What Is Asthma?

Asthma is a disease that affects your lungs. It is one of the most common long-term diseases of
children, but adults have asthma, too. Asthma causes repeated episodes of wheezing, breathlessness,
chest tightness, and nighttime or early morning coughing. If you have asthma, you have it all the
time, but you will have asthma attacks only when something bothers your lungs.

In most cases, we don't know what causes asthma, and we don't know how to cure it. We know that if
someone in your family has asthma, you are also more likely to have it.

You can control your asthma by knowing the warning signs of an attack, staying away from things that
trigger an attack, and following the advice of your doctor or other medical professional. When you
control your asthma:

you won't have symptoms such as wheezing or coughing,

you'll sleep better,

you won't miss work or school,

you can take part in all physical activities, and

you won't have to go to the hospital.

How Is Asthma Diagnosed?

Asthma can be hard to diagnose, especially in children younger than 5 years of age. Regular physical
checkups that include checking your lung function and checking for allergies can help your doctor or
other medical professional make the right diagnosis.

During a checkup, the doctor or other medical professional will ask you questions about whether you
cough a lot, especially at night, and whether your breathing problems are worse after physical activity
or during a particular time of year. Doctors will also ask about other symptoms, such as chest
tightness, wheezing, and colds that last more than 10 days. They will ask you whether your family
members have or have had asthma, allergies, or other breathing problems, and they will ask you
questions about your home. The doctor will also ask you about missing school or work and about any
trouble you may have doing certain activities.

A lung function test, called spirometry (spy-rom-e-tree), is another way to diagnose asthma. A
spirometer (spy-rom-e-ter) measures the largest amount of air you can exhale, or breathe out, after
taking a very deep breath. The spirometer can measure airflow before and after you use asthma
medicine.

What Is an Asthma Attack?

An asthma attack happens in your body's airways, which are the paths that carry air to your lungs. As
the air moves through your lungs, the airways become smaller, like the branches of a tree are smaller
than the tree trunk. During an asthma attack, the sides of the airways in your lungs swell and the
airways shrink. Less air gets in and out of your lungs, and mucus that your body produces clogs up
the airways even more. The attack may include coughing, chest tightness, wheezing, and trouble
breathing. Some people call an asthma attack an episode.

What Causes an Asthma Attack?

An asthma attack can occur when you are exposed to things in the environment, such as house dust
mites and tobacco smoke. These are called asthma triggers. Some of the most important triggers are
available at Important Asthma Triggers.
The above text is from the "You Can Control Your Asthma" [PDF, 4 MB] full-color brochure and is
suitable for downloading and printing.

The scope of the problem

Asthma is now the most common chronic illness in children, affecting one in every 15. In North
America, 5% of adults are also afflicted. In all, there are about 1 million Canadians and 15 million
Americans who suffer from this disease.

The number of new cases and the yearly rate of hospitalization for asthma have increased about
30% over the past 20 years. Even with advances in treatment, asthma deaths among young people
have more that doubled.

Allergy fact

There are about 5,000 deaths annually from asthma in the U.S. and about 500 deaths per year in
Canada.
Normal bronchial tubes
Before we can appreciate how asthma affects the bronchial airways, we should first take a quick
look at the structure and function of normal bronchial tubes.
The air we breathe in through our nose is processed to prepare it for presentation to our lower
respiratory tract. This air is moistened, heated, and cleansed prior to passage through the vocal
cords (larynx) and into the windpipe (trachea). Dry or cold air presented to our trachea can cause
coughing and wheezing as a normal response to this type of irritation. The air then enters the lungs
by way of two large air passages (bronchi), one for each lung. The bronchi divide within each lung
into smaller and smaller air tubes (bronchioles), just like branches of an inverted tree. Inhaled air is
brought through these airways to the millions of tiny air sacs (alveoli) that are contained in the lungs.
Oxygen (O2) passes from the air sacs into the bloodstream through numerous tiny blood vessels
called capillaries. Similarly, the body's waste product, carbon dioxide (CO2), is returned to the air
sacs and then eliminated upon each exhalation.
Normal bronchial tubes allow rapid passage of air in and out of the lungs to ensure that the levels of
O2 and CO2 remain constant in the bloodstream. The outer walls of the bronchial tubes are
surrounded by smooth muscles that contract and relax automatically with each breath. This allows
the required amount of air to enter and exit the lungs to achieve this normal exchange of O2 and
CO2. The contraction and relaxation of the bronchial smooth muscles are controlled by two different
nervous systems that work in harmony to keep the airways open.
The inner lining of the bronchial tubes, called the bronchial mucosa, contains: (1) mucus glands that
produce just enough mucus to properly lubricate the airways; and (2) a variety of so-called
inflammatory cells, such as eosinophils, lymphocytes, and mast cells. These cells are designed to
protect the bronchial mucosa from the microorganisms, allergens, and irritants we inhale, and which
can cause the bronchial tissue to swell. Remember, however, that these inflammatory cells are also
important players in the allergic reaction. Therefore, the presence of these cells in the bronchial
tubes causes them to be a prime target for allergic inflammation.
How does asthma affect breathing?
Asthma causes a narrowing of the breathing airways, which interferes with the normal movement of
air in and out of the lungs. Asthma involves only the bronchial tubes and does not affect the air sacs
or the lung tissue. The narrowing that occurs in asthma is caused by three major factors:
inflammation, bronchospasm, and hyperreactivity.

