Asthma

Chronic asthma is a long-term condition that causes attacks of symptoms such as coughing and breathlessness that often happen suddenly. It is often associated with an allergy. Without proper treatment, lung function and physical fitness can be impaired over time. With the help of certain medications, however, most people with asthma can keep their illness under control and live a largely symptom-free life.

As with other chronic illnesses, it is important to understand what you yourself can do and find out what kind of therapy is best suited to you.

Before starting any medical treatment, its potential benefits and drawbacks need to be considered. Depending on the severity of the asthma, various treatments and support options are possible. Asthma does not necessarily get worse over time, so people with mild asthma do not have to assume that they will one day have to cope with frequent and severe attacks.

Research into the best treatment options is ongoing. Talk to your doctor about what treatment options would be suitable for you.

1. Background

1. Background

1.1. What is asthma?

Chronic asthma is a long-term disease of the airways that is often closely associated with an allergy. Symptoms usually come suddenly in the form of attacks, sometimes even happening at night. The airways of people with asthma are overly sensitive. Those who frequently have asthma symptoms tend to always have slightly inflamed bronchi. Their mucous membranes are swollen, thick mucus is produced and the muscles around the airways contract or squeeze. This makes their airways narrow. [1] Various things, such as a simple common cold, can cause them to get even narrower, leading to short-term or long-term problems such as

• wheezing,
• coughing or the urge to cough,
• tightness in the chest,
• shortness of breath or difficulty breathing.

Like most chronic illnesses, asthma does not only affect one organ – in this case the lungs. It affects the whole person. For example, asthma symptoms at night can disturb sleep, making people tired and unable to concentrate properly during the day. Physical fitness can also be affected. [2],[3]

Georg, 70 years old

„For a long time it was difficult for me to accept living with asthma. I saw it as a burden, and even felt angry about it sometimes. But I have come to terms with it now.“

There is currently no cure for asthma. However, even severe asthma can be kept under control with the help of certain medications and other strategies. This means a person with asthma needs a good understanding of their illness and treatment. Although asthma is commonly differentiated into two different kinds, allergic and non-allergic, all asthma symptoms are generally treated with the same medication.

Many people are affected by asthma. Roughly 5 to 10 out of 100 children (5 to 10%) and about 5 out of 100 adults (5%) have asthma symptoms. Not everyone who has asthma as a child will also have it later on as an adult. [4]

Ms. Meier, mother of Lennard (9 years old)

„We haven’t given up hope that his asthma will eventually go away, or that he will at least be able to manage it with proper treatment so that he can lead a normal life later on. We no longer think the diagnosis is as bad as we thought at first.“

1.2. Healthy airways

The structure of the lungs is like a tree, with a trunk (the trachea or windpipe), two main branches (the main or stem bronchi), lots of small branches and twigs (bronchi and bronchioles) and – right at the end of the smallest twigs – many leaves (the alveoli or air sacs).

When we breathe in, the oxygen we take in from the air goes to our lungs and enters the bloodstream. It works like this: The air sacs have a good blood supply because the walls surrounding them contain a lot of small blood vessels called capillaries. The capillaries absorb oxygen from the inhaled air and release carbon dioxide (CO2) from the blood back into the air sacs, which we then breathe out. The oxygen is transported to the different parts of the body by red blood cells. This exchange of gases can only take place in the air sacs so it is important that the inhaled air can pass through the windpipe and bronchi without being obstructed.

We breathe in and out many times every minute. This normally happens without us having to think about it. Our “subconscious” breathing rate does not always remain the same, however. For various reasons it sometimes automatically becomes faster and shallower, or slower and deeper. During physical exertion such as sport, but also in some lung diseases, we breathe faster to ensure that enough gas is exchanged to cope with our body’s needs. When we are resting or sleeping, however, we breathe more slowly because our bodies use less oxygen and have less carbon dioxide to get rid of.

The airways are not rigid tubes. Bronchi and bronchioles are surrounded by muscle tissue which can contract, and cause the airways to narrow. This happens subconsciously as well. The airways are lined with mucous membranes which contain

• cells that produce mucus,
• immune cells that destroy or surround unwanted matter, and
• tiny hair-like structures (cilia) that beat rhythmically and move mucus out of the bronchi towards the windpipe.

The ability to become narrower, produce mucus and transport it out of the lungs gives the airways an effective self-defense system. Allergy triggers, dust and smoke particles, small foreign bodies, bacteria and viruses can trigger an immune response and give you the urge to cough. Coughing up mucus if you have bronchitis, for example, is a sign that your body is fighting an intruder.

 

Picture: Healthy lungs, gas exchange in the air sacs

1.3. Narrow airways

The mucous membranes lining the airways of people with chronic asthma are constantly on stand-by, ready to trigger an inflammatory response. [1], [5] As with any inflammatory reaction, the blood supply to the affected area increases. The mucous membranes redden and swell, and their cells produce thick mucus. In addition, the bronchial muscles cramp up. Together, all of these factors cause the bronchi to become narrower and prevent the air from flowing freely in and out of the lungs. This leads to shortness of breath. This is similar to what happens to the mucous membranes of the nose in hay fever: the airways of a person with asthma react inappropriately and far too strongly to substances that are usually harmless.

People with healthy lungs can perhaps imagine what asthma-induced shortness of breath feels like by trying to breathe through a straw for a few minutes. Even if you blow air into it and suck air out of it as hard as you can, you are unable to get enough air into and out of your lungs. Like the airways of somebody with asthma, the thin straw is simply too narrow.

In asthma, however, inhaling and exhaling is usually not equally difficult. It is typically more difficult to breathe out: The air enters the lungs but cannot easily leave them. If the asthma worsens, a whistling or rattling sound known as “wheezing” is made when exhaling. The person often has to cough or feels the urge to cough. 
 
 
picture: healthy and narrow airways

1.4. Asthma causes and triggers

Asthma is more common in some families than in others, which suggests that familial factors might play a role. Further risk factors for children include having other allergic disorders, such as hay fever or neurodermatitis, either themselves or in their family. Being born with low birth weight is another risk factor. Asthma is more common in boys than in girls. The most important yet avoidable risk factor is parental smoking. [6] Scientists do not yet understand why these risk factors make some people, but not others, more susceptible to asthma.

