Take Control

ofyour

Asthma!

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ASTHMA

OF IRELANDSOCIETYSO

FO

ASOCIETY

DNALERI

STHMA

Produced in partnership with the HSE National Asthma Programme.

TABLE OF CONTENTS

WHAT IS ASTHMA? page 2

ASTHMA TREATMENTS AND HOW page 14TO TAKE THEM

CONTROLLING YOUR ASTHMA page 22

WHAT TO DO IN AN ASTHMA ATTACK page 28

How to use the Peak Flow Meter and page 31Inhaler Technique

FURTHER INFORMATION ABOUT THE page 38ASTHMA SOCIETY OF IRELAND

GLOSSARY page 41

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1 in 10 adults and 1 in 5 children in Ireland have asthma.

If you have any further questions about asthma after readingthis booklet you can call the Asthma Adviceline on1850 44 55 64, Tuesday-Thursday 10am-1pm, or visit ourwebsite at www.asthmasociety.ie

Prompted and inspired by the questions raised on the AsthmaAdviceline this booklet provides information that will help youto understand the basic aspects of asthma. This will enableyou to manage your condition, reduce the problems it causesyou, and to lead a life which is not restricted by asthma.

INTRODUCTION

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What is asthma?

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The usual symptoms of someonewith asthma are: difficulty inbreathing or a tight feeling in thechest or wheezing (a whistlingnoise in the chest) or a cough orany combination of thesesymptoms. These may occur inepisodes, perhaps brought on bycolds, exercise, change oftemperature, dust or other irritantsin the air, or by an allergy e.g.pollen or animals. Episodes atnight are common. A few peoplehave these symptoms all the time.You need to see your health careprofessional, who will check thatthere is not some otherexplanation. The doctor can usuallydecide if you have asthma by:

- Recording your symptoms- Examining your chest- Performing breathing tests

They can then decide on theappropriate treatment.

Anyone can develop asthma. It isvery common in Ireland, where over470,000 adults and children haveasthma. It can start at any time oflife, although it most often beginsin childhood. In fact, as many asone quarter of all children willwheeze at some time. Sometimes itaffects several family members e.g.if you have parents or brothers andsisters with asthma you are morelikely to have it yourself. Conditionslike hay fever, eczema, or hives,which are usually the result ofallergy, may occur along withasthma.

WHAT HAPPENS INASTHMA?

In Asthma, the airways becomeover-sensitive and react to factorsthat would normally cause noproblem, such as cold air or dust.

Have you been told that you (or your child) have asthma?Perhaps you suspect you have it? This booklet aims to tellyou about asthma and what to do next.

Remember:

� Good treatment for asthma is available� Most people with asthma live life normally.

IS IT ASTHMA? WHY ME?

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Muscle around the wall of theairway tightens, making it narrow.The lining of the airways may swell(just like your nose during a cold)and sticky mucus is produced,clogging up the breathingpassages. With the tubes narrowedlike this, it becomes difficult for airto flow in and out and is why thechest has to work harder.

The swelling of the lining of theairways and mucus production maydevelop slowly. Over a period oftime and using various inhalers andor medications these symptomsmay resolve.

HOW IS ASTHMADIAGNOSED?

Before any treatment commences itis important that your health careprofessional confirms the diagnosisof asthma.

Your doctor will record a patienthistory. He may ask you thefollowing questions;

� How long have you had asthmalike symptoms?

� How frequent are the symptomsand how they affect your qualityof life?

� Have you had an attack orrecurrent attacks of wheezing orcoughing or shortness of breath?

� Do you have a troublesomecough at night?

� Do you wheeze or cough afterexercise?

� Do you experience wheezing,chest tightness, or cough afterexposure to airborne allergens orpollutants?

� Do your colds "go to the chest"or take more than 10 days toclear up?

� Are symptoms improved byappropriate asthma treatment?

� Is there a family history ofasthma?

The following tests are useful indiagnosing asthma;1. Spirometry is a breathing testthat gives measurements of lungfunction including a reversibilitytest that measures lung functionbefore and after a dose ofreliever to see if it has improvedyour lung function. This can behelpful with asthma diagnosis.

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2. Peak Expiratory Flow Rate (PEFR)is another breathing test whichmay be measured over a periodof time, even when symptomfree, performed in a GP surgery,hospital and even at home.

3. An exercise test may be useful tocheck if exercise worsens yoursymptoms.

TRIGGERS

Most people can think of severalthings that make their asthmaworse. These we call triggers.A trigger is anything that irritatesthe airways and causes thesymptoms of asthma to appear.It can be difficult to identify whattriggers your asthma.

The common triggers are:1. Colds and flu2. Cigarette smoking3. Exercise and activity4. Allergies to pets, house dust

mites, pollen moulds and fungalspores.

5. Weather changes6. Air pollutants7. Occupation8. Food and drink9. Emotions10. Pregnancy11. Sex12. Strong smells and sprays13. Medications

Often it’s not just one trigger thatsets off an episode of asthma but amixture of several triggers at thesame time.

Colds and FluColds and flu, along with throatand nose infections, can bring onasthma episodes. You cannot stopyourself catching these infectionsso deal with them as soon as theyappear. The annual flu andpneumonia vaccinations every fiveyears are recommended foreveryone over the age of 65 andthose who have moderate tosevere asthma. Ask your healthcare professional about gettingyour flu jab each year.

Cigarette smokingAvoidance of passive and activesmoking is the most importantmeasure for both adults andchildren. At least 75% of peoplewith asthma become wheezy in asmokey room. It has been shownthat children with asthma whoseparents smoke have more asthmaepisodes than children whoseparents don’t smoke.

Facts about smoking;

� If you smoke or are exposed topassive smoke you increase therisk of asthma attack and maypermanently damage yourairways.

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� If you smoke as a teenager youincrease the risk of your asthmapersisting.

� You put your children at risk ofasthma if you smoke aroundthem or during pregnancy.

� You also increase the risk ofdeveloping Chronic ObstructivePulmonary Disease (COPD). COPDis a term used to describe anyone of a combination of chronicbronchitis, emphysema andchronic asthma.

Exercise and ActivityIf your asthma is under control youshould be able to do most sport orexercise that you enjoy. Wheezing,tightness of the chest or coughingduring or after exercise or activityshows that this is a trigger of yourasthma. However, it's better tocontrol your asthma than to avoidexercise. If your asthma symptomsworsen during or after exercise itcould be a sign your asthma ispoorly controlled.

