Patient journey:
Follow these steps to a better quality of life
Phase 1: Self-management
When should I see a general practitioner?When should I see a general practitioner?
- Your symptoms of asthma are not controlled by lifestyle changes
- You are looking for a proper diagnosis and treatment by a physician
- You are looking for long-term sustained improvement of your symptoms
Depending on your countries medical system you may also be able to see a pulmonologist without prior consultation with a general practitioner (GP) if phase 1 is insufficient
Phase 2: General practitioner
When should I see a specialist?When should I see a specialist?
- You are still unable to control your symptoms despite first-line treatment
- You need reliever medication more than twice a month
- You suffer from asthma attacks
- You need specific allergy testing or lung function testing
- You are looking for long-term sustained improvement of your asthmatic symptoms
What is asthma?
Asthma is a common chronic respiratory illness. It affects 5-10% of the world’s population and combines a shortness of breath, wheezing and coughing fits. Asthma is caused by a combination of hereditary (genetic) and environmental factors (parents who smoke, an excess of allergens, air pollution, etc.), and leads to hyperreactive airways.
Symptoms worsen when exposed to certain stimuli, such as allergens, viruses, smoke, physical effort, etc. The nature of asthma is that symptoms and lung function change over time, even in the course of a single day, and every person with asthma may have good days and bad days (or longer periods). However, if asthma is properly treated (‘’well-controlled’’), there can also be long periods without symptoms or attacks.
What is an asthma attack, what causes it and what are the signs?
An asthma "attack" or episode is a period of time of increased asthma symptoms. The severity of symptoms during an attack can differ from person to person. The symptoms can be shortness of breath, cough, gasping and/or chest tightness which can be accompanied by anxiety or panic.
Several triggers or stimuli can cause asthma worsening (‘’exacerbation’’) or even an asthma attack: these include allergens, viruses, inhaled irritants such as tobacco smoke, fumes from open fireplaces, perfume, cleaning products, emotional stress, etc. An asthma attack is more likely to occur if the inflammation present in the airway of a person with asthma remains untreated.
An asthma attack can start suddenly or slowly. Mild attacks can usually settle down without treatment (e.g. stepping out of a room contaminated with a trigger (smoke, allergen, etc) into fresh air), although treatment usually helps to resolve them more quickly. Severe asthma symptoms can be life-threatening and need medical care. During an asthma attack, apart from massive bronchospasm, the lining of the airways in the lung swells further due to inflammation and there may be mucus plugging; these events cause substantial airways narrowing which causes the symptoms.
My child has asthma; how will this affect his/her life?
Childhood asthma is not a different disease from asthma in adults, but kids often have different symptoms. Doctors also call this type of asthma paediatric asthma. Asthma signs and symptoms vary from child to child and might get worse or better over time. In infants and young children, the primary symptoms of asthma are wheezing and coughing,
which are sometimes also caused by other conditions. Unfortunately, childhood asthma cannot be cured, and symptoms can continue into adulthood. But with the right treatment, you and your child can keep symptoms under control, prevent damage to the lungs and live a normal life. Depending on the triggers of your child's asthma, make adjustments at home, as well as in childcare facilities and other environments, to minimize your child's exposure to triggers.
COVID-19
I have asthma. Am I at risk to get more severe COVID-19 symptoms?
If your asthma is well-controlled, you are not at higher risk of severe infection with COVID-19 than the general population. In contrast, if your asthma is uncontrolled, it does become a risk factor of severe COVID-19. All efforts should be made to continue the use of your routine controller medication. Apart from this, as part of more general recommendations, it is important that you take into account the following other preventive measures: take care of your lifestyle including regular exercise in fresh air, healthy food and sufficient (healthy) sleep. Also, do not forget your annual flu vaccination.
Symptoms
Frequently Asked Questions
What are twitchy or hyperreactive airways?
Triggers may cause bronchospasm (where the tubes become narrow) and inflammation (or swelling of the lining) of the airways, known as the bronchial tubes, which become narrow through constriction and swelling. This causes an obstruction for the flow of air as it passes in and out of the lungs, making it difficult for a person to breathe. This is often accompanied with the production of too much mucus, which can cause further airway obstruction through plugging (or blocking the tubes).
What is an allergen?
An allergen is a harmless substance (antigen) that produces an abnormal immune response in a susceptible person. Allergen sources are commonly found in the home environment, and include house dust mites, furry pets (namely cat and dogs), mould and cockroaches, etc... . The most common sources of outdoor allergens are pollen such as tree, grass and weed pollen.
Who gets asthma? How many people suffer from asthma?
Asthma affects more than 5% of the worldwide population, with an increasing prevalence in developing countries. The disease usually develops during childhood, but it can also start at any time during adulthood, including the senior years. Both patient-specific (e.g. genetic) factors and external (e.g. parental smoking, allergen load, air pollution, etc) factors play a role in the development of allergic sensitisation and asthma development.
Is asthma a temporary or chronic disease?
Asthma is a chronic disease – which means that it is part of one’s condition, however, it may change over time. Although so far asthma cannot be cured, it can usually be controlled very well (for a long time) with a combination of customised measures including asthma-medications, anti-allergic therapy and lifestyle regimen. Currently, a lot of research is being performed to clarify still unknown asthma mechanisms. The results of these studies will help to understand more about why this disease develops, how we can control it even better or, hopefully, how it may be cured.
Is there a risk that my asthma will get worse with age?
Yes, when your asthma is poorly treated, your lung function may decrease more rapidly over time. However, taking regular controller medication (and following lifestyle regimen) as prescribed and explained by your doctor can prevent your asthma from worsening and will help to preserve your lung function.
Can a person die from asthma?
Unfortunately, people still die from acute and severe asthma. But this is unusual and can be prevented. Most asthma deaths occur in people who have not received adequate treatment. Learning about what triggers your asthma, including early warning and how to properly use your medications will help to keep your asthma under control.
Can asthma be outgrown?
Asthma is a chronic disease that will continue to bother if left untreated. In most children, wheezing episodes are transient and may disappear completely before the age of 3 years (60%) or even adolescence (20%). However, the more time symptoms last, the less likely they are to disappear. Waiting for this disease to be outgrown with age/time without appropriate preventive treatment can be very dangerous. On the contrary, adequate treatment is associated with better outcomes and longer periods without symptoms or asthma complaints.
What are asthma triggers?
Asthma triggers are factors that start asthma symptoms or an asthma attack by irritating the airways or worsening the inflammation in the airways. Asthma triggers are different from person to person and may include upper respiratory tract infections, such as the common cold or the flu, to allergens including dust mites, animal fur, pollens, moulds, etc.
Also inhaled irritants including air pollutants (cigarette smoke, fumes from cooking, heating or vehicle exhausts, cosmetics, aerosol sprays) and medicines (including aspirin) can evoke asthma symptoms. Exercise (especially in cold weather), emotional stress, and certain foods or beverages are also known asthma triggers. Identifying and avoiding your asthma triggers can help you keep your symptoms under control.
Triggers
Frequently Asked Questions
What are the main allergens that may trigger asthma?
House dust mites (small microscopic bugs that live inside our homes) and pollen are the main respiratory allergens. Indoors, people may also become allergic to pets (like cats, dogs, hamsters, rabbits or birds), to mold and cockroaches. Outdoors, pollen are a common cause of allergy and the type of pollen might vary depending on the area where you live. The most common pollen in Europe are birch and grass pollen but also parietaria, olive tree or ragweed. These pollen cause allergy and are very small and invisible to the human eye, different from bigger pollens from flowers which are harmless.
How much does tobacco smoking influence my asthma symptoms?
Smoke from cigarettes harms your body in many ways, but it is especially harmful to the respiratory system. The airways in a person with asthma are very sensitive and can therefore react more easily to smoke. Several studies suggest that people who smoke are more likely to develop asthma. Not only active but also passive smoking has a negative impact and influences asthma progression. In children exposed to tobacco smoke, the risk of having asthma symptoms doubles and the risk of having severe attack and need for hospitalization increases up to 6 times.
Can weather changes trigger asthma?
Yes, abrupt weather changes such as cold winds, humidity and storms can trigger asthma in some people. Some of these sudden changes cause the release of allergens, such as pollen, that can make asthma worse in people with seasonal allergies. Cold air can cause discomfort especially during exercise, having a direct irritant effect on inflamed airways. Additional factors such as exercise can further cause asthma (especially if untreated) to worsen (e.g. jogging or bicycling in cold and/or foggy weather, etc).
Can medications trigger asthma?
Yes, but only in few people and few medications can actually trigger asthma. The most common medicines that can trigger asthma are:
- aspirin (acetylsalicylic acid) and certain other non-steroidal anti-inflammatory drugs (NSAID, e.g. ibuprofen), which are mainly used as pain relievers.
- beta-blockers, which are used to treat high blood pressure, heart conditions, migraine or anxiety or beta blocker eye drops for glaucoma
Talk to your allergologist about this. Even if you develop symptoms with these drugs, it is usually possible to find an alternative treatment for you.
Can infections trigger asthma?
Yes, respiratory infections, such as pneumonia, colds or the flu can affect your lungs and trigger asthma symptoms, particularly in children. Especially following respiratory viral infections (e.g. common cold or flu), airways can remain ‘’twitchy’’ for several weeks or even months which is reflected in more symptoms e.g. during exercise, following irritants (allergens, but also tobacco smoke, perfume, etc) and/or prolonged coughing.
Can hormonal changes trigger asthma?
Yes, for example, some women start having asthma symptoms after menopause, others experience asthma worsening during the pre-menstrual phase or during pregnancy. However, this often relates to asthma not being well-controlled. For instance, if asthma is well-controlled before pregnancy, it is likely that asthma will remain well-controlled during pregnancy and labor (>80% of cases). On the contrary, if asthma is uncontrolled, 50% gets asthma worsening during pregnancy.
Can food trigger asthma? Should I stop drinking milk or change my diet in any way?
Asthma is not usually caused my food and most people with asthma have no food allergy. In most cases, there is no association with milk or any other food. However, some people with food allergy can also have asthma and in these cases, allergic reactions may be more severe, sometimes with asthma symptoms associated with rashes, swelling, vomiting or diarrhea. These reactions are classified as anaphylactic reactions and need immediate medical care. In these cases, asthma control is again essential because it allows reaction to be less severe.
Can other diseases worsen asthma?
Yes, if left untreated or uncontrolled, other diseases may contribute to worsen asthma, namely rhinitis (hay fever), sinusitis, nasal polyposis or gastro-esophageal reflux. We could even say that many asthma attacks begin in the nose… Treating and controlling nasal complaints is essential for good asthma control.
What lifestyle changes can help me?
By adapting your lifestyle and following a careful treatment procedure, it is possible to live largely without symptoms. It is therefore of the utmost importance that you work with your doctor to identify your personal asthma triggers and find a way to keep these under control.
Delay this for too long and you may cause permanent asthma damage: your airways will expand less broadly, resulting in a more limited lung capacity and asthma attacks. Certain lifestyle changes such as exercising regularly, keeping your weight healthy and stopping smoking can all benefit your asthma as well as your wider health.
Lifestyle
Frequently Asked Questions
What can I do to improve my home environment in general?
If you have asthma, an asthma attack can happen when you are exposed to certain asthma triggers. Learn with your doctor what your triggers are and how to avoid them. Many causes that potentially trigger asthma symptoms can be found in your home, including carpets, certain furnishings and cleaning products. House dust mites, animals, outdoor air pollution, cockroaches, moulds, pollen and tobacco smoke are all common asthma triggers. You may also come across triggers in other people's houses or in your workplace.
Will my asthma symptoms improve if I quit smoking?
People with asthma who continue smoking report significantly more chronic coughing and mucus than never-smokers and ex-smokers. People who have asthma and continue to smoke do not respond as well to preventer medication and are much more likely to develop chronic bronchitis/emphysema/COPD (chronic obstructive pulmonary disease). Therefore, all patients with asthma, even those with less severe asthma are advised to stop smoking and to avoid environmental tobacco smoke as much as possible.
I love to exercise; can I continue this while having asthma?
Asthma should not prevent you from staying active, since alternatively, regular exercise can even improve your asthma. Talk with your doctor about getting your asthma under better control, about the type of exercise and environmental factors (e.g. not exercising in cold, fog, or swimming in chlorinated water) and do not give up your workouts, sports, or other activities you enjoy. People with asthma who take regular exercise require less medication and have fewer asthma attacks.
How is the diagnosis made?
The first step towards a proper diagnosis: discuss your medical history, symptoms such as wheezing, coughing fits and a tight chest, and your sensitivity to triggers with your doctor. This will be followed by a physical examination, focusing on your chest, lungs, nose, throat, ears and eyes. Symptoms and medical examination are key to asthma diagnosis.
The most important tests depend on your case and include allergy tests and pulmonary function tests (spirometry with bronchodilation test). Where necessary, the doctor will perform an allergy test to identify the allergen that is presumably causing your symptoms. Depending on the availability of these tests, this can be either a blood test or a skin prick test. Allergy blood tests detect and measure the levels of allergen-specific antibodies in your blood and are preferred in patients with sensitive skin.
Diagnosis
Frequently Asked Questions
What are pulmonary function tests?
Pulmonary function tests are a series of different non-invasive breathing tests, usually done at a hospital or clinic that show how well the lungs are working. The tests measure lung volume, capacity, rates of flow, and gas exchange. Most of these breathing tests are done by blowing into a mouthpiece while sitting on a chair. Peak flow diaries can also be useful tool for making a diagnosis and monitoring, are performed at home (or even at work).
What is spirometry?
Spirometry is the most frequently used lung function test to confirm and monitor asthma. During this test, you breathe through your mouth (with the nose clipped) into a mouthpiece that is connected to a device, called a spirometer. Spirometry measures how much air you can inhale (breathe in) and exhale (breathe out) as well as how fast you can exhale – after a deep inhalation. The results of this test can help your doctor tell if you have asthma or how well your asthma is managed. Most often, a bronchodilator is administered and after 15 minutes spirometry is repeated, in order to check if there is an improvement in lung function with this medication.
What is first-line treatment?
Inhaled corticosteroids (puffers or dry powder inhalers) are the most efficacious treatments for asthma. Besides these, anti-leukotrienes (tablets, namely montelukast) are also available. Both are asthma controllers or preventive treatments, which are used for long periods of time to control airways inflammation.
These treatments are very efficacious and safe if properly used, allowing quality of life while preventing symptoms and asthma attacks. If you do not use your inhaler correctly, the medication will not get to their site of action and therefore will not work properly and will not be effective.
You might also be given a short course of oral steroid tablets/drops/injections to take for a few days until your symptoms are optimally controlled after an asthma attack.
What can I do during an asthma attack?
An asthma attack is a sudden worsening of asthma symptoms caused by the tightening of muscles around your airways (bronchospasm). You should stay calm and try to relax. Sit upright (do not lie down) and try to take slow, steady breaths. Tell someone that you are having asthma symptoms. Take the quick-relief medication as your
Asthma Action Plan tells you to. If the quick-relief medicine has not helped in 5-10 minutes, call your doctor or go to the nearest emergency centre or call an ambulance. Keep taking the quick-relief medicine, or as directed by your doctor, every 5-10 minutes until the ambulance arrives.
COVID-19
I take inhaled corticosteroids. Should I continue my treatment during the COVID-19 pandemic?
Until today there is no evidence suggesting that patients who are taking inhaled corticosteroids are at higher risk of COVID-19 infection or of more severe infection than the general population. To ensure that your asthma is well-controlled and consequently, to prevent a higher risk of COVID19, doctors advise to continue using your routine controller medication, including inhaled corticosteroids during the pandemic. Should your asthma symptoms worsen, do not hesitate to contact your physician.
I take tablets with corticosteroids. Should I continue my treatment during the COVID-19 pandemic?
Until today there is no evidence suggesting that a short course of tablets with corticosteroids impacts the evolution of COVID-19. This means that an asthma exacerbation should be treated as usual with oral corticosteroids. In case of long-term oral corticosteroid usage in combination with high-dose inhaled corticosteroids, monitoring of asthma and/or changing your medications should be conducted in close communication with your (respiratory) physician to prevent asthma exacerbations. Your (respiratory) physician may also decide to add other medications to the corticosteroids (e.g. long-acting relievers or leukotriene receptor antagonists or other medications) in order to reduce the overall dose of the corticosteroids. It is not advised to reduce your corticosteroid-containing medications yourself: this may induce health complications and your asthma control to worsen.