Georg, 70 years old

„I've had asthma since I was five years old – for 65 years now. We don’t really know what the causes are. Maybe it was the conditions when my family had to flee: facing the bitter cold and the lung infection I had. My genes may also have played a role, as my mother had asthma too.

I know that pollen triggers my asthma – especially from blooming trees, grass and rye. But sometimes I don’t know what has brought on an attack.“

The airways of people with asthma overreact to certain external factors, known as triggers. Triggers are not the cause of asthma, but they cause asthma symptoms to arise or make existing symptoms worse. Although not all people with asthma react to the same triggers, several substances, environmental factors and irritants are common problems. These include tobacco smoke (active and passive smoking), plant pollen, animal hair, house dust mite excrement, some types of food as well as cold air, perfume, air pollution or certain chemicals. In some people, physical or psychological stress that causes breathing to speed up can also induce an asthma attack.

It is often difficult, if not impossible, to avoid these substances and situations in daily life. Knowing what triggers your asthma can be helpful, but avoiding these triggers does not always prevent asthma symptoms. [7] In most cases, as long as people use their controller medication properly, triggers no longer play a big role.

Daniel, 34 years old

„As a child, I had allergic asthma. This has changed over time. Nowadays I have mixed asthma. Most of my attacks can’t be put down to a concrete trigger.

One thing I do know is that cigarette smoke can trigger an attack, as can certain perfumes and physical exertion. I also react strongly to sudden changes in the weather, such as fog. But I often simply don’t know what has caused it.“

2. Asthma diagnosis and severity

2.1. Signs and symptoms

Georg, 70 years old

„It’s not as if I can’t breathe at all during an asthma attack. I get a strange feeling in my chest area: it feels really tight. The breathing difficulties are accompanied by a very specific feeling of being unwell.“

Asthma, or a tendency to asthma, is often already diagnosed in childhood or adolescence. It is difficult to diagnose asthma in small children. Colds and infection of the bronchi (bronchitis) are common in this age group. They are caused by viruses in the airways and coughing is sometimes accompanied by slight whistling or rattling noises. Bronchitis can be difficult to distinguish from early signs of asthma in young children. Asthma-like symptoms in bronchitis tend to occur less often as children grow up. In children, chronic asthma is often associated with an allergy.

Other typical symptoms usually do not appear until later. [3] In adolescence and adulthood, asthma is characterized by the following symptoms:

• Shortness of breath (often in sudden attacks)
• Breathlessness on exertion
• Noisy breathing mostly when exhaling (wheezing, whistling, rattling)
• Tightness in the chest
• Coughing and/or the urge to cough

If you have asthma you will know from experience that all of the symptoms do not always occur at the same time. What’s more, all of the above-mentioned symptoms may also be caused by other illnesses. On the basis of certain tests, your doctor can determine whether the observed symptoms in you or your child are asthma-related or caused by something else. However, diagnosing asthma is not always straightforward. [1]

Asthma symptoms usually occur as sudden attacks and often happen at night. [1] This is one of the reasons why people who have this chronic illness often feel so tired and groggy during the day. [2] The attacks can gradually become worse over several hours, days or weeks and then subside again. Sometimes symptoms come and go depending on the season (for example pollen-induced asthma) or other external factors (triggers). They can also disappear completely for a while.

Daniel, 34 years old

„An asthma attack usually starts off as a tight feeling in my chest, then pretty soon after that I start to wheeze and my lungs make a sort of bubbling sound. It becomes difficult to exhale.“

In an asthma attack, what starts off as slightly labored breathing, coughing or wheezing can turn into serious breathing difficulties. Because it becomes more and more difficult to breathe out, it also becomes difficult to breathe in. The increasing breathing difficulties are often associated with chest tightness – a situation that can be frightening. This increasing fear can make the symptoms worse and easily lead to a vicious circle of breathlessness and panic. Seeing your child or partner gasping for breath can be an alarming experience and difficult to cope with. [8], [9]

The situation only becomes dangerous, however, if the labored and exhausting breathing leads to a lack of oxygen. Nowadays this can usually be avoided with very effective medication.

Helena, 31 years old

„Over time I have come to realize how little oxygen a person needs to survive, as long as they remain calm and do not start to panic. If I don’t feel well, I do breathing exercises. It really helps me.“

2.2. Diagnostic procedures and criteria

Lena, 59 years old

„Now I knew where the symptoms were coming from, which was a relief. I no longer had to worry about the reasons and causes.“

Helena, 31 years old

„I think I already had asthma as a child but it was only diagnosed when I was 24 years old. The symptoms that were present during my childhood were never really taken seriously.“

Many people with asthma, or parents of children with asthma, go through a period of worrying before they decide to consult a doctor. [9] Once the cause of the breathing difficulties has been clarified, however, it is possible to start therapy. In the case of asthma this means relieving symptoms as well as preventing them.

Doctors are only able to determine whether the symptoms are caused by asthma or another illness if they consider their patient’s symptom descriptions and the results of various tests together. The main diagnostic tools for suspected asthma are:

• an in-depth consultation between the patient and the doctor (medical history),
• a physical examination, and
• measurement of lung function (peak flow meter and/or spirometer).

Other tests such as “body plethysmography” may be necessary to rule out other causes.

