Causes

The causes of asthma are unclear although there is a strong genetic link - it can run in families. Environmental factors such as pollution, poor air quality and poverty can impact too.

Main Symptoms

The main symptoms of asthma include:

• Tight chest
• Cough
• A wheezy (whistling) noise when breathing
• Breathlessness

Not everyone always wheezes initially. Sometimes in early stages there is just a persistent cough, particularly at night.

It can be difficult to diagnose as several other conditions may have similar symptoms (for example a head cold).

Often the cough is worse at night or the symptoms may only appear at night. Sometimes they're relatively mild and sometimes they rapidly progress to become more severe.

An asthma attack occurs when the air passages become overwhelmed in response to a trigger. During an attack the following other symptoms may appear:

• Tightening of the chest
• Persistent cough at rest
• Audible wheezing
• Shortness of breath
• Difficulty speaking / going quiet- unable to complete a sentence in one breath
• Nasal flaring
• Use of accessory muscles to help breathing
• Panic
• Fast heart rate
• Pale colouring / going "blue" at the lips, fingertips
• Collapse

What is happening?

During an attack the passages lining the airways become swollen and inflamed and the muscles temporarily narrow, making it hard to get air in and out. Additionally, the air passages produce sticky mucus which further clogs the already narrowed airways.

Thus when the person breathes in and out a "whistling or wheezy" noise is heard.
The air passages become progressively narrow until they can close off altogether.

This process is reversible with prompt action and reliever medication to relax the muscles and reduce the inflammation.

Triggers

Asthma symptoms can be set off by a whole range of things, known as triggers.
The most common ones include:

• Animal fur/feathers
• Dust
• House mites
• Tree/grass pollen
• Mould
• The weather - changes in temperature
• Poor air quality
• Cigarette smoke
• Perfumes / chemical smells such as household cleaners and deodorants
• Laughter
• Exercise including sex
• Viral infections such as the common cold
• Latex gloves

Not everyone's asthma will be triggered by all of these and some may only react in certain circumstances. So on a given day one person may be triggered but not the other.

Occasionally occupational exposure to substances can cause asthma to develop.
Pregnancy and other hormonal changes can also have an impact on asthma symptoms.

Asthma Management

If their asthma is well controlled, most people will be able to live full and active lives with minimal concessions to their condition. It's primarily when it's poorly managed, or particularly severe, that it causes most problems. 

Action Plans

An Asthma action plan is a document used by an individual to help plan their care and to ensure that their condition / situation is managed effectively. The idea is to ensure that the person gets the same care, irrespective of who is looking after them.

Care plans are written documents that are often template-based but are then personalised for an individual.

Below are examples of the adult and child asthma action plans, which are produced by Asthma UK. Downloadable versions are available direct from their website (5).

They give information on what medication you should take each day, advice on monitoring worsening asthma symptoms and guidance on what to do in the event of an attack.

In schools, the asthma action plan is often included as a part of a school health-care plan for a particular child.

Asthma in Schools

With 1.1 million children affected by asthma in the UK, it is one of the most common long-term medical conditions that school staff have to deal with.

Sadly, a review of deaths found that 10 children under 10 died of asthma and a further 18 children aged between 10 and 19 died in 2015. Most died before they got to hospital.

However if the child's asthma is well controlled there is no reason for them not to fully participate in school life. 

The key to this is being well prepared:

• ensuring staff understand that particular child's condition
• appreciating what triggers attacks for them
• and knowing how to manage it and any other requirements.

The child, their parents and the school staff all need to be happy with this.

Children should be able to tell a member of staff when they need medication and staff should be on the lookout for early warning symptoms such as persistent cough at rest.

The Department for Education has guidance for Schools to support children with medical conditions.

Individual Health Care Plans for Pupils

Many children will have individual health care plans drawn up in combination with parents, the child and healthcare professionals so that the child is kept safe at school.