Treatment
Frequently Asked Questions
What are asthma puffers or inhalers?
These are devices that allow medication to be directly deposited in the airways, treating the site of inflammation without affecting other organs. There are two types of asthma puffers or inhalers. On the one hand, there are asthma controllers or preventive inhalers (with corticosteroids, or associated with bronchodilators). These are used daily and keep asthma under control. They also prevent asthma attacks. Controllers are used for longer periods of time and may be used throughout your life. If well used these treatments are safe and effective in asthma control. However, inhaled corticosteroids alone have no significant immediate effect during an asthma attack. In this case, bronchodilators are needed. These are the other type of inhalers: asthma relievers or rescue medication, whereby bronchodilators quickly relax the muscles surrounding the airways and allow more easy breathing. These are effective in most asthma attacks, but do not treat the underlying cause, namely the inflammation. A reliever should therefore be used as an ‘add-on’ treatment alongside a controller.
What are controllers?
Controllers have anti-inflammatory activity and mainly consist of corticosteroids often in combination with long-acting bronchodilators. Controllers usually need time to show effect (usually several weeks) and should be used for a longer period of time (mostly a lifetime) or as prescribed by your doctor. By controlling the airway inflammation, the asthma symptoms will diminish, and attacks can be prevented. Controllers do not immediately relieve wheezing, coughing or chest tightness, and should not be used alone to treat an asthma attack.
What are relievers?
There are short and long acting relievers. Short acting relievers can contain rapid-onset beta2 receptor agonists or muscarinic receptor antagonist, while long-acting reliever inhalers can contain long-acting beta agonists (LABA) and long-acting muscarinic receptor antagonists (LAMA). Some people with asthma are prescribed a long-acting reliever inhaler as an 'add-on' treatment. They work alongside the usual preventer inhaler every day to open up the airways and help make breathing easier. Long-acting reliever inhalers should only be used if you have also been prescribed a steroid preventer inhaler to use every day.
What effects do anti-inflammatory medications have?
Anti-inflammatory drugs reduce the airway inflammation and thus reduce or prevent swelling and tightening in the airways (‘’airway narrowing’’), can reduce mucus within the airways and have bronchoprotective properties (‘’reduce the twitchiness of the airways’’). Inhaled corticosteroids are the first-choice controller medications in most patients with asthma, while in severe asthma or during asthma attacks corticosteroids can be given as a tablet/drops or injected in a vein. Inhaled corticosteroids act locally in the airways and proved safe for long-term use at the doses most generally prescribed.
Are inhaled corticosteroids safe?
Inhaled corticosteroids have been the cornerstone of asthma treatment since their introduction to the market at the end of the 1970s. Inhaled steroids are generally well-tolerated and safe at the recommended dosages, even when taken for prolonged periods. Few patients may experience drug-related adverse effects, including mild symptoms such as a hoarse voice and thrush (fungal infection). Using a spacer device and rinsing the mouth with water after inhalation can prevent these usually benign side-effects.
How do steroid tablets/drops /injections work?
Steroid tablets/drops or injections contain a much higher dose of steroids than a controller inhaler. Your general practitioner will work out how much you need to take, and for how long, depending on your symptoms. These drugs aim to reduce inflammation but as they are taken in much higher doses and are not directly deposited in the airways, they affect other organs. Therefore, these drugs should be used only when prescribed by a medical doctor and for very short periods of time (a few days) in uncontrolled asthma/moderate-severe asthma attacks.
Are there any side effects from oral steroids or steroids injections?
Most people who take a short course of oral steroids or injection (for less than a week) will not experience significant side effects. You are more likely to notice side effects if you are on a high dose. Although the dose of steroids going into your body is higher if you are taking them in tablet/drops or injection forms, any side effects like stomach upset (from tablets/drops), increased appetite, and mood swings are usually temporary and will stop once the course of this medication has finished. Oral or injections with steroids can have severe side effects if they are kept for long periods of time or if used regularly / often, especially if on a high dose. Because tablets/drops or injections with corticosteroids affect your entire body instead of just a particular area, these routes of administration are much more likely to cause significant side effects on long-term use. Side effects may include:
- Elevated pressure in the eyes (glaucoma)
- Fluid retention, causing swelling in your lower legs
- High blood pressure
- Problems with mood swings, memory and behavior and other psychological effects, such as confusion or delirium
- Weight gain, with fat deposits in your abdomen, face and the back of your neck
When taking oral corticosteroids on longer term or several corticosteroid injections, you may experience:
- Clouding of the lens in one or both eyes (cataracts)
- Osteoporosis / thin bones and fractures
- High blood sugar, which can trigger or worsen diabetes
- Increased risk of infections, especially with common bacteria, viruses or molds
- Bruising, thin skin and slower wound healing
- Suppressed adrenal gland hormone production, leading to fatigue, loss of appetite, nausea and muscle weakness
When taken for longer periods, these drugs should never be stopped suddenly (they need to be slowly reduced according to medical criteria). Do not stop these drugs without medical advice. Never take these drugs for more than one or two weeks without medical supervision.
What to do after a doctor visit?
It is important to adhere to the therapy that your doctor has prescribed you and to monitor your symptoms in between consultations. Keep in mind that some treatments such as corticosteroids only show maximal effect after several days or weeks.