Consultation and physical examination

Lena, 59 years old

„Since childhood I have had an odd, mild cough. In the mornings I always used to spend a long time clearing my throat. On some days I found it difficult to breathe properly. Whenever I walked uphill I would quickly become exhausted. I just considered it to be normal for me.“

The in-depth consultation and subsequent physical examination form the basis of the diagnosis. The symptoms associated with asthma can also be an indication of other health problems. It is therefore important to share all of your observations and experiences with your doctor. Talk about your worries and daily problems associated with the symptoms too – every piece of information could be an important piece of the puzzle.

In order to get a clear picture, your doctor will ask you a number of questions, such as:

• what symptoms you experience and when,
• under what conditions they go away,
• whether you have any other illnesses, especially allergies,
• whether you frequently had coughs or whistling breathing sounds as a child,
• whether any family members have asthma or any allergies,
• whether you are taking medication and, if so, which medication, and
• whether you are exposed to certain substances (vapors, smoke, sprays) or physical or psychological strain in your private or professional environment.

In the subsequent physical examination the doctor will check your general state of health as well as the function of your lungs, heart and circulation. This is done, among other reasons, in order to rule out other illnesses.

Checking your lung function

Lung function tests measure how efficiently your lungs are working. If someone has asthma, it is important to determine whether inhaled air can flow freely through their bronchi or whether the usual flow of breath is impaired due to narrowed bronchi. This can usually be done on the basis of just two tests: peak flow measurement and spirometry.

Peak flow measurement is an important test of lung function that can be carried out at home. The measuring device, known as a “peak flow meter”, is easy to use. After taking a deep breath, you quickly blow into it as hard as you can. The speed at which air is exhaled from your lungs is measured. This speed depends on how wide or narrow your bronchi are. The peak flow reading provides information about how constricted the bronchi are at the time of measurement.

In spirometry (“measuring of breath”), both the force and the amount of air you breathe out is measured. Here you blow hard into the mouthpiece of the device, the so-called spirometer. The amount of air that you exhale in one second when blowing as hard as you can is measured. Doctors call this the “forced expiratory volume in 1 second” (FEV1). The test can usually be done by your family doctor and can also be used to monitor the progress of the illness. By comparing old and new spirometry values, you can see whether your lung capacity has improved or worsened over time.

Lena, 59 years old

„The doctor checked my lung function and I described my medical history to her. It turned out that I had probably had asthma for a long time without knowing it.“

Asthma symptoms can vary a lot. Even if you have asthma, your doctor may not find any signs of it when checking your lung function for the first time. [1] Nearly all of the tests measure how narrow your bronchi are. However, if you happen to be symptom-free when the test is done, your bronchi will be almost normal. To make sure you get an accurate result, after taking the first reading:

• you may be given a substance which causes the airways of people with asthma to temporarily become narrower (bronchial provocation test).
• you may be asked to get on a treadmill or an exercise bike (exercise test). The lung capacity of many people with asthma worsens following exercise.
• you may be given an asthma spray, which opens up the airways. If, when measured a second time after using the inhaler, your lung capacity has improved, this can indicate that you have asthma (reversibility testing).

The breathing difficulties could, however, also be caused by other illnesses such as chronic bronchitis. People who are overweight, generally unfit or smoke may also show symptoms typical of asthma such as shortness of breath in diagnostic tests, despite not having asthma.

Allergy tests and other examinations

Mr. Meier, father of Lennard (9 years old)

„As a young child he often had a spasmodic cough. Our doctor diagnosed allergic asthma, which came as quite a surprise to us.“

Asthma is diagnosed using the diagnostic procedures and tests described above. To find out whether asthma is caused by certain allergy-causing substances (allergens), other tests such as blood or provocation tests are carried out. Provocation tests look at whether a particular allergen triggers asthma attacks.

 Allergy-causing substances trigger asthma attacks in many, but not all, people with asthma. You therefore first of all have to find out whether you have an allergic tendency. Only then can the specific allergy-causing allergen be determined, for example with special skin tests. But a positive allergy skin test on its own is not enough to diagnose asthma.

It is important to let your doctor know if you have noticed any patterns in terms of when and in what situations your symptoms arise: on a sunny day in early summer, in cold winter air, in the morning or evening, at home or at work, after having certain kinds of food or drink, after touching pets or when cleaning the house?

It is normally only necessary to carry out further tests during the initial medical examination if the symptoms and test results are not typical for asthma and your doctor would like to rule out other illnesses, such as an inflammation of the lungs. Possible tests include a lung x-ray, a blood test or a blood gas analysis, in which blood is taken from the earlobe to determine whether the circulating blood contains enough oxygen.

2.3. Peak flow monitoring and asthma management plan

Mr. Meier, father of Lennard (9 years old)

„It isn’t always that easy to measure Lennard’s lung function regularly. If he is feeling unwell he notices it himself and uses the peak flow meter without being told to. Otherwise we have to remind and encourage him.“

Georg, 70 years old

„I measure my peak flow rate every morning. It’s just part of my daily routine, like brushing my teeth.“

The degree of narrowing in the airways and resulting severity of symptoms can vary over time. In order to identify patterns and determine the influence of factors such as medication, one idea is to keep a kind of symptom diary. You can also measure your peak flow rate, which expresses your lung capacity in numbers, and enter the values in a table. Here it is not so much the individual readings that count, but rather how the readings change over time. An asthma diary includes a record of peak flow measurements and a calendar in which you can make a note of the symptoms you experience, possible triggers and the medication you take.

The peak flow measurements or asthma diary are sometimes used as diagnostic tools. If the doctor does not find anything out of the ordinary during lung function tests in his or her practice, peak flow data may provide the necessary diagnostic information. To do this properly, you have to measure and record peak flow rates several times a day under everyday conditions for about one to two weeks. Considerable fluctuations between individual readings (for example, of over 20%) reflect the variability of airway constriction typical of asthma.

Together with your doctor, you can develop an asthma management plan – a practical written plan describing how to approach treatment and emergency situations. The treatment plan contains your personal details and emergency telephone numbers, as well as information about the medication that you use on a daily basis or when the need arises. The emergency plan describes in what situations you can use additional fixed doses of certain medications.

