Coping with asthma: beyond drugs

Drugs are the mainstay of asthma management, preventing exacerbations, alleviating symptoms and enhancing quality of life. But regularly taking your preventer and using your reliever as required aren’t the only steps you can take to improve control of your asthma. As this article illustrates, avoiding triggers, taking up vaccination, quitting smoking, losing weight, addressing psychological factors, improving your diet and using complementary therapies can all, combined with your drug treatment, help you cope with asthma.

Try to avoid the asthma trigger

Obviously, you should do your best to avoid your particular asthma triggers. But you need to be realistic. Avoiding some triggers is easier said than done, and a single approach is unlikely to make much difference to symptoms triggered by some allergens, such as house dust mite. Moreover, some methods can be expensive, and studies have assessed relatively few of these in adults. Some of the recommendations below are based on studies on children, so if you try them it might be worth keeping a diary to see if your symptoms improve.

Pollen

The type of pollen in the air depends on the time of year and the weather; concentrations of grass pollen usually peak in June and July, for example, but the grass pollen season can, depending on the climate, run from May to August. In contrast, levels of birch pollen usually peak in April, while nettle tends to release pollen between June and September. If allergy tests reveal you are sensitive to a particular pollen, try to reduce your exposure during the times when levels are likely to be highest.

It’s worth listening to, or visiting the webpage for, the weather forecast, which often warns when the pollen count is likely to be especially high. And on any given day, levels are likely to be higher at certain times. Grass pollen counts tend to peak in the morning and late afternoon of warm, dry days with a gentle wind, for example. You could consider staying indoors as far as possible, particularly in the early evening, when the weather forecast announces the pollen count is likely to be high.

Apart from keeping an eye on the weather, the following suggestions may reduce the risk that pollen will trigger an asthma attack (and hay fever if you suffer from both):

• Keep windows at home and in cars closed. You could ask your garage whether a new car has the option of special filters that reduce the amount of pollen that gets inside. In some cases, you may be able to fit the filters retrospectively.
• Pollen is sticky, so wash your hair regularly and change your clothes after being outside. A moustache can hold pollen right under your nose – make sure you shampoo any facial hair. Wash or wipe any pets that have been outside, especially if they’ve been in long grass or a wood.
• Get someone else to cut the grass. Obviously, this is especially important if you’re allergic to grass pollen.
• Don’t camp or picnic inland: try to holiday by the sea. Pollen counts tend to be lower on the coast than inland.
• Stock your home and garden with plants that produce relatively low levels of pollen, such as hibiscus, periwinkles, azaleas and roses. (Many people who think they’re allergic to roses are actually sensitive to grass pollen.)

House dust mite

Even a powerful vacuum cleaner won’t eradicate house dust mites: millions still call the most vigorously cleaned house their home. Indeed, some studies suggest that dry vacuum cleaners remove only between 5 and 30 per cent of the dust in a carpet. Other studies suggest that thorough vacuum cleaning may remove 70 per cent of mites – it depends on the cleaner, the conditions (such as the type of carpet) and how thoroughly the person vacuums. Wet vacuum and steam cleaners may remove more dust and mites – up to 80 per cent in some studies. However effective your cleaner, mites still breed rapidly so numbers return to the previous levels within a week or so. Nevertheless, while it’s difficult to keep the dust and levels of mite allergens from building up, regular vacuuming can still help.

You’ll probably need to combine several approaches to make a marked difference to levels of house dust mite. For example, beds are often the most important site of mite exposure. After all, you probably spend around a third of your life asleep. Many people allergic to the house dust mite encase their mattress in a protective cover. However, the level of exposure to mite allergens also depends on whether other items of bedding are covered or washed regularly. So, to tackle house dust mites, try the following:

• Wash bed linen using a cycle above 60°C, which kills the mites. Colder water washes away the allergen, but does not kill the mite.
• Put soft toys in the freezer or, if they won’t be damaged, wash them in hot water every 14 days.
• Use dust mite (or anti-allergy) covers on mattresses, duvets and pillows. The covers may not alleviate symptoms in everyone, but some people find they help.
• House dust mites like it hot. Turn the central heating down and open windows.
• Consider decorating with wooden flooring and blinds rather than carpets and thick curtains. Wooden floors and blinds are easier to wash. If you really want a carpet, buy one with a very short pile.
• When you buy new furniture, consider leather or other nonporous surfaces, which makes cleaning easier.
• Avoid clutter, which can become dusty and is often difficult to clean. Keep books and knick-knacks in a box rather than on shelves, and store your belongings in cupboards.
• Vacuum cleaning can shift allergen from the floor to the air. Using double walled bags and cleaners fitted with HEPA or electrostatic filters may reduce the amount of dust that vacuuming creates. If possible, ask someone else to vacuum. Otherwise, wear a mask and, whoever vacuums, try not to re-enter a room for at least three hours after dusting or vacuuming to allow airborne dust to resettle.
• Ionizers increase the electrical charge on airborne dust particles, which clump together and fall to the ground, thus reducing the amount you inhale. It sounds logical. But there’s no conclusive, scientific proof that ionizers improve asthma symptoms. Nonetheless, some people feel they help. (I used one on my desk for a while and it seemed to help. But that’s no guarantee it’ll work for you.)
• Some people find their symptoms improve after using miticides, which kill the mites. But follow the instructions carefully: some miticides can cause skin irritation.
• Remove sheepskins, which seem to harbour particularly large mite populations.
• The American College of Allergy, Asthma and Immunology suggests maintaining humidity below 55 per cent – so don’t use a humidifier or a vaporizer.

