I welcome the opportunity to write a blog on the subject of asthma.

I have been a consultant lung specialist for 40 years and over that period of time have done considerable research into various aspects of lung disease including asthma. I have also been interested in reading and collecting books, ideas and paraphanelia that have to do with asthma management in different countries and phases of history.

I will slant this presentation toward patients and potential patients and minimize the use of highly technical terms, references and statistics. I will keep my focus on individual management of asthma as opposed to the rigid population-based approach that is so popular at this time.

Let me emphasize that this question and answer format and content is entirely personal but is based on 40 years of experience, long-term thinking and research in this field. I hope that I will be able to clarify and interest people toward the ulitmate goal which would be more self-care as opposed to doctor based ambulatory, office and hospital care. I hope you enjoy reading it as much as I enjoyed preparing it.

One of my favourite quotations is of unknown origin to me; however it emphasizes the importance of clinical observation in the practice and advancement of medicine. Quote: I have learned a great deal from teachers, I have learned more from my colleagues and even more from my students; but I have learned most from my patients.

What is the most satisfying aspect of looking after and managing people with asthma? In my mind by far the most satisfying all around experience is to investigate somebody thoroughly and find that they really do not have asthma and will not be required to take regular medications or be followed on a regular basis. This is much more common than one would think and in my practice tends to account for about 10 to 15% of people referred to me by other physicians.

What is asthma? Asthma is a disease which tends to be lifelong and frequently intermittent. Sometimes there are very long periods of years between symptoms. It is not a single disease; or two diseases as we were taught in medical school when I was a student. There are many other diseases that look like asthma, behave like asthma, and even respond to treatment like asthma and are really not asthma at all. It takes a specialist with special tools at their disposal and a curious mind that tends to listen to what patients tell them to uncover these...for example, cardiac asthma, blood clots to the lungs, worm infestation of the lung, collapsing airways etc.

Okay but what is asthma really? The area of the body that is involved in asthma is the airways or bronchii, and not the lungs. Any disease process which causes increased inflammation, congestion, or abnormal function of the airways can look like asthma, behave like asthma or be asthma. This sounds very complicated; and it is. The usual expression of this disease process is a combination of any or all of the following symptoms; cough, sputum, wheezing, chest tightness and shortness of breath. Traditionally the key to the diagnosis of asthma has been reversibility of the abnormality by medication or with time. Although the symptoms can be improved and sometimes reversed, there is no such thing as a cure for asthma in our present state of knowledge.

What are the common types of asthma and how do they differ? Much is known and being constantly found about the mechanisms and management of different types of asthma. There is, however, considerable overlap in that a person with the most common, familial type of asthma can have an occupational asthma or drug induced asthma as well...once you try to solve an individual's problem it often becomes more complex rather than simpler.

The following list stresses the most common kinds of asthma and highlights the fact that each division has a different mechanism and frequently a much different management. If this is not recognized all people will be treated reflexly by prescribing the current popular inhaler or pill.

People have learned over the centuries that they can avoid certain environmental factors and behaviours to reduce the frequency and severity of their asthma. This perfectly valid and practical in the day to day coping with a lifetime of asthma. We can do much more to improve the lifestyle of an asthmatic.

Familial allergic asthma; this is the most common and well-known variety that tends to begin in childhood and has a familial incidence. It is a lifelong disease but frequently a child can 'outgrow' this for many years. These people usually have seasonal variation with worsening in the spring and in very cold weather. The affected person can frequently observe a relationship between the symptoms and an offending stimulus such as exposure to cat, strong perfumes, detergents, foods such as peanuts or shrimp etc.

How do you make the diagnosis? what is the best treatment? What is the role and responsibility of the individual with asthma to optimize the treatment? I have to control myself or I will turn this simple blog into a book...

Diagnosis Symptoms of cough, sputum production, wheezing, chest tightness and or shortness of breath which come and go and are improved with treatment. Usually requires a physician to make a diagnosis...he considers family history, the results of breathing tests, and blood tests showing a high level of an allergy protein called IGE, as well as allergy skin testing and history.

Best treatment. Once the known stimulus is identified your try to stay away from it. If you cannot, which may be the case with something like pollen, you may benefit from an allergist prescribing a serum to reduce the severity of the reaction. Since this may be immediate, within minutes, or delayed for several hours after exposure, medications are very helpful and, in some cases, essential.

Over-the-counter antihistamines and home folk remedies such as apple cider vinegar are very helpful. In the literature of 15th century England, and other countries, it was well known that if somebody had severe asthma and they lived in the mountains they would often improve if they were sent to the sea... and vice versa. If they lived in an industrial city they were sent to the desert. And all these environmental changes worked which emphasizes the fact that:

The best treatment for any disease is to individualize therapy for each particular patient and their lifestyle. Not everyone needs inhalers daily. Not everyone needs the same inhalers. Not everyone needs inhalers.

A brief word about medicines used to treat asthmatics:

There have been significant advances and refinements in the medication available. The most effective are inhaled steroids and bronchodilators(drugs that open up the breathing tubes.) Pills that reduce inflammation and the excessive response of an allergic person have a definite role in some patients.

It requires a physician to decide what meds are best for an individual during an attack, and after, and what if any medications are needed on a long term basis to reduce the number of exacerbations of asthma... as well as providing guidance as to how to improve the patient's lifestyle.

I have learned that there is no simple formula except the conscientious evaluation of each patient. My experience with this type of asthma is that it is very satisfying to manage... and that permanent damage of lung function is very rare. There is always room to improve it.

What is a patient's responsibility? Learn about your disease and monitor your symptoms. Learn to use a simple test such as those performed on a peak flow meter. Do not accept changes in lifestyle because of the asthma...consult your doctor and ask advice.

What do I mean by 'changes?' Tell your doctor if shortness of breath stops you doing things; if your asthma stops you sleeping normally; if you cannot do the things you'd like to do because of your asthma...tell the doctor because most of the time these problems can be sorted out to your advantage.

Learn how to use your medications properly...overuse of inhalers is as bad as underuse and both kinds of failure to follow advice are dangerous. Use your medicines as regularly as was suggested to you.

There are nearly eighteen other types of asthma that I could/should comment on... e.g. occupational, drug induced, asthmatic bronchitis...but I will leave these for another blog.

Written by Dr. E. Lilker. consultant respirologist, Toronto.

transcribed by J. Bart