Daniel, 34 years old

„If my peak flow rate drops very suddenly, I know which medication I have to take. This means that I don’t have to call an ambulance every time it happens. I try to sort it out myself. I have an emergency action plan which I follow.“

Asthma diaries and management plans might be helpful in terms of diagnosing and managing the illness. Whether and in what cases they are necessary for diagnosis or help to reduce symptoms cannot be reliably assessed at this point, because scientific research on these issues has produced contradictory results. [10], [11], [12], [13]

2.4. Asthma and other lung diseases

The description of symptoms and the results of tests do not always lead to a clear diagnosis. It is especially difficult to differentiate between susceptibility to frequent airway infections and early signs of asthma in young children. What’s more, there are a number of other illnesses that, although rare, lead to symptoms similar to those associated with asthma. Symptoms such as shortness of breath and more serious breathing difficulties can even be caused by problems in organs other than the lungs, such as the heart. If breathing difficulties only appear in middle age, other lung diseases are also considered, such as chronic obstructive pulmonary disease (COPD) or emphysema.

COPD usually first occurs in older people, often because of exposure to harmful substances such as cigarette smoke or dust over many years. Emphysema is a chronic condition in which the surface area of the lungs is decreased. In both diseases the air sacs (alveoli), where oxygen passes from the inhaled air into the bloodstream, become damaged. The constant breathing difficulties experienced by people with severe COPD or emphysema are not always easy to distinguish from the symptoms of serious forms of asthma.

Yet asthma, COPD and emphysema are by no means the same disease. They have different causes and symptoms, are treated differently and usually affect people with different genetic and physical dispositions.

2.5. Classification of asthma severity

Asthma symptoms can range from an occasional mild cough to a full-blown asthma attack with serious breathing difficulties. Doctors distinguish between four levels of severity. [1],[4] These levels guide the initial decision regarding what type of treatment and dose of medication to use. They are determined on the basis of both a description of symptoms and various medical test results. The four levels are:

• Level 1 – Intermittent: Occasional symptoms during the daytime and/or temporary worsening of symptoms over several hours or days and/or symptoms at night occurring up to twice a month. In children and teenagers: occasional cough / minor breathing difficulties with symptom-free periods lasting more than two months.
• Level 2 – Mild persistent: Daytime symptoms occurring between once a week and once a day and/or symptoms at night occurring more often than twice a month and/or impairment of physical activity and sleep due to worsening of symptoms. In children and teenagers: symptom-free periods lasting less than two months.
• Level 3 – Moderate persistent: Daytime and/or symptoms at night occurring more than once a week and/or impairment of physical activity and sleep due to worsening of symptoms and/or daily use of reliever medication necessary. In children and teenagers: symptoms several days a week, as well as at night.
• Level 4 – Severe persistent: Constant daytime symptoms and/or frequent worsening of symptoms and/or frequent symptoms at night and/or impairment of physical activity. In children and teenagers: constant daytime symptoms, often at night too.

2.6. Progression of asthma

Georg, 70 years old

„During my teenage years it wasn’t much of a problem. I was maybe slightly more susceptible to colds than others, but overall it didn’t play a major role in my life. When I grew older, as a young adult, things got worse again. I often had infections.“

The progression of asthma varies and symptoms do not necessarily worsen over time. With other chronic lung diseases like COPD or emphysema lung function deteriorates over time, but that does not always happen to people with asthma. Some people who have asthma as children or teenagers have hardly any symptoms, or even none at all, as adults. [14]

 Asthma can appear at any stage of life, but often first becomes noticeable in childhood or adolescence. Many people who get asthma have already previously had other allergy-related conditions (so-called atopic disorders) such as hay fever, allergic conjunctivitis, dry and sensitive skin or neurodermatitis. Asthma symptoms can disappear just as quickly as they appear. Sometimes other allergic disorders then come to the fore again. If adults with asthma experience a long symptom-free period, however, it does not mean that their asthma has been “cured”. Nevertheless, with the help of certain medications and other strategies, life can be fairly normal..

3. Asthma and self-management

3.1. Learning about asthma

Georg, 70 years old

„Towards the end of the 90s I had further treatment as part of a special asthma rehabilitation program. It was a real turning point for me. On top of the usual therapeutic procedures, we had so-called patient education. I was shown how I could get to know my disease and myself better. I acquired a new sense of awareness of my asthma. It really became clear to me there that asthma was a part of my life and that I had to live with it.“

If you are well-informed about your or your child’s asthma – its causes, triggers and how the medication works – you will probably find it easier to cope with the disease in everyday life. Doctors, good asthma self-management education or joining a self-help group might help you to become an expert in how to handle your own asthma.

Ms. Meier, mother of Lennard (9 years old)

„For about two years now we have been trying to teach him to take more responsibility for himself and his asthma. He should learn to think of it himself and become more aware of his disease.“

Asthma self-management education is offered by, among others, lung specialists and specialized rehabilitation facilities in Germany, for example. The aim is to learn

• what causes asthma and how it can be treated,
• how to recognize early signs of an asthma attack,
• how to avoid triggers, and
• what people with asthma and those around them can do in an emergency situation.

Asthma self-help groups are self-organized groups of people who have asthma or are close to someone who has asthma. They provide the opportunity to share experiences and support each other. This can help you to cope with asthma and raise awareness of the disease. However, the quality of information provided in the self-help group or by more central self-help organizations varies.

