Asthma Education Series: Asthma mythbusting

Okay, so. As part of my asthma education series, I’m gonna drop a bit of asthma mythbusting on you. Here’s 9 myths and one actual fact. The statement that’s actually true might surprise you. If you have more myths you’d like fact checked, drop them in the comments – I’m perfectly happy to post a sequel post.

  1. Most kids with asthma outgrow asthma: FALSE. While some do outgrow asthma, latest evidence suggests that up to half of those who initially seem to outgrow it relapse later in life (often in middle age). As well, kids with more severe asthma are less likely to even get a remission. In all, only about 20% of asthmatic kids will outgrow asthma entirely.
  2. If someone is having an asthma attack, you should move them somewhere cold: FALSE. While some first aid information for asthma says to move someone to clear air if there’s an airborne trigger (smoke, etc), cold air is actually an asthma trigger and is likely to make the flareup worse.
  3. Asthmatics don’t need their inhalers, what they need is willpower: FALSE. Asthma is a physiological condition with measurable obstruction to airways. You cannot will yourself past being unable to breathe.
  4. Kids who always get asthma attacks in gym class are just being lazy. FALSE. Exercise is an asthma trigger in 50% of cases. Flare-ups in response to exercise are thus a sign of inadequate asthma control, not of laziness.
  5. “When I was a kid, there didn’t seem to be as much asthma.” ACTUALLY TRUE. Asthma rates are increasing. They have been increasing since at least the 1950s, especially in the developed world, even controlling for improvements in screening and diagnosis. There didn’t seem to be as much asthma when you were a kid because there actually wasn’t. That said, increase in asthma rates nowadays does not mean that those who have asthma now are somehow faking or invalid in their diagnosis, it’s simply more common now than 30, 40, or 50 years ago.
  6. If you use your medicine “too much,” you’ll build a tolerance to it and then it won’t work. FALSE. Asthma medicines are not addictive and the body does not build a tolerance to them. What can happen, however, is that a person can use their rescue (reliever) medication to cover up a worsening of their overall asthma without actually treating the underlying cause of the symptoms (inflammation) which is just getting worse and worse. Eventually, this can lead to a very serious asthma attack that medicine doesn’t work for. This is why it’s important to apply your asthma action plan and talk with your doctor if you’re having more flare-ups and symptoms than normal.
  7. If you have asthma, you can’t do well in sports. FALSE. 20% of the Canadian Olympic Team has asthma.
  8. Kids/people with asthma shouldn’t exercise. FALSE. Exercise is associated with improved asthma control.
  9. Steroids used to treat asthma will make me bulk up. FALSE. You’re thinking anabolic steroids, which are the type used by athletes in doping scandals. The steroids used to treat asthma are corticosteroids, which work in a very different manner on a very different set of pathways. Additionally, most cases of asthma are treated with very low doses of inhaled steroids, which substantially lowers the risk of side-effects.
  10. An asthmatic complaining about my perfume/smoking/cleaning products is just being dramatic. FALSE. Many asthmatics are triggered by airborne irritants, including perfumes, cigarette smoke, and cleaning products. This induces asthma symptoms that may range from merely unpleasant (chest pain and coughing) to serious and potentially life threatening (severe difficulty breathing). An asthmatic who complains to you about your scented product is not being dramatic, they’re suffering. Be considerate of their condition and stop exposing them to a trigger. Reactions to triggers can sometimes be delayed, so even if someone doesn’t look like they’re suffering now, that doesn’t mean that they won’t be up all night coughing.

The previous post in this series is here.
The next post in this series is here.

Astham Education Series: Asthma equipment. Part 1: Med delivery systems

As I hinted in my last post in the series, this is going to be a post about all the different gadgets an asthmatic might have. The post will include links and descriptions, but as I have none of the rights to images, I won’t be using them directly here. Instead I’ll link to an article or image of one somewhere else and direct traffic to the person who created the image.

There are a few major categories that I’ll separate everything into just to keep stuff organized and a bit easier to follow: There are medication delivery systems – nebulizers, spacers, metered dose inhalers, dry powder inhalers, and the like. There are at home testing supplies – peak flow meter, pulmonary function testers, and pulse oximeters. There are accessories – specialized ways of carrying around your meds and equipment. Lastly, there are bookkeeping tools for keeping a symptom log – I’ll explore both hardcopy and software options.

This post, for the purpose of length, is going to be split into 3 parts: Medication delivery systems, at-home testing supplies, and accessories and bookkeeping supplies. This is the first part: Medication delivery systems.

What I call a medication delivery system is just a tool that lets you get your meds where they need to be. For people with injected drugs, this would be needles and syringes and suchlike. For asthmatics, they tend to be things that help you inhale stuff into your lungs (although some asthmatics, mostly extremely severe asthmatics, do use auto-injectors and injection pumps, so I’ll include those in this post, too).

The most recognizable medication delivery system is the metered dose inhaler (MDI). MDIs are a way of turning asthma medicine into a mist of fine particles small enough to get into your lungs. A good description of how they work can be found here. In short, the canister contains a mixture of propellant (a liquified, nontoxic and chemically inert gas), medicine, and one or more stabilizers.* The canister is connected to a valve which can only dispense a certain amount of the mixture at a time. When you squeeze the inhaler, the valve is opened briefly and the propellant expands rapidly, forcing the medicine out and into the air as a fine mist, which is then inhaled. Taking an MDI is a bit of an exercise in coordination. Instructions on how to use them properly are provided in detail by reliable medical websites such as Medline, or you can speak with a doctor, nurse, nurse practitioner, respiratory therapist, or pharmacist, all of whom should be able to instruct you in proper inhaler technique. In short, take the cap off, shake the inhaler, hold it about the width of two fingers in front of your mouth, breathe out gently and completely, then squeeze the canister down into the plastic holder as you inhale. Then hold your breath for 10 seconds, and breathe out slowly. It will take some practice to get the hang of the hand-lung coordination.