Pet dander

Understandably, many people with asthma don’t want to rehome their pets – they’re part of the family. You will want to be certain that the animals cause your symptoms before deciding to find them a new home. (Ask for an allergy test, which may rule out the pets as causes.) You could also try the following to reduce levels of dander:Wash bed linen at about 60°C.

• Wash soft toys at least once a fortnight,
• Keep pets off beds and other soft furnishings.
• Avoid feather pillows. Many people allergic to animal dander cross-react to feathers.
• Ask someone who is not allergic to wash and comb your pet. If you must groom the pet, wear a mask and gloves. People allergic to dander and other animals should remember that pet owners and others who work with animals may inadvertently transport dander on their clothing.

Fungi

Fungi inside and outside the house can trigger asthma in sensitive people. You can reduce your exposure to indoor fungi in several ways:

• Regularly wipe any visible mould from bathrooms and windows with cleaners containing an antifungal or a 5 per cent bleach solution. (Wear a mask and non-latex gloves.) Make sure you clean shower curtains, tiles, shower stall, tub and toilet tank. Don’t carpet the bathroom.
• Wash down walls with an antifungal before decorating. Use paints that contain an antifungal.
• Keep rooms dry and well ventilated. You could use a dehumidifier to keep the humidity below 50 per cent. Use the fan or open the window to reduce mould while bathing or cooking. Dry all clothing immediately after washing.
• High-efficiency particulate air filtration and air conditioning may reduce the amount of airborne antigen and alleviate asthma symptoms in individuals with fungal allergies.
• Convection heaters reduce the viability of mould spores and inhibit the spread of mildew.
• Bark often contains high levels of mould. If you use a fireplace or wood-burning stove, don’t store any firewood inside (or, if there is no alternative, only a day’s supply).
• Avoid foam rubber pillows and mattresses, which may be more likely to attract mould than other types of bedding.
• Wardrobes are often damp and dark and attract mould. Make sure you dry shoes and boots thoroughly before storing. You could use a chemical moisture-remover inside wardrobes.
• Empty the waste bin frequently. Keep the bins clean to prevent mould.
• Empty the drip pan under your refrigerator regularly. The combination of food particles and standing water is an ideal breeding ground for mould.

Vaccination

Flu

In the spring of 2009, Edgar Hernandez – a 5-year-old from La Gloria, a rural town some 155 miles east of Mexico City – suffered a fever and headache so intense that his eyes hurt. Edgar was the earliest confirmed case of the strain of ‘swine flu’ called H1N1/2009. He survived, but over the next 18 months around 18,500 people worldwide died from the infection and hundreds of thousands suffered severe symptoms, according to The Lancet.

Although experts had long predicted a flu pandemic, most expected a bird-flu strain arising in South Asia to sweep the world – but a pig farm close to La Gloria is probably ground zero for H1N1/2009. And some virologists foresaw a catastrophe, warning that a repeat of the 1918 Spanish flu pandemic could claim between 180 million and 360 million lives. Thankfully, H1N1/2009 killed fewer people than many seasonal outbreaks: 474 people died during the 2009–10 pandemic in the UK, while according to government figures 1,965 people died from flu in the 2004–5 winter season, 10,351 in 2008–9 season and 21,497 in 1999–2000.

But the fears and the death rates even in non-epidemic years show that influenza isn’t just a bad cold. Flu is potentially fatal, especially for people with chronic respiratory diseases (including severe asthma, COPD or bronchitis), heart conditions and certain other ailments. Older people are also more likely to suffer serious complications – such as bronchitis or pneumonia – if they contract flu. So it’s important to get your flu jab.

However, government figures suggest that only around 70 per cent of patients over 65 years of age were immunized with the seasonal flu vaccine during 2009–10, and only around half of high-risk patients (including those with severe asthma) below 65 years of age. If you are in a vulnerable group, your GP surgery should offer you a flu jab. If you feel you should have the jab but aren’t offered it, speak to your GP or practice nurse.

Pneumonia (pneumococcal vaccination)

Around 1 per cent of the UK population contract pneumonia annually, especially during the autumn and winter. During a bout of pneumonia, fluid accumulates in the inflamed alveoli and small airways. This makes breathing difficult and reduces the amount of oxygen that passes into the blood. Most people feel ill and are feverish and ‘off their food’ for a few days. However, in 2008, almost 29,000 people in the UK died from pneumonia. Although a plethora of pathogens potentially cause pneumonia, bacteria cause around half of all cases.

Doctors may advocate pneumococcal vaccine for people with asthma or for adults aged at least 65 years. Streptococcus pneumoniae, the agent that causes many cases of pneumonia, can also lead to blood poisoning (septicaemia) and meningitis. The vaccines used in the elderly and high-risk groups may reduce the risk of pneumonia and other serious pneumococcal diseases by between 50 and 70 per cent.

While vaccination makes sense, there is surprisingly little evidence that asthmatic adults benefit. Nevertheless, a study of asthmatic children by Sheikh and colleagues found that pneumococcal vaccination decreased the number of acute asthma exacerbations from ten to seven per child per year. We clearly need further studies. But as pneumonia is potentially so dangerous, it’s worth discussing vaccination with your doctor or nurse.

Quit smoking

Smoking is rapidly becoming socially unacceptable – just look at the huddles of smokers outside offices, pubs and restaurants. During the 1940s, around 70 per cent of men and 40 per cent of women smoked. According to government statistics, the proportion of adults in England who smoke fell from 28 to 21 per cent between 1998 and 2008. Nevertheless, in England more than a fifth of adults – about 8.8 million people – still smoke. Around half of those who don’t quit smoking will die prematurely from their addiction. Indeed, during 2008 more than 80,000 people died prematurely in England from smoking-related diseases. For example:

• Smokers are roughly twice as likely to die from cancer as non-smokers.
• Smoking causes around half of all cases of heart disease.
• Smoking increases the likelihood of suffering a stroke up to three-fold.
• Smoking underlies a fifth of deaths among middle-aged people.

As we’ve mentioned in other articles about asthma, smoking (even second-hand) exacerbates asthma and makes the disease more difficult to control. For example, smoking seems to reduce the effectiveness of inhaled steroids.

On the other hand, quitting smoking reduces your likelihood of developing the main smoking-related diseases and helps prevent exacerbations. According to the Department of Health, a lifelong smoker loses, on average, around ten years of life. A person who stops smoking at 30 or 40 years of age gains, on average, ten or nine years of life respectively. Even a 60-year-old gains three years of life by quitting. So, it’s never too late to quit.

If the benefits to your health are not enough to make you quit, think of the harm you’re doing to the people around you. Second-hand smoke contains more than 4,000 chemicals, including over 50 carcinogens. This chemical cocktail increases the risk of asthma attacks and other serious diseases – including lung cancer, heart disease, childhood respiratory disease and sudden infant death syndrome – in people who inhale second-hand smoke. For example, the risks that a woman who has never smoked will develop lung cancer and heart disease are 24 and 30 per cent greater, respectively, if she lives with a smoker.

However, fewer than one in every 30 smokers manages to quit each year, and of these more than half relapse within a year. And you need to quit, not cut down. People who reduce cigarette consumption usually inhale more deeply to get the same amount of nicotine. Nevertheless, cutting back does seem to increase the likelihood that you’ll eventually quit. In some studies, people who halved their cigarette consumption increased their chances of eventual cessation by 70 per cent compared with those who never cut back. In other words, reduction can take you a large step towards kicking the habit. But don’t stop there.

You’ll need to deal with nicotine’s withdrawal symptoms, which can leave you irritable, restless and anxious as well as experiencing insomnia and craving a cigarette. In general, these withdrawal symptoms abate over two weeks or so. But nicotine replacement therapy (NRT) can make life a little easier. Government statistics suggest that nearly a fifth of smokers buy NRT to aid cessation. It’s money well spent: NRT increases quit rates by between 50 and 100 per cent.

You can chose from various types of NRT. Patches reduce withdrawal symptoms but have a relatively slow onset of action while nicotine chewing gum, lozenges, inhalers and nasal spray act more quickly. Talk to your pharmacist or doctor to find the right combination for you. If you still find quitting tough even after trying NRT, doctors can prescribe other treatments. But there’s no quick fix. You’ll still need to be committed to quitting.

Tips to help you quit

Breaking tobacco’s hold is tough. But, in addition to using NRT, a few simple hints may make life easier:

• Set a quit date, when you will stop completely. Plan ahead: keep a diary of problems and situations that tempt you to light up, such as meals, pubs or breaks at work. Many people associate tobacco with alcohol and coffee, for example.
• Try to find something to take your mind off smoking. If you find yourself smoking when you get home in the evening, try a new hobby or exercise. Most people find that the craving for a cigarette usually only lasts a couple of minutes. Some people find that just sucking a hard sweet helps take their mind off the craving.
• You may want to ask your family and friends for advice and support.
• Smoking is expensive. Keep a note of how much you save and spend at least some of it on something special for yourself. 
• Some people find that they become more hungry when they lose weight, so try to avoid reaching for the chocolate. Have a healthy snack handy.

Coping with relapses

Nicotine is incredibly addictive, on some measures more addictive than heroin and cocaine. Not surprisingly, many people don’t manage to quit first time – tobacco’s grip is just too strong. But if you relapse, try not to become too dispirited. Regard it as a temporary setback rather than meaning you are permanently hooked. Set yourself another quit date and try again.

It’s also worth trying to identify why you relapsed. Were you stressed out? If so, why? Did you met up with particular friends? Was smoking linked to a particular time, place or event? Once you know why you slipped you can develop strategies to stop the problem in the future.

Losing weight

According to government statistics, 24 per cent of men and 25 per cent of women in England are obese. Furthermore, 42 per cent of men and 32 per cent of women are overweight. Apart from increasing your risk of developing type 2 diabetes, heart disease and some cancers (including colon, kidney and breast), excess weight can exacerbate your asthma symptoms. And as we’ve already seen, obesity is a risk factor for severe asthma. Indeed, obese and overweight asthmatics typically show greater airway obstruction and are more likely to endure nocturnal symptoms than those who maintain a healthy weight.

On the other hand, losing weight alleviates symptoms and improves diurnal and day-to-day variations in peak flow, FEV1 and airway resistance. In part, these improvements result from the reductions in the amount of fat within or pressing down on the airways. Fat can narrow and change the airway’s shape from a circle to a less efficient oval. Abdominal fat may also prevent the diaphragm from descending as far as in people of a healthy weight. Last but not least, obese people tend to have smaller lung volumes than those of healthy weight.

In part, the link between excess weight and asthma arises because fat isn’t just inert blubber – it’s a chemical factory. Cells that make up fat (adipocytes) pump out several chemical messengers that increase inflammation in the lungs and other parts of the body. So, as Mancuso points out, excessive fat deposits increase susceptibility to pulmonary infections and exacerbate the airway inflammation associated with environmental triggers.

Losing any excess weight is not easy: after all, millions of years of evolution drive us to consume food in times of feast to help us survive during times of famine. (Today, of course, few people in the Western world experience famine. But the drive to eat hasn’t changed so we pile on the pounds.) And you can’t stop eating as you can quit smoking. However, the following six tips may help:

1. Try to take 30 to 60 minutes of aerobic exercise each day. That doesn’t necessarily mean training for a marathon: brisk walking, jogging, taking an aerobics class or using a machine like a stationary bike or treadmill will all help you lose weight. You don’t even need to do it in one go. You can break the exercise down into chunks of 10 or 15 minutes.
2. Keep a food diary and record everything you eat and drink for a couple of weeks. It’s often easy to see where you inadvertently pile on the extra calories: the odd biscuit here, the extra glass of wine or full-fat latte there. It all adds up. You could use one of the online tools that estimate your calorie intake and track weight loss over time (see Useful addresses).
3. Be realistic: don’t try to lose too much weight too quickly. Few people keep the weight off if they crash diet. Steadily losing around a pound or two a week reduces your chance of putting it back on again.
4. Be specific. Don’t say that you want to lose weight: rather, resolve to lose two stone. (Several internet sites allow you to estimate your body mass index and ideal weight, which helps you set yourself a target, such as: http://www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx Alternately, ask your doctor, practice nurse or pharmacist to calculate your body mass index for you.)
5. Set yourself small attainable goals, such as switching from full fat to skimmed milk, walking 15 minutes during your lunch break each day, going to the gym three times a week, and only indulging in chocolate on Fridays.
6. Don’t let a slip-up derail your diet. Try to identify why you indulged – what were the triggers? A particular occasion? Stress? Once you know why you slipped you can develop strategies to stop the problem in the future.

If all this fails, try talking to your GP. A growing number of medicines may help kick-start your weight loss. None of these tips is a magic cure for being overweight and you’ll still need to change your lifestyle. However, you may find that they help put you on the right course towards weight loss.

Psychological factors

Living with asthma – or any chronic disease – can cause considerable stress and have a marked impact on your family, social and work life. And you live with a lingering fear that you’ll suffer a severe, perhaps life-threatening, exacerbation. So, not surprisingly, suffering from asthma can cause or exacerbate anxiety, depression and other psychiatric ailments. In turn, suffering from some psychiatric conditions can make your asthma worse.

For example, Schmitz and colleagues found that in the two weeks preceding their study, 17 per cent of those with asthma and low levels of psychological distress had spent time in bed or reduced normal activities for all or most of the day because of asthma. This compared with 35 per cent of asthmatics with moderate psychological distress and 69 per cent of those enduring high levels of psychological distress.

Indeed, some psychiatric problems may trigger asthma, perhaps by unmasking a pre-existing disease. Loerbroks and colleagues found that patients that scored highly on questionnaires measuring neuroticism (a personality trait linked to stress) were around three times more likely to develop asthma than those with low scores on this trait. Divorce or the end of a ‘life partnership’ approximately doubled the likelihood of developing asthma.

Depression

Depression and anxiety also seem to worsen asthma. Depression is more than being ‘a bit down’: it’s a profound feeling of debilitating mental and physical lethargy, a pervasive sense of worthlessness and intense, deep, unshakable sadness. If you’ve never experienced true depression, it’s difficult to appreciate just how devastating the condition can be. Ng and co-researchers found that among patients aged 60 years and above, asthma roughly doubled the likelihood of suffering from depression compared with people without asthma and other chronic illnesses.

not surprisingly, depression compromises our ability to solve problems. In many cases, the strategies a depressed person develops to cope with asthma make matters worse. For example, if you are depressed this can induce a profound lethargy that saps your will and undermines your motivation to follow your doctor’s or nurse’s advice on when to use your medications for asthma and other diseases. In other cases, you may deny that you suffer from asthma – depression shunts the condition to the back of your mind.

Anxiety

Anxiety is more than feeling a little wound up, worried or stressed out. It’s a feeling of intense, sometimes debilitating, fear – even abject terror. Asthma, especially if severe or poorly controlled, can cause considerable anxiety. After all, asthma attacks are often frightening and the next attack could be the one that proves fatal. Not surprisingly, people with asthma are especially likely to develop anxiety disorders, including:

• generalized anxiety – anxiety all the time;
• panic disorder – unpredictable, intense anxiety attacks (according to the Royal College of Psychiatrists, around a quarter of people who go to an A&E department suffering from chest pain have suffered a panic attack rather than a heart attack);
• social phobia – intense anxiety when you are with other people.

To make matters worse, anxiety stimulates the adrenal glands (on top of your kidneys) to pour adrenaline into your bloodstream, causing your breathing to become faster to take in more oxygen. Obviously, changes to respiration worry asthmatics. The adrenaline rush also heightens alertness and the senses, increasing awareness of the changes. It’s easy to become trapped in a self-perpetuating cycle of anxiety and asthma.

Once again, anxiety can compromise your ability to take rational decisions about your asthma. For example, you need to be alert for signs of worsening asthma and severe attacks. But anxiety can lead to you becoming over-cautious, so you may needlessly use medication, attend A&E or miss work. And if you are anxious about side effects, you may not use your inhaler as needed.

Stress and the immune system

Stress can affect the immune system – which makes biological sense. Essentially, the biological changes associated with stress evolved to protect us from potential physical threats by allowing us to fight back or run away, so the increased immune activity allows stress to prepare us to tackle an infection.

Unfortunately, excessive stress (especially if protracted) may undermine your immune defences. For example, natural killer cells, a type of white blood cell, attack and destroy infected or cancerous cells. One study of students found that the activity of the natural killer cells declined around the time of their examinations. Indeed, several studies suggest that excessive stress reduces the effectiveness of some types of white blood cell and increases the risk of infection. One study infected students experimentally with influenza virus. Stressed-out students suffered worse symptoms and produced more mucus than their less worried counterparts. These changes would be bad news for people with asthma.

Other studies confirm that stress affects the immune system. For example, your immune system needs to mount an adequate response (such as pumping out sufficiently high levels of protective antibodies) after a vaccination to reduce your chances of contracting the infection. However, in one study, carers looking after a husband or wife with dementia found that levels of a cytokine (chemical mediator) that increases the activity of the immune system rose more quickly and persisted for longer after a vaccination than in less chronically stressed adults. In another study, carers generated lower levels of protective antibodies following a flu jab. Overall, Byrne-Davis and Vedhara comment, chronic stress can prematurely age the immune response.

Getting help

It’s important to get help for depression, anxiety and any other psychiatric conditions. If symptoms have a marked impact on your daily life, the doctor may suggest anti-depressants or drugs to alleviate anxiety. Don’t dismiss these out of hand. As mentioned above, it’s often difficult to plan the most appropriate strategy for your asthma or your life when you’re carrying the burden of depression or anxiety. While drugs can ease the symptoms, they don’t cure the problem. Nevertheless, psychiatric medicines may offer you a ‘window of opportunity’ to improve your asthma control and deal with any other life issues you currently face.

