ASTHMA - Full extract 

Karen is 14 and has had asthma since she was a young child. Until a few months ago, her asthma had been fairly well controlled. Around that time she started to become tight in the chest and very wheezy during her netball games. She found that she needed to use her asthma-relieving inhaler several times during the game, as well as beforehand.

Previously she had been on a preventive inhaler but had run out of it several months earlier. We had discussed doing peak flow measurements some time ago but she had not got around to picking up her flowmeter. I used to see her every few months, but it had been almost a year since she had been in for a check-up. Apparently, she had been picking up asthma inhalers without a prescription and also using her older brother's medication.

One evening after a netball final, she walked out into the cool night air and suddenly became very short of breath. She reached for her inhaler and had several puffs, with no effect. She became so short of breath that she began to panic. She staggered inside and her coach called an ambulance. Our practice being only around the corner, they gave us a call too.

When I entered the stadium I saw Karen lying on the floor surrounded by several people. She was pale, sweating and had rapid shallow breathing. She was unable to talk and barely conscious. We gave her nebulised Ventolin as well as oxygen by a face mask. The Mobile Intensive Care Ambulance arrived within minutes. An intravenous line was inserted, and oxygen and Ventolin were continued as she was taken to the nearest casualty department. She was already feeling a little easier before she arrived at the hospital.

She was in hospital for three days and made a complete recovery. The whole episode was a difficult learning experience, to say the least. She now takes more interest in her asthma, and manages it much better. She is on long-term preventive medications and just uses relievers when necessary. She has had no significant attacks of asthma since.

Asthma should always be treated with a great deal of care. As well as being a very distressing condition, it causes about 700 deaths in Australia each year, more than half of which are preventable. However, with improved education and management, this figure is starting to decrease. 

Some people feel uncomfortable about the label "asthma" and may refer to it as "the wheezes" or "wheezy bronchitis". Asthma is one of those conditions where it is better to call a spade a spade. A clear understanding of what asthma is all about is fundamental to good asthma management. Most GP's have a range of handout booklets or videos. The Asthma Foundation¹ can also provide a great deal of information. 

Asthma is a condition characterized by temporary, widespread narrowing of the bronchial tubes and at times excessive production of mucus. There may be a wheeze or shortness of breath; this may be precipitated by things like exercise, a respiratory infection, smoke, dust or pollution. It can also appear for the first time as a persistent cough. With children, a dry night-time cough is often a clue to underlying asthma. 

Asthma is very common, affecting about 25% of Australian children and 10% adults. New Zealand is the only country with a higher incidence of asthma than Australia. For reasons not clear, the condition still appears to be on the increase. The precise cause of asthma is not fully understood. However, along with eczema and hayfever it can have an allergic basis and does tend to run in certain families. We are increasingly regarding asthma as an inflammatory condition of the bronchial tubes and this is the basis of medications we use to prevent asthma from occurring. 

The aim of treatment is excellent asthma control so that the person can maintain a normal, healthy lifestyle. In response to the disturbing mortality rate in Australia, the treatment of asthma has become very streamlined in recent years, for both acute asthma and the prevention of further attacks. The National Asthma Campaign has been largely responsible for this better treatment approach. The campaign has involved respiratory specialists, GP's, pharmacists, other health professionals, and the general public. 

In the acute situation inhaled relieving medications are necessary. These are the bronchodilators like Ventolin and Bricanyl. They are administered by inhalers, spacers and other devices and usually give quick relief. If the symptoms do not improve with the relieving medication it can be repeated. It is very important to have a clear written action-plan worked out with the doctor, so that the person knows exactly what to do in an urgent situation. 

In severe cases it may be necessary to take a larger dose of relieving medication, cortisone tablets and urgently go to hospital, by ambulance if the person is very distressed. 

In hospital, treatment can be continued with oxygen, frequent nebulized bronchodilators and intravenous hydrocortisone. The person's condition can be closely monitored under the care of specialist respiratory physicians and nursing staff. Transfer to the intensive care unit can also be arranged if necessary. 

These days we encourage older children and adults to use mini-flowmeters to get a more accurate assessment of the degree of airways narrowing, and help with the action-plan. Patients with asthma should know what their best flowrate figure is, and how to respond if it drops significantly.

Occasional media reports question the safety of relieving medications like Ventolin and Bricanyl. It should be understood that these medications are very safe and can be lifesaving. Problems arise when people use these medications several times a day without medical supervision. This should suggest that the asthma is not well controlled and that a review by the doctor is required. 

Preventative treatment has become a major focus of asthma treatment. For a start, it is important to minimize exposure to dust, smoke and other aggravating factors. In addition, people who are having frequent asthma should be considered for preventive medications. These are the inhaled steroids like Flixotide and Pulmicort or an alternative type of medication called Intal. 

Preventive medications should be taken every day, even if the asthma appears to be under control. At a later date the doctor may be able to recommend a reduction in the dosage or even discontinue the medication altogether. The inhaled steroids work very well and can dramatically reduce asthma frequency and severity. More recent research has raised the question whether inhaled steroids have a growth-limiting effect on children. For this reason Intal may be preferred as a preventive in milder asthma. However, in more severe or persistent asthma, inhaled steroids are often still required. 

Symptom-controllers like Serevent and Oxis are another type of medication that are being increasingly used these days. They are slow-acting relieving medications that are usually inhaled twice daily. Although they are not effective in acute asthma, they can control symptoms very effectively in people with chronic asthma, especially troublesome night-time symptoms. Frequently they are used in combination with inhaled steroids.

Leukotreine antagonists such as Singulair are a new once-daily oral non-steroid medication for asthma. They act by reducing the allergic inflammatory response in the cells which line the bronchial tubes.

Health Tips:
* Education and communication are so important in the management of asthma. If you or a family member have asthma, learn as much as you can about the condition.

  * Most people with asthma enjoy a perfectly normal lifestyle. However, if you have asthma you need an action-plan.

Web links:
¹Asthma Foundation of Victoria: www.asthma.org.au

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001