Asthma care instructions

What is asthma

Asthma is an long-lasting inflammation of the bronchial mucosa, which leads to a variable narrowing of the bronchi caused by increased contractability of the smooth muscles surrounding the bronchi. Asthma can start at any age, and its symptoms may be vary according to the season or be continuous. Typically an asthma diagnosis is based on the patient’s symptoms, clinical findings and pulmonary function tests. Early diagnosis and proper treatment can slow the progression of the disease and preserve lung function. Uncontrolled asthma can lead to permanent stiffening of the small bronchi with concurrent decrease in lung function, but through proper treatment majority of asthma patient’s lung function remains good despite years of illness.

Risk factors and prevention

Multiple genetic and environmental factors take part in the development of asthma. Allergic rhinitis has been linked to an increased risk of developing asthma, and rhinitis desensitization may prevent its development entirely. Passive smoking is known to increase the risk of asthma in children by approximately1,3-fold. Household pets increase the risk of sensitization and respiratory allergy symptoms, whereas the results of studies about the development of atopic syndrome due to animal exposure in infancy are conflicting. Also a number of viral and bacterial diseases have been associated with childhood asthma.

Signs and symptoms

Common symptoms include: increased mucus secretion, cough, wheezing, shortness of breath and recurrent respiratory tract infections. Children may also suffer from fatigue, delayed growth, reduced activity or malaise.

Aggravating factors

Generally, symptoms are usually worse at night and in the early morning or in response to exercise or cold air. Specific aggravating factors include respiratory tract infections, inhaled allergens, physical exertion, unusually cold/dry/hot/humid air, food materials, tobacco smoke, dust, stronger odors, acetylsalicylic acid (aspirin) and its derivatives, neglect of proper self-care, gastroesophageal reflux disease as well as excessive stress.

Treatment

The goal for the treatment of asthma is to allow the patient “to be able to live normally with normal lung function” - i.e. when well-treated, the illness should have no impact on the patient’s life beyond taking the required medication. After the diagnosis has been made and the initial symptoms have disappeared, the patient should feel well and be able to work normally. Acute asthma attacks or exacerbations should be encountered as rarely as possible. The treatment is usually well-received with little to none perceived side effects. In addition, it is also important to give the patient the required means to recognize the symptoms of an acute asthma attack so that he/she can react accordingly.

Patients suffering from allergic asthma should try to avoid inhalable allergens. For the patients with non-allergic asthma this is not required. Living environment reorganization is recommended, as the most common allergens include animal fur, pollen, dust from textiles and clothing and food. The objective of the reorganization is to ensure good indoor air quality, but the results are not permanent and will have to be sustained through regular cleaning. Desensitization therapy, which reduces hyperreactivity in the bronchi, is also an option. If forced to take part in dusty jobs, the patient should take care to use a respirator. Regular physical exercise is recommended, as it strengthens the respiratory muscles, improves respiratory function, facilitates the detachment of mucus from the bronchi, and relaxes and refreshes mentally. In case of obesity, losing weight usually helps with shortness of breath and reduces the need for medication. In extremely cold conditions (<-10C), physical exertion should be avoided, and a protective mask should be used if necessary.

Smoking and asthma

Patients who smoke should quit smoking. If a smoker lives with the patient, he/she preferably should stop smoking, but if this cannot be achieved, at least he/she should make sure not to smoke inside the home or in other confined areas where the patient spends time in. Both active and passive smoking cause damage to the respiratory mucus membranes and increase the risk of allergic sensitization and the development of asthma. Smoking also predisposes patients to infections and worsens allergic symptoms.

Thought bubble - What happens when you stop smoking

1 days to 1 week: Carbon monoxide will leave your bloodstream replaced by fresh oxygen, your sense of smell and taste will improve, breathing will feel easier and your blood pressure and heart rate will start to normalize.

1 days to 1 week: Carbon monoxide will leave your bloodstream replaced by fresh oxygen, your sense of smell and taste will improve, breathing will feel easier and your blood pressure and heart rate will start to normalize.

