Asthma: Types, causes, symptoms and treatments for adults and children

Despite being the most common lung disease in the UK, there isn’t a cure for asthma. However, there are treatments and ways to manage it

Asthma is the most common lung disease in the UK affecting 5.4 million people (one in 12 adults and one in 11 children).
The fact that it’s so common doesn’t mean the condition shouldn’t be taken seriously though, as 750,000 people are hospitalised due to asthma every year in the UK, and there are four deaths a day from asthma attacks.
Asthma symptoms can start in childhood when the immune system is still developing, or it can begin for the first time in adults, and the symptoms can come and go.
Environmental triggers for symptoms include pollen, viruses, air pollution, tobacco smoke, pet dander, dust and dust mites, cold weather and chemicals. Other triggers include stress, exercise, and even hormonal changes in women such as those brought about by the menstrual cycle and the menopause.
Although there’s no cure for asthma, the symptoms can be controlled with medication that has to be taken daily.
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“Asthma is a lung condition caused by inflammation and narrowing of the airways into the lungs which makes it hard to breathe,” says Dr Pujan Patel, a consultant in respiratory medicine at the Royal Brompton and Harefield Hospital, London. “It affects people in different ways, and the more we learn about the condition the more we realise it’s very complex and variable.”
“The most common causes of asthma symptoms are allergies such as house dust, pet dander and mould and infections, so if you breathe in an allergen such as dust or mould, or a virus such as the cold or flu virus, and you have asthma, your lungs will react more aggressively than normal lungs,” says Dr Patel.
“There is also a genetic component – asthma does run in families and there are lots of studies that reinforce that concept. It’s that unfortunate combination of environmental triggers such as pollution, allergies and infections, and genetic predisposition that leads to the development of asthma.”
The classic signs of asthma include coughing, wheezing, shortness of breath and a tight chest.
“People often report tightness across the middle of the chest and all around their chest,” explains Dr Patel. “It’s normal to feel shortness of breath after exercising but with asthma you may get this with completing normal daily activities such as getting dressed, having a shower, or walking up the stairs.
“The wheezing in asthma typically starts being audible when you breathe out, so if you initially start wheezing when you breathe in there’s a high probability it’s another condition and not asthma.”
Common asthma symptoms can include:
Asthma is more common in children than adults, while it affects more boys than girls before puberty, asthma is more common in middle-aged females than males.
“Children can grow out of asthma,” says Jonathan Grigg, a professor of paediatric respiratory and environmental medicine at Queen Mary University of London.
“In particular, most pre-school children with asthma-type symptoms will be symptom-free by school age. In older children, the hormones that come with puberty can either improve asthma control, or switch it off altogether,” continues Prof Grigg. “However, there is always a risk that asthma may return in later life.”
Adult-onset asthma disproportionately affects women, often around the menopause. In such cases, symptoms tend to be more persistent, rather than intermittent.
There is no test that will definitely tell you if you have asthma or not because symptoms can come and go and may not be present when you are tested, explains GP Dr Andy Whittamore, the clinical lead at Asthma and Lung UK.
Of tests that help with diagnosis, alongside answering questions about your symptoms, the most commonly performed one is a peak flow test, which measures the amount of air that can be forcefully breathed out of the lungs, where you inhale and then breathe out as hard and as fast as possible into a hand-held plastic peak flow meter. “Your peak-flow score gives an idea of how narrow the airways are at that moment,” says Dr Whittamore.
“Another more in-depth test is called spirometry, which is available in hospitals and some GP practices and measures how much air you can breathe in and out of your lungs, as well as how easily and fast you can blow the air out of your lungs.”
A newer test now available to GPs, is a FeNO (fractional exhaled nitric oxide) test. High levels of nitric oxide in your breath can be a sign that you have inflamed airways and may have asthma.
Dr Whittamore says that to make a diagnosis, he often asks patients to keep a two-week symptom diary of peak flow readings taken twice a day and takes a careful medical history, asking about symptoms, when they occur, and any triggers and family history of asthma.
“Patients are then given an asthma plan to manage their condition in the long term,” adds Dr Whittamore
Asthma symptoms can be controlled with medication, including low dose steroid inhalers to reduce and prevent inflammation in the airways. 
If inhalers alone don’t control symptoms, add-on treatments such as leukotriene receptor antagonist tablets may be prescribed. These are anti-asthma drugs, a hybrid of anti-inflammatory and bronchodilator drugs, which work by relaxing muscles in the lungs and widening the airways.
Approximately 5 to 10 per cent of patients with asthma continue to have asthma attacks despite being on the maximum dose of appropriate inhalers. These people are often classed as having severe asthma and they can be potentially treated with injections of drugs called biologics, or biological therapies, which cost around £15,000 a year. “These switch off the inflammation which causes asthma within the lungs. Upwards of 80 per cent of patients started on them don’t have any asthma attacks – they are complete game changers,” says Dr Patel.
“The trouble is, specialists often get to see these patients too late as biologics can only be prescribed at one of 14 NHS serious asthma centres. It can take an average of four years before patients are referred by their GP to one of these centres and by that time, patients’ bodies and minds have been damaged by steroid side effects and exhaustion from frequent asthma attacks,” Dr Pate continues.
“Only 20 per cent of people who could benefit from biologics are actually receiving them currently, although this is improving.” If you are having frequent asthma attacks because your asthma is not well controlled, ask your GP for a referral to a severe asthma centre.
Inhalers (“puffers”) deliver medication directly into the lungs to reduce the inflammation in the airways.
There are three types of medicine in inhalers. The most important inhaler is a low dose steroid which dampens down the inflammation that causes the symptoms and asthma attacks. These need to be used every day to dampen down the inflammation and make it less likely that someone will react to their trigger.
“Everyone with asthma should also have a reliever inhaler (often blue) to treat asthma symptoms if they occur. There are also longer acting bronchodilators which open up the airways – these are given alongside the steroid inhaler and usually in a combination inhaler,” says Dr Whittamore.
“It’s really important that a healthcare professional demonstrates to a patient how to use an inhaler and checks they are using it correctly.” 
It’s important to use a preventer inhaler as instructed to stop symptoms occurring. “Compliance is a big problem with preventative inhalers, which need to be used every day, but because people don’t feel the immediate benefit in the same way as with relievers, they get complacent and don’t use them. They can then end up with symptoms or an asthma attack,”  Dr Whittamore adds.
“It’s really important to carry your reliever with you at all times to treat any flare up of symptoms.”
Asthma attacks involve a worsening of asthma symptoms such as coughing, wheezing and a tight chest, which reliever inhalers don’t ease completely. 
Being too breathless to speak, eat, or sleep, and unable to catch your breath, are classic symptoms. Peak flow scores will be lower than normal. Anyone experiencing asthma symptoms at night should contact their GP.
“Asthma attacks tend to come on gradually. The symptoms will build cumulatively and in most cases the patient will find their reliever inhalers are not working for them to ease the attack. A minority of patients will have a sudden onset of symptoms, and these can be equally severe,”  says Dr Patel.
“Asthma attacks can be life-threatening and four people a day die from them in the UK, yet more than three quarters of the deaths could be prevented with basic asthma care.”
If you have had an asthma attack requiring steroid tablets, get your GP to arrange an asthma review to assess your asthma risk via a quick FeNO breath test and a simple blood test for eosinophil levels (another measure of inflammation).
“We tell people to try and stay calm and sit down if they are having an asthma attack, which can be difficult as being unable to breathe can provoke anxiety, which makes the symptoms worse,” says Dr Patel.
“They should then use their reliever inhaler, taking one puff every 30 to 60 seconds for up to 10 puffs. If there is no improvement, they should call 999 for an ambulance to get them to hospital.”
“Asthmatic coughs tend to be more pronounced in the evenings and at night compared to post-viral coughs,” Dr Patel explains. “The first thing to do is to identify if there is inflammation in your airways by having a spirometry lung function test or a FeNO test. If these tests are negative, it’s not likely to be an asthma cough and more likely to be a hypersensitivity cough, driven by irritation of nerves in the airways after an infection. If your tests are positive for inflammation, you may need a steroid inhaler to be prescribed or your dose increased.”
In some cases, exercise can be a trigger for asthma (called exercise-induced bronchoconstriction), but this can usually be managed with medication.
“Exercise is a definite trigger for asthma symptoms in some people, but exercise is also really good for the lungs, so we don’t want people to stop doing it,” says Dr Whittamore. “Your healthcare professional can help tailor your medication to support this and prevent attacks.”
Dr Patel adds that it’s generally moderate to high intensity that can induce asthma (jogging rather than walking), although this can vary.
Asthma symptoms can start at any time in life, not just in childhood. “A common time for asthma to develop in women is in their 40s,” explains Dr Patel. “Sometimes symptoms can start in adulthood following viral infections, or after exposure to occupational irritants such as wheat flour or certain chemicals. People who had asthma in childhood could also have a recurrence of symptoms in adulthood.”
“Severe asthma, which is hard to control with drugs, is classed as a disability under the Equality Act 2010,” Dr Patel clarifies.
A lot of children grow out of asthma, but it is much more unusual if you develop asthma as an adult for it to then go into remission.
“Because asthma is a variable condition it may appear that people grow out of it,” says Dr Whittamore. “Many people with asthma in childhood do continue to get asthma symptoms as adults and many others can notice symptoms even after several years.”
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