What to do:� Ensure the coach is aware thatyou have asthma.

� Always make sure you use yourreliever inhaler (blue) immediatelybefore you warm up.

� Always start the session withwarm-up exercises (15-20 minutes)

� Avoid triggers if possible (seeabove)

� Always make sure to bring yourreliever medication with you andthat it is easily accessible

� Always ensure to warm downafter exercise

What are the best types of exercisefor people with asthma?Some of our top athletes in Irelandhave asthma. They make sure theirasthma is well controlled andbecause of this they are able tocompete at a national andinternational level. If your asthmais under control you should be ableto do most sport or exercise thatyou enjoy. For a gentle introductionto exercise you might like to trysome of the following exerciseoptions;

� Yoga (helps to relax the body andimprove your breathing technique)

� Fitness classes involving shortperiods of aerobic exercise

� Swimming (however, chemicalsused in pools may be a triggerfor some people).

Some sports and activities, forexample, scuba diving, climbing,hiking or skiing at high altitudes,can cause problems for somepeople with asthma. Speak to your

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health care professional if you arethinking about doing any of theseactivities.

People involved in competitivesport should ensure that theirmedication complies with thecurrent regulations of their sportingbodies. For further informationplease see our Factsheet on Asthma& Exercise.

AllergiesSome people are particularlysensitive to certain things theycome into contact with every day.These are “allergens” and they areimportant in hay fever and eczemaas well as asthma. Hay fever causesitching, a runny nose and sneezing.Eczema causes redness and itchingof the skin.

The most common causes ofallergies are:

� House dust mites

� Pets

� Pollens

� Moulds and Fungal Spores

For further information please seeour Asthma and Allergic Rhinitisbooklet.

House Dust MitesHouse dust mites are too tiny tosee. They eat the flakes of skin we

constantly shed. House dust mitesare in every home and it does notmean that our homes are dirty.They are found in furniture andcarpets and especially in our beds.We breathe in their waste productswhich may cause an allergicresponse in your airways. Signs ofallergy to dust mites may includewheezing when you are vacuumingor dusting; when you enter a dustyroom or house; asthma symptomsduring the night or first thing in themorning.

What to do:� Use complete barrier coveringsystems on your mattress, duvetand pillow

� If planning home renovations,remove carpets and replace withhard flooring.

� Vacuum all areas frequently. Usea vacuum cleaner with a HEPAfilter. Your supplier can give youinformation on this. Vacuumcleaners with HEPA filters aremore effective at picking up thedust mite and do not scatterdust. Ask someone to vacuumwhile you avoid the area.

� Damp dust surfaces or use anattachment on your vacuumcleaner.

� Reduce soft toy exposure andwash at 60˚c.

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� Hot wash (at 60˚c) sheets, duvetcovers and pillowcases once aweek. Although some people areallergic to feathers there is noconclusive evidence to show thatsynthetic, “hypo-allergenic” pilloware any better.

� Clean your soft furnishings withanti house dust mite chemicals.(Use with caution, as these cancause asthma symptoms forsome people)

If your symptoms do not improveon taking these measures there islimited benefit in continuing withthese measures.

PetsComplete avoidance of petallergens is impossible as theallergens are found in manyenvironments outside the home.Removal of such animals from thehome is encouraged. It can be alengthy period before allergenlevels decrease on removal of petsfrom the home. Cats are the secondmajor source of indoor allergen. Ahigh proportion of families keepcats and the allergens they producetend to stay in the house for longperiods. They are not a goodchoice of pet for families who havemembers with allergies. Other petsdo not seem to produce suchpotent allergens, but dogs, rabbits,

guinea pigs, hamsters and mice cancause problems for some people.

What to do:� Try to find a new home for yourpet, alternatively, never allowpets into the bedroom and ifpossible, keep them outside.

PollensPollens can come from grasses,trees and shrubs. Privet hedgeshave received publicity as a triggerfor asthma but not everyone withasthma is sensitive to it. Grassesand weeds are so widespread andhave such a long season that theyare the major pollen problem inIreland. Most grasses and weedshave two to six month seasons. Ifyou have a passion for gardeningor being outdoors, you can readmore advice in our Gardening withAsthma and Allergies booklet.

What to do:� If pollen triggers your asthma itis important to review yourtreatment with your health careprofessional in advance of thehay fever season.

� Look out for pollen forecasts onthe television, in newspapersand on our websitewww.asthmasociety.ie. If highcounts are forecast in yourregion, try to reduce time spent

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outside and continue to use yourprescribed medication. For moreinformation refer to our Asthmaand Allergic Rhinitis booklet.

Moulds and Fungal SporesMoulds release tiny seeds calledspores into the air, which cantrigger asthma symptoms in somepeople. Mould spores are found inany damp place - from piles ofautumn leaves and woody areas tobathrooms, kitchens and even pilesof damp clothes.

What to do:� Ensure the house is wellventilated.

� Remove mould or mildew fromwalls, shower curtains etc.

� Air clothes and wardrobesregularly.

� Avoid contact with spores fromrotting vegetation e.g. compost,leaf-mould

� Mowing the lawn may disturbpollen and spores

� If you are considering airconditioning for your house,investigate before you buy, it canbe expensive and not all typesare suitable

� Vacuum filters need to beeffective against the extremely

small pollen and fungal spores.(The type of filter required is aHEPA. This is a type not a brandname).

Weather ChangesOften changes of weather (ratherthan a particular temperature) cantrigger asthma. The arrival of springand autumn seem to be triggertimes. Asthma can be troublesomein winter but more usually becauseof colds and flu rather than theseason itself.

What to do:� Take your usual dose of relieverinhaler before going out on cold,dry days.

� If you are sensitive to cold windsmog, heat or other atmospherevariations take your relieverbefore leaving the home.

� If it is cold and windy, wear ascarf over your face to help towarm up the air before youbreathe in.

� Try to avoid going out in themiddle of the day on hot,smoggy days.

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Air PollutantsExamples of air pollutants includefactory smoke, car exhaust fumes,cigarette smoke, fly sprays, strongperfumes, and aerosol cleaningsprays.

What to do:� Try to find what the trigger is.