Inflammation

The first and most important factor causing narrowing of the bronchial tubes is inflammation. The
bronchial tubes become red, irritated, and swollen. This inflammation increases the thickness of the
wall of the bronchial tubes and thus results in a smaller passageway for air to flow through. The
inflammation occurs in response to an allergen or irritant and results from the action of chemical
mediators (histamine,leukotrienes, and others). The inflamed tissues produce an excess amount of
"sticky" mucus into the tubes. The mucus can clump together and form "plugs" that can clog the
smaller airways. Specialized allergy and inflammation cells (eosinophils and white blood cells),
which accumulate at the site, cause tissue damage. These damaged cells are shed into the airways,
thereby contributing to the narrowing.
Bronchospasm

The muscles around the bronchial tubes tighten during an attack of asthma. This muscle constriction
of the airways is called bronchospasm. Bronchospasm causes the airway to narrow further.
Chemical mediators and nerves in the bronchial tubes cause the muscles to constrict.
Bronchospasm can occur in all humans and can be brought on by inhaling cold or dry air.
Hyperreactivity (hypersensitivity)

In patients with asthma, the chronically inflamed and constricted airways become highly sensitive, or
reactive, to triggers such as allergens, irritants, and infections. Exposure to these triggers may result
in progressively more inflammation and narrowing.
The combination of these three factors results in difficulty with breathing out, or exhaling. As a result,
the air needs to be forcefully exhaled to overcome the narrowing, thereby causing the typical
"wheezing" sound. People with asthma also frequently "cough" in an attempt to expel the thick
mucus plugs. Reducing the flow of air may result in less oxygen passing into the bloodstream, and if
very severe, carbon dioxide may dangerously accumulate in the blood.

Asthma inhalers: Which one's right for you?

Here's information that will help you weigh the pros and cons of different asthma
inhalers.

By Mayo Clinic staff

 Asthma inhalers are hand-held portable devices that deliver medication to your lungs. A variety of asthma
inhalers are available to help control asthma symptoms in adults and children. Certain types of asthma
inhalers may work better for you than do others. Finding the right asthma inhaler can help make sure you
get the right dose of medication to prevent or treat asthma attacks whenever you need it.

Types of asthma inhalers include:

Metered dose inhalers. These inhalers consist of a pressurized canister containing medication that fits
into a boot-shaped plastic mouthpiece. With most metered dose inhalers, medication is released by
pushing the canister into the boot. One type of metered dose inhaler releases medication automatically
when you inhale. Some metered dose inhalers have counters so that you know how many doses remain.
If there's no counter, you'll need to track the number of doses you've used to tell when the inhaler's low on
medication.

Metered dose inhaler with a spacer. A spacer holds medication after it's released, making it easier to
inhale the full dose. Releasing the medication into the spacer gives you time to inhale more slowly,
decreasing the amount of medicine that's left on the back of your throat and increasing the amount that
reaches your lungs. Some metered dose inhalers have a built-in spacer. Others can be used with a
separate spacer that attaches to the inhaler.

Dry powder inhaler. These inhalers don't use a chemical propellant to push the medication out of the
inhaler. Instead, the medication is released by breathing in a deep, fast breath. Available types include a
dry powder tube inhaler, a powder disk inhaler and a single-dose powder disk inhaler.

Comparing inhaler types

Choosing the right kind of asthma inhaler for you depends on several factors. Keep in mind, some
medications are available only with certain inhaler types. The chart below can help you understand the
pros and cons of each type. Work with your doctor to find the inhaler that best meets your needs.