If you have trouble with taking an MDI properly, or if you are prone to severe attacks, you and your doctor may decide it’s a good idea to add a valved holding chamber or spacer. These are long, hollow, antistatic bubbles or tubes designed to eliminate the hand-lung coordination aspect of MDI use. How to use a spacer varies slightly depending on the design and brand, but typically you insert the MDI into one end, and either put the mask over the face of the person using it (if it has a mask) or put your mouth around the mouthpiece, then the medication is taken as directed by the spacer manufacturer. Spacers tend to be bulky and obvious, so it will usually attract attention and questions if you have or use one.

Let’s say you need a medicine that doesn’t come in a metered dose inhaler, or that you can’t do the breathing necessary to use one, even with a spacer. This is where nebulizers come in. Nebulizers are machines designed to make a mist of your medicine, which you then inhale. Because they tend not to be airtight, they’re not nearly as efficient with the medicine as MDIs or spacers, and as a result, you will have to use more medicine for the same effect. Like with spacers, proper nebulizer use varies a bit from device to device, but if you have one, you can speak to your pharmacist about how to use it. They are fairly straightforward once you know how to set them up, but they’re noisy and time-consuming relative to inhalers.

Next up is dry powder inhalers (DPIs). DPIs are a good alternative for those who don’t like noise or those who find they’re sensitive to propellants or stabilizers (of which I am one – certain brands of rescue puffer have a stabilizer that results in my asthma attack getting worse, not better, so I have to be careful which rescue inhalers I buy). DPIs do not have stabilizers or propellants. Instead they’re use dry, finely ground powder compounded with a bulking agent (usually lactose) contained in a capsule. Using the DPI properly pierces the capsule, and then you inhaling medicine from the inhaler carries it into your lungs. For DPIs to be appropriate for you, you need to be able to make a certain minimum inhalation force because otherwise the powder won’t get carried into your lungs, and so your doctor will usually give you a practice unit which will make noise when you inhale properly. If you’re unable to inhale strongly enough, DPIs are not an option for you.

The last two medication delivery devices are relatively rare for asthmatics. They are infusion pumps and auto-injectors. Infusion pumps for asthma are only used by those with very severe asthma, who need a constant supply of bronchodialator drug (often salbutamol or terbutaline) in their blood system. Often, they use subdermal infusion pumps similar to those used by people with diabetes. I’ve never been severe enough to need one, so I don’t know what they’re like, but they come with many of the same hazards of an insulin infusion pump, and hygiene is very important to avoid infection. Auto-injectors are used by those asthmatics who are prone to status asthmaticus and anaphylaxis. These auto-injectors are exactly the same as those used to treat severe allergic reaction and use the exact same drug (epinephrine) because in many cases, severe asthma attacks are severe allergic reactions. Information on how to use these auto-injectors properly is available from any manufacturer or first aid course.

That’s pretty much it for medication delivery devices for asthma. I haven’t covered any of the out-of-date and obsolete forms of asthma medication delivery devices, though I might examine that history in a later post. In my next post of this series, I’ll talk about home testing devices.

*As an aside, a lot of MDIs contain ethanol as a stabilizer, and this has been known to cause false positives on breathalyzer tests when the breathalyzer is performed shortly after taking your inhaler.

The previous post in this series is here.
The next post in this series is here.

Asthma Education Series, Lifestyle for Asthma Control, part 2: Exercise.

So, I kind of got incredibly busy for the rest of June and had to leave my asthma education month stuff on its own for a while. Which is unfortunate. However, i don’t want to wait until next year to finish the posts I had planned, so I’ll just continue the asthma education series and post whenever I feel like it.

So. This post was a hard one to write without coming off as being elitist or body shaming. If I am, please let me know so I can rewrite it, because that’s not the vibe I want to give here at all.

Moving on: The other hand of the lifestyle coin, when it comes to asthma control, is exercise. Exercise is associated with improved asthma control, according to the best available data. Exercise has a number of other benefits, including healthier cardiovascular system, improved mental health, improved lung capacity, and improved exercise tolerance. For this reason, it’s been advised since the 1980s for people with asthma to exercise.

I will not lie: Exercise can trigger your asthma, and that can range from merely unpleasant to downright scary. However, if you work with your doctor, a plan can usually be devised to allow you to exercise without attacks. Some asthmatic people (myself included) have to take some medicine before we do certain types of exercise. Other asthmatic people find that just having a longer, slower warmup helps.

I will also not lie on the next point: If you are sedentary and you have exercise-triggered asthma, exercise will not be comfortable. It probably will induce symptoms. The best available evidence, however, suggests that if you keep at it, your exercise-induced asthma will gradually become less severe, your exercise tolerance will increase, and your overall asthma control will improve.

(note that this is not the case for exercise-induced bronchospasm, which is thought to be a type of lung repetitive strain injury from high-performance exercise and unlike asthma, is not inflammatory or chronic. EIB will tend not to improve without treatment, even if you push through it with your exercise)

Since exercise can be for many people a trigger, exercising with very poorly controlled asthma or during a flareup can be dangerous. As well, starting a new exercise plan without consulting your doctor might be dangerous. If you want to increase your fitness level, talk to your doctor about what to do and when if you want to exercise but are an asthmatic who is triggered by exercise. Get a plan for how much asthma symptoms are safe for you to tolerate and how soon you can return to exercise once a flare is under control.

There is no hard evidence on what, if any, exercises are better for people with asthma, though many asthmatics (myself included) find that sustained, high-intensity exercises like endurance running to be hard on us while exercises that vary in intensity or which require careful control of breathing like martial arts or swimming to be easier on us. Try out many things and see what is easier on you.