� If exhaust fumes are a problem,carry a reliever inhaler in your car.

� Keep well informed about airquality if pollution triggers yourasthma.

� Ozone can be a problem forsome people, and levels arelikely to be higher on hot sunnydays. Avoid being outdoorsespecially in the afternoon if youfeel that this may be a trigger foryou.

� Ensure that your home is wellventilated so that fumes do notaccumulate.

� Get heating systems servicedregularly.

OccupationsIf you developed asthma as anadult, it may be work related.Occupational asthma can some-times take weeks, months or yearsto develop. Look out for thefollowing signs:

� Your symptoms worsening duringthe week, at work or after work

� Your sleep is being disruptedbecause of increased symptoms.

� Your symptoms improving whenyou are not at work (for examplewhen you are on holiday or atweekends).

� Development of new symptomsof rhinitis, cough, and/or wheezeparticularly in non-smokersshould raise suspicion.

The major triggers of asthma atwork include:� Chemicals (isocyanates) found inspray-paint, foam molding,adhesives, and foundry cores andsurface coatings

� Dust from flour and grain

� Wood dust (particularly hardwood and red cedar wood dust)

� Colophony (fumes from glues,soldering and floor cleaners)

� Dust from insects, animals andtheir waste products

� Latex

� Stress

� Tobacco smoke

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If you notice anything that makesyour asthma worse, discuss it withyour health care professional andwith the Health and Safety Officerin your workplace. Taking action toreduce these triggers is vital. It isalso important that you are referredto an occupational asthmaspecialist to confirm the diagnosis.

Food and DrinkFood allergy as an exacerbatingfactor for asthma is uncommon andoccurs mainly in young children.Food avoidance should not berecommended until an allergy hasbeen clearly demonstrated. Whenfood allergy is demonstrated, thepatient should be referred to aspecialist in that area.Most people with asthma are notrequired to follow a special diet.Certain foods can make symptomsworse. The foods most commonlyassociated with food allergy arecow's milk, wheat, seafood,shellfish, eggs, soybeans andpeanuts. These can also cause yourface, tongue and mouth to swell.Milk allergy affecting asthma occursin approximately one out of 50children under the age of two. Inolder children and adults it is lessfrequent, approximately one in 500people. Often it is not the food ordrink as much as the substances oradditives in them e.g. preservativesand colouring.

What to do:� If you have an immediatereaction to a certain food, avoidit in future

� Check labels on all tinned andpackaged food, ensuring they arefree from the substances you areallergic to

� If you want to try an additive-freediet, contact the Asthma Societyfor a list of commonly usedadditives

� Discuss with your health careprofessional if you areconsidering changes in yourchild’s diet, as it may beimportant and necessary forhealthy growth

� Some people with asthma arevery intolerant of foodscontaining salicylates, which isthe main chemical in aspirin.Tomatoes, cucumbers and severalfruits, especially kiwi fruit,contain salicylates

� Do not stop dairy products forchildren under 14 without firstconsulting your health careprofessional.

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MedicinesAspirin and other nonsteroidal anti-inflammatory drugs i.e. ibubrufen,difene etc can cause severeexacerbations and should beavoided if there is a history ofreacting to these agents. Closemedical supervision is essentialwhen using Beta-blocker drugs totreat blood pressure and heartdisease administered orally ortopically for glaucoma when theseare used by patients with asthma.

EmotionsAt times people become worried,uptight or stressed as well as beingexcited or happy. What is ofconcern for people with asthma arethe extremes of these emotions, orwhen one upsetting emotion islong-term. The part your emotionsplay in your asthma can be difficultto pinpoint. If your feelings aren’twell balanced then they may bemaking your asthma worse. Thereare skilled people to help you, yourhealth care professional may beable to assist or refer you on.

Furthermore, ongoing monitoring ofyour condition, as well as takingyour medication regularly, shouldhelp to minimize your symptoms.

HormonesSome women find their asthma canbe affected around puberty, beforetheir periods, during pregnancy andduring the menopause. If yourasthma gets worse, see your doctorso that you can discuss anychanges in medicine that may helpto improve your symptoms.

Sexual activityIf you are concerned about yourasthma symptoms becoming worseduring sexual activity, you cancontrol your symptoms as youwould with any other form ofexercise. Take your usual does ofreliever inhaler beforehand.

SummaryEvery person with asthma hasdifferent triggers. Identifying themis not always easy but it is wellworthwhile trying. Using a peakflow meter (see page 26) orrecording symptoms when yourasthma gets worse will help youfind out your triggers. Payparticular attention to your triggerswhen your asthma is troublesome,as you will react more to them atthis time. Make a list of yourpossible triggers and take this listnext time you visit your health careprofessional.

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Asthma treatments and how to take them

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RELIEVERS

� Everyone with asthma shouldhave a reliever inhaler.

� A Reliever is a medication thatyou can take immediately whenasthma symptoms appear. Theyquickly relax the musclessurrounding the narrowedairways. This allows the airwaysto open wider making it easier to

breathe again. However relieversdo not reduce swelling in theairways.

� They are essential in treatingasthma attacks.

� They can be taken if you canpredict when your symptoms mayappear. Ie; If taken beforeexercise.

� Relievers are usually blueinhalers. They work almostimmediately to relieve thesymptoms of asthma. That is whythey are sometimes called rescueor quick fix relievers.

� If you are using your relieverinhaler two or more times aweek, and you should seekreview with your health careprofessional.

� Relievers are a safe and effectivemedicine and have few sideeffects. Some relievers mayslightly increase your heartbeat

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470,000 people in Ireland have asthma and the majority ofthese do not have their symptoms under control.

Ensure you take medication properly, particularly preventer/controller medication.

Preventer/controllerInhalerPPreveInhal

or give you mild muscle shakes.These effects are more commonwhen taking high doses. Theseside effects generally subside.

CONTROLLERS

Controller inhalers taken on a dailybasis are an effective therapy incontrolling asthma.

� Controllers control the swellingand inflammation in the airways.

� Their effects build up over aperiod of time so they need to betaken every day, usually morningand evening, even when you arefeeling well.

� You will be started on anappropriate level of treatment toget your symptoms undercontrol; once this has beenachieved the treatment may bereduced to the lowest possibledose.

