Though many people are reluctant to admit that they have asthma, this is the commonest chronic respiratory disease seen in Sri Lanka with 15 to 20% of the population being afflicted. There has been a significant rise in the number of asthma patients in recent times, with as many as 180,000 hospital admissions and 800 deaths a year. Although the social stigma attached to the disease prevents many from saying they are asthmatic, many people will admit that they have 'wheezing attacks' on and off.
All those who complain about wheezing, though, are not asthmatics. There are other conditions that give rise to this symptom. Yet the commonest cause for repeated attacks of wheezing is asthma.
The usual clinical features of asthma are:

• coughing
• wheezing or a whistling noise in the chest
• Shortness of breath
• a tight feeling in the chest

If these symptoms recur, you could be having asthma. The symptoms are not present all the time. You could have the symptoms during an attack but be perfectly normal in between. In a few people, the disease is so severe that periods of good health are rare.

However, if the symptoms are of recent onset or you've just had one such episode, other conditions which give rise to the same symptoms should be considered. For instance they could be related to some heart problems.

Asthma can begin at any age. It is fairly common during childhood and a significant number of children grow out of it during adolescence. In some it goes on into adulthood. Children who grow out of it during their teens can have it again when they are older.

Symptoms occurring for the first time during adulthood in a person who never had wheezing as a child, could be related to some other disease. Therefore a doctor needs to assess your symptoms and decide on the condition.

What is asthma?

Asthma is a longstanding disease that affects the lungs when the soft skin lining the respiratory passage is highly sensitive to various substances found in the environment. They can be allergens, substances that trigger allergic response or irritants that irritate the respiratory passage. When the lining of the respiratory passage comes into contact with those substances, it triggers an inflammatory response which results in a flare-up or an exacerbation of asthma.

The inflammatory response causes the airways to get narrowed suddenly and secretions to fill up the respiratory passage. It produces a cough, difficulty in breathing, tightening of the chest and whistling noises in the chest. Although there could be minor changes in the respiratory tract with longstanding asthma, it is considered a 'reversible air flow limitation' because once the inflammatory response ceases, the airway is back to its normal function.

Therefore, quite contrary to popular belief, asthma should not be a condition that should restrict your day-to-day life. With medication and certain lifestyle modifications, the majority of asthma patients can lead a more or less normal life.

Depending on the severity and the frequency of the symptoms, you will be categorized as having mild intermittent disease, moderate or severe disease. This actually is a technical classification that helps the doctor to decide on the treatment plan.

Living a good quality life for asthma patients includes modifying your lifestyle and getting appropriate medication. Lifestyle modifications include mainly the identification and avoidance of trigger factors or the factors that set off an attack.

Well known trigger factors

• viral infections (such as a cold)
• tobacco, pollutants (such as wood smoke)
• cold air
• exercise
• fumes from chemicals or perfume
• sinus infections
• Heartburn
• strong emotions or stress

Pay attention to the way these things affect your asthma. If you and your doctor figure out which things aggravate your asthma, you can start trying to address them. Remember that everything on this list will not trigger a flare-up in every asthmatic. You yourself will have to identify your triggers. Some people may get it as an allergic response to some food item and another will get it by exercising. Thus avoidance of trigger factors should not unnecessarily restrict your life.

The second important aspect in asthma control is medication. Unfortunately there are lots of misconceptions about the drugs used for asthma. There are two types of medication, the symptom reliever medication (to be taken at a flare-up) and the preventive medication (to be taken on a regular basis. If you get infrequent mild attacks which do not affect your day-to-day life badly then you are most likely to be prescribed the symptom reliever medication to be taken at a flare-up. This is given as an inhaler so that it can be directly delivered to the lung. This promotes quick action and minimizes absorption of drug into the blood so that the side effects are less than the tablet form. Some people still believe that they can get addicted to inhalers. This is a myth. Inhalers are a more effective and safe way of delivering the asthma medication.

However, if the disease severity or the frequency is such that it affects your lifestyle, you will be put on preventive medication to be taken on a regular basis. Usually these are steroids and if it cannot be controlled only with inhalers the doctors would suggest oral tablets.

Apart from steroids there is other medication that prevents exacerbation. The most important advice is that you are not supposed to alter the dose of these drugs on your own. There is no point in taking a high dose of these medications when there is a flare-up. This is meant to prevent flare-ups on a regular basis.

Some people do worry about the side-effects of steroids and other medication given for asthma. Prescribing medication for asthma is done after weighing the risks and the benefits of the drug, with a view to improving your quality of life without unnecessary side-effects. Hence, it is always advisable to continue your medication as your doctor prescribes, not altering the doses and the frequencies as you want.

Your doctor will also advise on what to do during a flare-up or attack. Here is a rough guide.

• Take two puffs of your reliever (blue) inhaler
• Sit up and loosen tight clothing
• If there is no immediate improvement during an attack, repeat the dose of reliever inhaler as advised by your doctor. (Please have the instructions written so that a family members can help you during an attack)

If your symptoms do not improve with the prescribed dose, or if you are in doubt, seek medical advice, especially if:

• You are too breathless or exhausted to talk
• Your lips are blue

If the symptoms are getting worse, the doctor will start you on nebulizer medication, oxygen and other necessary drugs. During a flare-up, your usual medication regimen will be altered but after a few days when you improve, it can be resumed. However if disease control seems insufficient, the treatment plan will be altered as necessary.

If your asthma is not under control discuss the following possibilities with your doctor:

• Is there a triggering factor at my home environment or workplace?
• Do I take the medication as advised?
• Do I use the correct inhaler technique?
• Is it necessary to review the medication?
• Is the diagnosis correct?

Some asthma medicines are taken with a metered-dose inhaler. Your doctor will show you how to use an inhaler. Here are the basic steps:

• Remove the cap and hold the inhaler upright. Make sure the mouth piece is clean.
• Shake the canister holding it upright. Unless you shake it, you will only get a reduced dose of the drug.
• Tilt your head back and breathe out.
• Take the mouthpiece into your mouth. Or, if you're using a spacer, put the end of it in your mouth and seal your lips around it. (A spacer is a tube that you attach to your inhaler. It makes using an inhaler easier.)
• Press down on the inhaler to release the medicine as you breathe slowly, deeply and steadily in for 3 to 5 seconds.
• Hold your breath for 10 seconds so the medicine can get into your lungs.
• Repeat as your doctor suggests. Wait 1 minute between puffs.
• Rinse your mouth after inhaling the complete dose.

For dry powder inhalers

• If the drug is a capsule, insert it into the lower compartment of the inhaler. If it's a turbo haler hold it upright and twist the base.
• Depending on the device, you can press the buttons on either sides or twist the base while holding the mouth piece. This will pierce the capsule or crush the tablet releasing the powder.
• Breathe out fully and seal your lips around the mouthpiece.
• Breathe as rapidly and deeply through the mouthpiece.
• Hold your breath for 10 seconds but do not exhale through the inhaler.
• Repeat until the powder is over in the capsule and discard the empty shell of the capsule.