Georg, 70 years old

„Self-help organizations have played a crucial role in coping with my disease. I have found talking to others in similar situations particularly helpful.“

3.2. Managing your asthma

Helena, 31 years old

„Once I had been diagnosed with asthma I tried to rearrange my life accordingly. It dominated my life at first. Everything revolved around my disease … Now I am happy to have accepted it as being just one part of me.“

Chronic diseases can have a big impact on the lives of those affected and the people close to them, especially if their condition is serious. Having to live with a chronic disease is not always easy to accept. Yet people with asthma do not want to be seen as being ill or weak. [2], [15], [16], [17]

Many people would prefer to avoid taking medication for a long time because of the possible adverse effects. [16],[18], [19], [20] Yet medication is often essential if you want to keep the disease under control and prevent asthma attacks. Enough comprehensive information, good self-management and disease management can help you to cope better with your disease and become more independent. [10]

Ms. Meier, mother of Lennard (9 years old)

„Lennard doesn’t get sick any more often than his classmates do. The medicine seems to reduce inflammations so well that he even seems to get sick less often than his friends do. He does sports too, without any problems.“

Asthma attacks can be frightening. The parents of children with asthma find asthma attacks at night especially alarming. [8], [9] If, however, everyone in the family learns what to do in an emergency, the child and their parents should feel more at ease and able to act appropriately when needed. Good disease management can therefore make a big difference. For example, it has been shown to reduce the number of times people go to hospital for emergency treatment. [10]

On top of having to learn how to cope with the disease, the costs of asthma treatment can become a burden. [18] Managing your disease means learning how to optimize your use of the available health care options, knowing who to turn to, where to find appropriate support, advice and the best possible treatment.

3.3. Disease management programs

Since 2006 state health insurance funds in Germany have offered adults, teenagers and children over the age of five with asthma the possibility of taking part in a “disease management program“ (DMP) for asthma. DMPs provide comprehensive health care services to optimize the management of certain chronic diseases. Doctors who participate in such programs have to fulfill certain quality requirements. You can contact your insurer to find out whether it offers a DMP for asthma. Similar chronic disease management programs are available in other countries, too.

The objective of asthma treatment programs is to reduce the number of asthma attacks involving serious breathing difficulties, prevent the progression of the disease and improve quality of life. Participating in one of these programs in Germany involves learning background information, attending asthma self-management courses as well as having regular medical examinations and consultations with doctors. In addition, DMPs aim to improve cooperation between the various relevant doctors and institutions that provide asthma care, such as family doctors, specialists and clinics. One of its aims is to avoid situations in which procedures are unnecessarily carried out twice. People who participate in a German DMP need to commit to actively managing their treatment themselves – for instance, by regularly seeing a doctor (every three or six months).

4. Treatment options

Daniel, 34 years old

„When I was about 19 years old I found a lung specialist who made me feel I was in very good hands. He was the first one who really explained asthma to me and put me on appropriate medication.“

Good management of chronic asthma involves treating symptoms as well as preventing them. Preventive measures include taking medication on the one hand, and avoiding asthma triggers that are definitely known on the other. The medical treatment is determined together with a doctor. It is particularly important that application and dosage are tailored individually to the severity of your asthma.

The main aim of asthma treatment is to reduce the frequency and severity of symptoms as much as possible. If this aim is achieved, doctors say the asthma is “well controlled”. Successful treatment should also enable people who have asthma to go about their daily lives as actively and freely as possible, both physically and socially. Last, but not least, the treatment should ideally have as few adverse effects as possible.

Ms. Meier, mother of Lennard (9 years old)

„It’s important that you can trust your doctor. We are very happy with ours, who is a pediatrician and also specializes in lung diseases. And then it is important to stay calm and get informed in peace and quiet. We responded to the diagnosis pretty frantically, but the disease isn’t likely to suddenly get worse over night. Of course, it all depends on how serious the asthma is. In our case it is very straightforward.“

4.1. Treatment with medication

Georg, 70 years old

„I am a very active person by nature. Thanks to my medication, my quality of life isn’t restricted. The drugs available today are really excellent and I can actively contribute to my own wellbeing.“

Controller and reliever medication

There are generally two main types of asthma medication, known as “controllers” and “relievers”. Controller medication, also called “preventer” medication, works slowly over time and is taken regularly in order to prevent asthma attacks. It does so by suppressing the constant inflammatory response of the airways, among other things, thereby targeting the main problem in asthma. [1] Controllers are used every day, independently of symptoms, in order to “control” asthma in the long term.

Georg, 70 years old

„I take medication every day. There were times in the past when I didn’t take it as regularly as I should have. Then I started having asthma attacks again. I can’t afford not to take my medication.“

Corticoids or glucocorticoids, commonly referred to as “corticosteroids”, “cortisone” or “steroids”, are important controller medications. Long-acting beta-2 agonists are used too. They work by opening up the airways. Long-acting beta-2 agonists have to be taken together with corticosteroids because they could be harmful otherwise. Research suggests that long-term treatment with beta-2-agonists alone could lead to life-threatening asthma attacks. [21] In certain cases so-called leukotriene antagonists can be used in long-term asthma treatment too, usually in addition to corticosteroids. Leukotriene antagonists work by blocking the lung’s response to leukotrienes. Leukotrienes are messenger substances that play a key role in the inflammatory response in the airways.

Unlike controller medication, relievers alleviate acute asthma symptoms. They start working fast, and their duration of effect varies, depending on the exact medication. [1] These are mainly medications that open the bronchi by relaxing cramped airway muscles. Many commonly used relievers contain beta-2-agonists such as salbutamol (also known as albuterol). They are taken as soon as asthma symptoms start or if they are expected to arise (for example, before doing physical exercise) and provide fast relief. So, in contrast to controller medication, reliever or “rescue” medication is only taken when necessary rather than every day. It quickly opens the airways in acute cases yet does not fight the underlying inflammation.

People who have chronic asthma therefore typically use preventive controller medication on a daily basis and fast-acting reliever medication when the need arises. The treatment with controllers and relievers varies from individual to individual and depends on the severity of their asthma. The choice of treatment always depends on how severe the symptoms are. [22] This can range from occasional symptoms, for which regular treatment might not be needed, to severe persistent asthma requiring other therapy.

Your doctor may use a four-step approach as the basis for treatment choices, where the intensity of treatment increases with every step. [4] You can find out more about this approach from your doctor or in asthma self-management courses.

