfires and incinerators
• Animal dander, for example from dogs and cats
• House dust mites
• Pollen, from trees and grasses
• Industrial fumes, especially those containing sulphur dioxide
• Paint fumes
• Household chemicals, such as those found in air fresheners and aerosols
• Natural gas, fumes from cavity wall insulation
• Perfumed cosmetics
• Strongly scented flowers

Asthma and cigarette smoke

Cigarette smoke contains a number of different chemicals and gases that can irritate the lungs. The more inflamed your lungs, the greater the risk cigarette smoke will make your symptoms worse.

Some ways to reduce the effects of cigarettes:

• Stop smoking - this is especially important if you're a parent or planning to have a baby. Children whose mothers smoke are more likely to have asthma
• Avoid passive smoking as best you can
• Always have your reliever with you
• Ask people not to smoke in your presence, especially if you start to develop asthma symptoms

Asthma and cold air

This is a non-specific trigger. Changes in air temperature, especially going from a warm room into cold air outside, often provoke symptoms. You could try to do the following:

• Take a couple of puffs of your reliever before going outside
• Cover your mouth and nose with a scarf
• Use your preventer exactly as prescribed to reduce the risk of attacks due to cold air

Asthma and exercise

Some asthmatics find exercise brings on an attack and may need to use their reliever before starting any exercise.

Asthma and drugs

Certain prescription and over-the-counter drugs may trigger asthma attacks. They include aspirin and non-steroidal anti-inflammatory drugs such as ibuprofen and beta blockers used to treat heart disease and glaucoma. You should:

• Avoid drugs that may cause asthma symptoms
• Always remind your doctor about your asthma when being prescribed drugs
• Tell the pharmacist you have asthma if you're buying over-the-counter drugs

Asthma and emotions

Crying, getting excited or upset, and even laughing can all trigger symptoms, especially in small children. Using your medicines as recommended by your doctor will help you avoid problems.

Asthma and house dust mites

These tiny animals live on discarded flakes of human skin. Although some people with asthma react to the mites themselves, most are sensitive to the layer of protein that covers the mites' faeces.

Old sofas, armchairs, mattresses and fitted carpets all harbour mites, which thrive in the warm, damp atmosphere of today's centrally heated homes.

Although it's impossible to eliminate house dust mite dung entirely, there are many things you can do to reduce it:

• Hard floors, such as lino, wood or tiles, are easier to clean and keep dust free than carpets
• Rugs should be washed regularly and hung out to dry in the sunshine
• Special mattress and pillow covers are available
• Wash blankets and duvets regularly and hang outside to dry
• Air your bedroom daily by opening windows to reduce moisture levels, and wash curtains regularly
• Soft toys should be washed and dried (preferably) in a tumble dryer. Placing them in a plastic bag in your freezer, one day a week, will also help reduce the number of mites.

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What is asthma?

Asthma affects the small airways (bronchioles) that carry air in and out of the lungs. If you have asthma your airways can become inflamed, swollen and constricted (or narrowed) and excess mucus is produced.

More than 5.2 million people in the UK are being treated for asthma and about 1.1 million of these are children. Asthma affects approximately one in 12 adults and one in eight children in the UK. This means there is a person with asthma in one in five households in the UK. It can affect almost anyone, at any age, anywhere although it tends to be worse in children and young adults.

Asthma is becoming increasingly common in the developed world and is now the most common chronic condition in the west. Aspects of the modern environment that are thought to be contributing factors include:

• Air pollution
• Processed foods
• Centrally heated and double-glazed houses (ideal breeding grounds for house dust mites)

Asthma symptoms

An asthma attack describes the symptoms of tightness in the chest, a wheezing or whistling noise in the chest, coughing and difficulty breathing that occur when the airways become narrowed, inflamed and blocked by plugs of mucus.

An attack can occur suddenly. However, many people with asthma learn to recognise the warning symptoms - such as an itchy nose or itchy skin, dizziness or light-headedness, or an irritating cough.

Learning the warning signs can often alert someone with asthma in time to take preventive action.

Asthma is a chronic condition, which means attacks occur over a long period of time. Although there are times when acute episodes strike asthmatics, most people can say there are long periods during which they have few, if any, symptoms.

The main symptoms of asthma are:

• Coughing
• Wheezing
• Shortness of breath
• Tight feeling in the chest

Causes of asthma

Asthma has many different causes, but scientists still don't know exactly what these are. You may have oversensitive airways, a family history of asthma or be allergic to one or more asthma triggers.

Some doctors believe the airways become oversensitive because cells in the lungs are damaged by viruses. Others believe the initial damage is caused by an allergic reaction causing the lungs to overreact to viral infections.

One of the most common predisposing factors for asthma is an allergy to:

• House dust mites
• Mould spores
• Pollen
• Pets
• Food allergies

Most people find there are several things that can trigger their asthma.

Genetics and asthma

Asthma tends to run in families that are prone to allergies. So, belonging to a family where some members have asthma and others have other allergies, such as eczema, hay fever or allergic rhinitis, makes a person more likely to have asthma themselves.

However, because there are so many factors involved, it can be difficult to predict exactly who in a family will develop the condition.

Although asthmatic and allergic tendencies are inherited, there is no single gene involved. Rather, there are a number of different ones that react with factors in your environment to trigger the onset of asthma.

Scientists are searching for the genes involved in asthma that may eventually lead to a cure.

Environmental factors and asthma

Environmental factors that increase the risk of developing asthma include:

• Exposure to allergens during pregnancy (for example from foods in the mother's diet) that sensitise the unborn baby's immune system
• Infections such as colds during early life
• Being brought up in a house where there is a pet (especially a cat)
• Being introduced to certain foods such as cow's milk and eggs at a young age
• Being born at a time of year when the pollen count is high
• Being exposed to cigarette smoke in the uterus or early life - babies whose mothers smoke are twice as likely to develop asthma
• Air pollution

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Allergic asthma

Causes of asthma

Asthma often runs in atopic families. Children are also more likely to develop asthma if their mother smoked during pregnancy or while breastfeeding. 

Most people find several things trigger their asthma. Some of the most common predisposing factors for asthma are allergies to:

• House dust mites
• Mould spores
• Pollen
• Pets
• Food or food preservatives

Asthma triggers include:

• Viral infections, such as colds and flu
• Cigarette smoke
• Certain forms of exercise, such as running
• Exposure to cold, dry air
• Laughing and other emotions
• Medication containing aspirin
• Drinks containing sulphur dioxide, such as squashes and lemon barley water

Symptoms of asthma

The main symptoms are coughing, wheezing, shortness of breath and a tight feeling in the chest.

Asthma treatments

There are two main treatments for asthma:

• Relievers - salbutamol and terbutaline
• Preventers - beclomethasone, budesonide, fluticasone, mometasone and ciclesonide

These come in a variety of delivery devices, such as aerosol or powder inhalers and nebulisers. You breathe the medicine in through your mouth, directly into your lungs.

Relievers are drugs called bronchodilators (based on adrenaline) that relax the muscles which surround the airways, making it easier to breathe. You should take these as directed by your doctor as soon as symptoms appear. 

Taking a dose of the reliever inhaler before exercise will increase your stamina and prevent breathing difficulty.

Preventers are drugs (usually low-dose steroids) that reduce inflammation in the airways and make them less sensitive. This means you're less likely to react when exposed to a trigger. 

The protective effect of this medicine is built up over a period of time, so you must take your preventer regularly, as directed by your doctor. 

Combination preventer and long-acting reliever (formoterol and salmeterol) inhalers have become popular and seem to be particularly good at controlling more severe and persistent asthma.

If your asthma is really bad, your doctor may also prescribe a short course of steroid tablets to calm your inflamed airways.

Newer anti-inflammatory medication includes leukotriene receptor antagonists (montelukast and zafirlukast), which are particularly useful for brittle asthma and patients with aspirin-sensitive asthma.

The most recent addition to the list of possible treatments for asthma is a new injection medication (omalizumab) for those with severe allergic asthma, which works by dampening down the IgE allergic reaction.

An older orally administered bronchodilator, theophylline, isn't often used these days owing to its unpredictable toxic side-effects and need for blood testing.

There is little scientific evidence to support the use of breathing exercises, such as Buteyko, in the treatment of asthma. However, some people with asthma find breathing exercises calm their symptoms and reduce their need for reliever medication.

You can help to avoid asthma attacks by taking preventer medicine regularly and avoiding your triggers. You can also monitor your asthma by asking your doctor to provide you with a peak flow meter, a simple device that measures the amount of breath in your lungs.  

Most childhood asthma is caused by an allergy. Skin-prick and RAST tests may be able to discover the allergen. Practical steps can then be taken to avoid it, be it house dust mites, cats, dogs or other pets. Even mould spores and pollen grains can trigger seasonal asthma attacks. 

If you're prone to sudden or severe asthma attacks, keep asthma diary cards and a peak flow meter on hand to monitor your lung airflow so you can take early action. 

Discuss an asthma action plan with your GP, who may issue an emergency supply of oral steroid pills. You may need to increase your medication dosage if your peak flow measurement drops steadily.

Remember, never stop taking your preventer medication, even when your symptoms are stable. Don't wait until your symptoms get worse - they'll be harder to treat.

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