You could, for example, learn more about asthma and discuss steps you can take to improve your control with your doctor or asthma nurse. A change in your asthma medication may improve your symptoms and, in turn, reduce your anxiety or depression. You might want to discuss ways to improve your adherence with your treatment or tackle some of the triggers around your home. Putting yourself in control of your problems is one of the best ways to beat anxiety and depression. On the other hand, feeling that your problems control you is one of the most common causes of anxiety, depression and stress.

Nevertheless, some people need additional help. Your GP may be able to recommend a local counsellor. Alternatively, you could contact the British Association for Counselling and Psychotherapy or see if your doctor can refer you on the NHS. ‘Talking therapies’, such as cognitive behavioural therapy (CBT), help you identify the feelings, thoughts and behaviours that you associate with asthma. CBT will then help you question and test the feelings, thoughts, behaviours and beliefs to discover those that are unhelpful and unrealistic. In other words, CBT helps you face issues you have been avoiding and try out new ways of behaving and reacting. Furthermore, many complementary therapies (see below) help you relax, which bolsters your defences against stress.

Diet

You are what you eat, but studies examining the effect of diet on asthma show mixed results. For example, some studies, but not all, suggest that high levels of salt in the diet increase airway responsiveness.

Furthermore, Inuits seem to be less vulnerable to several diseases, including diabetes, heart disease and asthma, than people in Western countries, despite living on a diet that consists almost entirely of meat and living in a very cold environment. But their diets are high in fish and animals that eat fish (such as seals). Some fish oils (n-3, also called omega-3, fatty acids) appear to be anti-inflammatory, which may be why Inuits are at lower risk. Certainly, some studies suggest that diets high in oily fish (such as mackerel, fresh tuna and fresh salmon) seem to protect against asthma. Other studies have found that, in smokers, consumption of fish and n-3 fatty acids reduced the risk of emphysema, chronic bronchitis and low spirometry values. But not all studies have found a benefit.

While these results are mixed, reducing salt consumption also protects against raised blood pressure, while diets high in oily fish seem to protect against several other conditions, including heart disease. It’s less clear whether supplements offer any benefit over increasing fatty fish consumption, although they may be an alternative for people who really don’t like fatty fish. You could increase your consumption of fatty fish and see if your symptoms improve.

Furthermore, some additives and preservatives (e.g. tartrazine) and certain foods (notably milk, egg and wheat) may precipitate asthma in sensitive people. However, you shouldn’t start cutting milk, egg and other basic foods from your diet without advice from a dietician. If you feel that foods exacerbate your symptoms, you should discuss your concerns with your doctor or asthma nurse.

Complementary treatments

Complementary medicines are increasingly popular. A postal survey of 1,308 asthma patients in England performed by Shaw and collaborators during 2005–6 found that 15 per cent had used complementary therapies. Around a fifth (18 per cent) used the therapy to help their asthma, such as opening their airways. Other common reasons included a belief that the therapy was natural or safe (12 per cent), a recommendation by a family member or friend (12 per cent), and to aid relaxation and calm breathing (8 per cent).

Homeopathy emerged as the most popular complementary treatment among asthmatics (used by 68 per cent), followed by herbal treatments (63 per cent), relaxation (56 per cent), acupuncture (46 per cent) and the Buteyko breathing method (41 per cent). Obviously, some people tried more than one therapy.

Many of the people with asthma felt they benefited from the complementary treatment. Shaw and colleagues found that more than half said that the therapy always (23 per cent) or usually (33 per cent) helped their asthma. A further 28 per cent said that the complementary treatment sometimes helped. Fewer asthma symptoms (reported by 44 per cent) and helping to calm breathing and reduce panic (37 per cent) were the most common benefits.

Nevertheless, many conventional doctors and nurses remain cynical, partly because few complementary therapies undergo the same rigorous scrutiny as modern medicines. But clinical studies are expensive and pharmaceutical companies fund most trials, so this lack of studies isn’t that surprising. It’s worth remembering that no evidence of effectiveness isn’t necessarily the same as evidence of no effect.

Cynics add that the placebo effect accounts for most of the benefits produced by complementary medicines. In other words, if you think that treatment will work, you’ll probably feel better. (We’ve already seen that the immune system and nervous system are intimately linked.) And the symptoms and severity of asthma wax and wane, so symptoms may improve without treatment. Even without treatment, many mild or moderate exacerbations will fade to your average daily symptoms. (Doctors call this ‘regression to the mean’ – the mean is the average.)