Exercise is not a silver bullet for asthma – it will not replace your daily control medicine, nor will you ever stop an attack in its tracks with some jumping jacks. However, evidence is mounting that regular exercise plays an important role in asthma control and quality of life for people with asthma. If it’s possible for you, starting a new exercise routine may be a good idea for helping your overall health and asthma control.

In my next post in the series, I’ll talk a bit about asthma gear – what gadgets people with asthma can carry, what they’re used for, and how they work.

The previous post in this series is here.
The next post in this series is here.

Lifestyle for Asthma Control 1: Trigger avoidance

So, I’ve had three posts on asthma treatment on the medical end of things. This post and the next post will be on lifestyle factors that the literature strongly supports: Namely trigger avoidance and exercise.

Asthma triggers are things that provoke asthma symptoms. Some things are very common, while others are a bit weirder. I’m going to talk a bit about how to find out what your triggers are, the most common triggers, and then talk about steps you can take to avoid them.

There are two main ways that triggers can be discovered: The first is through self-monitoring of symptoms and looking for patterns in your asthma flareups. The single most beneficial way to self-monitor symptoms and look for patterns is through keeping an asthma diary.  An asthma diary is a place where you record your peak flow (if you have a peak flow meter), how often you’ve needed your inhaler, and anything you think might’ve had something to do with your symptoms that day. If you notice that the same thing keeps popping up in your diary, try avoiding that thing and see if your diary entries after avoiding it show improved control. If the improvement is substantial, then it’s probably a trigger. Your asthma diary can either be a hard copy or be electronic. A number of asthma apps exist if you like mobile record-keeping. Personally, I like using a spreadsheet – a bit less user-friendly, but I can include everything I want on it.

The second way you can try to figure out what triggers you is through allergy testing. Most people with asthma who also have allergies find that their allergies trigger their asthma, so avoiding things you’re allergic to is a good way of helping out your asthma control. There are five different types of allergy testing: Skin prick testing, intradermal testing, oral challenge, patch testing, and blood testing. What type of test is used depends on the type and severity of the allergy suspected. All allergy tests except blood tests carry the risk of anaphylaxis, a type of very serious and potentially life-threatening allergic reaction, and so in people with a history of anaphylaxis to the suspected allergen, blood tests are usually preferred.

Asthma triggers fall into two general categories: Inflammatory triggers and symptom triggers. People with non-allergic asthma are only bothered by symptom triggers while people with allergic asthma are usually bothered by both symptom and inflammatory triggers, though the exact set of triggers will vary person to person.

Symptom triggers include:

  • Smoke – including wood smoke, tobacco, and incense
  • Exercise
  • Cold air
  • Car exhaust
  • Strong scents
  • Chemical fumes
  • Air pollution
  • Intense emotions
  • Certain food additives, including sulphates and nitrates

Common inflammatory asthma triggers include:

  • Dust and dust mites
  • Animals
  • Cockroaches
  • Mould
  • Pollen
  • Viral infections (especially upper-respiratory tract infections)
  • Certain air pollution
  • Food allergies

Note that these lists of common triggers are by no means exhaustive. I’ve met people for whom laughter is an asthma trigger, and others who find that foggy days or bad weather trigger them – if a trigger isn’t on these lists, that doesn’t mean it doesn’t trigger a person’s asthma. It just means that it’s a bit less common a trigger.

How you avoid triggers will depend on the trigger in question. For pollen and air pollution, look up your region’s pollen count and air quality. In Canada, air quality is measured through the Air Quality Health Index. Other countries have their own monitoring systems. Once you’ve found what the air is like that day, decide accordingly: On high-pollen and/or low air quality days, I don’t exercise outside. If it’s medium, I might exercise with premedication, and then change clothes and have a shower when I get inside.

Where animals are concerned, the most effective way of avoiding the trigger is to avoid the animal. I had to give away my pet cats. On that note, there is no such thing has hypoallergenic pets. If you don’t want to give away your pets, this website has a list of ways to reduce pet dander.

Where dust is concerned, make sure you clean regularly and wash bedding and curtains weekly in hot water.

For other triggers, strategies for trigger avoidance can be found online, but in general it all boils down to: avoid it where possible, and take steps to mitigate it if it’s impossible to avoid.

The previous post in this series is here.
The next post in this series is here.

Asthma Treatment 4: Maitnenance meds

So, yesterday, I talked about what asthma control is.

Today, and for the next two posts, I’m going to write about how you get and maintain asthma control. There are three pillars to getting good asthma control: Medicine, exercise, and trigger management. Today, I’m going to talk about medicine.

Most people with asthma need at least one maintenance medicine. Only the mildest of asthmatics can maintain control with just a rescue puffer. Maintenance or preventer meds are taken every day, usually twice a day, to help control asthma. There are several main classes of maintenance asthma medicines:

  • Inhaled corticosteroids
  • Inhaled non-steroidal anti-inflammatories
  • Long-acting bronchodialators
  • Leukotriene receptor antagonists
  • Methylxanthines
  • Antihistamines
  • Oral corticosteroids
  • Humanized antibodies

Inhaled corticosteroids (abbreviated in papers as ICS) are finely-ground anti-inflammatory steroid that you inhale. They work by reducing the inflammation of your airways, making them less swollen and twitchy. They’re the single most common type of asthma maintenance med, and most people who are on other maintenance meds will be on one or more ICS drugs as well. They’re typically delivered either through a dry powder inhaler or through a metered dose inhaler. Sometimes, they’re delivered through a nebulizer. There are too many ICS drugs to list, but a list of common drugs in this class may be found here.

Inhaled non-steroidal anti-inflammatory drugs are an older class of asthma medicine, still used in those with steroid-resistant asthma or those who have a history of bad reactions to inhaled corticosteroids. They work by stabilizing mast cells and preventing the allergic reaction that leads to swelling, inflammation, and twitchy airways. There are two drugs in this class: cromolyn sodium and necromil sodium. They’re not used very often anymore because they’re inconvenient (you need to take them four times a day) and are held to be less safe than ICS and leukotriene receptor antagonists. Since MDIs stopped being produced in 2010 when the CFC propellant was banned, they can only be delivered through a nebulizer. This class has mostly been replaced by the leukotriene receptor antagonists discussed below.

Long-acting bronchodialators (abbreviated LABAs) are a class of drugs that works by binding to a receptor on the outside of the cell, which causes relaxation of the smooth muscle. In this way, they work exactly like asthma rescue medicines, but they last longer. This longer lasting action comes at a price: they usually aren’t fast acting, and so with one exception (formoterol), they can’t be used as asthma rescue medicines. They stop, reverse, and prevent bronchospasms. These medicines are not without risk: The benefit of LABAs to quality of life and asthma control must be weighed against a small but significantly increased risk of sudden, severe and life threatening asthma attacks. This increased risk is either greatly reduced or eliminated entirely (literature is contradictory on this point) in people who are taking inhaled corticosteroids, and therefore these medications are contraindicated in asthma patients who are not taking ICS therapy. What that means is that if you are asthmatic and your doctor has you on a LABA without an ICS, you should talk with your doctor about whether it’s a good idea.

Leukotriene receptor antagonists (abbreviated LRTAs) are a class of drugs that work by inhibiting the action of leukotrienes. In short, they stop allergic reactions before they begin. Common drugs in this class are montekulast, zafirlukast, and zileuton. LRTAs come with a warning for possible neuropsychiatric side effects, the effects of which can be delayed by several years. As such, LRTAs, like LABAs, are a class of drug that is approached with caution and only when a risk-benefit analysis indicates that the potential benefit outweighs the potential risk.

Methylxanthines (also called theophyllines) are a class of drug that is related to caffeine. They are stimulants, anti-inflammatories, and bronchodialators. They work by relaxing the airways and possibly by reducing the inflammation that causes asthma symptoms. There is also some evidence that theophylline might reverse steroid insensitivity in severe asthmatics. Theophylline has a relatively narrow therapeutic window, and when I was on it as a kid, I had to go for weekly blood tests to make sure it wasn’t building up in my system to toxic levels. Due to their side-effects and potential toxicity, theophyllines are only used in people whose asthma is very severe and uncontrolled. On a completely-unrelated-to-the-medicine note: theophylline syrup tastes absolutely terrible, and I learned to swallow pills at four so I wouldn’t have to take it anymore.

Antihistamines are drugs which prevent allergic reactions by either preventing the production of histamine or preventing the binding of histamine to its receptor. It is a broad class which includes many different sub-families but they all work by preventing the allergic reaction from completing by stopping the action of histamine on cells. This in turn prevents allergic inflammation and bronchospasm. Some people with allergic asthma (me included) have allergy medicines included for some asthma attacks (I’m supposed to take diphenhydramine if I think allergies might be playing a role in my asthma attack). There are far, far, far, far, far too many antihistamines to even try to list all of them, but a partial list of antihistamines may be found here.

Oral corticosteroids are the pill version of inhaled corticosteroids, and work in a similar manner, except throughout your whole body rather than just at your lungs. Due to systemic application, they come with a lot of very nasty side-effects, and the risk of side-effects increases as the length of time you’re on them increases. For this reason, doctors try to avoid treating people with oral steroids, and won’t prescribe them except for serious flares or for those who can’t control their asthma any other way.

Humanized antibodies represent the only class of asthma drug I’ve never been on. The only asthma drug in this class is Omalizumab. There is a not-unsubstantial risk of anaphylaxis associated with humanized antibody treatment, and for this reason, humanized antibody treatment is only prescribed to those with moderate to severe asthma that is unresponsive to steroid treatment. They work by blocking cell receptors that lead to serious allergic reactions, including severe allergic asthma and anaphylaxis. Xolair is also very expensive. Depending on dose, it can cost up to $2,000/mo.

For asthma treatment, doctors usually follow a stepwise approach to treatment: This means that asthma medicine is increased if you’re doing badly and if you’re doing well for more than six months, they will try reducing your medicine to see if you can manage on lower doses. This allows for the fact that asthma can change in severity and may actually get better over time, while allowing doctors to respond if your asthma control is lacking. Canadian Thoracic Society sets the guidelines for asthma treatment in Canada, while equivalent organizations set similar guidelines in other countries.

The previous post in this series is here.
The next post in this series is here.

Asthma Treatment 3: Asthma Control

So, today’s post is late because I had planned to write tomorrow’s post instead, but I couldn’t make it make sense, until I realized that you have to know what asthma control is to understand it. So I’m going to write about asthma control.

Put simply, good asthma control happens when your asthma is managed with medication and lifestyle to a sufficient degree that your asthma has the minimum possible impact on your life.

Bad asthma control happens when your asthma is inadequately managed with medication and lifestyle, such that your asthma has a larger impact on your life than necessary.

For the vast majority of asthmatics (all mild intermittent and mild persistent, and most moderate asthmatics), that means good control according to their country’s asthma control guidelines. In Canada, this means all of the following:

  • No daytime attacks
  • No night-time symptoms
  • Reliever medication use <4x/wk
  • No school or work absenteeism due to asthma
  • Normal lung function tests

For a minority of people with asthma (me among them), textbook asthma control is not possible. In our cases, good control is defined by our doctors.

Improving your asthma control is not only helpful to your quality of life and mental well-being, it’s also important for your personal safety. Poor asthma control is a risk factor for fatal and near fatal asthma. Asthma control is thus a safety issue in addition to a wellbeing issue.

If you have asthma, you might be wondering how to tell if you have poor asthma control? Here’s some signs of poor asthma control:

  • Waking up at night one or more times a week because of asthma
  • Rescue puffer does not work as quickly or as completely as it used to
  • You’re using your puffer more than three times a week
  • Your asthma is stopping you from regular activities, like exercise or housecleaning
  • If you have a peak flow meter, your peak flow is regularly <80% of your personal best
  • You’ve needed oral steroids for an asthma flare twice or more in the past year

If you prefer quiz-format monitoring, there are several quizzes around the internet for checking your asthma control. Sites with asthma control quizzes include WebMD,and the Asthma Society of Canada.

What things help asthma control (maintenance treatments and lifestyle changes) and hinder it (triggers) will be discussed in later posts.

The previous post in this series is here.
The next post in this series is here.

Asthma treatment 2: Acute care

So, maybe you’re an author wondering how to write hospital treatment of an asthma attack. Or maybe you’re an asthma patient who’s never been to the ER/A&E before but has had a few times where they think they should have gone but didn’t because they were scared of what would happen. Or maybe you’re someone who is wondering whether or not those difficulty breathing spells they take sometimes are asthma attacks. Or maybe you’re just curious what they can do at an ER/A&E for an asthma attack. This post is for you.

I discussed in a previous post what standard first aid treatment for asthma is, and I also talked about what asthma flareups feel like to me. According to my asthma action plan (I’ll discuss those in a few days – short version is written instructions on how to manage flares from my doctor), severe and above flares that don’t respond to inhaler are ER-worthy. Mild and moderate flares can be handled with watchful waiting, applying my action plan, and seeing if it resolves the flareup. But what actually happens in the ER?

If you have anxiety, or if you’re a person who hates disruptions to their routine (hi), or if you have any of a number of disabilities that make handling new situations more difficult (also hi), the unknown factor might be enough to turn you away from seeking help at the ER. That’s why I’m writing this post: To try to take some of the fear and uncertainty away. Because as scary as it is to go to the ER and acknowledging the existance of ER docs who don’t know how to handle asthma well, the ER is still the safest place for a person to be during a severe attack.

So, let’s say you’re having a bad asthma attack. You’ve never had one this bad before, and your inhaler isn’t helping. You go to the hospital. I suggest bringing someone you trust with you, if possible, because if your asthma is bad, you might not be in good condition to advocate for yourself. I would also recommend bringing a copy of your last lung function tests if you have them and your asthma action plan if you have that (a list of your medications will work just as well for this). Remember to bring your health card or insurance.

The very first thing you’re going to have to do is check in. Look for a sign that says “Check-in” or “Registration” or something that looks like an administrative desk. Usually these have seats beside them and are in a little corner to shield the sound. Some very big hospitals have more than one. If you can’t find it, there should be a nurse monitoring the waiting room to keep an eye on those still waiting. Ask the nurse where to check in.

In check-in, they’ll ask you questions: When did symptoms start? Are you having chest pain? How much asthma medicine have you taken? Do you have any allergies? Etc. They’ll ask you some seemingly-unrelated questions to make sure it is asthma they’re dealing with. Answer all questions honestly, and include any other things you may have taken (even alternative medicine and illicit drugs: Alt med stuff because it can interact with medicines they might give you, and illicit drugs for the same reason. Don’t worry about legal troubles: in most areas, hospitals are not allowed to tell the cops whether you’re on drugs or not). The triage nurse will use these answers and your vitals to assign you a priority in the system.

The triage nurse will take your vitals next. This will probably include probably your temperature, blood pressure, heart rate, and blood oxygen saturation at the registration desk. Temperature should be old hat to anyone who’s used a thermometer before. Blood pressure is a cuff that goes around your arm. They inflate it until they can’t hear any circulation below the cuff, then slowly let the air out until they can first hear your pulse and then hear your venous flow. It shouldn’t hurt but might if you’re sensitive to pressure. It is somewhat uncomfortable. Heartrate is measured either by them holding your wrist and looking at the clock or with a pulse oximeter. The pulse oximeter just goes over a finger (they might have you hold something warm for a few seconds if your hands are cold to ensure an accurate reading). It works by shining a light through the tip of your finger and detecting how much of a certain frequency is absorbed. More absorbance = more oxygen bound to your blood. This test should not hurt at all. If it does, they’re doing it wrong. You will then show insurance and get your hospital bracelet, either at the registration desk or at another desk.

Depending on how severe you seem and how much room they have, they might take you back immediately at this point, or they might send you to the waiting room. If you’re sent to the waiting room, try to be patient and stay calm. If your breathing continues to worsen while in the waiting room, inform the nurse when they check on you. If you feel like you might pass out, inform the nurse immediately.

You will eventually be called to a room when they have a space for your priority. They might have a respiratory therapist visit you to take your lung function. This is essentially a set of specialized breathing exercises into a machine that measures how much air you can move. It might cause more muscle pain if you’re already experiencing chest wall pain from the attack, but the test shouldn’t hurt on its own. In smaller hospitals, they might just have a nurse take your peak flow, which is not as accurate, but is cheaper and faster. Tell the RT or nurse your personal best numbers if you know them and offer a copy of your recent lung function tests if you have them. The RT or nurse can get a more accurate idea of how well you’re breathing with your personal numbers than they can with average charts. If you don’t have that information, they’ll compare your numbers to predicted numbers based on averages for your height, weight, and ethnicity. The doctor who sees you will use this information along with your vitals and their examination to decide what treatment is most appropriate.

If an RT saw you, a nurse might come in and start an IV. Otherwise, the existing nurse might start an IV at this point. They may also draw some blood for blood tests, if the doctor has reason to suspect an infection. Needles obviously hurt a bit. It might hurt more than normal if your blood pressure was low, as that can make it harder to find veins. If your breathing is very bad, they won’t have time to use anesthetic cream or stuff like that if you’re hypersensitive to the pain, unfortunately. If your oxygen saturation was low, they might start you on some oxygen to bring it up to normal, usually with a nasal cannula (this is a tube with prongs that stick up your nose. It’s uncomfortable and might make you sneeze, but it doesn’t hurt).

Next, a doctor will probably come in to examine you. They will listen to your chest with a stethoscope, and they might do some percussion tests (tapping on your chest as they listen through a stethoscope, also doesn’t hurt). The doctor will probably chat with you a bit and might ask some questions you’ve already been asked. They’re not trying to waste your time, they’re trying to get a feel for how short-of-breath you are.

I can’t predict the order of stuff that might happen after this, so I’ll just describe the things that might happen, as how they treat you will depend on how badly you’re breathing and whether or not it’s responding to first line treatment.

They might order a chest X-ray. They will give you a lead apron for your abdomen. Then they will have you stand or sit in front of the backdrop of the X-ray machine. They’ll ask you to raise your arms, take a deep breath and hold it, then they’ll take the X-ray. They will have you turn 90 degrees and repeat the process. This will let them see whether your lungs have the normal shape or whether they’re hyperinflated or collapsed and will let them see whether you have scarring or fluid in your lungs. Chest X-rays don’t hurt at all, but the room and machine are both usually cold.

They will probably give you one or more breathing treatments. This might be through a nebulizer or through an inhaler with a spacer. The nebulizer makes a mist of asthma medicine, which you then breathe in. It might have a mask (which will go over your mouth and nose) or a mouthpiece (which you hold in your mouth). Just try to breathe normally while you’re taking it. Nebs don’t hurt at all.

They might give you steroids, magnesium, or bronchodialators through an IV. These are all strong asthma medicines. Aside from the needle part, it shouldn’t hurt. The steroids will probably make you irritable, emotional, and insomniac. They really suck. I’ve never had magnesium so I can’t say what it’s like. Bronchodialators will make your heart pound and your hands shake.

If your attack is severe, then to get an idea of how tired you’re getting, they’ll measure the levels of different gasses in your blood. To do that more accurately than allowed by a pulse oximeter, they need to get an arterial line – this is a needle that goes into an artery. This does hurt. They will probably bring someone who’s good at it in to make it as painless as possible, but it will hurt.

If none of that works and you’re getting very tired or your blood gases are showing that you’re not moving air well enough, they might put you on BiPAP or CPAP. BiPAP and CPAP are both forms of non-invasive ventilation – they will help you breathe when your muscles are too tired to do it yourself. I haven’t been on it since I was a very little kid and I don’t really remember much except the mask digs uncomfortably into your nose and it feels really weird. Finally, if all of the above fails, they might intubate you and take you to the ICU. You probably won’t be aware of anything, as they will sedate you before they intubate you. Only the most serious of attacks need ventilation, and usually attacks can be turned around at the hospital before it gets to that point.

Most asthma attacks that result in a trip to the ER are treated successfully with breathing treatments and maybe some steroids. Once you start to improve, they will probably keep you for a few hours to make sure the attack doesn’t come back as soon as the bronchodialators start to wear off and they will probably give you a prescription for oral steroids. These come with some not pleasant at all side effects, but the benefits of being able to breathe outweigh the risks, so you should take them. Take them exactly according to the instructions given to you (this will probably include a taper) because if you don’t, you could induce an adrenal crisis.

I hope this helps take away some of the fear, uncertainty and mystery factor surrounding going to the ER for asthma. Hopefully you will never have an asthma attack serious enough to need hospitalization, but if you do, now you know what to expect.

The previous post in this series is here.
The next post in the series is here.

Asthma treatment, part one: First aid

So, at this point I’ve provided a big load of theoretical information in the previous posts (I will probably get a master list up tonight, hopefully). You know how asthma works, what it’s symptoms are, and how we classify it. In spite of my inclination toward theoretical and mechanistic knowledge, I’m going to take a break from the wheres and whys and hows and provide a bit of practical first-aid knowledge.

Note that I am not a doctor. Nothing I write here is medical advice, I am relaying currently-recommended guidelines for first aid. I will reference articles written by medical professionals. I strongly recommend that everyone get first aid and CPR qualified if finances allow it so you have a more nuanced how-to than being pointed to articles online can give you.

There are two major classes of situation you might find yourself in when dealing with someone who is having asthma symptoms: when the person does have their inhaler, and when they don’t. If you are not a medical professional, you don’t have the expertise (or the instrumentation) to tell the difference between mild, moderate, severe, potentially life-threatening, and live threatening flareups, so I won’t talk about those differences in this post.

If an inhaler is present, that makes things easier. Saint John Ambulance provides the following steps:

  1. Keep the person calm. I will add here, from experience as a patient: If you want to keep the person having an attack calm, you have to act calm yourself. This means: Try to keep your voice quiet. Do not hover. Keep motions slow and steady. Make sure the person wants to be touched if you want to touch them to reassure them. Try not to let your voice shake. Do not lie: Don’t say “you’ll be just fine!” if you’re not sure of it. Socially savvy people will be able to feel your uncertainty and get more scared. Instead focus on things you know are true, like the fact that help is on the way.
  2. Encourage them to use their inhaler. I will add:  They should know how to use it, but you might have to help them get and maybe use it depending on how bad the attack is. A rescue inhaler is usually (not always) a blue metered-dose inhaler. If the person can’t talk or move much, you might have to look through their things to find it. Ask first. “Do you need your inhaler?” “Do you want me to get it for you?” If the person can answer in words, then ask, “Where is it?” If they can’t answer in words, it’s 20 questions time. Common places for inhalers are purses, coat pockets, sweater pockets, gym bags, back packs, night stands, and bathroom drawers. If they have a spacer device (a tube about 7-10 cm (3-4″) long, with a mouthpiece on one end and a rubber rear end with a hole to put the inhaler mouthpiece in on the other end), get them to use that as spacers are better at delivering medicine. At this point, if you can, ask them if they have an asthma action plan, and if they do, ask what they’re supposed to do in yellow zone if they can answer.
  3. Tell the person having an attack to breathe slowly and deeply. You might have to breathe with them so they have a breathing pace to follow (“Breathe slow and deep” becomes meaningless when you’re having a bad one because your whole world is need air need air need air, I say from experience). Get the person sitting down if possible. If they’re having a bad attack, they might want to stand or even pace. If you can convince them to sit, do so, but don’t fight with them over it.
  4. Have them continue to take their inhaler as instructed by their doctor until their breathing improves or until they’ve taken a total of 10 puffs or followed their yellow zone instructions. If their breathing improves significantly then congratulations! You’re done! If it doesn’t, progress to step 5.
  5. Call emergency services. Tell EMS that you have a person who is having an asthma attack and their inhaler isn’t helping. Tell them how many doses of inhaler the person has had, and some basic things about the person who is having the attack – how old are they? Do you know if they have a history of severe asthma? Are they wheezing or coughing a lot? Are they able to talk at all right now? If yes, do they speak normally or *breathe* do *breathe* they *breathe* talk *breathe* like *breathe* this? If they took medicine other than their inhaler, what did they take? What control meds are they on, if you know? And so on. Tell EMS where you are, how to find you if you’re in a large building (in a house, “We’re in the dining room!” is fine, but “I’m in apartment 437” doesn’t help people who don’t know where on your floor room 437 is. It will save them time if they don’t have to ask the building manager for directions.


If at any point, the person passes out or starts to seem confused or drunk or disoriented, call EMS immediately, and if you know it, start rescue breathing. If you don’t know it, get the operator to talk you through. If the attack is getting worse but you haven’t gotten to 10 doses of inhaler yet, call EMS immediately. If you or they think the attack is severe, call EMS immediately. If you are scared and don’t think you can handle it, call EMS. Always err on the side of calling EMS. They would rather you call unnecessarily than not call in an emergency.

If the person does not have an inhaler, see if someone around has one you can borrow. In some areas, they put inhalers in emergency kits, so check the emergency kit, too. If you can get an inhaler, follow the steps above. If you can’t, try to keep the person calm and help them breathe slowly. If the person is a child or is elderly or has other medical conditions that might make breathing harder, call EMS immediately. Able adults can tolerate asthma attacks much better than kids, elderly people, and those with other disabilities. If air quality in the room is bad (like say if someone burned something in the kitchen), move them to a room with better air. Do not move them somewhere with cold air. It is a myth that cold fresh air helps asthma. In reality, cold air triggers asthma. You could make the attack worse if you get them to sit right in front of the air conditioner or go outside in winter.

Try to help them to stay calm and comfortable until the attack passes or help gets there if you’ve already called for help. If the attack seems severe (they can’t talk in full sentences, or they’re wheezing very loudly or they were wheezing but aren’t anymore but seem more distressed, or if they’re coughing so badly they can’t speak much or if they seem to be working hard to breathe), you or they are getting scared, or it just seems to be getting worse, call EMS. As above, it is always better to err on the side of calling EMS than not.

Finally, something which holds true for all cases: unless you’re in a place with no ambulance service, do not attempt to take the person to the hospital yourself. Do not do this. Call EMS instead. You do not have the medical equipment or the expertise to deal with it if the person passes out on you. You can’t help prevent them from passing out by providing oxygen. You don’t have equipment for emergency airway management or the strong medicine for opening airways that EMS has access to in most areas. Don’t try to meet the ambulance – they might drive past you in the confusion. The person is better off waiting for an ambulance wherever they are. Waiting might feel like you’re doing nothing, but if you’ve called EMS, it’s the best thing you can do.

The previous post in this series is here.
The next post in this series is here.

Asthma classifications: Severity model

So, now that we’ve discussed a bit about what asthma is, how it works, and what it looks like, why don’t I explain how asthma is classified? You’ve seen me toss around terms like “mild intermittent” “moderate” and “severe” here, but what do those terms mean? How do we classify asthma?

Well, there’s two ways: a severity model, which I’ll discuss today, and a phenotype + severity model, which I will discuss in a later post. The severity model has been used for decades, although how we classify people into each category has been refined as technology – and especially treatment – improves. There are four main categories of asthma severity:

  • Mild intermittent
  • Mild persistent
  • Moderate
  • Severe

And some more recent classification schemes include a fifth category either below or above the current severe category as “severe” encompasses too wide a range of severity to really be useful now that treatment has improved, so the fifth category was introduced to provide a more useful classification. The Canadian guidelines use “very severe,” which as it sounds is more severe than severe asthma. Under these recent Canadian guidelines, I’m classified as a severe asthmatic, but internationally, I’d be more likely to be classified as a moderate asthmatic, so that’s what I tend to use on the blog, lest I give people the wrong impression.

With the severity model, it is important to remember that doctors pick the most severe category you fit at least one criterion of. This is to prevent under-estimating a person’s severity and under-treating them (something that happened to me back when my asthma was starting to get bad again). So when you’re reading the descriptions of severity categories, remember that any one of the things I list put you in the next category up. Or, as my doctor says, “You take the worst of pulmonary function, symptoms, and medication needs, and that’s your severity.” Another important thing is that symptoms listed are what your symptoms are like without any treatment. So if you were off meds entirely, this is how bad your asthma would be. For simplicity, I’ll use the common international classifications in this post, but you can look up your country’s classification scheme if you’re curious – most countries I’ve searched post them online.

Mild intermittent asthma is defined as asthma where people experience symptoms no more than twice a week, wake up no more than twice a month, need their quick-relief puffer no more than twice a week, don’t have asthma interfere with daily activities at all peak flow and pulmonary function are normal between attacks, and asthma flares only rarely (<1/yr) require oral steroids. People with mild intermittent asthma can go weeks, months, or even years between significant flareups. Mild intermittent asthmatics need only a rescue inhaler to achieve good control.

Mild persistent asthma happens when people experience symptoms more than twice a week but not daily, or wake up 3-4 times a month, or use their quick-relief inhaler more than twice a week but not daily, or have minor limitations of daily activities without treatment or have peak flow readings of 80-100% between fares, or need oral steroids 2+ times a year. Mild persistent asthmatics are able to achieve good control, but need daily maintenance therapy, usually with low- to moderate-doses of inhaled corticosteroids.

Moderate persistent asthma happens when someone has daily symptoms, or wakes up more than once a week, or needs their quick relief puffer daily, or has some limitations of daily activity, or has peak flow of 60-80%, or peak flow variability of 15-30%, or asthma flares need oral steroids twice a year. Moderate persistent asthmatics are able to achieve good control, and are treated with high-dose corticosteroids, with or without other treatment.

Severe persistent asthma happens when someone has symptoms all day, or wake up every night, or need their inhaler several times a day, or limits activities daily, or have peak flow of <60%, or have peak flow variability of >30%, or need steroids for asthma several times a year. Severe asthmatics may or may not be able to achieve good control, always need other treatment in addition to high-dose corticosteroids. Many severe asthmatics need daily oral steroids.

Because it’s dangerous to take someone off their meds to see how bad their asthma is, in Canada, we’ve started categorizing severity based on how much meds you need to achieve control and whether or not you’re able to achieve textbook control.

The previous post in this series may be found here.
The next post in this series may be found here.

Asthma: The symptoms

So, as you’ve learned from my previous post, asthma is a lung disorder characterized by chronic, reversible airway obstruction due to lung inflammation and bronchospasm. But what does that mean in terms of how it looks on the outside? What does it make a person do or feel?

That’s what I’m going to talk about today: Asthma symptoms.

Asthma symptoms are wide and varied, and depend to some degree on how severe your asthma is and what type of asthma you have (I’ll talk about types and classifications of asthma in later posts). Some of the most common symptoms include:

  • Wheezing is what happens when your lungs are tight enough that when you breathe out it makes a whistling sound. The whistling sound may be quiet or loud. Wheezing is always a sign of airway obstruction, even if it’s not caused by asthma. Asthmatics vary greatly in how much we wheeze, and sometimes we don’t wheeze much at all. Some asthmatics I’ve met describe wheezing as feeling like a rubbing feeling in their chest, whereas for me it feels more like a deep vibration. Others say they don’t really notice what wheezing feels like.
  • Coughing is, well, coughing. It happens when your cough reflex is triggered. It may or may not be a sign of airway obstruction, but it’s a sign of airway inflammation. Asthmatic people – particularly those with cough-variant asthma – tend to cough a lot. You may or may not cough up gunk (the medical term for this gunk is sputum) when you have asthma. Sputum is often clear between and during attacks and may look pus-like afterwards. An asthma cough is a deep, chesty cough that often but not always is loud. It’s not the little “ahem-ahem” they sometimes show on TV. Asthma coughs rock your whole body and can cause things like pulled muscles because you’re coughing so hard. Think less “I have a mild cold” and more “bronchitis”. In fact, asthma is often misdiagnosed as recurring episodes of acute bronchitis, especially in mild intermittent asthmatics, who may go months or years between symptoms.
  • Shortness of breath is a thing that I prefer the alternative name of: air hunger. Air hunger is far more descriptive and accurate than the shortness of breath name. It’s that feeling that you can’t get enough air, and to me it’s the single most unpleasant asthma symptom out there. It is a fundamentally different feeling from that normal people get when they work out too hard, and one that’s hard to describe. It’s one of those things that if you’re not sure whether or not you’ve ever experienced it, you haven’t. When you’re air hungry you know. Everything in your body screams, “must get air” and you can’t, like the proverbial person stuck on a life raft in the middle of the ocean. Air, air, everywhere, so why can’t I breathe?
  • Chest tightness is a catch-all term for dull chest pain, chest discomfort, and chest pressure. It is a general term for discomfort in the general chest area without another explanation and that doesn’t fall under some other category like a pulled muscle or the crushing pain of a heart attack. I pretty much always have some degree of chest tightness. I’m kind of used to it. For me, chest tightness feels like that burning chest feeling you get if you’ve spent too long at the bottom of the pool. Others describe it as feeling like an iron band is around their chest. I couldn’t find a good description link for chest tightness because it is a rather vague and ill-defined term.

The above four symptoms are the classical asthma symptoms, and the most common. Almost all asthmatics will have at least one and often more than one of those symptoms. Less common symptoms of asthma include prolonged exhalations, feeling as if you have to work to exhale, and feeling as if you can’t get all of your air out when you breathe out, all of which are signs of air trapping, with which I’m very familiar (in fact, as I write this, my I:E ratio is 1:5, where normal is 1:2. And, no, I’m not wheezing. I almost never wheeze). My doctor has told me that small-airway inflammation can cause air-trapping without wheezing, and this is backed up by my lung function tests, which indicate a more obstruction in my small airways than my large ones (more on lung function tests in a later post). Additionally, there are symptoms that are not necessarily associated with flares but that may be signs a flare is coming. These warning signs include:

  • Frequent cough
  • Reduced peak flow meter readings (more on this in a later post)
  • Losing your breath easily
  • Shortness of breath
  • Feeling tired, weak, or not with it during exercise
  • Coughing or wheezing more than normal during exercise
  • Being tired, irritable, grouchy, cranky, or moody
  • Cold or allergy symptoms
  • Difficulty sleeping because of nighttime symptoms
  • Anxiety
  • Dark bags under your eyes
  • Rapid breathing
  • Sighing
  • Yawning
  • Itchy neck
  • and others

The above is by no means an exhaustive list. Asthma symptoms are as varied as people with asthma, and each person who has it should keep a symptom diary until they figure out what their early warning signs are.

The previous post in this series is here.
The next post is here.