They include details of any medical condition, treatments and actions required to keep them safe. Essentially, they're a blueprint for the child so that any member of staff who needs to view it to keep the child safe, will have an understanding of what to do.

Healthcare plans are confidential documents and must be stored securely. They should be reviewed at least annually or more frequently if the child's condition requires it.

Template documents are available from the Department for Education. Alternatively action plans such as those developed by Asthma UK may be used, depending on the extent of the child's medical needs.

Predicting an Attack

In some circumstances it is possible to predict an acute asthma attack as they can develop over a few hours or days. Signs that the child's control of asthma is getting worse may include:

• Night time waking due to symptoms such as coughing. This often leads to the child becoming more tired during the day.
• If the child is using their reliever inhaler more than 2-3 times a week
• If they're not responding well to the reliever inhaler when it is used
• If exercise is causing more or worse symptoms than usual

Using an asthma plan will help staff understand when symptoms are starting and how best to manage them. This plan can be updated as more is understood about the child's particular triggers or symptoms.

Knowing what triggers the child's asthma is crucial as well as knowing the steps to deal with an attack should one occur.

Medication in Schools

All medication used in schools should have prior written consent from parents. Each child should bring their medication and spacer into school with them. Processes need to be put in place to ensure that they are accessible and in date.

If a child's inhaler medication appears to be empty, not working or not available (for example left at home) then the school's own medication can be used.

Spare Medication

Since September 2014, schools have been able to purchase spare inhalers (the Emergency Salbutamol Kit) for use in school. Those pupils entitled to use the school's own medication will be those who normally have an inhaler in school and whose parents have already given written permission for it to be used.

Head teachers can purchase these inhalers from pharmacies. The request needs to be on headed paper detailing the number of inhalers and spacers required and for what purpose. It is important to consider school layout, number of children affected by asthma in the school and school trips when considering how many to purchase.

The type of inhaler schools can purchase will be a metered dose one. Parents need to be informed that this is the type of spare inhaler held by the school as it may be a different delivery mechanism to the child's normal one.

Emergency Salbutomol kit

The emergency kit should include:

• Salbutomol metered dose inhaler- at least one
• At least two single use plastic spacers compatible with the inhaler
• Instructions on using inhaler and spacer
• Cleaning instructions
• Manufacturers info
• Checklist of inhalers identified by batch no, expiry date
• List children permitted to use inhaler as detailed via IHP
• Arrangements for replacing the inhalers
• Record of administration

School staff must always keep formal records of all medication taken, including when spare inhalers are used.

Prevention

Managing asthma and preventing attacks happening is key.

Most asthmatics will take preventative medication to stop asthma flare ups. It's designed to stop their air passages being quite so sensitive. Essentially they "coat" the lining of air passages, so that they don't react as quickly to the triggers.

They are not fool-proof. They slow down the sensitivity of the lungs but if the triggers are large enough the person's airways can be overwhelmed and an asthma attack will occur.

Regularly using a preventer as prescribed means that you're less likely to have an attack and so may need to use the reliever inhalers less.

This is the key to good control. Using a preventer inhaler regularly even when you don't have symptoms is important as it takes a while to build up in the system and become effective.

The medication used to do this is often something called a cortico steroid. This is different to the steroids that body builders use.

We make cortico steroids naturally in our bodies. This a low dose copy of a naturally occurring substance to reduce inflammation.

Flare-ups often happen because people stop taking their preventer, believing that they don't need them as they haven't had to use the reliever medication.

Most Common Types of Inhaler

There are many different types of inhaler, but the following represent the most common ones that you're likely to encounter:

As you can see, inhalers come in a variety of brands, colours and formats.

The most common are the 'pressurised metered dose inhalers (pMDIs), such as Ventolin, which give the dose in aerosol form. They are the ones which should be used with spacer devices.

The Easi-breathe devices are breath-activated inhalers (BAI). Breathing in activates the delivery of the drug. These devices are used without spacers.