That’s undoubtedly true. However, the placebo effect and the natural resolution also contribute to conventional medicines’ benefits. Because of this, many studies of conventional drugs compare the treatment to a placebo – a tablet or inhaler that looks the same as the medicine but doesn’t contain any active ingredient. In the best-designed studies, neither the patient nor the doctor knows whether the treatment is active or a placebo. (The technical term is a ‘double-blind’ study.) Kemeny and colleagues examined the placebo response in 55 patients with mild intermittent and persistent asthma and stable airway hyper-reactivity. The placebo (inactive) bronchodilator reduced bronchial hyper-reactivity: the average concentration of methacholine needed to reduce FEV1 by 20 per cent nearly doubled. Asthmatic symptoms ‘responded’ to the placebo in 18 per cent of patients.

Furthermore, cynics may point out that few studies show that complementary therapies improve lung function in people with asthma. However, improvements in measures of asthma control – such as limitation of activity, shortness of breath and wheezing – are not necessarily linked to changes in lung function. (A treatment may reduce over-inflation of lungs, for example.) This means that a complementary therapy may still improve symptoms and enhance quality of life, even if peak flow doesn’t change markedly.

And some complementary therapies make sense biologically. If a technique improves breathing, it’s logical that it might improve asthma. Even treatments that – from the perspective of conventional medicine – seem to lack any rational scientific basis may help. Reflexology, for example, can help you relax, and this, in turn, will help alleviate stress-related symptoms and improve your quality of life even without, according to conventional medicine, any direct impact on the causes of asthma.

Don’t underestimate relaxation’s benefits! Hypnosis and other relaxation therapies benefited asthma in two of five well-designed trials. Muscle relaxation could conceivably improve lung function in patients with asthma. So, if you want to try a complementary therapy, learn as much as you can about the treatment, see a reputable therapist and keep a diary of symptoms to see if there is any improvement. Bear in mind that stress may make your asthma worse.

Do regard these as complementary – not alternative – medicines. Don’t stop taking your conventional medicines, and make sure your asthma nurse or doctor knows – even if he or she is cynical. A common misconception suggests that because complementary therapies are natural they are therefore safe. However, many complementary therapies can also cause side effects: some herbs, for example, can be highly toxic and interact with other drugs you’re taking. You should always talk to your doctor or asthma nurse before trying a complementary treatment.

If you feel that the therapy improves your symptoms and you feel ready to step down your conventional treatment, speak to your doctor or asthma nurse before cutting back. (You should be regularly reviewed in any case and the treatment reduced to the minimum that controls symptoms.) In general, provided there’s no medical reason why you shouldn’t and if you find it improves your quality of life, it may be worth trying a complementary treatment – even if it ‘just’ helps you relax.

Acupuncture

Many people with asthma report that acupuncture alleviates their symptoms, although the evidence from clinical trials is mixed. For example, Choi and colleagues reported that 12 sessions of acupuncture added to conventional treatment over four weeks did not improve average morning peak flow or FEV1 in asthmatic adults. However, quality of life and Transition Dyspnoea Index – a questionnaire measuring breathlessness related to activities of daily living – both improved. While the extent of acupuncture’s benefits remains a moot point, some people find this ancient technique alleviates their symptoms and improves their quality of life.

Alexander therapy

Alexander therapy aims to re-educate the body, correct bad posture, bring the body into ‘natural alignment’ and aid relaxation. In some ways, it makes sense that Alexander therapy may benefit asthma. The chest needs to stretch optimally during inhalation and exhalation. Bad posture can hinder the chest’s movement and compress the airways, so opening the airways by improving bad posture seems logical.

Many actors, musicians and singers find that the Alexander technique enhances their ability to project their voice and improves stamina. Some asthma patients find that the Alexander technique improves their symptoms and reduces their need for medicine. Indeed, one small study suggested that the Alexander technique improved lung function; peak flow improved by 9 per cent, for example. However, after examining the scientific studies Dennis concluded that there is too little scientific evidence to suggest the Alexander technique alleviates asthma, although some people undoubtedly feel it helps.

Breathing techniques

Before modern drugs, many patients and physicians relied on breathing exercises to control asthma symptoms. However, despite the advent of modern drugs many asthma patients still show poor breathing techniques that could, in some cases, make their symptoms worse. For instance, people with asthma may breathe through their mouth only, or may not use their chest muscles correctly. Other people with asthma breathe too rapidly (hyperventilation).

Dysfunctional breathing can exacerbate asthma and, in some cases, even trigger attacks. So, there now seems little doubt that learning to breathe correctly can improve asthma. And there’s been a resurgence of interest in recent years, partly in the wake of patients reporting impressive results with yogic breathing and the Buteyko method. In addition to any direct effect on asthma symptoms, several breathing techniques, such as those derived from yoga or Buddhist meditation, can help you relax.