� Controller inhalers usuallycontain a low dose ofcorticosteroid (steroid) medication.There are several kinds of inhaledcorticosteroids, but they all workin the same way to reduce theinflammation in your airways.

� Combination inhalers contain aninhaled corticosteroid and a longacting reliever medication in onedevice.

OTHER TREATMENTS AND‘ADD-ON THERAPIES’

If your asthma is not wellcontrolled by using your controllermedicine regularly, contact yourhealth care professional, who maysuggest other treatments or 'add-on therapies'.

The first 'add-on therapy' to betried is usually a leukotrienereceptor antagonist (LRA) whichblocks the action of naturallyoccurring chemicals in the lungs,called leukotrienes, which lead toinflammation in both upper andlower airways.

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ControllerInhaler

Long-acting relievers continueworking for a longer time thannormal relievers and are usuallytaken twice a day to have an effect.Another treatment which may beprescribed by your doctor is asustainedrelease theophyllinetablet.

� Before changing any medicines oroffering you new ones, yourhealth care professional candiscuss compliance i.e. inhalertechnique, if you are taking themregularly and at the prescribeddose.

When are Glucocorticoid(steroid) tablets used inasthma?If your asthma deteriorates, yourdoctor may prescribe a shortcourse of glucocorticoid (steroid)tablets. They work quickly andpowerfully to help soothe yourinflamed airways. Short courses oftablets should have minimum sideeffects. Glucocorticoid tablets canlower the body's resistance tochickenpox, so you should contactyour doctor if you are takingglucocosteroids and come intocontact with chickenpox. Alwaystalk to your health careprofessional about any concernsyou have about the side effects ofyour asthma treatment.

Concerns about inhaledsteroids controllerMany people are anxious about theside effects of corticosteroid usedin treatment of asthma.

Points to remember:� The inhaled steroid used to treatasthma are called corticosteroids

� Corticosteroids are a copy ofthose produced naturally in ourbodies

� They are completely different tothe anabolic steroids used bybody builders and athletes. Mostpeople with asthma use low doseinhaled corticosteroids, whichtargets the airways directly, sovery little is absorbed into therest of the body.

There is a small risk of a mouthinfection called thrush andhoarseness of the voice.

This can be avoided by

� Correct inhaler technique

� The use of a spacer if appropriate

� Mouth rinsing

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MANAGING ADULTASTHMA IN STEPS

Together with your health careprofessional you can establish ifyou are getting the appropriatetreatment for your asthma.

Developing a management plan inpartnership with your health careprofessional can also ensure thatone is controlled on a minimumlevel of medication that keeps theirasthma under control.

The key to continued control is totake your controller medicationdaily even when you are feelingwell. The beneficial effects of thecontroller medication build up overa period of time so they need to betaken every day, usually morningand evening, even when you arewell.

Keep your controller inhaler in ahandy place – so that taking itbecomes part of your daily routine.

How do I take my asthmamedicine?Many asthma medicines are givenby inhalers. There are a variety ofdifferent types of inhaler. Tabletsmay also be given as part of yourtreatment. Whichever inhaler youhave it is important that you use it

correctly. This helps send themedicine straight to where it'sneeded, inside the airways of yourlungs. Your health care professionalcan help you choose the bestdevice for you and show you howto use it correctly.

What is a spacer?

A spacer is a plastic container orholding chamber, usually in twohalves that click together. At oneend there is a mouthpiece or maskand at the other end there is anopening for the aerosol inhaler.There are several different brandsof spacer, which fit inhalers and areavailable on prescription (includingVolumatic and Babyhaler) andbrands that are not currentlyavailable on prescription (includingAerochamber). All these devices areavailable to buy from the AsthmaSociety at cost price plus postageand packaging.

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Please call the Asthma Societyoffice on 01 817 8886 or emailoffice@asthmasociety.ie.

Why use a Spacer device?� They make aerosol inhalerseasier to use and more effective

� They increase the deposition ofinhaled medicine into your lungs.

� They are a convenient andcompact alternative to nebulisedtherapy.

� Spacers may be used in acuteattacks of Asthma

� They help reduce the possibilityof side effects from the higherdoses of inhaled corticosteroids(controller)

How to use a spacer device:� Your health care professional willdemonstrate how to use yourinhaler and spacer.

� Ensure that the spacer iscompatible with your inhaler.

� There are several methods ofusing a spacer device and yourhealth care professional willdemonstarate the method mostsuitable for you.

� Clean your spacer according tomanufacteruers instructions.

Spacers should be replacedaccording to manufacturers’instructions.

When is nebulised therapyused?

A nebuliser compressor is amachine which creates a mist ofmedicine which is breathed inthrough a mask or mouthpiece.Nebulised therapy is often used togive high doses of a relievermedicine in an emergency. With somany improved inhaler devices andspacers available, there is lessneed for nebulised therapy.However, in certain circumstances,a hospital consultant may prescribeone.

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CompressorNebuliser

COMPLEMENTARYMEDICINES AND ASTHMA

Many people find thatcomplementary therapies,particularly yoga, acupuncture andhomeopathy, seem to improve theirasthma symptoms. However, thereis little scientific evidence thatcomplementary treatments used ontheir own are effective. That is whyit is better to regard them as'complementary' rather than'alternative'. If you want to try oneof the many complementarytreatments available, tell yourhealth care professional andcontinue taking your normalasthma medication.

IoniserIonisers aim to clean the airthrough the use of electrostaticcharges. Although, there is someevidence that they reduceallergens, other research showsthat they can increase symptomssuch as night-time cough inchildren. The Asthma Society ofIreland does not endorse their use.

Air Filter DevicesThere are a variety of air cleaningdevices that have been developedfor the control of indoor allergensand irritants. They vary widely indesign, methods of operation, cost

and level of efficiency. Clinicalstudies have failed to substantiatea significant impact of air cleanerson patient’s symptoms. Theyshould not be the primary meansof improving air quality and therefore should be used alongsideother allergen control measures. Ifyou are considering buying an airfilter, check what type of allergensit can filter as house dust miteallergens are heavy large particlesand will not be airborne but it maybe valuable for other allergensincluding those of dogs and cats.