If your symptoms remain bothersome, if you still need to use reliever medication more than twice a month or if you develop new symptoms, it is important to take a new appointment with your doctor. If you have tried all first-line treatments and remain uncontrolled or if you are looking for long-term effects, you might consider taking an appointment with a pulmonologist or allergologist.
In case you also experience symptoms of the upper airways such as sneezing, itching, runny or blocked nose, you should report them to your doctor and consider making an appointment with an ear-nose-throat (ENT) doctor or allergologist.
How is the diagnosis made?
The first step towards a proper diagnosis: discuss your medical history, symptoms such as wheezing, coughing fits and a tight chest, tiredness, and your sensitivity to triggers (allergens, exercise, respiratory infections, …) with your doctor. This will be followed by a physical examination, focusing on your ears, eyes, nose, throat, skin, chest and lungs. Your doctor will decide the tests to determine your lung capacity. This may involve a spirometry with bronchodilation test, a plethysmography, a challenge test or FeNO (fraction of exhaled nitric oxide) test.
Your doctor will also conduct an allergy test. After all, allergies can cause asthma. The risk is significant, as around 60% of asthma patients suffer from allergic asthma. In the case of this asthma variant, environmental factors, such as pollen and dust mite, trigger the airways because your immune system considers them to be ‘dangerous’. Result: inflammation of the airways. Specific treatments exist in the case of allergic asthma.
If your asthma remains uncontrolled despite adequately taking your inhalers, the doctor may perform some additional test to determine the type of inflammation that is causing your symptoms. This may be either a blood test or a sputum induction to determine the level of inflammatory cells.
Why is it important to check my allergies when I have asthma?
Usually the diagnosis of asthma involves your medical history, symptoms, relationship with triggers, lung function tests and sometimes some additional tests. Allergic asthma is the most common type of asthma, affecting around 60% of people with asthma, especially if started at a young age. Both allergic and non-allergic asthma cause the same symptoms as discussed above.
Allergic asthma occurs when allergens in your environment trigger symptoms of asthma. Allergens cause an inflammatory reaction within the airways because your immune system ‘’thinks’’ they are harmful. If pollen is one of your triggers, you will probably notice that your asthma symptoms worsen around the same time every year. The doctor may suggest allergy testing (either a skin test or a blood test) to identify some of your triggers.
Common allergens that can cause asthma worsening or trigger an asthma attack include grass, tree and plant pollen, moulds, dust mites, pet dander (e.g. cat, dog, horse, rabbit, guinea-pigs, etc) or cockroaches. Some of these allergens show associations with food allergies, such as pollen with some fruits, etc. Apart from this, and often independent of asthma, some individuals can be allergic to certain foods such as peanuts, eggs, sea-products including shrimps and fish.
In all these cases, it is important to identify the allergen that causes symptoms for an adequate management (including medications, desensitization/allergy vaccines or avoidance whenever possible).
Diagnosis
Frequently Asked Questions
What is a peak flow meter?
A peak flow meter is a portable, inexpensive, handheld device that measures the air flow out of your lungs following a forced expiration. Peak flow measurements can be related to normal values and repeated measurements (e.g. two times per day during a longer period of time), can help to check control of your asthma and warn you that an asthma attack might happen soon.
What is spirometry?
Spirometry is the most frequently used lung function test to evaluate and monitor asthma. During this test, you breathe through your mouth (with the nose clipped) into a mouthpiece that is connected to a device, called a spirometer. Spirometry measures how much air you can inhale (breathe in) and exhale (breathe out) as well as how fast you can exhale – after a deep inhalation. The results of this test can help your doctor tell if you have asthma or how well your asthma is managed or controlled.
What is reversibility testing?
Reversibility testing is an additional test that can be requested by your doctor to be performed after reviewing the spirometry results. This test consists of repeating the spirometry 15-30 minutes after inhaling 2 or more puffs of a bronchodilator or reliever (usually salbutamol) to see if your lung function increases. This provides the doctor information on the underlying mechanisms of the airway response, need for treatment and best treatment options.
What is a FeNO test?
A FeNO test, also called exhaled nitric oxide testing, is a fast, safe and painless procedure. The test measures the amount of inflammation in your lungs reflecting ‘’disease activity’’. When you have asthma, your airways become inflamed and your nitric oxide values rise. Inhaled corticosteroids (these are anti-inflammatory medications used as standard therapy to control asthma) decrease inflammation and thus decrease FeNO. This result needs to be interpreted by your physician as it depends on several other conditions.
What is a methacholine bronchoprovocation or challenge test?
This is a standard lung function test to support or exclude the diagnosis of asthma in case your medical history and spirometry results are inconclusive. The test examines the ‘’twitchiness’’ of the airways; this is, how easy your airways respond to stimuli. During this test (which usually lasts approximately 1 hour), you will be asked to inhale gradually increasing concentrations of an airway narrowing substance, and the effect on the lung function is measured by spirometry. Once a certain decrease in lung function has been reached (‘’threshold’’) or the last concentration given, the test is completed. After the test you will receive a medication via inhalation to relieve the airway narrowing. A positive test confirms airways hyperreactivity (airway “twitchiness”) but it does not necessarily mean that you have asthma.
What is an exercise challenge test?
