Asthma is much more than just the wheeze when symptoms appear, writes Louis Roller

More than two million Australians have asthma – about one in 10 adults and about one in nine or 10 children.

Asthma and allergies are closely linked and asthma is more common in families with allergies or asthma; however, not everyone with asthma has allergies.

Adults of any age can develop asthma, even if they did not have asthma as a child.

Some people have asthma during childhood, but later have very few or no symptoms as adults. Many preschool children who wheeze do not have asthma by primary school age.

Indoor and outdoor pollution can increase the risk of developing asthma.

Athletes can develop asthma after very intensive training over several years, especially while breathing air that is polluted, cold or dry.

The most common symptoms of asthma are: wheezing, shortness of breath, tightness in the chest, coughing. Beware of hearing, “it’s only a cough”.

However, one does not need to have all of these symptoms to be diagnosed with asthma.

Noisy breathing, such as a rattling sound, is common in healthy babies and preschoolers. This is not the same as wheezing and does not mean the child has asthma.

Many people think they have asthma only when they have asthma symptoms. In fact, the airways are sensitive all the time and most people with asthma have permanently  inflamed airways when not taking regular preventer treatment.

From time to time, the airways tighten or become constricted so there is less space to breathe through, leading to asthma symptoms.

Asthma causes three main changes to the airways inside the lungs, and all these can happen together:

  • the thin layer of muscle within the wall of an airway can contract to make it tighter and narrower – reliever medicines work by relaxing these muscles in the airways;
  • the inside walls of the airways can become swollen, leaving less space inside – preventer medicines work by reducing the inflammation that causes the swelling; and
  • mucus can block the inside of the airways – preventer medicines also reduce mucus.

Asthma triggers can cause the airways to become narrow and inflamed, leading to asthma symptoms. Avoiding triggers, if possible, can help to control asthma. Anything that causes a reaction can set off asthma symptoms.

These triggers differ between individuals. Over time, many people will get to know which circumstances can make your asthma get worse. Some can be avoided altogether.  

Common triggers include: respiratory infections (such as colds and flu), cigarette smoke, allergy; related triggers (such as, house dust mites, pollens, pets or molds), weather (such as cold air, change in temperature, thunderstorms), work-related triggers (such as wood dust, chemicals, metal salts), irritating substances breathed in the air (such as bushfire smoke), certain medicines, e.g. aspirin & NSAIDs, some antihypertensive drugs (beta-blockers) stress and high emotions, such as crying)

Exercise is another common trigger, but this can usually be managed by warming up properly and taking some extra asthma medication before beginning.

There are now a plethora of asthma medications and pharmacists must be up to date with all the latest developments.

The medications are divided into relievers (inhaled bronchodilators [short-acting (SABAs) beta2-agonists or long-acting (LABAs) beta2-agonists]), and preventers (inhaled corticosteroids). Various combinations of bronchodilators with preventers are available.

There are a large variety of combinations and devices and the pharmacist is obliged to be able to demonstrate how to use them to their patients.

Pharmacists should also counsel patients about the use and upkeep of spacers.

Practice points

  • Some medications, eg beta-blockers (including eye drops), and some complementary medicines, eg royal jelly and echinacea, may trigger bronchospasm; avoid aspirin and NSAIDs in patients who have had an asthmatic reaction to them.
  • Check inhaler technique and compliance regularly; poor compliance and inadequate technique are common causes of poor asthma control. Never ask a patient if they know how to use their inhalers, as the answer will invariably, be yes when in reality, the answer might be no.
  • Develop and regularly review a written action plan based on patient’s symptoms, peak expiratory flow or both, that enables people to manage their illness; accompany this by regular medical review and patient education.

Thunderstorm asthma is a form of asthma that is triggered by an uncommon combination of high pollen (usually during late spring to early summer) and a certain kind of thunderstorm.

A severe thunderstorm asthma event occurred in Melbourne and Geelong in November 2016, which resulted in thousands of emergency ambulance calls and a large surge in emergency departments presentations, hospital admissions, after-hours calls to primary care, and 10 deaths due to asthma.

This was the largest recorded epidemic thunderstorm asthma event in the world.

  • Anyone can be affected, even if there is no history of asthma.
  • People at increased risk have a history of asthma, have unrecognised asthma, have hay- fever (allergic rhinitis), particularly seasonal hay fever, or are allergic to grass pollen.
  • People experiencing asthma symptoms even if for the first time should not ignore it, and should seek medical advice as soon as possible.
  • An asthma flare up can vary in severity and can be life threatening. If there are signs that a person’s condition is deteriorating, urgent care should be sought. Call Triple Zero (000).
  • Be aware of forecast thunderstorms in the pollen season particularly on days with a HIGH or EXTREME pollen count.
  • Where possible, stay indoors with doors and windows closed until the storm front has passed.

National Asthma Council website at www.nationalasthma.org.au)

Therapeutic Guidelines Respiratory, Version 5, 2015.

Associate Professor Louis Roller, from the Faculty of Pharmacy and Pharmaceutical Sciences Monash University, was the 2014 recipient of the PSA Lifetime Achievement Award.