Against this background, doctors at Papworth Hospital near Cambridge developed a sequence of breathing and relaxation exercises for asthma during the 1960s. When you’re stressed or anxious you probably take rapid, shallow breaths using, predominately, the muscles at the top of your chest. The Papworth technique counters this ‘over-breathing’ by encouraging more relaxed breathing using the abdomen and diaphragm. Essentially, patients drop their shoulders, relax their abdomens and breathe deeply and calmly. Holloway and West reported that six months after people had spent five sessions learning the technique, the severity of asthma symptoms had declined by around a third; a year later, symptom severity had still declined by a quarter. Although most objective measures of lung function showed no change, the technique also alleviated anxiety and depression.

Yoga and Buteyko breathing techniques aim to control hyperventilation by reducing respiration rate. Doctors who reviewed the studies assessing these techniques concluded that breathing exercises do not change lung function. However, one study found that a yogic breath-control exercise called pranayama slightly reduces airway responsiveness to histamine (see challenge tests, p. 64). Furthermore, several trials suggest that while Buteyko does not enhance lung function, symptoms improve and bronchodilator use declines.

In another study, a physiotherapist taught breathing exercises to people with poorly controlled mild to moderate asthma over three sessions. Thomas and colleagues commented that, six months after learning the breathing exercises, patients reported improved asthma-related quality of life compared to a group who received education about the disease from a nurse: in these two groups, 91 per cent and 64 per cent respectively showed a ‘clinically important’ improvement in asthma-related quality of life. (Of course, the study also underscores the benefit of education in asthma.) Patients who had learnt the breathing exercises reported less anxiety and depression, although neither airway inflammation nor hyper-responsiveness had changed.

Herbal medicine

Some herbal remedies undoubtedly alleviate asthma. For example, one review reported that nine out of 17 trials examining herbal treatments reported some improvement in lung function. However, determining which herbs work can be difficult: one Chinese herb decoction (Ding Chuan Tang), which improved airway hyper-responsiveness in children with stable asthma, contains nine components, so more than one plant may be responsible for the benefits and each plant may contain thousands of potentially active ingredients.

Indeed, numerous herbs used in traditional medicines worldwide are anti-inflammatory, act as bronchodilators or help you deal with stress and anxiety. (While it doesn’t mean that it will work for you, I’ve found herbal remedies invaluable for asthma and other conditions over the years.) However, some herbs can interfere with other drugs or cause side effects. Some herbs contain salicylates and may therefore trigger symptoms in people with aspirin-sensitive asthma. So, if you want to try herbal treatments, ensure that you contact a registered medical herbalist and inform your GP, nurse, pharmacist and other healthcare professionals.

Homeopathy

Few alternative treatments provoke as much controversy as homeopathy. Based on the idea that like treats like, homeopathy uses a very dilute preparation of a chemical that produces the same symptoms as the disease, e.g. grass or ragweed for people allergic to those plants. According to conventional medicine these dilutions are simply too low to have any biological effect, so any benefit is down to the placebo effect and natural resolution.

Yet the idea that homeopathy works remains remarkably persistent. Quite apart from thousands of anecdotal stories, a review found that two of three methodologically sound randomized controlled trials reported some positive effects. However, these studies did not make the homeopathic treatment specific to each individual, which practitioners say is essential to gain the full benefit. And many doctors criticize the rigour of the limited scientific evidence that supports homeopathy.

On the other hand, if homeopathy doesn’t have a biological action it won’t do you any harm provided you take your conventional medicines. If you want to try homeopathy, you need to balance the lack of a scientific basis and the dearth, in many doctors’ view, of rigorous studies against the anecdotal reports. If you decide to proceed, keep a diary to see if your symptoms improve and for how long. (Indeed, this is a good idea for any complementary medicine.) This can then help you decide whether it’s worth the money.

A final word

We’ve seen that asthma is common: doctors currently treat around 4.3 million adults for asthma in the UK alone. Adults are also more likely to die from asthma than children. Tragically, better care could prevent up to 90 per cent of deaths and 75 per cent of admissions to hospital due to asthma, as well as enhancing quality of life, helping you perform the normal activities of daily life everyone else seems to take for granted and reducing the time you take sick from work. So, you need to get your asthma under control.

Nevertheless, asthma in adults often doesn’t receive the attention it deserves. While children and adults share several risk factors and the broad approaches to treatment are similar, there are some important differences. To take one obvious example, work-related factors cause up to a quarter of asthma cases among adults and contribute to approximately 15 per cent of severe exacerbations. However, combining treatments, avoiding triggers and considering other interventions should help you cope with asthma.