LIFE WITH ASTHMA

Item

Title: LIFE WITH ASTHMA
extracted text: A BRITISH MEDICAL ASSOCIATION PUBLICATION

LIFE WITH
ASTHMA

Life with Asthma

H Wykeham Balme MD FRCP

JAICO PUBLISHING HOUSE
Bombay • Delhi • Bangalore • Calcutta
Hyderabad • Madras

© Family Doctor Publications 1986

This is a Family Doctor booklet published in arrangement with
the British Medical Association, BMA House, Tavistock Square,
London WC1H 9JR.

35'0

First Jaico Impression: 1989
Second Jaico Impression: 1990

Published in India by:
Ashwin J Shah
Jaico Publishing House
121 M G Road
BOMBAY-400 023.

Contents
Introduction

3

Normal breathing

3

What is asthma?

6

Treatment for asthma

10

Asthma in children

21

The severe attack

25

Asthma that goes on and on

26

The future

27

Your questions answered

28

introduction
Many people suffer from asthma a condition in which the
patient gets sudden attacks of difficulty in breathing. Small
children as well as adults are affected and it is a frightening
experience that may lead to feelings of panic—in itself making
the situation worse.
This booklet does not set out to tell you how to diagnose or
treat asthma for every patient needs the individual attention
of his own doctor. It does, however, tell you the basic things
you need to understand about asthma, what can be done to
help, and how to live life to the full in spite of it.

Help is at hand
There is no doubt that many asthma sufferers seek little or no
medical advice: they tend to listen to unorthodox practitioners
(whether genuine friends or quacks) using methods that are
relatively useless and sometimes frankly dangerous. As
asthma can itself be unpleasantly dangerous at times and as
orthodox medical treatment can be extremely effective, this
seems a bit hard on them.
Asthma is horrid. Normally our breathing is quite effortless
and not even noticed, but with asthma it becomes an effort.
Frightening, too, if the asthma is bad —not knowing if you are
going to get enough breath to be all right: it can even be life
threatening.
But I will have to start at the beginning and explain what
asthma is. To do this I must first tell you about normal
breathing, bronchial tubes and lung tissue; and something
about germs, fumes, and allergies.

Normal breathing
When we breathe we suck air into our chests by making them
expand. This we do by means of muscles so attached to the ribs
that when they contract (ie shorten) they lever them both
upwards and outwards and thereby expand the rib cage.

3

Another muscle doing this for us too is the diaphragm, which
the floor of the rib cage is made of. This is so dome shaped that
when it contracts it flattens out greatly and again enlarges the
cage. In doing this it of course compresses the contents of the
belly (abdomen) and so makes the abdominal wall bulge out a
little which is what we can see. Air is sucked in through
mouth and nose. It does not really matter which, but the nose is
in general better as At is equipped to notice any smells,
humidifies the air so that the throat does not dry uncomforta
bly, and filters off much of the dust that we unfortunately
breathe.
Breathing out
Breathing out takes less effort than breathing in as the rib
cage tends to fall in again on its own, the abdominal wall
flattens naturally, and the lungs themselves, having a lot of
elastic in them, tend to deflate anyway. So you virtually
breathe out just by stopping breathing in. But if you want to
you can breathe out very powerfully indeed by forcibly con
tracting your abdominal muscles and another set of chest
muscles which are attached to the ribs the opposite way round
from the first group and bring the ribs down and closely
together again. You can also if you need to increase the effort
of breathing in call into play some muscles in the neck which
help to lift the ribs up more. You can see these muscles
working hard in anybody whose breathing is very difficult.
One way traffic
The air that is sucked in, whether through mouth or nose, gets
to the back of the throat, and down, and then comes to an
astonishing and dangerous crossroads where it negotiates the
pathway for food and drink. It is vitally important that food
should not get breathed into the lungs where it could cause
tremendous trouble so there is a complicated mechanism at
this collision area to prevent that happening. If by chance the
mechanism lets us down and food "goes the wrong way” we
know all about it immediately, and nothing can prevent us
coughing until the last crumb has been safely salvaged. It is all
part of the struggle to keep the lungs free of dirt, germs, flying
insects, dust, and anything else that might harm them.
Air goes through the voice box (larynx) and on down
through the windpipe (trachea). This is nearly an inch wide,
kept permanently open by tough gristle (cartilage), but flexible
and able to concertina in and out a bit because this cartilage is