HumidifiersA humidifier may be used to avoidexcessive dryness in the home.When using a humidifier therelative humidity in the homeshould be maintained below 60%and ideally between 30%-50%.These machines may be potentiallyharmful, as increased humidity mayencourage the growth of bothmould and house dust mites. If thehumidifier is not properly cleanedit can harbour and moisten mouldspores. The Asthma Society ofIreland does not endorse the use ofhumidifiers in the homes of thosewith asthma and those who aresensitive to the house dust mite.

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Controlling Your Asthma

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MANAGING ADULTASTHMA IN STEPS

When doctors decide how best totreat your asthma, they use a“stepwise” approach. Each stepshows what treatment is needed tocontrol your asthma. If thetreatment on one step is notworking, your doctor mayrecommend moving up to the nextstep. More importantly, if yourasthma is well controlled yourdoctor may recommend movingdown a step.

Step 1If you are using your relieverinhaler twice or less per week youshould go to step 2.

Step 2In addition to your reliever, you willnow need to take regular controllertreatment to reduce theinflammation in your airways. Thiswill almost always be a low-dosesteroid inhaler and/or LRA(leukotriene receptor antagonist).

Step 3If your asthma is not fullycontrolled, before increasingcontroller treatment, your doctorshould offer you a trial of ‘add-ontherapy’, such as a long-actingreliever. Symptoms should then beassessed to see if there has beenan improvement. There are other‘add-on’ treatments available and ifthe long-acting reliever medicinehas no effect, your doctor should

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The whole aim of managing asthma is to put you in controlof your asthma, rather than letting the asthma control you.The best way of getting control of your asthma is to work inclose partnership with your doctor or asthma nurse.Together, you will be able to decide whether you are gettingthe best treatment for your asthma. The key to keepingyour asthma under control is to continue to take yourcontroller medication every day – even when you’re feelingwell. It works over a period of time to give your airways theprotection they need. Keep your preventer/controller in ahandy place – so that taking it becomes part of your dailyroutine.

stop this treatment beforeintroducing other medicines.Patients who are not controlled onStep 3 medications should bereferred to a respiratory specialistfor further investigation.

Step 4Selection of treatment at Step 4depends on the response to priortreatments at Step 2 and Step 3.Increase in controller medication, inaddition to further add-ontherapies, may be introduced togain control at this stage.

Step 5Your symptoms are still difficult tocontrol, even on maximumamounts of medicine. Your GP mayrefer you to a respiratory specialistto investigate your conditionfurther and also assess if you aresuitable for other treatment.

Stepping Up and Stepping DownYou should be on the lowest doseof medicine to control your asthma.Once your asthma is under control,your doctor may consider “steppingdown” your medicines to see ifyour symptoms will stay controlledon a lower dose. It is importantthat your doctor or nurse reviewsyour symptoms after yourmedicines have been “steppeddown” to see what effect it hashad.

Your asthma should be stable andwell controlled for at least 3months before your doctor willconsider reducing your medication.

PERSONAL ASTHMA DIARYAND ACTION PLAN

Your health care professional maysuggest a Personal Asthma Diaryand Action Plan.

Asthma management plans areavailable from the Asthma Societyof Ireland.

Your health care professional cancomplete this management plan indiscussion with you. The plan willcontain information includingdetails of your asthma medication,key signs to tell you when yourasthma symptoms are gettingworse, what to do about it, andemergency information on action tofollow if you have an asthmaattack.

The plan allows you to vary yourmedicines within agreed limits togain better control of your asthma.

Ensure you have your asthmareviewed once a year or sooner ifyour symptoms are getting worse.

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WHAT IS A PEAKEXPIRATORY FLOW RATE(PEFR)?

A PEFR reading is a measurementof how fast you can blow air out ofyour lungs. Your peak flow readingis established by blowing into asmall plastic tube called a peakflow meter. The meter has a markerwhich slides up the scale as youblow out. The better controlledyour asthma the higher your peakflow score will be.

There is no best peak flow scorewhich is good for every one. Yourpredicted best score will varyaccording to your age, sex andheight.

Your health care professional willprobably ask you to take a seriesof peak flow readings over severalweeks. You should take readingsevery morning and evening, beforeyou use your inhalers. Your healthcare professional will give you adiary to enter the results and thenreview the recordings after aperiod.

Measuring your peak flow isimportant because

� You can tell how well yourasthma is controlled, rather thanguessing.

� You can ascertain if yourtreatment is effective.

� You will know if you need tochange your medication.

� The diary will help your healthcare professional assess thecourse of your asthma since yourlast visit and will enable them tomake appropriate decisionsabout your asthma managementat those times when you need toact on your own.

When you have measured yournormal best peak flow reading, itmay not be necessary to continuedaily readings. Then if you arefeeling unwell or wakening at night,using the reliever inhaler moreoften, increased cough wheeze orbreathlessness, or reduced level ofability to exercise, you can checkyour peak flow and compare it toyour normal best reading.

For a step by step approach onhow to use your peak flow meterplease see Pg 31.

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HOW CAN I TELL IF MYASTHMA IS GETTING BETTEROR WORSE?

There are other ways in which youcan keep a check on your asthma.

If you notice any of the following,you should see your health careprofessional who can help you toregain control of your asthma.

� Waking at night with coughing orwheezing or shortness of breathor a tight chest or anycombination of the afore-mentioned.

� Increased shortness of breath onwaking up in the morning.

� Requiring increased use ofreliever treatment or notresponding to reliever treatment.

� Unable to continue your usuallevel of activity or exercise.

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What to do in anasthma attack

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THE FIVE MINUTE RULE

The Five Minute Rule contains therecommended steps to follow in anasthma attack.

1. Ensure the reliever inhaler istaken immediately. This isusually blue and opens upnarrowed air passages.

2. Sit down and loosen tightclothing.

3. Stay calm. Attacks may befrightening and it is importantto stay calm.

4. If there is no immediateimprovement continue to takethe reliever inhaler every minutefor five minutes or untilsymptoms improve: two puffs ifMDI/evohaler or one puff ifturbohaler or diskus.

5. If symptoms do not improve infive minutes, or if you are indoubt, call 999 or 112 or adoctor urgently. Continue totake reliever inhaler until helparrives or symptoms improve.

Do not be afraid of causing a fuss,even at night.

If you are admitted to hospital oran accident and emergencydepartment because of yourasthma, take details of yourtreatment with you.

You should also make anappointment with your doctor ornurse after you are discharged fromhospital, so that you can reviewyour asthma treatment to avoid thesituation arising again.