Asthma inhaler features

Metered dose inhaler with a

Metered dose inhaler Dry powder inhaler
spacer

Small and convenient to carry. Less convenient to carry than a metered Small and convenient to carry.

dose inhaler without a spacer.

Doesn't require a deep, fast breath. Doesn't require a deep, fast breath. Requires a deep, fast breath.

Accidently breathing out a little isn't a Accidently breathing out a little isn't a Accidently breathing out a little can

problem. problem. blow away the medication.

Some inhalers require coordinating your A spacer makes it easier to coordinate Doesn't require coordinating your

breath with medication release. your breath with medication release. breath with medication release.

Can result in medication on the back of Less medication settles on the back of Can result in medication on the back

your throat and tongue. your throat and tongue. of your throat and tongue.

Some models don't show how many Some models don't show how many It's clear when the device is running

doses remain. doses remain. out of medication.

Requires shaking and priming. Requires shaking and priming and correct Single-dose models require loading

use of the spacer. capsules for each use.

Humidity doesn't affect medication. Humidity doesn't affect medication. High humidity can cause medication

to clump.

Use of a cocking device generally isn't Use of a cocking device generally isn't May require dexterity to use a

necessary. necessary. cocking device.

Inhalers for Asthma

An inhaler is a device holding a medicine that you take by breathing in (inhaling). Inhalers are
the main treatment for asthma. There are many different types of inhaler, which can be
confusing. This leaflet gives information on: the drugs (medicines) that are inside inhalers, the
various types of inhaler device, and some general information about inhalers.

This leaflet is about inhalers for asthma. See separate leaflet in this series called 'Asthma', which gives more
general information about asthma. There are also separate leaflets called'Asthma - Picture Summary', 'Asthma -
Peak Flow Meter' and 'Inhalers for Chronic Obstructive Pulmonary Disease'.
On this page
 The drugs (medicines) inside inhalers
Inhaler devices
Common questions and further information
Further help and information
References
The drugs (medicines) inside inhalers
The drug inside an inhaler goes straight into the airways when you breathe in. This means that you need a
much smaller dose than if you were to take the drug as a tablet or liquid by mouth. The airways and lungs are
treated, but little of the drug gets into the rest of the body.

The proper drug name is called the generic name. Different drug companies can use the generic drug and
produce different brands - the proprietary drug names. There are many different brands of inhalers. Inhalers
can have generic names and be produced by different drug companies too. For some drugs there are different
inhaler devices that deliver the same drug. This means that there are many types of inhaler available on
prescription, all of which are produced in different colours. This can be confusing.

Because there are lots of different coloured inhalers available, it is helpful to remember their names, as well as
the colour of the device. This might be important if you need to see a doctor who does not have your medical
records (such as in A+E, if you are on holiday, or outside the normal opening hours of your GP surgery). It
might be helpful to keep a list of the names of your medicines and inhalers in your wallet or purse. This
information will prevent mistakes and confusion.

In the treatment of asthma, the drugs inside inhalers can be grouped into relievers (short-acting
bronchodilators), preventers (steroid inhalers) and long-acting bronchodilators.

Reliever inhalers - contain bronchodilator drugs

You can take a reliever inhaler as required to ease symptoms when you are breathless, wheezy or tight-chested.
The drug in a reliever inhaler relaxes the muscle in the airways. This opens the airways wider, and symptoms
usually quickly ease. These drugs are called bronchodilators as they dilate (widen) the bronchi (airways).

The two main reliever drugs are salbutamol and terbutaline. These come in various brands made by different
companies. There are different inhaler devices that deliver the same reliever drug. Salbutamol brands include
Airomir, Asmasal, Salamol, Salbulin, Pulvinal Salbutamol and Ventolin. Terbutaline often goes by
the brand name Bricanyl. These inhalers are often (but not always) blue in colour. Other inhalers containing
different medicines can be blue too. Always read the label.

If you only have symptoms every now and then, then the occasional use of a reliever inhaler may be all that
you need.
If you need a reliever three times a week or more to ease symptoms, a preventer inhaler is usually
advised.
Preventer inhalers - usually contain a steroid drug
These are taken every day to prevent symptoms from developing. The type of drug commonly used in
preventer inhalers is a steroid. Steroids work by reducing the inflammation in the airways. When the
inflammation has gone, the airways are much less likely to become narrow and cause symptoms such as
wheezing.

Steroid inhalers are usually taken twice per day. If you have an exacerbation (flare-up) of your asthma
symptoms, you may be advised to take the preventer inhaler more often.