Lena, 59 years old

„I go to my doctor for a check-up once a year and talk to her about how I am getting on. If I started feeling unwell or noticed that something wasn’t quite right, I wouldn’t hesitate to make an appointment to see her.“

Many people with asthma prefer to use medication that has an immediately noticeable effect. They generally only take it if and when they have symptoms, and are therefore less likely to take preventive medication. Long-term controller medication can, however, only help reduce the number and severity of asthma attacks if taken regularly.

Ms. Meier, mother of Lennard (9 years old)

„He does take his medicine, but not always regularly. We sometimes have to remind him, especially when he isn’t feeling unwell. He doesn’t really see the connection and doesn’t understand why he should take medicine if he is feeling OK.“

Medication dosage forms and adverse effects

Asthma medication can be taken in several ways. It can be inhaled using metered-dose inhalers (liquid sprays) or dry powder inhalers, commonly known as “puffers”, or swallowed as tablets. Injections may sometimes be necessary. Different combinations of medications are used in each step of asthma treatment. The doses of some medications are fixed, whereas for others the dose can and should be adjusted according to your needs.

To make sure that the medication reaches even the smaller bronchi, you have to learn how to inhale it properly. This is sometimes difficult, especially for children. A number of devices which aim to make it easier to inhale medication are available. You can find out more about the advantages and disadvantages of the different devices, how to use them and how to clean them by asking your doctor or taking a relevant asthma education course.

During severe asthma attacks it is difficult to use inhaled medication effectively due to the extreme narrowing of the airways and increased production of mucus. In such urgent cases medication can be given in the form of an injection or an intravenous drip. One of the aims of taking long-term controller medication is to prevent such emergencies from happening.

As well as having positive effects, medication can also be associated with negative (adverse) effects. Inhaling asthma drugs usually causes fewer adverse effects than swallowing them in the form of tablets. In very mild asthma, the adverse effects of some medications could outweigh their potential benefits. You can discuss the advantages and disadvantages of each treatment option with your doctor. Moderate or severe asthma has to be treated with medication in order to avoid persistent symptoms and reduced physical fitness.

Many people are particularly concerned about adverse effects from the long-term use of corticosteroids. They can usually be inhaled in the form of a liquid spray or dry powder. If medication is chosen and used correctly, long-term treatment will not necessarily cause adverse effects. [23], [24], [25], [26], [27], [28] The main advantage of corticosteroids is that they can considerably reduce the number of severe or even life-threatening asthma attacks. [1] In severe asthma, the dangers posed by attacks are far greater than those associated with the long-term use of medication.

Daniel, 34 years old

„At first I wasn’t happy about having to take steroids. I always used to think that they were dangerous because of the side effects they could have. But it has become clear to me that they really help and that I feel better when I take them.“

    

4.2. Complementary medicine

Many people with asthma use complementary treatments. [29], [30] This “alternative medicine” is called complementary because it seen as an addition to conventional medicine and medical care. The spectrum of alternative treatments includes the traditional healing practices of various cultures as well as newly developed treatment approaches. So far, only a few studies on complementary options have produced reliable results about their effects on asthma. We will keep you up-to-date on research developments in this area..

Not all complementary medicine approaches have been well studied. The following are commonly tried out by people with asthma [29]:

• Breathing exercises
• Homeopathy
• Herbal medicines
• Relaxation techniques
• Yoga or yoga-based breathing exercises
• Massage
• TCM (traditional Chinese medicine), e.g. acupuncture
• Dieting, dietary supplements
• Mental training, hypnosis

Some research suggests that massage, yoga and certain breathing exercises might be helpful in asthma. However, the studies that have been carried out so far are not conclusive, and sometimes have contradictory results. More good quality research is needed to be certain if these are effective in reducing asthma symptoms. [30]

Herbal remedies sometimes interact with other medicines [31], so do not forget to let your doctor know if you are taking any herbal or other complementary medication.

In homeopathic medicine, substances of herbal, animal or mineral origin are taken in a highly diluted (“potentiated”) form. Based on the principle that “like cures like”, the person takes minute doses of a substance that, in undiluted form, produces symptoms similar to the illness itself. Researchers from the Cochrane Collaboration analyzed 6 trials on homeopathic therapies in asthma, involving a total of 556 participants. Due to the fact that the trials were carried out very differently to each other and were of varying quality, the researchers concluded there was not enough evidence to know if homeopathic remedies help people with asthma. [32]

Acupuncture is a traditional Chinese medical practice. It is based on the idea that inserting fine needles at specific points on the body’s surface influences the flow of energy and “harmonizes” imbalances. A Cochrane review of 11 studies involving a total of 324 participants could not find proof in the available data that acupuncture is effective in asthma. [33]

There are not enough data to show whether or not the following complementary therapy approaches are effective in asthma:

• Cave therapy (speleotherapy): This involves repeatedly spending several hours in a special underground cave or mine that is thought to have a positive effect on asthma due certain criteria such as clean air, mineral content, beneficial radiation, air pressure or climatic conditions. [34]
• Alexander technique: This therapeutic technique is believed to improve breathing by learning to be more aware of your body, correcting harmful postures and patterns of movement. [35]
• Manual therapy (physiotherapists or chiropractors): Special hands-on manipulation of parts of the body is believed to release tension in the rib cage area, thereby making it easier to breathe. [36]

4.3. Breathing exercises

People with asthma have a choice of many different breathing exercises and techniques. They are meant to have a general relaxing effect on the one hand and help to maintain calm, controlled breathing during asthma attacks on the other.

Relaxation and breathing techniques such as those practiced in yoga may help in the management of asthma. However, in a review by the Cochrane Collaboration, researchers could not find any trials that were big enough showing that these techniques have an overall beneficial effect on asthma. [37] You can read more about breathing training here (URL: http://www.informedhealthonline.org/here.94.en.html) .