This is a lung function test to confirm the diagnosis of asthma in case your medical history and spirometry results are inconclusive, or asthma symptoms arise from exercise. This test also examines the ‘’twitchiness’’ of the airways and allows for the diagnosis of exercise-induced bronchoconstriction (airway narrowing). During this test (which usually lasts approximately 1 hour), you will be asked to perform a spirometry and then exercise in a treadmill or stationary bicycle (adapted to your condition) for a few minutes. The effect of exercise on the lung function is then measured by repeated spirometry. After the test, you may receive a drug via inhalation to relieve the airway narrowing, if necessary. Alternatively, a eucapnic hyperventilation test can be proposed in a specialized centre to confirm the presence of airway narrowing evoked by exercise.
What is a plethysmography test?
A plethysmography test can measure your total lung capacity and provides an overview of your lung volumes. This test gives healthcare providers information about how well your lungs are functioning. Although spirometry is the standard way to measure lung volumes and provides information on airway narrowing, lung plethysmography is a more extensive test. During the test you will sit in a sealed chamber, the size of a telephone booth. As your chest moves while you breathe, it changes the pressure and amount of air in the chamber. The test is painless and only takes a couple of minutes.
What is a lung diffusion test?
A lung diffusion test is used to examine how your lungs are processing air. Along with other tests, it can help your doctor determine whether your respiratory system is working properly and efficiently. For the test, you will be sitting down and wearing a mouthpiece that fits tightly around your lips. You will also need to wear clips on your nose, so you cannot breathe through it. When you breathe your lungs take in oxygen, which then passes into your bloodstream and is expelled by your lungs as carbon dioxide. The exhaled gas is analysed to determine how much carbon monoxide was absorbed by your body during your breath. A lung diffusion test is completely safe and only takes about 15 minutes.
What is a sputum induction test?
This test is only performed in specialized centers in case your doctor wants insights in the type of inflammation that is causing your symptoms. You will be asked to inhale a hypertonic saline solution via a nebulizer for several minutes. Afterwards, you can more easily expectorate sputum out of your airways. The sputum sample will be analyzed in the laboratory to determine the levels of inflammatory cells such as eosinophils or neutrophils.
What is second-line treatment?
There are two types of asthma medication. On the one hand, there are asthma controllers or preventive treatments (most often with corticosteroids). These are used daily and keep asthma under control, thanks to corticosteroids and bronchodilators, or anti-leukotrienes (namely montelukast). They also prevent asthma attacks. Controllers are used safely and effectively for long-time periods or throughout your life. However, these treatments have no significant immediate effect during an asthma attack.
On the other hand, there are asthma relievers or rescue medication, whereby bronchodilators quickly relax the muscles surrounding the airways. These are effective in most asthma attacks, but do not treat the underlying cause, namely the inflammation. A reliever should therefore be used as an ‘add-on’ treatment alongside a controller.
You might be given a short course of oral steroid tablets/drops to take until your symptoms are fully under control after an asthma attack. If you do not use your inhaler correctly, the medication will not get to their site of action and therefore will not work properly and will not be effective.
Immunotherapy (or allergy vaccines) is recommended in mild or average cases of allergic asthma. Asthma must be well controlled to take this treatment. This involves the application of allergens under your tongue (SLIT - sublingual immunotherapy) in tablet or spray/drop form, after which you are required to swallow, or regular (usually monthly) injections (SCIT - subcutaneous immunotherapy) in your arm.
In the event of severe asthma, monoclonal antibodies (or biologicals) may be considered. These monoclonal antibodies target specific immune substances in our body that play a crucial role in the inflammation of the airways. A number of these monoclonal antibodies are available and will be prescribed, depending on the type of inflammatory reaction and allergy status.
If you are over the age of 18 and have a severe form of asthma, for which normal treatment fails to provide relief, then bronchial thermoplasty, a procedure performed on the airway wall, may also be considered.
What is allergen immunotherapy?
Allergen immunotherapy, or allergy vaccine, is an immune-modulating treatment, aiming for the cause of the allergic disease. It involves the gradual exposure of your body with an increasing amount of allergen making your immune system tolerant. This can be carried out with tablets or drops containing the allergen under the tongue (this is called sublingual allergen immunotherapy, SLIT) or injections under the skin (subcutaneous allergen immunotherapy, SCIT). This is a truly personalized treatment; the allergens that are used in this treatment, either under the tongue or with injections, are selected according to your own allergies and symptoms.
According to current evidence, allergen immunotherapy can be recommended in mild and moderate allergic asthma, provided that asthma is caused by this allergen, and that this allergen cannot be completely avoided (e.g. house dust mite or pollen) or when looking for long-term efficacy. Another prerequisite is that asthma should be otherwise adequately controlled by pharmacotherapy (medications) without a substantial airway narrowing.
Immunotherapy is only available for a limited number of allergens and is known to be effective in reducing the risk of asthma onset and has been progressively applied for the treatment of allergic asthma. It has the potential to achieve reductions in symptom and medication scores, but there is no clear or consistent evidence that measures of lung function can be improved.
Treatment response can be expected after several weeks/months. It is therefore very important to adhere to the therapy. When an effective dose is reached (the maintenance dose), you will need to continue treatment up to three to five years, both for sublingual and subcutaneous routes. Allergen immunotherapy should only be carried out under the close supervision of a healthcare provider with experience in immunotherapy as there is a risk of adverse allergic events. You should have a written action plan including which medication you should take in the event of an allergic reaction.
What are monoclonal antibodies or biologics?
Monoclonal antibodies or biologics are designed to target specific substances in your immune system that cause inflammation. The term “biologic” is used for medications that are made from living animals, plants, or cells, instead of through a chemical process. All of the biologic medications currently used for asthma are antibodies, a kind of protein that occurs naturally in our bodies and plays an important role in our immune system.