Pharmacotherapy

Instructions for using the inhaler:

1. Brush your teeth
2. Stand or sit upright
3. Remove the mouthpiece cover. Shake the inhaler 4-5 times. Hold the inhaler upright with your thumb underneath the mouthpiece.
4. Exhale as deeply as possible, then place the mouthpiece between your teeth without biting it and close your lips around it. Depress the canister and inhale strongly and deeply.
5. Hold your breath for 5-10 seconds, you can take the inhaler out of your mouth at the end of the inhalation while still holding your breath.
6. Afterwards, rinse your mouth with water, then spit the water out. This is to prevent fungal infections in the throat, and your voice not becoming hoarse.

Instructions for using an asthma spacer (e.g. volumatic)

Multiple breaths technique

1. Remove cap, shake the inhaler and insert it into the device.
2. Place the mouthpiece in your mouth.
3. Start breathing in and out slowly and gently. (This will make a clicking sound as the valve opens and closes.)
4. Once your breathing pattern is well established, depress the canister and leave the device in the same position while you continue breathing in and out for at least 5 times.
5. Remove the device from your mouth.
6. Wait about 30 seconds before repeating steps 1 through 5.

Single breath technique

1. Remove cap, shake the inhaler and insert it into the device.
2. Place the mouthpiece in your mouth.
3. Press canister once to release a dose of the medicine.
4. Take in a slow, deep breath.
5. Hold your breath for about 10 seconds, then breathe out through the mouthpiece.
6. Breathe in again without releasing more medicine.
7. Remove the device from your mouth.
8. Wait about 30 seconds before repeating steps 1 through 7.

Always demonstrate to the patient how to use the spacer device

PEF measurement

PEF (short for “peak expiratory flow) is a method for measuring how efficiently a patient is able to breathe out air, and is used to estimate the severity and type of certain pulmonary diseases such as asthma. These measurements are performed daily in two sets, once in the morning after waking up before taking any asthma medication, and once in the evening. In practice the measurements are done by exhaling as strongly and quickly as possible on the device three times in a row and writing down the results. Exhaling should be performed while sitting up straight. In order for the results to be reliable, the patient’s lips must be tightly around the mouthpiece of the meter and the maximum difference between the three measurements in a set cannot exceed 20L/min.

Typical warning signs or symptoms of exacerbation of asthma

• increased shortness of breath
• increase in sputum/mucus
• waking up in the middle of the night because of difficulty of breathing or coughing
• the need for short-acting asthma medication is increased
• PEF values are lower than earlier and a dose of short-acting medication does not
• increase the PEF values above the earlier average
• Tolerance for exertion and/or cold air decreases

Typical symptoms of an acute asthma attack

• increased shortness of breath and wheezing may be heard
• speaking becomes more difficult with dyspnea (loss of breath) sometimes making full sentences impossible
• exhalation is prolonged and breathing shallow
• in life-threatening situations breathing may slow down and earlier wheezing even disappear due to the shallowness of the breathing. The patient may be cyanotic and confused (signs of hypoxia). Bradycardia and hypotension may occur.

Primary care in case of shortness of breath

• Make sure the patient is as calm as possible. When heart rate decreases, breathing becomes easier.
• Assist the patient to sit on a chair so that he can keep his arms on the table. Put a pillow under the patient’s arms. This eases the burden on the lungs.
• Make sure you can find the patient’s prescribed medication.
• Loosen the clothes and possible accessories around the neck, the chest and the abdomen of the patient to release possible compression.
• Open the window to let fresh air in as long as the outside air isn’t too cold or damp.
• If possible, give the patient something warm or mucolytic to try to help with mucus.
• Should the condition not improve, give the patient his/her medication according to the prescriptions.
• Do not leave the patient alone until he/she feels better.
• During exacerbation, double the dosage of the medication meant for the long-term control of the disease (typically inhalable corticosteroids like budesonide or fluticasone or a combination drug with one of them included) for 2-4 weeks.

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