Certain techniques are meant to help people breathe calmly and more effectively during, or at the beginning, of an attack. Panic and fear can lead to ineffective “panting” or hyperventilation in such situations.

Even during more serious asthma attacks, most people do not have major difficulties inhaling. It is the exhaling that is usually the problem. Learning breath management techniques such as “pursed-lip breathing”, as well as adopting certain postures that unburden the breathing organs, may make it easier to breathe out.

5. Living with asthma

Daniel, 34 years old

„I try to enjoy life as much as I can. I love being in nature and around animals. If I’m not feeling well I go somewhere where I can relax. In my experience, nowadays it is possible to live a good life with asthma and its symptoms.“

When asthma symptoms appear and the disease is diagnosed, people often find it unsettling and difficult to cope with at first. It is easier to manage asthma if you start to take charge of your treatment yourself and keep your asthma in mind during everyday activities. [3] [10] [38] Most people are mainly concerned about how to best prevent asthma attacks and live as normal a life as possible. With the support of their families, doctors, information and asthma self-management education, as well as by trying out what is good for them and what is not, most people with asthma find a way to live as well as possible with asthma. Joining a self-help group and sharing experiences with people who are affected by the same problems is helpful for some.

Just as it is important for every individual to find out what medications suit them best, most people with asthma try to find out the best way to organize their lives in order to minimize the burden of asthma. In doing so, they generally try to limit the amount of medication and avoid adverse effects. [19] [20] [38] Good self-management of medication requires close cooperation with your doctor.

Georg, 70 years old

„Nowadays I see myself as the manager of my disease. Of course, I need a doctor to prescribe the medication for me, but I often adjust the dose myself.“

Avoiding asthma triggers is an important part of asthma management. One thing is clear: giving up smoking is a significant step that can be taken to reduce your own asthma symptoms or those of people you live or work with.

5.1. Kicking the smoking habit

Lena, 59 years old

„I used to smoke, which I believe is one of the reasons why I am so sensitive to cigarette smoke now. If we go out for a meal we try to go early in the hope that there won’t be many people there and that no one will be smoking. Otherwise the smoke makes me cough after a while. It would be wonderful if smoking were banned in restaurants and pubs.“

Smoking tobacco, in any form, can cause a number of illnesses or make them worse. [39] Especially people with asthma, who have oversensitive airways, benefit from giving up smoking or not starting to smoke in the first place. When cigarette smoke is inhaled, many chemical substances other than nicotine and tar are deposited directly in the airways. Some, such as heavy metals and pesticides, are toxic. Just like other triggers, the contents of cigarette smoke can make the inflammation of the mucous membranes worse and cause the airways to become even narrower. Besides this, if cigarette smoke is inhaled regularly chronic bronchitis could develop over time. This is not only true for smokers, but for passive smokers too. Children are often exposed to cigarette smoke at home. Having parents who smoke is one of the main risk factors for asthma. [14], [6] You can read more about the research on how family and friends influence the smoking habits of young people here (URL: http://www.informedhealthonline.org/here.318.en.html) .

If teenagers who have asthma start smoking their symptoms can become worse. Yet some evidence suggests that teenagers with asthma are equally, if not more prepared, to risk damaging their health than teenagers who do not have asthma. [40]

Georg, 70 Jahre

„I smoked for about six years, from the age of 18 onwards. I stopped smoking after I was rushed to hospital with serious breathing difficulties. It made me realize that I had to kick the habit.“

People who smoke will know how difficult it is to quit smoking. There are several therapies that can help make quitting a bit easier. You can find useful information on this topic here (URL: http://www.informedhealthonline.org/here.222.en.html) .

5.2. Physical exercise

Georg, 70 years old

„In 1982, during a stay at a health clinic, it became clear that the medical world had changed its mind: I was suddenly told that I should do sports and no longer had to avoid strenuous activities. A year later I decided to join a running group. Two years after that I ran my first marathon.“

Because physical exertion is a relatively common asthma trigger, many affected people think that they ought to avoid exercise. [41] Doctors call asthma attacks which are caused by exercise “exercise-induced asthma”. In children, coughing or labored breathing after running around may be a first sign of asthma. As with other asthma triggers, the goal of asthma treatment is to prevent symptoms from occurring after exercise.

Sport and physical activity are important for most people who have asthma. Trials involving people with asthma who do sports indicate that regular physical activity helps to strengthen their heart and lung capacity. As well as improving the uptake of oxygen, it increases the amount of air that is exhaled. However, so far sport has not been clearly proven to have a positive or negative effect on asthma symptoms. [42],[43]

Lena, 59 years old

„Being active has had a positive effect. My physical stamina is quite good and the doctors say that I have a surprisingly good lung capacity.“

Certain types of physical activity, such as swimming, are probably less likely than others to trigger an exercise-induced asthma attack. [44] Before any types of sport can be labeled “asthma-friendly”, however, more scientific evidence on the effects of certain activities is needed. It is important to choose a type of sport which you enjoy and can do regularly.

Doing regular exercise also helps to keep your weight under control. Being very overweight makes you less mobile and can cause even people who do not have asthma to get out of breath.

Not everyone is enthusiastic about doing sports or having a more active lifestyle. Many do not have the time, others think they are simply not very athletic, and some people have difficulties getting motivated about exercise. If you think you need help and support you can consult your doctor or contact a local sports club. Nowadays there are many opportunities for doing sports together with other affected people in lungs sports groups. It is also possible to get comprehensive information on different sporting activities.

5.3. Worries and concerns

Helena, 31 years old

„I have a more positive attitude towards life now. When I first had inflammation of the lungs I was pretty depressed for a while, and I started to think I wouldn’t be able to cope. Nowadays I take it as a sign that my body needs a break and I make sure that I take the time to relax. I’m okay with it.“

Mental wellbeing is important in asthma, just as it is with all other chronic diseases. Breathing is one of the basics of life. When someone has difficulties breathing it can feel life-threatening, both for the person having the asthma attack as well as for other people, such as parents who see their child gasping for air. The fear of breathlessness, and in some cases the disappointment of unsuccessful treatment, can leave people feeling scared and discouraged.