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Occasionally an asthma attack may occur no matter howcareful you are about taking your asthma treatment andavoiding triggers. An asthma attack normally doesn’t occursuddenly; most people find that asthma attacks are theresult of a gradual worsening of symptoms over a few days.If your symptoms are getting worse, do not ignore them.Quite often using your reliever may be all that is needed toget your asthma under control again. At other timessymptoms are more severe and more urgent action isrequired.

HOW TO USE THE PEAKFLOW METER

1. Measure your peak flow ratemorning and evening beforetaking your inhalers.

2. Sit up straight.3. Push the pointer on the peak

flow meter to base/zero.4. Take a deep breath in.5. Grip the mouthpiece with your

teeth and seal with your lips.Take care not to cover or blockthe pointer with your finger.

6. Blow as hard and fast as youcan. (Short, sharp blast)

7. Do this 3 times and record thehighest reading.

If you are unsure of how to useyour peak flow meter go to theAsthma Society of Ireland websitewww.asthmasociety.ie to view avideo demonstration.

Peak flow meters can be purchasedat cost price from the AsthmaSociety of Ireland.

INHALER TECHNIQUE

How to use the diskus

1. Hold the outer casing of theDiskus in one hand whilstpushing the thumb grip awayuntil a click is heard.

2. Hold Diskus with mouthpiecetowards you, slide lever awayuntil it clicks. This makes thedose available for inhalationand moves the dose counter on.

3. Holding Diskus level, breatheout gently away from thedevice, put mouthpiece inmouth and suck in steadily anddeeply.

4. Remove Diskus from mouth andhold breath for about 10seconds.

5. To close, slide thumb grip backtowards you as far as it will gountil it clicks.

6. For a second dose repeat steps1-5.

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How to use the Easi-breathe

1. Shake inhaler.2. Hold inhaler upright. Open the

cap.3. Breathe out gently. Keep inhaler

upright, put mouthpiece inmouth and close lips and teetharound it (the air holes on thetop must not be blocked by thehand).

4. Breathe in slowly and deeplythrough mouthpiece. Don’t stopbreathing when the inhaler‘puffs’ and continue taking in areally deep breath.

5. Hold breath for about tenseconds.

6. After use, hold inhaler uprightand immediately close cap.

7. For a seond dose, wait a minutebefore repeating steps 1-6.

OptimizerThe optimizer is used when yourinhaler is a steroid based inhaler,in order to reduce the local sideeffects such as hoarseness andthrush. Follow the same steps asfor the Easi-breathe, on Step 2open the cap and put the optimizeron the device. Then continue tofollow Steps 3-7.

How to use the Novolizer

1. Take the cap off and prime it bypressing the button at the back.The bottom window will turngreen when the medication isready to take.

2. Exhale, and put the mouthpiecein your mouth.

3. Take a deep breath in (it isimportant to remember that asyou inhale the medication youare going to hear a click, youbreath through this click, don’tstop when you hear it. Thisindicates that you are using thedevice correctly.)

4. Hold for the count of 10, or aslong as possible.

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5. Exhale through your nose.6. The bottom window should now

be red, if you have used thedevice correctly.

7. Remember to replace the capafterwards.

How to use the metered doseinhaler

1. Remove cap and shake inhaler.2. Breathe out gently.3. Place the mouthpiece between

your teeth and close your lipsaround it but do not bite it.

4. Just after starting to breathe inthrough your mouth press downon the top of the inhaler torelease a puff while stillbreathing in steadily anddeeply.

5. Hold your breath, take theinhaler from your mouth andyour finger from the top of theinhaler. Continue holding yourbreath for a few seconds, or foras long as is comfortable.

6. After use always replace themouthpiece cover to keep outdust and fluff.

(Do not rush steps 3 – 5)

How to use the Turbohaler

1. Unscrew the cover and lift it off.You may hear a rattling sound.

2. Hold your Turbohaler uprightand turn the grip as far as it willgo in one direction. Then turn itas far as it will go in the otherdirection (it doesn’t matterwhich way you turn it first). Youshould hear a click sound. YourTurbohaler is now loaded and

33

ready to use. Only load yourTurnohaler when you are readyto use it.

3. Hold your Turbohaler away fromyour mouth and breathe outgently (as far as comfortable).Do not breathe through yourTurbohaler.

4. Place the mouthpiece gentlybetween your teeth, close yourlips and breathe in deeply andforcefully through your mouth.Do not chew or bite themouthpiece.

5. Remove your Turbohaler fromyour mouth then breathe outgently (there is no need to holdyour breath). If you are to takea second inhalation repeatsteps 2 to 5.

6. Replace the cover tightly afteruse.

How to use the spacer devicee.g. Volumatic

Multiple breath technique1. Remove cap, shake inhaler and

insert into device.2. Grip mouthpiece with your teeth

and seal with your lips.3. Start breathing in and out

slowly and gently. (This willmake a clicking sound as thevalve opens and closes)

4. Once breathing pattern is wellestablished, depress canisterand leave device in sameposition as you continue tobreathe (tidal breathing) severalmore times.

5. Remove device from mouth.6. If you need to take more than 1

puff repeat steps 2 – 5.

Single breath technique1. Remove cap, shake inhaler and

insert into device.2. Grip mouthpiece with your teeth

and seal with your lips.3. Press canister once to release a

dose of drug.4. Take a deep, slow breath in.5. Hold breath for about 10

seconds, then breathe outthrough the mouthpiece.

6. Breathe in again but do notpress the canister.

7. Remove device from mouth.8. If you need to take more than 1

puff repeat steps 2 – 7.

To clean the device, followmanufacturer’s instructions.

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An example of aSpacer with RelieverInhaler attached

How to use the Aerochamber

1. Remove cap.2. Shake inhaler and insert in back

of Aerochamber.3. Grip mouthpiece with your teeth

and seal with your lips.4. Press the canister once to

release a dose of the drug.5. Take a deep, slow breath in. (If

you hear a whistling sound, youare breathing in too quickly).

6. Hold breath for about tenseconds, then breathe outthrought the mouthpiece.

7. Breathe in again but do notpress canister.

8. Remove mouthpiece frommouth and breathe out.

9. Wait a few seconds before asecond dose is taken, andrepeat steps 2-8.

How to use the ApirivaRespimat Inhaler

Your health care professionalshould prepare the Respimatinhaler for first time use, afterwhich you should follow theinstructions below.1. With the transparent cap closed,

press the safety catch and pulloff the clear base.