4

arranged in rings. You can just feel them in the front of the
lowest part of your neck. The trachea goes on down into the
chest and then divides into two, one division (main bronchus)
going to each side. These straightway enter the lungs and
thereupon divide again and again (up to about 25 times in some
parts) getting ever smaller but still retaining the stiffening of
cartilage until they are right down to a millimetre or less in
diameter. Even then the little tubes, now called bronchioles,
have a lattice work of muscle fibres in them that probably help
to keep them open all the time, allowing air to flow forwards
and backwards with hardly any restriction at all. The angles at
which the branches come off the main stems, and the relative
sizes of the different tubes, are exactly what modern engineer
ing science has worked out to be the ideal arrangement. Air
flow is miraculously free and unimpeded.

Frog in the throat
These small air tubes also make themselves a lining of sticky
slime (mucus) which traps any minute dust particles or germs
that land on it. Furthermore they then send this slime back up
to the super-sensitive larynx by wafting it along on countless
millions of minute microscopic waving hairs (cilia). Here the
mucus tickles us, so we "clear our throat", cough it up, and

5

either spit it out and get rid of it, or else swallow it and thereby
immerse all unwelcome invaders in the sterilising bath of acid
digestive juices in our stomachs. It all forms an excellent house
cleaning service, a marvellous protection against lung disease.
You can see why it is terribly important to keep those cilia
good and healthy.
Working non-stop
The bronchioles, after further division, eventually open out
into the minute little air sacs (alveoli) that are the true gas
exchange organs and are what the lungs are all about. They
are about a fifth of a millimetre in diameter (less than a
hundredth of an inch), and there are about 300 000 000 of them,
so their total surface area is somewhere about 80 square
yards say the size of a tennis court. Their microscopically
thin walls allow atmospheric oxygen from the breathed-in air
to seep across, within about half a second, into the network of
superfine (capillary) blood vessels that are there and thus get
into the general blood stream. At the same time the unwanted
carbon dioxide present in the blood stream, derived from the
general chemical workings of the body and equivalent to the
flue gases coming from a fire, seep across from the capillary
network into the alveoli (going in the reverse direction, that
is) and hence into the bronchioles, bronchi, trachea, throat,
mouth or nose, and finally into the room.

What is asthma?
The trouble in asthma lies with those little bronchi and
bronchioles. They become extremely irritable and during an
attack they suddenly behave as if they were at action stations
to repel all invaders. To achieve this they narrow right down,
the muscle fibres in their walls contracting hard to do so. This
hard contraction of millions upon millions of minute little
muscle fibres in the bronchial and bronchiolar walls is as it
were the enemy in asthma, for if only they can be made to relax
out of their cramp like spasm ("bronchospasm") the attack will
be relieved. In addition, though, the very substance of their
walls swells, and this narrows the internal diameter further
6

still. Finally, presumably in order to sweep out any invaders
that get in after all, the manufacture of sticky mucus acceler
ates, so that thick goo now comes to line what little remains of
the air passageways.
Out of breath
All this of course disastrously cuts down on the free flow of air.
Greater efforts of breathing are now required to get it flowing
at all and as a result the sufferer feels all out of the blue, and
for no apparent reason at all, very nastily short of breath.
Definite efforts have to be made to squeeze air out of the
chest—it is no longer just a matter of relaxing things—and
these very efforts inevitably squeeze the air tubes narrower
still. It therefore becomes even harder to breathe out than in
and the chest can be felt to get ever tighter and more blown up
with air.
Scary situation
If it is the first attack the sufferer may well feel a bit desperate,
start to panic, and try different positions for breathing in. This
restless movement only makes him worse, for the extra muscu
lar effort means that more air is needed and this is just what he
cannot manage to provide. If he can calm himself he will be
much better, but it is a terrifying situation to be in and this is a
difficult thing to do. Slowly he gets more used to it and realises
he can stick it out, but hours may go by before he has much
spare breath for moving around, or even for eating and drink
ing. Talking itself has to be rationed. Slowly the asthma eases
off, and as it does so an attack of coughing may occur, bringing
up some of that sticky mucus.
An attack like this will happen to anybody if he breathes
into his lungs enough of a really irritant gas—like sulphur
dioxide for instance. In the patient with asthma it is allergy
that basically does it instead. What happens in allergy is that
some tiny harmless little scrap of animal or vegetable matter,
that has never previously caused any trouble at all, becomes
capable of producing an intense irritable inflammatory reac
tion in a particular person. The fault lies not with the sub
stance itself but with the person: ie he has become allergic to
it.