It takes 7-14 days for the steroid in a preventer inhaler to build up its effect. This means it will not give any
immediate relief of symptoms (like a reliever does). After a week or so of treatment with a preventer, the
symptoms have often gone, or are much reduced. It can, however, take up to six weeks for maximum benefit.

If your asthma symptoms are well controlled with a regular preventer you may then not need to use a reliever
inhaler very often, if at all.

Inhalers that contain drugs called cromoglycate (brand name Intal) or nedocromil (brand name Tilade) are
sometimes used as preventers. However, they do not usually work as well as steroids.

The main inhaled steroid preventer medications are:

Beclometasone. Brands include Asmabec, Beclazone, Becodisks, Clenil Modulite, Pulvinal

Beclometasone and Qvar. These inhalers are usually brown and sometimes red in colour.
Budesonide. Brands include Easyhaler Budesonide, Novolizer Budesonide and Pulmicort.
Ciclesonide. Brand name Alvesco.
Fluticasone. Brand name Flixotide. This is a yellow-coloured or orange-coloured inhaler.
Mometasone. Brand name Asmanex Twisthaler.
Long-acting bronchodilator inhalers
The drugs in these inhalers work in a similar way to relievers, but work for up to 12 hours after taking each
dose. They include salmeterol (brand name Serevent - a green-coloured inhaler) and formoterol (brand
names Atimos, Foradil, and Oxis).

A long-acting bronchodilator may be advised in addition to a steroid inhaler if symptoms are not fully
controlled by the steroid inhaler alone.

Some brands of inhaler contain a steroid plus a long acting bronchodilator for people who need both to control
their symptoms. Examples of combination inhalers are:
Fostair (formoterol and beclometasone).
 Seretide (salmeterol and fluticasone). This is a purple-coloured inhaler.
Symbicort (formoterol and budesonide).
Inhaler devices
Different inhaler devices suit different people. Inhaler devices can be divided into four main groups:

Pressurised metered dose inhalers (MDIs).

Breath-activated inhalers - MDIs and dry powder inhalers.
Inhalers with spacer devices.
Nebulisers.
The standard MDI inhaler

A standard MDI is shown on the right. The MDI has been used for over 40 years and is
used to deliver various types and brands of drugs. It contains a pressurised inactive gas that propels a dose of
drug in each 'puff'. Each dose is released by pressing the top of the inhaler. This type of inhaler is quick to use,
small, and convenient to carry. It needs good co-ordination to press the canister, and breathe in fully at the
same time. Sometimes these are known as evohalers (depending upon the manufacturer).

The standard MDI is the most widely used inhaler. However, many people do not use it to its best effect.
Common errors include: not shaking the inhaler before using it; inhaling too sharply or at the wrong time; not
holding your breath long enough after breathing in the contents.

Until recently, the propellant gas in MDI inhalers has been a chlorofluorocarbon (CFC). However, CFCs
damage the Earth's ozone layer, and so are being phased out. The newer CFC-free inhalers work just as well,
but they use a different propellant gas that does not damage the ozone layer.

Breath-activated inhalers
These are alternatives to the standard MDI. Some are still pressurised MDIs, but don't require you to press a
canister on top. The autohaler shown on the right is an example. Another example of a breath-activated MDI is
the easi-breathe inhaler.

Other breath-activated inhalers are also called dry powder inhalers. These inhalers do not contain the
pressurised inactive gas to propel the drug. You don't have to push the canister to release a dose. Instead, you
trigger a dose by breathing in at the mouthpiece. Accuhalers, clickhalers, easyhalers, novolizers, turbohalers,
diskhalers and twisthalers are all breath-activated dry powder inhalers. You need to breathe in fairly hard to get
the powder into your lungs. Some types are shown below.

The individual devices all have some differences in how they are operated but, generally, they require less co-
ordination than the standard MDI. They tend to be slightly bigger than the standard MDI.

Spacer devices
 Spacer devices are used with pressurised MDIs. There are various types -
an example is shown opposite. The spacer between the inhaler and the mouth holds the drug like a reservoir
when the inhaler is pressed. A valve at the mouth end ensures that the drug is kept within the spacer until you
breathe in. When you breathe out, the valve closes. You don't need to have good co-ordination to use a spacer
device.

A facemask can be fitted on to some types of spacers, instead of a mouthpiece. This is sometimes done for
young children and babies who can then use the inhaler simply by breathing in and out normally through the
mask.