2. Push the narrow end of thecartridge into the inhaler until itclicks into place. The cartridgeshould be pushed gentlyagainst a firm surface to ensurethat it has gone all the way in.Do not remove the cartridgeonce it has been inserted intothe inhaler.

3. Replace the clear base. Do notremove the clear base again.

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4. Hold the Respimat inhalerupright, with the transparentcap closed. Turn the base in thedirection of the red arrows onthe label until it clicks (halfturn)

5. Open the cap and breathe outslowly and fully.

6. Place the mouthpiece betweenyour teeth, seal with your lips,making sure not to cover the airvents. Point the inhaler to theback of your throat.

7. Press on the dose releasebutton and inhale slowly andfully through mouth.

8. Hold for ten seconds beforerepeating steps 1-6.

How to use the SpirivaHandihaler

1. Open the dust cap by pulling itupwards. Then open the mouth-piece.

2. Remove a Spiriva capsule fromthe blister (only immediatelybefore use) and place theSpiriva capsule in the centrechamber. It does not matterwhich way the capsule is placedin the chamber.

3. Close the mouthpiece firmlyuntil you hear a click, leavingthe dust cap open.

4. Hold the Handihaler withmouthpiece upwards and pressthe green piercing buttoncompletely in once, and thenrelease.

5. Breathe out completely. Pleaseavoid breathing into themouthpiece at any time.

6. Raise the Handihaler to yourmouth and close your lipstightly around the mouthpiece.Keep your head in an uprightposition and breathe in slowlyand deeply but at a ratesufficient to hear the capsulevibrate. Breathe until your lungsare full: then hold your breathas long as comfortable and atthe same time take theHandihaler out of your mouth.Resume normal breathing.Repeat steps 5 & 6 once, thiswill empty the capsulecompletely.

7. Open the mouthpiece again. Tipout the used capsule anddispose.

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These are the inhaler devices currentlyavailable. As new devices are developed upto date information will be available on ourwebsite at www.asthmasociety.ie.

3737

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Further information about the Asthma Society of Ireland

38

3939

ASTHMA SOCIETY OFIRELAND PUBLICATIONS

We have a range of informationmaterials on many topics relatedto or associated with asthma.These are available to view anddownload on our websitewww.asthmasociety.ie.Materials are also available onrequest from our office:

Tel: 01 817 8886Email: office@asthmasociety.ie

ASTHMA SOCIETY OFIRELAND WEBSITE

Read the latest independentadvice and news on asthma atwww.asthmasociety.ie

ASTHMA SOCIETY OFIRELAND ADVICELINE

Ask for help and advice from anasthma nurse specialist, who hasthe time to listen to your concernsand discuss what is right for youor your child – in confidence. Ourteam can also refer you to otherorganizations, which may be ableto help.

AAsstthhmmaa AAddvviicceelliinnee::1850 44 54 6410am–1pm, Monday - Friday.

40

Authors:

This booklet would not have been possible without the work andcooperation of the following, to whom we express our sincere thanks:

Medical Advisory Committee of the Asthma Society of Ireland

Frances Guiney, Asthma Nurse, Asthma Society of Ireland

Dr. Basil Elnazir, Chairman of the Medical Advisory Committee

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Acupuncture: A part of traditionalChinese medicine based aroundcorrecting the flow of Chithroughout the body. The mostwell-known technique is the useof needles, but suction andsimple pressure with fingers isalso used.

Allergen: If you are ‘allergic’ tosomething, allergens are the tinyparticles or substances to whichyou react when you come intocontact with them.

Allergy: To have an allergy meansto overreact to something in aharmful way when you come intocontact with it. If you have anallergy to grass pollen you willhave streaming eyes and nose,and sneezing when you come intocontact with it (hay fever).Someone who is not allergic tograss pollen will not even noticegrass pollen when they come intocontact with it.

Anabolic Steroids: These drugs arenot used in the treatment ofasthma. They cause the body tobuild up muscle, and because ofthis have been taken by someathletes to improve performanceand strength. They should not beconfused with corticosteroids,which are used to treat asthmaand a number of other medicalconditions.

Anti-Inflammatory: These aredrugs which have an actionagainst inflammation. Manydiseases or conditions of thebody – from asthma to arthritis orbowel disease – result ininflammation. Anti-inflammatorydrugs reduce this inflammationand help the body to keepfunctioning as normal.

Beta Blocker Drugs: These arevery important drugs which maybe used to treat high bloodpressure, angina, anxiety,glaucoma and a number of otherconditions. They have directly theopposite action to the betaagonists, so they are of no helpto people with asthma, and canbe dangerous. Nobody withasthma should take beta blockers,even in the form of eye drops,e.g. timolol, also known asTimoptol.

Colophony: A solid form of resin,used in many industries and animportant ingredient in industrialflux. Also known as Rosin.Prolonged exposure to the fumesreleased during soldering cancause occupational asthma.

Complementary Therapies: Non-medical treatments which may betaken alongside conventional drugtreatments. Alternative therapiesis another term often used, but

GLOSSARY

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this suggests that the therapy istaken instead of rather thanalongside conventional treatments.Popular complementary therapiesinclude homeopathy, acupuncture,osteopathy, breathing techniquessuch as buteyko and chiropractic.

Compressor: is a machine thatallows a nebulizer to convert aliquid medication into a very finemist which maybe breathed inthrough a mask or mouthpiece.

Corticosteroid: This is a group ofchemicals produced naturally bythe body (mainly in the adrenalglands) and also synthetically asdrugs. They are vital for the body’sown action against infection andstress; and in disease when givenas drugs they are amongst themost effective and powerfulagents to treat inflammation.

Exacerbation: an increase inseverity of symptoms.

Fungal Spores: Spores are micro-scopic reproductive structuresdispersed by many kinds of fungi,plants and algae. They float easilyin the air and are allergens,potentially causing asthma attacksin those allergic to that species ofspore.

Glaucoma: An eye disorder inwhich the optic nerve suffersdamage, permanently impairingvision in the affected eye. Strange

as it may seem, certain eye dropsprescribed for glaucoma mayaggravate asthma, as they arebeta blockers. If you have bothglaucoma and asthma, you shoulddiscuss this with your doctor.