Family connection
Some people and families can be allergic in various different
ways to many different things. Allergic inflammation can then

7

occur in the skin as eczema, in the nose as hay fever, or in the
bronchi as asthma. Infantile eczema may even be followed by
asthma in childhood and later by hay fever in adolescence. The
word "atopy" is applied to allergic people: they are said to be
"atopic".
So the asthmatic is a person whose small bronchi are liable
to get congested and constricted should he breathe in even
only minute amounts of whatever he has become allergic to.
This might be grass pollen, cat fur, mould spores, or minute
fragments from the tiny little mites that live in ordinary house
dust; or it could be one or several of many other things.
Occasionally odd foods can do it. like strawberries or shellfish
The attack that is brought on usually lasts a few hours and
then slowly clears away complete!) as the allergic inflam
mation in the tubes disappears. It could be days, weeks, or
months before another attack occurs, during which time most
asthmatic people are quite all right. There are some people,
however, the extra unlucky ones, in whom some of the inflam
mation persists, the bronchial tubes remain narrowed down,
stay congested and "juicy' . and symptoms only subside and do
not disappear completely.

Develops gradually
Asthma often starts in the 2 or 3 year old child and may take a
few years to show itself in its true colours. At first it may just
be a matter of recurrent wheezy colds in the chest ("wheezy
bronchitis”) from virus infections. The allergy to house dust,
or whatever, only becomes obvious later on.
It is an odd thing that once a person is asthmatic he is likely
to find that the particular offending material to which he is
allergic is by no means the only thing that will bring on
attacks: sudden changes in temperature or humidity, the
inhalation of cigarette smoke, the development of an ordinary
chest cold, and many emotional stresses will do it too. Exercise
is particularly likely to do this a five minute run perhaps or a
game of football though strangely enough swimming is
usually all right.
Asthma and the mind
The effect of emotions in triggering off an asthma attack is
often very striking indeed, but this should not really be
surprising for most bodily functions are after all greatly
influenced by them, as every blushing bride, queasy examina
tion candidate, and palpitating horror film viewer can testify.

8

In some cases of allergic asthma their effect is so powerful that
the majority of attacks may seem to result purely from emo
tional stress. This is why asthma is commonly held to be a
psychosomatic disorder, this being a term indicating that it is
the mind ("psyche”) that is the root cause of trouble in the
body ("soma”). Usually it is unpleasant stress that does it like
apprehension at going back to school but it may be quite the
opposite the keen bridge player for instance being incapaci
tated by an attack before the game even starts.
A rose by any other name
Some people show an astonishing degree of suggestibility, like
the person allergic to certain flowers who develops a genuinely
severe asthma attack when exposed to a plastic imitation.
Such experiences are commonplace in asthma clinics but they
do not alter the fact that the disease is basically allergic.
Emotions, among many other things, may trigger off an attack
but it was allergy that loaded the gun in the first place.

Searching for clues
Working out what the sufferer is allergic to is sometimes easy
but often not. One does it by methodical detective work, noting
what occasions bring attacks on. For instance, if the attacks
occur mainly in early summer a likely culprit is allergy to
grass pollen. Attacks mainly during the working week suggest
an occupational exposure some particular sawdust for in
stance. If during the weekend, it may be horses, dogs, or garden
moulds. If when out visiting it could well be dry rot or other
moulds in the house. If it happens exclusively at night it points
towards house dust in the bedroom or mattress, feathers in the
pillows, or cats on the bedclothes. The general rule, also, is
that the offending substance will not be anything new but will
be something to which exposure has taken place in the past
without trouble. After all, it takes time and more than one
exposure for allergy to develop.
Skin tests may be helpful. A drop of water containing a tiny
trace of the suspected material is pricked or actually injected
into the skin of the forearm, on the inner side where the skin is
soft and hairless, and with luck if the patient is allergic to it he
will develop a red blotch there, looking somewhat like a single
spot of nettle rash.
Many of these tests can be done at one sitting, testing for
house dust, pollens, animal dander, and so on. The results can
be useful, but many experts claim that they are only a little

9

more accurate than our present day weather forecasting, and
perhaps this is about right. No doubt much depends on the care
with which they are carried out.

Treatment for asthma
Nowadays there are several different ways of treating asthma,
which are much more effective than a generation ago, and
treatment can to some extent be tailored to fit the individual
patient and the individual attack.
Bronchodilators
The tiny muscle elements that are in the walls of the small
bronchi and bronchioles are in a cramp-like state of contrac
tion ("bronchospasm”) during attacks of asthma and there are
many drugs ("bronchodilators") that will make them relax,
stop contracting, and thereby allow the tiny tubes to open out
again. These may be given as tablets or medicines by mouth, by
injection, or perhaps preferably by inhalation.
Bronchodilators are constantly being improved in the con
tinual and highly competitive search for the ideal thing
something that works quickly and effectively on the bronchial
muscles alone, not affecting the very similar muscle elements
that are present in all the other organs of the body. It would
have to be absolutely safe and cause no unpleasant side effects,
even in very young children and even if it had to be taken daily
for a very long time.

New drugs to the rescue
Fortunately, there has already been a good deal of success in
this search, so that the older drugs like adrenaline, ephedrine,
and isoprenaline have been supplanted by newcomers, like
salbutamol, orciprenaline, and terbutaline. (All these drugs
have separate trade names given to them by the individual
drug firms. They will be referred to here collectively as "sal
butamol etc” but this is purely for convenience and does not in
any way mean that salbutamol is the best of them.) Ephedrine,
though very helpful against asthma, makes the heart thump
uncomfortably strongly, the patient nervy and wakeful, makes

10

his hands shake, and hinders the action of his bladder some
what. Salbutamol etc, equally effective against asthma, have
much less effect on these other organs and are usually prefer
able, even though they are nowhere near perfect yet.
If the drug is taken by mouth as a tablet or medicine it gets
absorbed by the stomach and sent in the blood stream all over
the body, so most goes to parts that do not want it and in them
it may cause adverse reactions. Only a minute fraction gets to
those muscle elements in the bronchioles and bronchi where it
is needed. If on the other hand it can be inhaled so that it
carries on down into the lungs into the small bronchioles, far
less is wasted and therefore a much smaller dose is needed.
This means that far less is absorbed into the general body
system and therefore less trouble is going to arise from the
effects it produces on the other organs of the body.
Much research has resulted in very ingenious ways of
achieving this. The problem is to produce a fine enough mist
containing a standard dose of the drug dissolved in it for the
tiny droplets to escape being trapped in the mouth, throat,
larynx, trachea, major bronchi, and their bigger branches and
to reach far enough down to the really small ones to be trapped
and held. This must not be too haphazard as it is important
that the patient should be able to rely on getting a reasonably
standard quantity of drug down there.
Special inhalers
Various inhalers have been devised and if used properly
achieve this result. They differ with each drug but basically
the procedure is the same for all. The patient first breathes out
as far as he can, taking plenty of time to do so. He then puts the
appropriate part of the inhaler into his mouth and closes his
lips around it firmly. He next has to make the inhaler squirt
out its fine medicated mist, usually by pressing down on the
container vessel that is in it, and at the very same moment he
must take a really big deep breath right in.

Learning how
Taking this deep breath is the difficult part, the part that most
people get wrong for the simple reason that it is a very
unnatural thing to do. Remember that we have all sorts of
reflexes and automatic reactions to stop the wrong stuff
getting into our lungs, so the natural thing to do if you notice
anything funny in youf mouth is to stop breathing in im
mediately and to breathe the stuff out again without delay.

11

You have to learn to overcome this if you are going to get
any benefit at all from your inhaler. And then, having at length
learned how to breathe the mist in deeply, you have to learn to
hold your breath in for several seconds in order to give it time
to settle in your tiny bronchial tubes before you breathe out
again. You will lose too much of it if you do not do this. The
whole procedure, quick though it is to perform, is trickier than
you might think and hence the advice in this booklet (so often
repeated) that you should get somebody else to check that you
are carrying it out correctly.
Your friend in need
Used well, inhalers are excellent, effective, and safe. It seemed
likely a few years ago that they were dangerous, for deaths
were reported after their use and dire warnings were given
that on no account should they be used more often than was
advised on the prescription. These warnings no longer apply.
Modern drugs are better and safer and it is unquestionably
more dangerous to use them too little than to use them too
much. It is now realised that many of those tragedies attri
buted to the aerosols of isoprenaline then in use were due not
to the inhalers at all but to the asthma attack itself.

12

The message is quite clear now: look on the inhaler as a good
friend and use it as much as you need to. Use it quickly and use
it plenty. The only real snag is an entirely different one: it is
that if the attack of asthma gets really bad it becomes quite
impossible to take a deep breath to breathe the mist down far
enough into the lungs to be effective and give the relief needed.

In an emergency
In urgent circumstances like this tougher measures are
needed. An excellent and very effective bronchodilator drug is
aminophylline, and this can be given by injection into a vein
("intravenous”). It is a tricky job, definitely not one for home
use by the family, for the injection has to be given unbe
lievably slowly and carefully. It is one for the doctor only,
whether in general practice or in hospital. It works im
mediately and is standard emergency treatment nowadays.
The same drug in different guises can be given by mouth as a
tablet or medicine and its effect is comparable with salbutamol
etc. It can be used with them or instead of them but sometimes
there is a case for reserving its use for emergencies. The reason
is that a doctor would not like to give aminophylline by
emergency intravenous injection if the patient had already
been taking it by mouth. To do so might be a bit dangerous.
Steroids
A totally different and much more basic approach to the
treatment of asthma is to try to settle down the allergic
inflammation itself rather than just attack one of the results of
it, which is all that the bronchodilator drugs that we have just
been considering do. The drugs that settle the allergic inflam
mation are the steroids like prednisone and prednisolone,
derived originally from cortisone. They are mysterious and
wonderful things, a basic part of life itself, and they have
effects on every cell, tissue, and organ of the body. They can
save lives in asthma, and are used regularly for severe attacks
in hospital. Unfortunatelj’ they take a few hours to work even
if given by intravenous injection. Clearly therefore there is no
point in taking them if attacks only last for an hour or two
every now and then but they are excellent if there is any
reason to think that an attack may go on for many hours and
be severe.
Side effects with steroids are not a problem in the shorter
term; it is only their prolonged use in high dosage over months
and years that leads to the moon face, hairy cheeks, fat trunk,

13

bruising legs, ulcerated shins, weakened bones, shortened
height, and all the rest of the well known troubles. Despite aH
this they are still of great benefit to many who suffer from
persistent asthma for whom bronchodilators are simply no
good enough and who would otherwise be condemned to a lite
of perpetual wheeze and disabling shortness of breath.
Careful control of dosage minimises risks but it becomes a
bit of a "tight rope act” —on the one hand taking enough of the
drug to prevent the asthma getting out of control while on the
other not taking so much of it that one s future health is
threatened by irreversible side effects. Sadly, this means that
for many sufferers there can be no question of taking a big
enough dose to suppress the symptoms completely or even
anywhere near completely. The build up of side effects as the
years go by would become too great.
Fortunately inhalers again come to the rescue. Ingenious
ones are available, this time delivering a very fine dust of
powdered steroid Only minute doses are needed if the drug is
taken this way and side effects are avoided but once again
technique is everything and any errors mean that no benefit is
obtained. Read and reread the instructions therefore if you
have been advised to take this form of treatment and get your
doctor to check on your method, just to make sure.
Cromoglycate
Another drug given by special inhaler is disodium cromogly
cate. It too attacks the basic allergy but in a very different way
and it takes several weeks to work. Taken correctly it virtually
cures most young asthmatics by preventing attacks but it has
to be taken several times a day, every day without fail, attacks
or no. It may have to be taken for years and it is fortunate that
it is quite safe to do this.
Many people misunderstand the drug and do not take it long
enough or regularly enough for it to work, abandoning it after
only a week or two or after only somewhat irregular use This
is nowhere near a long enough trial. It should be given at least
a mon.h, and preferably three, before being abandoned.
canno/do at^ll0!?601 u tO W°rk during an attack but tbiS it
tried t, action
’S qTe USeless then and should
even be
prevenuHvl u."
.PTC"lalive
-hat a marvellous
literally tranifn™^ / b d asth.matics have had their lives
invalidism aggravated bv th tUrning f^om one of dangerous
one of literally normal health m'Sery °f steroid side effects to