The Flixotide preventer is an example of a dry powder inhaler. As its name suggests, it delivers the medicine as a dry powder. The lever in the side is clicked across and released, at which point the user is able to inhale the powder.

There are at least 15 different types of inhaler. It's not always obvious how each type should be taken so if you're not sure you can take a look at Asthma + Lung UK's handy video guides. Be aware, particularly for younger children, you may need to supervise their technique.

Combination Inhalers

Some people are prescribed combination inhalers. These give a combination of two medicines: a long acting reliever medicine and a corticosteroid to prevent attacks. Examples of this type of medicine are Seretide, Fostair and Symbicort.

People on these inhalers may still need a blue reliever as well in case of an attack as the long acting reliever medication in the combination inhaler may not be strong enough.

There are exceptions to this. Those on what is called a MART regime (Maintenance and Reliever Therapy) may only have one inhaler. These people should have an asthma action plan to tell them what to do if they have an attack.

Checking Breathing - Peak Flows

A peak flow meter is a device which measures how quickly you can blow air out of your lungs. How fast you can blow the air out indicates whether your air passages have narrowed. The Peak Expiratory Flow (PEF) It is measured in litres of air blown out/minute.

Peak flow meters are a useful way of monitoring asthma control and being aware of when symptoms are not as controlled as they should be. Knowing what your baseline peak flow reading is enables you to manage your symptoms better.

Peak flow scores are dependent on a variety of factors, including, gender, age, height. People will be taught to use it by their GP or Practice nurse.
Each time it used the person blows into it three times. Their best score is the one that is recorded. Peak flow charts can be downloaded from Asthma UK (4).

Generally when your peak flow rate drops significantly (usually by about a third from your usual peak) it is time to contact your GP.

Using Spacers

Some people will be prescribed spacers to use with their inhalers.

Traditionally children were given them as it was felt that they often struggled to use their metered dose inhaler effectively. However it's now recognised that everyone can benefit from using a spacer if the inhaler accommodates them.

Not all inhaler devices require the use of a spacer. Primarily they are used with the traditional metered dose inhaler type.

Taking a dose of medication directly from an inhaler requires a slow deep breath in at the same time as activating the inhaler and then holding the breath for up to 10 seconds. This is difficult to coordinate when one is already short of breath and there is evidence that people don't get the right dose.

Using a spacer ensures that the right amount of medication is delivered to the lungs where it is needed. The medicine collects in the chamber and so it is easier to breath in and less time critical. 

The person's healthcare professional should have taught them how to use their medication with a spacing device. There are two methods: the tidal or multiple breath technique or the single breath and hold. There's more information about using spacers with your inhaler on Asthma UK's website.

Regular use of a spacing device has been shown to improve asthma control meaning that patients need to take less medicine. Using spacers also reduces the risks of side effects, in particular oral thrush.

Spacers need to cleaned regularly with warm soapy water and allowed to air dry.

COVID-19 and Asthma

Respiratory infections can set off an asthma attacks and so Coronavirus may trigger it for some.

This is one of the reasons why those who have severe asthma were contacted by their GP during the peak of the pandemic, asking them to shield.

Active Monitoring of Symptoms

To help in maintaining good control over your asthma, it's useful to monitor your symptoms regularly. You'll then be better prepared to respond to any changes in your symptoms:

• Follow your asthma plan.
• Start a peak flow diary so that you pick up on the early warning symptoms.
• Carry your blue reliever inhaler at all times
• If your asthma gets worse contact your GP or 111, or if you have a severe attack call 999. 

References & Useful Links

1: Medical News Today Article on the history of asthma

2: Data from the European Lung Foundation

3. Video guides from Asthma + Lung UK on how to take a range of inhalers

4. Peak flow information from Asthma + Lung UK

5. Downloadable Asthma Action Plans from Asthma + Lung UK