HEPA Filter: A High EfficiencyParticulate Air filter is a type of airfilter that satisfies certainstandards of efficiency such asthose set by the United StatesDepartment of Energy.

Homeopathy: is based on theprinciple that diluting an activesubstance in a particular way canmake the active substance morepowerful despite the dilution. Itshould be used alongsideconventional treatments ratherthan replacing them.

Hormones: Chemical substancesproduced by the endocrine andother glands or cells and releasedinto the bloodstream to act uponspecific receptor sites in otherparts of the body so as to bringabout various effects.

Humidity: Humidity is a term forthe amount of water vapour in air.

Inflammation: The reaction of thebody to some injury, infection ordisease process. Generally, itspurpose is to protect the bodyagainst the spread of injury orinfection. But in some cases, as inpoorly controlled asthma, the

43

inflammation becomes chronic,and this tends to damage thebody rather than protect it.

Inhaler: A medical device used fordelivering medication into thebody via the lungs. It is mainlyused in the treatment of asthmaand COPD (Chronic ObstructivePulmonary Disease).

Ionizer: The air contains many tinyparticles which carry an electriccharge, positive or negative.Ionizers are machines whichchange positively chargedparticles in the air to negative,and this has the effect ofremoving them from the air.However research studies haveshown that they may in factworsen asthma symptoms.

Isocyanates: Compounds used inthe production of pesticides, theyare powerful irritants in the eyesand respiratory tracts.

Latex: A fluid found in manydifferent flowering plants andtrees. It is also used to refer tonatural latex rubber, such as inlatex gloves. Latex from someplants contains commerciallyusable rubber, which is wherenatural rubber comes from. It isan allergen as some people areallergic to it.

Leukotriene Receptor Antagonist:block the action of naturally

occurring chemicals in the lungscalled leukotrienes which areknown to cause narrowing of theairways and inflammation in thelungs which can lead to asthmasymptoms.

Menopause: The permanentending of menstruation in women,typically but not always duringtheir late 40s or early 50s. Itsignals the end of the fertilephase of a woman’s life.

Moulds: These are fungi that growon decaying food and deadleaves, and on walls and windowsin damp houses. They producemillions of microscopic spores,which float about invisibly in theair, and it is these that canprovoke allergic reactions.

Nebulizer: A nebulizer is a devicewhich breaks up liquid drugs intotiny droplets, forming a mistwhich you can then breathe intoyour lungs.

NSAIDs: (Non-Steroidal Anti-Inflammation Drugs). A class ofdrugs with painkilling andinflammation reducing properties.

Optimiser: is used when yourinhaler is a steroid based inhalerto reduce local side effects suchas hoarseness and thrush.

Ozone: A gas, related to oxygen,which is present in small amountsin the atmosphere.

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Peak Expiratory Flow Rate: Asimple but effective measure ofhow fast someone can blow airout of their lungs. The instrumentused to measure it is a peak flowmeter. People with asthma canhave a lower peak flow if theirasthma is not under control.

Personal Asthma Diary and ActionPlan helps people with Asthmamake changes to their treatmentas indicated by symptoms and/orpeak expiratory flow inaccordance with specific writteninstructions.

Preservatives: A preservative is anaturally occurring or syntheticsubstance that is added toproducts such as foods,pharmaceuticals, paints, biologicalsamples, wood, etc. to preventdecomposition.

Puberty: The process of physicalchanges by which a child’s bodybecomes an adult body capable ofreproduction.

Reliever: The most frequentlyused type of anti-asthma drug.Relievers relax muscle spasm(tightness) around the airways,helping to open up the airwaysand relieve symptoms. Relieversare best used when needed ratherthan regularly.

Rhinitis: Inflammation of the liningof the nose – similar to the

process of asthma in the airways.The commonest reason for rhinitisis allergy to grass pollen (hayfever, or seasonal rhinitis). Thesymptoms of rhinitis are runningof the nose, blocking, sneezingand itching.

Salicylates: A substance that issimilar to aspirin, found in manytypes of food.

Spacer: A plastic container orholding chamber, usually in twohalves that click together. At oneend there is a mouthpiece ormask and at the other end thereis an opening for the aerosolinhaler. They are useful becausethey allow the aerosol propellantto evaporate, leaving tiny dropletsof the drug to be inhaled. Theyare especially useful for takinginhaled corticosteroids as itimproves delivery of medicationand helps improve asthma control.

Symptom: A symptom is adeparture from normal function orfeeling which is noticed by apatient, indicating the presence ofa disease or abnormality.

Theophylline: An add on asthmamedication used in themanagement of asthma.

Trigger: Factors which may bringon symptoms or attacks ofasthma.

Address

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Donations of 250 per annum ( 21 per month) or more made by PAYE taxpayers could be of extra benefit to the Asthma Society of Ireland as it may be eligible for tax relief of up to 174 from the Revenue Commissioners at no extra cost to you. Contact us for more details.

Becoming a member of theAsthma Society of IrelandDon’t let asthma control you – take control of your asthma

Please pay the Asthma Society of Ireland the sum of:

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and afterwards on the same day monthly quarterly annually

until further notice and please debit my account accordingly.

Office use only Instructions to bank or building society: pay to Asthma Society of Ireland A/C 37426590, sort code 90-00-17, Bank of Ireland, College Green, Dublin 2, quoting reference

(Please make this at least a month from today’s date)

26 Mountjoy Square, Dublin 1Cumann Asma na hÉireann26 Cearnóg Mhuinseo, Áth Cliath 1Tel: (01) 878 8511 Fax: (01) 878 8128Asthma Advice Line: 1850 44 54 64Email: office@asthmasociety.iewww.asthmasociety.ie

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Top tips on exercising with Asthma

For more information or to order copies of any of these materials please visit our website on www.asthmasociety.ie or telephone us on 01 878 8511.

Asthma Attack Card

Reach your peak with Asthma

information posterReach your peak with Asthma DVD

Asthma – and Allergic Rhinitis

Best Practice Asthma Management Guidelines for Primary Schools in

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Best Practice Asthma Management Guidelines for Primary Schools in

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Asthma in babies andyoung children

Asthma inbabies and young childrenInformation for parents