Monoclonal antibodies are used for severe asthma treatment as an add-on option and do not replace your existing controller and reliever medications, although some people may eventually be able to reduce the dose of their inhaled or oral corticosteroid.
COVID-19
I take inhaled corticosteroids. Should I continue my treatment during the COVID-19 pandemic?
Until today there is no evidence suggesting that patients who are taking inhaled corticosteroids are at higher risk of COVID-19 infection or of more severe infection than the general population. To ensure that your asthma is well-controlled and consequently, to prevent a higher risk of COVID19, doctors advise to continue using your routine controller medication, including inhaled corticosteroids during the pandemic. Should your asthma symptoms worsen, do not hesitate to contact your physician.
I take tablets with corticosteroids. Should I continue my treatment during the COVID-19 pandemic?
Until today there is no evidence suggesting that a short course of tablets with corticosteroids impacts the evolution of COVID-19. This means that an asthma exacerbation should be treated as usual with oral corticosteroids. In case of long-term oral corticosteroid usage in combination with high-dose inhaled corticosteroids, monitoring of asthma and/or changing your medications should be conducted in close communication with your (respiratory) physician to prevent asthma exacerbations. Your (respiratory) physician may also decide to add other medications to the corticosteroids (e.g. long-acting relievers or leukotriene receptor antagonists or other medications) in order to reduce the overall dose of the corticosteroids. It is not advised to reduce your corticosteroid-containing medications yourself: this may induce health complications and your asthma control to worsen.
I take biologic therapy for my asthma. Should I continue my treatment during the COVID-19 pandemic?
Biologic treatment should be continued in patients who are not infected with COVID-19. It is advised to use self-administration devices at home, whenever this option is available to minimize face-to-face contact in the clinic. Patients who are infected with COVID-19 should, irrespective of the severity of their infection and symptoms, contact their (respiratory) physician on the continuation of their asthma medications including their biologics treatment.
Treatment
Frequently Asked Questions
What are controllers?
Controllers have anti-inflammatory activity and mainly consist of corticosteroids often in combination with long-acting bronchodilators. Controllers usually need time to show effect (usually several weeks) and should be used for a longer period of time (mostly a lifetime) or as prescribed by your doctor. By controlling the airway inflammation, the asthma symptoms will diminish, and attacks can be prevented. Controllers do not immediately relieve wheezing, coughing or chest tightness, and should not be used alone to treat a severe asthma attack.
What are relievers?
There are short and long acting relievers. Short acting relievers can contain rapid-onset beta2 receptor agonists or muscarinic antagonist, while long-acting reliever inhalers can contain long-acting beta agonists (LABA) and long-acting muscarinic receptor antagonists (LAMA). Some people with asthma are prescribed a long-acting reliever inhaler as an 'add-on' treatment. They work alongside the usual preventer inhaler every day to open up the airways and help make breathing easier. Long-acting reliever inhalers should only be used if you have also been prescribed a steroid preventer inhaler to use every day.
What effects do anti-inflammatory medications have?
Anti-inflammatory drugs reduce the airway inflammation and thus reduce or prevent swelling and tightening in the airways (‘’airway narrowing’’), can reduce mucus within the airways and have bronchoprotective properties (‘’reduce the twitchiness of the airways’’). Inhaled corticosteroids are the first-choice controller medications in most patients with asthma, while in severe asthma or during asthma attacks corticosteroids can be given as a tablet/drops or injected in a vein. Inhaled corticosteroids act locally in the airways and proved safe at the doses most generally prescribed.
How do steroid tablets/drops /injections work?
Steroid tablets/drops or injections contain a much higher dose of steroids than a controller inhaler. Your general practitioner will work out how much you need to take, and for how long, depending on your symptoms. These drugs aim to reduce inflammation but as they are taken in much higher doses and are not directly deposited in the airways, they affect other organs. Therefore, these drugs should be used only when prescribed by a medical doctor and for very short periods of time (a few days) in uncontrolled asthma/moderate-severe asthma attacks.
Are there any side effects from oral steroids or steroid injections?
Most people who take a short course of oral steroids or injection (for less than a week) will not experience significant side effects. You are more likely to notice side effects if you are on a high dose.
Although the dose of steroids going into your body is higher if you are taking them in tablet/drops or injection forms, any side effects like stomach upset (from tablets/drops), increased appetite, and mood swings are usually temporary and will stop once the course of this medication has finished.
Oral or injections with steroids can have severe side effects if they are kept for long periods of time or if used regularly / often, especially if on a high dose. Because tablets/drops or injections with corticosteroids affect your entire body instead of just a particular area, these routes of administration are much more likely to cause significant side effects on long-term use. Side effects may include:
- Elevated pressure in the eyes (glaucoma)
- Fluid retention, causing swelling in your lower legs
- High blood pressure
- Problems with mood swings, memory and behavior and other psychological effects, such as confusion or delirium
- Weight gain, with fat deposits in your abdomen, face and the back of your neck
When taking oral corticosteroids on longer term or several corticosteroid injections, you may experience:
- Clouding of the lens in one or both eyes (cataracts)
- Osteoporosis / thin bones and fractures
- High blood sugar, which can trigger or worsen diabetes
- Increased risk of infections, especially with common bacteria, viruses or molds
- Bruising, thin skin and slower wound healing
- Suppressed adrenal gland hormone production, leading to fatigue, loss of appetite, nausea and muscle weakness
When taken for longer periods, these drugs should never be stopped fast (they need to be slowly reduced according to medical criteria). Do not stop these drugs without medical advice. Never take these drugs for more than one or two weeks without medical supervision.
