Managing your Asthma during the Winter Months

Noelle Madden - Pharmacist, Nov 2020.

It is estimated that approximately 450,000 people in Ireland have asthma.

Probably the most important thing to know if you or a family member suffer from asthma is that it is a chronic inflammatory condition of the Lungs.

As you can see in the above diagram asthmatic people have Airway Inflammation present even on a good day when they may have no symptoms. That inflammation is part of asthma, it narrows the airway and is there to some degree of inflammation in the lungs of an asthmatic 24/7.

When something triggers your asthma, your airways will move towards the picture on the far right, the inflammation worsens and the airway narrows even more making it hard to breathe and especially to breathe out.

The typical symptoms of Asthma include:

• Wheeze
• Breathlessness
• Chest tightness
• Cough

Some people may only experience two of the above symptoms, others may get them all but what is constant is the underlying inflammation present in the lungs.

That is why inhaled corticosteroids are the cornerstone of treatment of asthma as they treat the underlying inflammation in the airways.

The guidelines for treating asthma have recently been updated, the GINA (Global Initiative for Asthma) Guidelines 2019 so on your next review of your asthma control and treatment with your doctor or asthma nurse, some changes may be made to your treatment plan.

The most notable change in the recent GINA Guidelines 2019 is that inhaled corticosteroid treatment is recommended for all symptomatic asthmatic patients no matter how mild their asthma is.

Previously mild asthmatics were managed with rescue/reliever (blue) inhaler to be used only when the patient had symptoms of their asthma. However, it is now recommended that even mild asthmatics when they need to use their rescue/blue inhaler they should also use an inhaled corticosteroid/brown inhaler prescribed for them. This ensures that the underlying inflammation is addressed by the inhaled corticosteroid (brown inhaler) whilst the rescue (blue inhaler) helps to open up the airways.

For some patients their doctor may recommend a combination inhaler containing budesonide (corticosteroid) & formoterol (long acting airway opener with a rapid onset of action) to be used as both their maintenance and their rescue inhaler.

Understanding that asthma is a lifelong inflammatory condition helps us to understand the need for taking the preventer/steroid inhaler continuously even when the asthmatic is well as it is helping to control the underlying inflammation in the airways.

Unfortunately, the routine overuse of short acting rescue (blue) inhalers on their own is widespread in Ireland. This poses a serious risk of severe asthma exacerbations for such patients as the underlying inflammation in their airways is not being treated.

So the general rule of thumb is that if you need to use your rescue/blue inhaler more than twice a week then you need to see your doctor for a review as your asthma is not adequately controlled.

Similarly, if you are using an inhaler with a combination of both budesonide (steroid) + formoterol (rapid onset, long acting reliever/rescue) inhaler eg. Symbicort , as both your maintenance and rescue treatment, then if you need to use rescue doses more than twice a week you need to tell your doctor and review your inhaler technique and perhaps your treatment.

So, WHAT DOES WELL CONTROLLED ASTHMA LOOK LIKE?

• No troublesome symptoms by day or by night.
• No cough.
• No shortness of breath.
• No wheezing.
• Can exercise and carry out daily activities with no problems.
• Needing to use reliever/rescue(blue) inhaler less than 2 times per week.

So if your asthma is properly controlled, you should only need 1-2 immediate acting reliever/rescue (blue) inhalers per year, think about that… is that your situation? If not, it’s time for a review with your doctor and an update of your treatment and your asthma management plan.

A good analogy is:

1. Your inhaled corticosteroid(brown inhaler) is your friend, you need it every day to control airway inflammation
2. Your inhaled reliever/rescue (blue) inhaler is your life jacket, you need it when you have symptoms of asthma 

What can you do to help your asthma?

• Fess up to the doctor exactly what medicines you have and haven’t been using from the prescription he/she last gave you. If you don’t your treatment will be increased up to the next level as your doctor will believe what you had been given in the last prescription has not worked. Let’s be honest, the doctor can prescribe the newest, latest, all bells and whistles inhaler but unless you the patient uses it as your doctor has prescribed you to do…it’s not going to work!
• Don’t be afraid to use your steroid/preventer (brown) inhaler. Some people worry about the side effects of steroid inhalers but the steroid dose is low and it is delivered directly to the lungs to treat the inflammation that is present there 24/7 as discussed above. If you avoid using your daily low dose inhaled steroid then chances are you are going to need at least one course of oral steroid this Winter which exposes your entire body to potential steroid side effects.
• The other important thing is to make sure that you are using your inhaler properly…you may believe that you are but you should ask your pharmacist/doctor/asthma nurse to check this for you at least once a year and every time you are prescribed an inhaler that you have not used before. The Asthma Society of Ireland www.asthma.ie provides really helpful videos demonstrating inhaler technique which can be accessed free of charge on their website. They also provide a WhatsApp messaging service run by experienced asthma nurses who can help you with any questions that you may have regarding your asthma, the number is (086)0590132 and again this is a free service.
• If there is a spacer device available for the inhalers that you have been prescribed then it is a must have for every asthmatic for 2 reasons:

1. No matter what age you are, a spacer device will ensure better delivery of your inhaled medicine to your lungs which ensures you get a better response from your medicine and it will also reduce the side effects of the inhaled medicine with better delivery to the lungs.
2. If you find yourself in the throws of a severe asthma attack and needing to follow the red zone of your asthma management plan then the spacer can greatly help delivery of the one puff of your inhaler per minute for 10 minutes, to your lungs at a time when you may be finding it very difficult to breathe.

• Every asthmatic should have an ASTHMA Action Plan that is unique to them, their symptoms and their treatment plan.
• Visit the Asthma Society of Ireland website www.asthma.ie where you will find an Asthma Action Plan which you can download & fill out with your doctor/asthma nurse at your next visit. Make sure that your family & friends are aware that you have an asthma action plan and that they know where it is kept. Ideally you should make several copies and place one on the fridge door, one at work/school and also have a copy saved on your mobile phone in case an asthma attack happens while you are out.
• Another important thing this time of year is to ensure that you avail of the annual Flu Vaccine which protects you against viral flu and also the Pneumococcal Vaccine which protects you against severe pneumonias and dangerous sepsis caused by pneumococcal bacteria, if you are due it. Limiting your susceptibility to viral and bacterial infections helps to eliminate some asthma triggers.
• If you suffer with asthma and you have not already had your flu vaccine for 2020/2021, please contact Rosscarbery Pharmacy and we will advise you about availability as currently there have been issues with attaining sufficient supply from the HSE Cold Chain to meet demand.
• In terms of lifestyle advice, aim to live your best life with Asthma, after all it is a lifelong condition so you need to learn to manage it.

1. Keep active, 20 minutes per day of exercise is recommended. If exercise provokes asthma symptoms then this is an indicator that your asthma is poorly controlled and you need to visit your doctor.
2. Maintain a healthy weight.
3. Stop smoking if you smoke and also encourage others in your household to stop smoking.
4. Know and understand your Asthma Action Plan including the medicines that have been prescribed for you, how to use them properly and what each of them is for.

I hope you have found this information helpful.
Stay Safe & Stay Well this Winter,
Noelle & all the team at Rosscarbery Pharmacy