Understanding Asthma

Updated 29th November 2017, updated 22nd October 2024

What is it?

Asthma is a chronic inflammatory disease that affects the airways – the small tubes that carry air in and out of the lungs. On response to a trigger, the muscles around the walls of the airways tighten and become narrower. The lining of the airways also produce a sticky mucus. As the airways narrow, it becomes difficult for air to move in and out.

As muscle tone is required for inhalation and muscle relaxation is required for exhalation, a common and noticeable issue with asthma is a difficulty in exhaling.

What causes asthma?

Factors include:

Family history
Lifestyle – e.g. hygiene and diet and environment
Smoking
Exposure to irritants in the workplace such as dust and chemicals
Environmental pollution can make asthma symptoms worse
Adult-onset asthma may develop after a viral infection

What are the triggers?

A number of factors can trigger an Asthma attack; most of these airborne irritants or particulate but other environmental, physical or emotional factors can cause or exacerbate the symptoms.

Knowing these factors can help you prevent a casualty from experiencing an attack or help relieve the symptoms by being aware of their environment or changing their behaviours.

Aerosols
Air pollutants - dust, soot, smoke and fumes
Animal hair
Colds & viral infections
Emotions - Stress, depression, anxiety or even a fit of laughter can trigger asthma symptoms.
Exercise
Food - including cow’s milk, eggs, fish, shellfish, yeast products, nuts, and some food colourings and preservatives
Hormones - increased incidence around puberty, menstrual cycle, pregnancy and menopause
House-dust mites
Medicines - Aspirin and non-steroidal anti-inflammatory tablets such as ibuprofen and voltarol
Pollen, Moulds and fungi
Weather

How is it managed?

Asthma is commonly managed with an inhaled medication; a delivery route that is very fast-acting. It can also be controlled by parental (digested) medication.

A casualty suffering from an asthma attack needs their medication as quickly as possible – an inherent problem with a breathing condition that relies on an inhaled medication for treatment is that the worse the condition becomes, the harder it can be for the casualty to medicate.

Relievers

Everyone with asthma should have a bronchodilating reliever inhaler. Reliever inhalers are usually blue and contain the beta-2 agonist salubutamol (Ventolin® ) or Terbutaline, another bronchodilator which goes by the trade name Bricanyl®. Terbutaline is often delivered in a blue Turbohaler

Relievers are medicines that are taken immediately to relieve asthma symptoms. They quickly relax the muscles surrounding the narrowed airways allowing the airways to open wider, making it easier to breathe again.

A casualty should take a dose of a reliever inhaler as soon as they feel symptoms of an Asthma attack. A casualty who needs to use their reliever inhaler three or more times a week may not be well controlled and should have their medication reviewed.

Preventer inhalers

Preventers control the swelling and inflammation in the airways, reducing their sensitivity and the risk of severe attacks. The protective effect builds up over a period of time so they need to be taken every day (usually morning and evening) even when they are feeling well.

Preventers do not give immediate or quick relief when the casualty is breathless but instead, they reduce long-term inflammation. Preventive inhalers usually contain a low dose of corticosteroid medicine.

Preventers are usually brown, red or orange inhalers.

Preventive inhalers will not relieve the symptoms of an Asthma attack and should never be offered to a casualty where a reliever inhaler is needed.

Spacers

Spacers are large plastic or metal chambers that have an aperture at one end for the reliever inhaler to fit. The spacer enables the medication to be aerated, making it easier to inhale.

Spacers are very important because:

they make aerosol inhalers easier to use and more effective
they get more medicine into the lungs than when using the inhaler on its own
they are convenient and compact and work at least as well as nebulisers at treating most asthma attacks in children and adults

If the casualty is struggling to use their inhaler, an improvised space can be fashioned by cutting the end off a 500ml drinks bottle and inserting the inhaler into the top.

Treatment

The casualty is having difficulty breathing – this is incredibly distressing and, remembering that emotions can trigger an Asthma attack it can become psychosomatic; the more anxious the casualty becomes, the worse their symptoms become, the harder it is to breathe, the more anxious they become...

Attempt to remove the casualty from the trigger or remove the trigger from the casualty by changing the environment ( e.g opening doors or windows to ventilate, removing the casualty to a different environment).
A casualty will always find the most comfortable position - whether this is to alleviate pain from an injury or discomfort from an illness so so not worry about the optimum position - the casualty will position themselves.
Do not attempt to lie them down.
Loosen anything around the casualty's neck; the first couple of shirt buttons or an inch or two of their zip. Whilst this is not imparing their breathing, many find less restrictions around their neck psychologically comforting.
Look into the casualty's eyes and hold their attention.
- Ask them; “Do you have Asthma?” , “Do you have your medication?”
- Ask “Yes” or “No” questions which they are able to respond to without talking.
Do not underestimate the power of emotional support. Give positive statements such as "Stay calm" as opposed to "Don't panic". The brain hears the verb first and has to process the fact that the instruction is a negative. What does someone climbing a ladder do immediately after you shout "Don't look down!" ?

Asthma treatment guidelines
Severity	Signs & Symptoms	Treatment (1)
Moderate	Wheezing Difficulty in breathing (typically difficulty exhaling) Shortness of breath Tightness of chest Coughing Potentially sputum The casualty may be adopting a position which make breathing easier such as leaning forward or may look panicked	For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs. For a child, give a puff every 30–60 seconds, up to 10 puffs. Each puff should be given one at a time and inhaled with five tidal breaths. Repeat every 10–20 minutes according to clinical response. Move to a calm environment Reassure the casualty
Acute	Any of: respiratory rate ≥ 25 breaths per minute Heart rate > 110 bpm Inability to complete sentences in one breath	Move to a calm environment Reassure the casualty Administer their relieving medication as above and consider improvising a Spacer Administer O2 if available to ensure SpO2 at 94% or above Consider respiratory support if unresponsive Arrange immediate transfer to hospital
Life threatening	Any of: Reduced level of response Exhaustion Cyanosis Poor respiratory effort Sp02 < 92%	As above

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What to do if the casualty does not have an inhaler?

It is tempting to ask if anyone else has an inhaler that the casualty can use. Legally we cannot allow the casualty to administer someone else’s inhaler and, as such we cannot endorse it.

The Law:

Inhaled medications are Prescription Only Medicines (POMs). It is illegal to administer such medicines without the prescription of a doctor. Read this article on the control of medicines.

Some POMs have dispensations which allow anyone to administer the medication in an emergency - notably an Adrenaline Auto Injector ( Epipen ) - and are listed in Schedule 19 of the Human Medicines Regulations 2012 but Salbutamol in a Metered Dose Inhaler was not included in this list. This was a gross omission and led to new legislation needing to be drawn up to enable schools to hold an emergency Inhaler (2) despite the risks of adverse reaction to salbutamol being low and short-acting.

Type of Inhaler:

Another issue with using someone else’s inhaler is it may not be the correct one.

There are several types of inhalers, each with its own mechanism of use.

Don't assume all inhalers are the same.

Reality:

An asthma attack can be a life-threatening medical emergency with an average 1,500 deaths per year in the UK (3).

In a remote setting consider using anyone’s Salbutamol inhaler if: