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Thursday 16 March 2006, 3.00-3.30pm
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Programme 6. - Asthma


THURSDAY 16/03/06 1500-1530








Hello. With well tried and tested treatments for asthma why do so many people still struggle with sometimes distressing symptoms of wheezing, cough and breathlessness? Could it be because they don't use their medication as prescribed? Well of course no one wants to be on long term inhalers containing steroids, people do worry about side effects, but what are the alternatives? Does it help, for example, to learn breathing techniques or even to refurbish the house in the hope of eliminating dust mites which might just possibly be triggering attacks?

Well put your questions today to our expert. He's Professor Chris Griffiths of Barts and the London, who's also a GP with a special interest in asthma. We've got a lot of calls, the first one is waiting. On the line now Peter MacKenzie's in Colchester. Peter, your question on asthma.

Okay, I'd like to ask do steroid inhalers have any thinning effect on internal tissues in the same way as steroid ointment on the skin?

Are you taking steroid inhalers?

Yeah I take a steratide - seretide, sorry, seretide, it's a fluticasone propionate, I've written down.

More information than we need at this point but thank you.

I'm sure it is.

Yeah, could it be thinning the skin, which is something you can see when you put these steroid creams on your skin, could it be thinning the skin of the lungs or the lining of the lungs I suppose?

Or the little veins I'm thinking of - the capillaries?

Okay, Chris what's the answer?

Good question Peter. The short answer is no ...

Oh that's good, that's relieving.

Often the strength of the creams that people use on their skin is quite powerful and so that maybe explaining why you're seeing thinning there. But the short answer is no and the longer answer is that the inhaled steroids that you're using are having a very important effect in controlling your asthma and asthma is in essence a condition where the airways - the tubes - that lead down into your lungs through which you breathe are inflamed and narrowed and so that corticosteroids have a very important anti-inflammatory action.

And they've done a very good job for me anyway.

They're terribly important because they control your symptoms, they mean that you're less likely to get asthma attacks, all the data shows that you're less likely to be admitted to hospital, they even prevent death in severe cases. And there's some very interesting data that's come through in the last year suggesting that if you're not taking inhaled steroids for asthma the, if you like, the elasticity of your lungs can deteriorate faster. So they can even, as it were, keep your lungs healthier for longer. So they've got a very good protective effect.

So they're doing the right thing for you in helping you Peter, so it sounds as though you shouldn't be worrying about them. But if I can move to an e-mail. We've got a Mrs Borren who wants to ask about using her inhalers. Now I guess what Peter's talking about - the steroid inhaler - is the preventer inhaler, to stop the inflammation, the brown inhaler but there's a blue puffer as well, isn't there, which helps relieve the airways. And anyway the question is she's finding it hard to use her brown inhaler without using the blue reliever inhaler first. So how should she juggle her medication, I think is the question, and juggle, some people certainly have to do.

Exactly. And just as a bit of background, the most common treatments for asthma are basically two sorts of inhalers - there's the blue quick reliever inhaler and that acts to relax the tiny muscles that surround the airways through which you breathe, so that you can open them up. But the real cornerstone for asthma treatment, as we just talked about, are the anti-inflammatory inhaled low dose steroids. So there are two - a blue quick reliever, relaxes the muscles, and the brown anti-inflammatory one. And about 10 years ago we always used to advise patients to take the blue quick reliever first to open up the airways and that would mean that when they took the brown preventer inhaler it would get down more effectively into their lungs. And so what the lady, who's e-mailed in this, is asking is a reasonable question because that's what we used to advise. People don't really advise that necessarily these days. So she doesn't need to take the blue inhaler before the brown one, if she does it won't harm her and so if she wants to continue doing that then she's perfectly able comfortably to do that. If she's finding that she needs to use the blue quick reliever inhaler a lot during the day it suggests that her asthma isn't sufficiently well controlled on the dose of the brown anti-inflammatory inhaler. If that's the case then she could go to her GP or practice nurse and ask about whether or not using a long acting reliever inhaler would be helpful - these are inhalers that have come in, in the last 10 years or so and they're a very important advance. The reason being that what they've meant is this: in the old days we used to have to advise people to take high doses of inhaled steroids but with these new longer acting relievers people can stay on a low dose of inhaled steroids, which people like, and they can add in these extra long acting inhalers. They get the benefit of better asthma control without the risks of taking high doses of inhaled steroids. So she might be interested in asking her GP or practice nurse about a long acting reliever like salmeterol or formoterol.

Thank you very much. We'll go to another caller. Michael is waiting to speak to us and is interested in getting a diagnosis, for your son, I think, Michael?

Yes, good afternoon Professor Griffiths.

Good afternoon.

My son, who is now sixteen and a half, has been largely clear of any form of asthma symptoms for the last - probably the last three years, hasn't required any medication and hasn't shown any symptoms at all that we were concerned about. Last summer, after or during an extended training holiday, he went down with a chest infection. When we returned home, and on hindsight we probably should have seen a doctor abroad where we were, but when we returned home we went to see our local GP who prescribed him a five day course of antibiotics which failed to clear up the chest infection. He was then prescribed a stronger antibiotic together with a steroid inhaler - symbicort - and in the course of that next course of antibiotics the chest infection cleared up and all was well. But he was advised to stay on this symbicort. Now he's looking at various career options and one of them requires that he has to have been clear of any asthma symptoms for a minimum of four years. Now we feel that the clock has started again as a result of him being reclassified, so to speak, as being potentially asthmatic whereas I think our feeling is that the chest infection probably wasn't related to asthma, although he's now been put back on to an asthma register ...

Okay let - sorry ...

My question really is how do we get him back off a register having been put on it?

Yes it's interesting isn't it because sometimes you want a diagnosis and sometimes you want or don't want a diagnosis of asthma in this case. Let's talk about getting a proper diagnosis. Is there a definitive test?

Asthma's a tricky thing to diagnose but there are important tests. The first is to listen to what the patient, if you like, is describing and if they're describing typical symptoms of asthma then that would make you want to try to carry out an objective test.

And the very simple typical systems - symptoms rather would be coughing ...

Coughing or wheezing, wheezing at night particularly, coughing and wheezing on exercise - those sorts of symptoms. But moving on to more objective tests. There are very simple breathing tests that you can carry out in a GP's surgery. That look at the key feature of asthma which is whether or not the obstruction to your breathing, the difficulty breathing, can be reversed. Reversibility is a key feature of asthma. It's terribly important to get the diagnosis right and one of the failings I think of the medical profession has been a bit - to be a bit over enthusiastic in diagnosing asthma in the last 20 years or so. I mean if your son does have asthma then clearly that has implications for what he wants to do in life. So I would think that he could go back to his GP and say I really want to know whether I do or don't have asthma and have a discussion about how to prove or disprove that. One option might be to say okay stop the inhaled treatment that he's been taking, wait for a month or so and then repeat the breathing tests that were to confirm or refute the diagnosis of asthma. But if you do the breathing test while he's continuing to take the symbicort, that he is taking, that might obscure and invalidate the test. So one option would be to discuss with the GP about stopping the inhaled treatment, give it a month or so and then repeat the test. Does asthma come back once it's gone away again? Well it can do, there's been some important research where children have been followed up over 15 or 20 years and there's data from New Zealand in particular that suggests that in about 10% of children asthma will go away but then come back again. So the other side of the coin perhaps of your question is this, that if he does have asthma then he does need the treatment and so that's why it's important to get the diagnosis right.

Okay, I think that's been a very helpful answer, thank you very much. Can I put in a quick e-mail now from Tracy and she's not the only one to have contacted us asking the question about loads of phlegm produced by asthma and she's asking why.

Loads of phlegm. Well the first point is that asthma often gets worse or is triggered by viruses such as the common cold and if you do have the common cold it can trigger off, particularly in people with asthma, a bronchitis and as we say your cold's gone to your chest. So that would be a way in which someone with asthma might get, as it were, a lot of phlegm. I mean the - if you, as it were, to look down inside the lungs of someone with asthma, the tubes that they breathe through, would be inflamed and filled with mucus and so that in itself is, as it were, a source of extra phlegm. I don't know how old this lady is ...

It doesn't say I'm afraid.

Doesn't say. Older people who've been smoking for a long time that can cause the lungs to produce a lot of extra phlegm as well, so that might suggest that she might not have asthma but she might have another condition like chronic obstructive pulmonary disease. If she's concerned about the exact diagnosis then she should go back to her GP and check that out.

Okay, and here's a time check, it's - well it's fourteen minutes past three and you're listening to Check Up with me Barbara Myers and my guest today Professor Chris Griffiths and we're dealing with the subject of asthma and we've got a lot of calls waiting. Cedric Hilary is calling us from County Durham. Cedric, your question about lifestyle and asthma, what's your question in detail?

Well I'm a 61 year old male that was told I had late onset asthma about three or four years ago. I take Seretide 125 twice a day, a couple of puffs, and I've done the usual things by having a mattress protector, allergen free pillows, pillow protector, I've got a Dyson vacuum cleaner. When I developed this condition, it came as a complete blow because I'm a keen cyclist and hill walker, I'm quite active, I don't smoke but I did live in a house that was damp in places. Since then, last year, I moved to a bungalow which isn't damp, I've retired from a job that was fairly stressful and I was just totally burnt out with. I have quite a healthy lifestyle I think and I feel frustrated that I'm stuck with this condition and I would like to sort of be more proactive in doing something myself to sort of come off medication or beat it altogether if that's possible.

Well let's get some advice on that, it sounds as though you're doing a lot of things in terms of lifestyle changes, some of them quite expensive with new mattresses etc. Let me ask first on your behalf - Chris, does that help, is there any value in doing that sort of refurbishment and what's the reason for it and then we can perhaps talk about late onset, something that happens out of the blue in middle age.

Asthma's primarily an allergic condition and in the same way that hay fever goes away in the winter when there isn't many pollen you would hope that asthma would go away if you remove the, as it were, the allergic triggers that trigger off asthma. And there's been a - if you like - a quest over the last probably 15 years at least to try to find ways to change the environment in houses, is it to remove the carpets, is it mattress covers or whatever, to try to reduce levels of allergenic triggers, such that asthma control can be improved. There was a big trial done only a year or so ago by a team in Manchester that tested mattress covers and to everybody's disappointment that was negative and didn't show that mattress covers helped. On a more positive note there's been a big trial done in the States in children recently where they didn't just address one area of the house, they gave the parents and the children advice about how to avoid passive smoking, how to use mattress covers, they gave them special Hoovers with special filters and so on, so a whole range of measures, a bit like you've done, and I'm pleased to say that that did work and in these families the children's asthma control improved a lot. So the jury's rather out on this and it's difficult to be sure because obviously there's a huge cost to making major changes to your environment and people shouldn't be advised to do it if it's not something that's been effective. So there is, as it were, cautious evidence in favour of making the sorts of changes that actually you've already done in your house.

Do you want to make a comment too about what Cedric said about being a keen cyclist and although he's had stress in his life this has come on in middle age, it's not something he had from childhood, how often does that happen and any theories as to why suddenly you get these symptoms?

Do you mean adult onset asthma?


Yes, that's a very interesting question. People tend to assume that asthma is asthma - it's all one beast, as it were. But it's clear - and this is something that researchers are trying to tackle, certainly over the next decade, is the fact that there maybe different, as it were, subgroups of asthma - childhood onset asthma may be different to asthma that comes on as an adult. Why asthma should come on in an adult, there might be a range of reasons, particularly occupational causes are an important possibility, so if you've worked in an environment that might have thrown up some new trigger to sensitise your lungs to make them inflamed and produce asthmatic symptoms. These are the sorts of things that trigger adult onset asthma, there's smoking as well of course. So yes it's an area ...

It's a complex picture, it's common and plenty of people out there with it. We know about treatments but actually fundamentally still a lot of question marks about the real causes, whether it's environmental, whether there's a predisposition and in fact how important it is to have the loaded gun and then the trigger factors together.

I mean what's clear is that the huge increase in allergic diseases like hay fever and so forth, eczema and asthma over the last 20 or 30 years, suggests that environmental causes are key to this because the genetic make up of the human population doesn't change that rapidly. So environmental factors are going to be terribly important but what's also clear is we don't all get asthma, so if some people are susceptible and some people aren't and the susceptibility probably reflects our genetic make up. So it is, as you say, advance of predisposition and environmental triggers.

Let's see what Becky Harris wants to ask, she's in Cowley. Hello Becky, your question to Chris Griffiths.

Yes hello. I've been asthmatic pretty much since childhood. When I got pregnant five years ago my asthma seemed to disappear and I then had another child about 18 months ago and everything was fine until about six months ago it seemed to return.

Well we can hear the product of the pregnancy yes, but it's come back again. So you had a bit of respite ...

Yes and I wasn't taking anything and I've had to go back on to taking Seretide.