There are several different types of spacer. Examples are: Able Spacer, Aerochamber Plus,
Nebuchamber, Optichamber, Pocket Chamber, Volumatic and Vortex. Some spacer devices fit all
MDIs; others are only compatible with specific brands of inhalers.

Tips on using a spacer device

The following are tips if you are prescribed a holding spacer. These have a valve at the mouth end - the spacer
in the picture above is an example:
If your dose is more than one puff, then do one puff at a time.
Shake the inhaler before firing each puff.
Start breathing in from the mouthpiece as soon as possible after firing the puff.
Try to hold your breath for a few moments when you have breathed in.
Breathe in and out a few times before firing the next puff. Try to hold your breath for a few moments
each time you breathe in.
Check that the valve opens and closes with each breath.
A facemask can be put on to the valve end for babies and young children. They just breathe normally
with their face against the mask. The valve opens and closes with each breath in and out. Hold the spacer
slightly tilted with the inhaler end uppermost to help the valve open and close easily.
Static charge can build up on the inside of the plastic chamber. This can attract particles of drug, and
reduce the output when the spacer is used. To prevent this, wash the plastic spacer as directed by the
maker's instructions. This is usually before first use, and then about once a month with washing up liquid
and water. Let it dry in air without rinsing or wiping.
Nebulisers
Nebulisers are machines that turn the liquid form of your short-acting bronchodilator medicines into a fine
mist, like an aerosol. You breathe this in with a facemask or a mouthpiece. Nebulisers are no more effective
than normal inhalers but they are extremely useful in people who are very fatigued (tired) with their breathing,
or people who are very breathless. Nebulisers are used mainly in hospital for severe attacks of asthma when
large doses of inhaled drugs are needed. They are used less commonly than in the past as modern spacer
devices are usually just as good as nebulisers for giving large doses of inhaled drugs. You do not need any co-
ordination to use a nebuliser - you just breathe in and out, and you will breathe the drug in.

Common questions and further information

Do you get side-effects from inhalers?
At standard inhaled doses, the amount of drug is small compared with tablets or liquid drugs. Therefore, side
effects tend to be much less of a problem than with tablets or liquid drugs. This is one of their main
advantages. However, some side effects do occur in some people. Read the packet insert for details of possible
side-effects.

One problem that might occur when using a steroid inhaler (especially if you are taking a high dose) is that the
back of your throat may get sore. Thrush infection in the mouth may develop. This can usually be treated
easily with a course of pastilles that you suck or liquid that you hold in your mouth. You might also notice that
your voice becomes more hoarse.

If you rinse your mouth with water and brush your teeth after using a steroid inhaler you are less likely to
develop a sore throat or thrush. Also, some inhaler devices (such as spacers) are less likely to cause throat
problems. A change to a different device may help if mouth problems or thrush occur.

Note: a persistent hoarse voice that does not settle, needs further investigation as it can be due to other
causes. If you have this symptom you should tell your GP.

If you use a high dose of inhaled steroid over a long time it may be a risk factor for developing osteoporosis.
You can help to prevent osteoporosis by taking regular exercise, not smoking, and eating a diet with enough
calcium.

Children who use an inhaled steroid over a long time should have their growth monitored. There is a small risk
that enough steroid may get from the lungs and into the body (via the bloodstream), to delay growth. This risk
has to be balanced against the risk of a child with asthma not having a steroid preventer. Long-term ill-health
(such as with conditions like severe asthma) could also affect a child's growth).
Which is the best inhaler device to use?
This depends on various factors such as:

Convenience. Some inhalers are small, can go easily in a pocket, and are quick to use. For example, the
standard MDI inhaler.
Your age. Children under the age of six generally cannot use dry powder inhalers. This is because such a
strong breath is needed to inhale the drug within the inhaler. Children aged under 12 generally cannot use
standard MDI inhalers without a spacer. Some elderly people find the MDI inhalers difficult to use.
 Your co-ordination. Some devices need more co-ordination than others.
Side-effects. Some of the inhaler drug hits the back of the throat. Sometimes this can cause problems
such as thrush in the mouth. This tends to be more of a problem with higher doses of steroid inhalers.
Less drug hits the throat when using a spacer device. Therefore, a spacer device may be advised if you
get throat problems, or need a high dose of inhaled steroid.
Often the choice of inhaler is just personal preference. Most GPs and practice nurses have a range of devices to
demonstrate, and let you get a feel for them. If you are unhappy with the one you are using then ask your GP or
practice nurse if you can try a different type.