What is bronchial thermoplasty?
Bronchial thermoplasty is a medical procedure for people with severe or persistent asthma who cannot be optimally controlled with usual asthma treatments and lifestyle adjustments. In most of these patients there is no prominent airway inflammation, but other factors play a role (e.g. airway muscle thickening).
Bronchial thermoplasty reduces the amount of thickened smooth muscle on the inside walls of the airways. It also makes your airways less likely to contract and narrow in the future. For this procedure you will need to visit a hospital or specialist centre. Under sedation, a thin, flexible tube (bronchoscope) is passed through the nose or mouth and down into the lower airways. A special wire is then passed down through this tube into the airways. This wire delivers short, controlled pulses of heat to the airway wall to reduce the excess smooth muscle tissue. The patient is monitored after the procedure and may usually be dismissed within 24 hrs after the procedure. A full course of bronchial thermoplasty treatment includes three separate bronchoscopic procedures. Long term effects of bronchial thermoplasty have not been evaluated, so far.
What are the benefits of monoclonal antibodies?
Monoclonal therapy has shown to decrease the frequency of asthma attacks, including emergency room visits, hospitalizations, and need for oral steroids. Other benefits include reduced asthma symptoms, reduced dosage of other controller medication and improvement in quality of life.
How do monoclonal antibodies work?
Depending on the monoclonal antibody, they specifically target different substances. Some antibodies work by binding immunoglobulin E (IgE), thus preventing it from interacting with the receptor on the surface of inflammatory cells or other effects. Other monoclonal antibodies target interleukin-4 (IL-4) and interleukin-13 (IL-13) which have several biologic roles including in the physiologic changes induced by allergic inflammation. Others target interleukin-5 (IL-5), an immune system protein that normally activates the production of a type of inflammatory cells called eosinophils.
How are monoclonal antibodies administered?
Monoclonal antibodies so far on the market are administered subcutaneously or intravenously (i.e. with an injection) – usually once per 2 to 8 weeks depending on the biologic. Most biologics are currently administered in a doctor’s office, other biologics can be administered at home after learning how to use it yourself.
How long do I need to be on a biologic?
There are currently no set recommendations on how long a patient should be on a biologic. Guidelines recommend trialling the medication, in most cases for about four months, to see if it is improving your asthma symptoms. Many people use biologic treatments for long periods of time, most use it for several years with maintained effects.
Are monoclonal antibodies safe?
Commercialized monoclonal antibodies are generally well tolerated, although injection site reactions may be more common. Other reported adverse events are usually mild to moderate, headaches and upper respiratory tract infections have been reported. These drugs should only be given by expert physicians who will closely monitor your health and adjust the best possible treatment for you.
What is the difference between SCIT and SLIT?
Subcutaneous allergen immunotherapy (SCIT) injections are administered right under the skin. In the beginning, injections are given weekly and this progresses to monthly administration after a number of weeks. Because SCIT treatment has a small but present risk of a severe allergic reaction, the treatment is performed by a trained health care provider/professional. After the injection you will have to stay at the health care professional for an observation period of minimum 30 minutes
Sublingual immunotherapy treatment (SLIT) tablets or drops containing the allergen are administered under the patient’s tongue and swallowed. The safety profile of SLIT is high; therefore, SLIT can be self-administrated by patients at home. It is recommended that the first dose is taken in the presence of a health care provider.
What are typical side effects related to SCIT?
Common local reactions to SCIT are a red and itchy swelling of the skin at the site of injection that will disappear within several hours to days. Sporadically some systemic reactions occur such as itchy eyes, sneezing and shortness of breath. In very rare cases, a severe reaction can occur resulting in a sudden drop in blood pressure. This is why it is recommended that patients wait in their doctor's office for at least 30 minutes after SCIT treatment.
What are typical side effects related to SLIT?
SLIT is usually a well-tolerated treatment with a good safety profile. For this reason, it can be administered at home by the patient itself in contrast to SCIT which has to be administered by a doctor. Like all treatments, SLIT can also cause a variety of side effects which are usually mild and transient. Some common side effects are an itchy nose, ears or eyes, swelling of the mouth and lips, coughing and sneezing. Some rare side effects are nausea and abdominal pain. Very uncommon side effects are intensive itching in palms of hand and soles of feet, urticaria and swelling of mouth and throat that create a feeling of fullness in the throat. Most of these side effects occur within the first week of treatment and then reduce over time.
What to do after a specialist visit?
For some people, taking medicines every day may feel complicated or ‘’restricting’’. It might feel strange to be asked to take controller medicine every day, even when you feel well. However, controller medication is used to control and to prevent asthma symptoms, and to prevent asthma attacks and lung function decline.
We should remember that asthma is an inflammatory disease and it requires regular daily treatment in most cases, much like in hypertension or diabetes or other chronic diseases. Thus, controller medications should be taken as recommended by your doctor, in most cases every day regardless of how the person's asthma is doing that day. Improved patient adherence leads to improvements in asthma control, quality of life and prevents symptoms and attacks.
Follow-up
Frequently Asked Questions
How can I know if my asthma is well-controlled?
If your symptoms remain bothersome, if you still need reliever medication (particularly if twice or more a week) or if you develop new symptoms, it is important to take a new appointment with your doctor. In case you also experience symptoms of the upper airways such itching, sneezing, a runny or blocked nose, you should report them to your doctor and consider making an appointment with an ear-nose and throat doctor or an allergologist.
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