Emotional strain may also cause asthma attacks for many people with asthma. Stressful situations, in which they are under pressure, scared or nervous can make them breathe faster, bring on a cough or lead to breathing difficulties. Uncertainty, fear and feeling down often make the asthma symptoms worse, leading to a vicious circle which needs to be broken. A negative state of mind may make it more difficult to manage the disease confidently and independently. [2] There is no clear evidence, though, that psychological interventions improve asthma symptoms. [45], [46]

5.4. Family and friends

Daniel, 34 years old

„I think that my family and friends worry more than I do.“

The support of family members and friends can be invaluable in asthma. [15] It is therefore important that they also know how to handle emergency situations. Learning how to deal with the disease helps to reduce fears and concerns and to live a fairly normal life. [3] 

Generally, the more people there are who know about chronic diseases like asthma, the better. Well-informed individuals can provide both children and adults with essential support. This is especially true concerning serious attacks, when receiving help could make all the difference.

Ms. Meier, mother of Lennard (9 years old)

„We have an emergency medication kit which we put together with the help of our doctor. The symptoms then usually subside after a few days. So far it has never been so bad that we needed additional help or had to call an ambulance.“

Asthma can place a heavy burden on family life, especially if it is a child who has the disease. Before the child starts receiving treatment, serious breathing difficulties are always particularly worrying for parents. Small children are often unable to understand why they have to take medication regularly. This makes it more difficult for parents to make sure their child stays with their management plan. Having to responsibly handle a chronic disease can be quite demanding for children, who would prefer to have the kind of carefree childhood some of their friends have.

Sometimes children and teenagers learn to use symptoms such as coughing or breathing difficulties to their own advantage, in order to get their own way. This can challenge the harmony in a family. Good asthma management education for children should take this aspect into consideration.

5.5. Triggers in the home environment

Mr. Meier, father of Lennard (9 years old)

„At first we were quite worried about it. There’s a lot of advice available out there, for instance that you should avoid carpets, pets, feather bedding and use leather furniture. We did our own research and thought about it a lot, probably more than necessary.“

Along with cigarette smoke, other substances and irritants are a problem for a great number of people with asthma. For example, people who are allergic to certain types of pollen or animal hair are also likely to experience asthma symptoms if they come into contact with them. In other people, asthma symptoms may be triggered by physical factors such as cold air or medication such as ASA (acetylsalicylic acid). [47] Household chemicals and cosmetics can also trigger attacks.

Asthma is a complex disease and it is not clear whether trying to avoid triggers is always worth the major effort it often involves. [7] Making certain changes in your home environment, for instance, may help some people but not necessarily others. [7]

Animals

The hair of cats, dogs or guinea pigs, and particularly the dandruff of furry pets are common allergens. The allergic reaction is triggered by a protein found for example in the skin, in the sebaceous glands of the skin, in saliva and in urine. Sebum and grooming carry these proteins onto the animal’s hair. With dandruff they are then spread into the air and into the house dust. In order to prevent this from happening, people are typically advised to keep their pet’s living area separate from their own, regularly wash their pet or, if necessary, give their pet away. So far there have been no scientific trials looking at whether these measures alone can prevent asthma symptoms. Air-purifying devices designed to remove allergenic substances from the air have not been proven to be effective. [48]

Mr. Meier, father of Lennard (9 years old)

„Right at the beginning we vacuumed the house a lot, but things returned to normal after a while. Lennard is mainly allergic to animal fur, so we have to avoid contact with animals.“

House dust mites

Tiny house dust mites can be found anywhere where humans live, work or go to school because they feed on our dead skin cells. The excrement and dead body parts of house dust mites tend to collect on mattresses, bed covers, pillows, carpets, curtains and soft toys. House dust mite particles are easily breathed into the airways and are probably the most common trigger of allergic asthma. Every home and workplace contains house dust mites. They are not a sign of poor hygiene.

It has not yet been proven whether or not asthma symptoms are affected by taking certain physical and chemical measures to reduce the house dust mite load in the home (such as using special mite-proof mattress covers and anti-mite sprays). [7], [49] Scientists have also questioned the benefit of common advice, for example:

• Removing unnecessary “dust-mite magnets” such as carpets, pillows, bed throws and thick curtains from the bedroom,
• Keeping rooms cool and dry,
• Changing your bedding regularly and washing it at a temperature of at least 60° C,
• Airing and vacuuming living and sleeping areas regularly

It is impossible to completely get rid of house dust mites or avoid them totally with these approaches, which is probably one of the reasons why they are not very effective at preventing asthma. [7], [49] The full explanation is, however, likely to be more complicated [7], and researchers are still looking for answers.

Feather bedding

Another common piece of advice given to people who have asthma and allergies is to replace feather and down bedding with synthetic alternatives. This is meant to help prevent asthma symptoms at night. Yet some evidence suggests that using feather bedding could even be associated with fewer asthma attacks. [50] Many questions remain unanswered here too, which at the same time shows why reliable trials are so important: At the moment we do not even know whether the previously given advice to avoid feather bedding may actually turn out to be harmful in the end.

6. Summary

Asthma is a chronic disease with recurring symptoms and can substantially reduce a person’s overall physical fitness. But good asthma treatment and management helps to improve quality of life. Nowadays, together with their doctor, people with asthma are able to tailor their treatment to their own personal needs and symptoms, using very effective medicines. They can also actively take measures in daily life which contribute to the success of their treatment and to independently dealing with their disease. These include not smoking and avoiding passive smoke. Both taking medication and making lifestyle changes require commitment and persistence in order to achieve the goal of the treatment: living a largely symptom-free life with asthma.

Sources