Does it happen frequently in your experience Chris that people actually the symptoms disappear during pregnancy?

Yes just one of three things happen in pregnancy and all three can happen. One is your experience that it goes away, the second is that it stays about the same and in a proportion of people about 10% it can actually get dramatically worse. So I guess you were in the lucky third which is good. I mean why it should go away is very difficult to say. A lot of very complex immunological things are happening during pregnancy, if you think about it, a pregnant mother is carrying a child that has a different genetic makeup to the mother and so the immune system has to cope with as it were nurturing a - don't want to say it's a foreign body, in immunological terms it is, has to nurture a foreign body and not reject it, like it might reject a graft so to speak. So a lot of very complicated immunological processes are happening in pregnancy and I wouldn't pretend to understand them. I guess one of the key points to make here is that asthma medications are absolutely safe in pregnancy, every pregnant woman is told not to take medicines in pregnancy but asthma medication is a very important exception. Obviously asthma that gets out of control can have catastrophic implications for the mother and the child that she's carrying. So inhaled steroids are safe in pregnancy, even steroid tablets for a bad asthma attack are safe in pregnancy. So women who are pregnant shouldn't feel as though they're damaging their child through continuing to take their asthma medication, they're actually taking a responsible line.

Becky thanks for that question, I guess you know the answer if you want to have some relief from your asthma, might be a third pregnancy? Any thoughts? Okay we'll move to Emma now, she's in Wales and wants to know a little bit about breathing techniques and how they might help with asthma. Emma your question?

Hi, I just wanted to know if there are any simple techniques that encourage breathing via your nose rather than your mouth?

Have you been recommended to try breathing through your nose for your asthma?

I haven't but I was listening to yesterday's programme ...

Oh yes, this was Case Notes.

Yes, it mentioned it there and I'm also very aware myself of breathing through my mouth, rather than my nose.

Right, any techniques to help change from mouth breathing to nose breathing and is that important?

It's a really interesting question. I'm not sure that I've got enough experience to say exactly how to breathe but it's clear that a lot of people who have asthma have perhaps a slightly deranged pattern of breathing and many people who don't have asthma have deranged patterns of breathing and are mistakenly diagnosed as having asthma. So it's an area of particular interest over the last five years and you'll know that there's been excitement around intervention - breathing interventions like the Buteyko technique.

That's right, I've heard of that.

I mean the research around Buteyko and breathing training and even yoga techniques for breathing is encouraging insofar as it's - people who do them seem to find that they often need less of their quick reliever - salbutamol medication - but they don't seem to have an effect on the actual disease process such that lung function, breathing capacity is altered. So there's a sort of cautious thumbs up for these breathing retraining techniques.

And is it important to learn and then practise your breathing technique because I guess the real difficult time is when you are in a bit an attack and you can't get your breath, it's rather late to try things at that point, you might be far too panicked to breathe easily?

Well I think being calm and being conscious of breathing in a comfortable way is a very important part of managing your own asthma attack. And so practising that and being able to do it in an emergency is very important. I think if you want specific advice about how to breathe probably the thing to do is to - well one option would be to call the Asthma UK Advice Line, which you'll get on their website and they would probably put you in touch with relevant advice and how that would work.

Okay. A last caller - and we'll go to Donald Griffiths in North Wales. Donald.

Hello there. My - hello there - my eldest son from very young was diagnosed with asthma. He was in and out of an oxygen tent very, very often, in fact we were told just to take him in hospital not to phone the local doctor. By the time he got in his early teens I was getting - we were all getting very distressed with it and a doctor from the next village - not our GP but a personal friend of mine inasmuch as I was his personal electrician. And so I went to seem him and asked him about this and he said the best thing to do with Martin, he said, of you can do it is to keep him perfectly fit, really, really fit.

Has that helped, I mean I have to ask you very quickly, has that done the trick?

I haven't finished.

I'm afraid we're - almost out of time so ...

Okay, anyway what we had to do was buy him a bicycle, he loved the bicycle, he rode the bicycle to and from work today, he's 41 years old now and he hasn't looked back.

Very good indeed. We will stop right there. Thank you very much for that, that's going to be very helpful for people, as indeed it will be to go to our website if you want more information on asthma or you can call our action line on 0800 044 044. Thanks for all your calls, thanks to my guest today Professor Chris Griffiths. Join us again next week for hernia.


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