14

Often it is wise for them to take extra doses ("puffs”) from
their inhalers if extra dangers loom up—a sudden plague of
cats or in anticipation of a bout of violent exercise. There are
several international athletes who would be incapacitated by
their asthma but for this drug; they take it regularly together
with an extra puff or two before the game or race starts.
Nothing is perfect, however, and nor is this drug. Many of
the cases of asthma that start later in life, in middle age or so,
gain no benefit from it at all even after months of patient trial.
Some of the younger ones are unlucky too, particularly those
unfortunates who suffer from the more unrelenting and per
sistent form of the disease and who are sadly the very ones who
most need its help.

Antibiotics
What of antibiotics? In the older patienj. it often seems that
allergy plays much less of a part in provoking attacks of
asthma, infection being more important. As in chronic bron
chitis, it is mostly the ordinary germs that do this, and perhaps
in these people those hair-like cilia in the bronchial tubes are
not doing their cleaning up job properly (sometimes because
they are being paralysed by cigarette smoke, which they hate).
When this happens the patient finds himself coughing up a lot
of yellowish or greenish phlegm and this is the time when
antibiotics are often needed. As they clear the phlegm the
tightness in the chest begins to lessen.

Keep clear of colds
In very young children attacks often seem to be caused by
ordinary household coughs and colds, the child who is develop
ing into an asthmatic getting wheezy whereas the other chil
dren do not. It would be nice to be able to stop these infections
promptly too but unfortunately they are nearly always due to
viruses, against which antibiotics are useless. They are best
avoided therefore as even the best of them can give trouble.

Antihistamine
Antihistamine drugs are very effective against some forms of
allergy like hay fever but they are not usually any good
against asthma. There is no harm in trying them sometimes but
do not waste time with them in a severe attack. Remember that
they all cause drowsiness and so must never be taken when
driving or operating machinery and especially not with alco

hol.
15

Sleeping tablets
During a bad attack of asthma the patient’s very life depends
on cont inning the fight to get breath in and out of his lungs. All
sleeping tablets take some of this fight out of him and are
then-fore dangerous at such times. They are even risky to take
during mild attacks as nobody can predict with certainty that
tin- condition will stay mild.
Even experienced patients and experienced doctors havp
been taken rudely by surprise at times. Do not take them
therefore unless specifically advised to do so by your doctor: do
not even ask him to supply them.

Oxygen
If you really need oxygen you probably ought to be in hospital.
There are just a few special occasions in which it is wise to
have a supply at home and this will be decided by your doctor.
But remember that it is dangerous stuff, more dangerous than
petrol, and on no account let any enterprising child fiddle with
it as if it were part of a chemistry set. Oxygen fires spread with
unimaginable speed and ferocity.

Desensitisation
If a patient’s asthma is clearly due to an allergy to something
definite, it is sometimes possible to lessen this allergy by giving
frequent injections of minute but increasing quantities of the
offending substance. This works well in hay fever but is
disappointing in asthma and not many doctors advise it nowa
days. It is not entirely without danger either for each injection
naturally carries a risk of promoting an attack instead of
preventing it and even of bringing on an extra severe and
complicated attack too.
If the patient is allergic to many different things and skin
testing may clearly show that he is there is not much point
either for he would be all too likely to develop allergy to
something else in due course and all the effort would be
wasted. It is usually better to rely on regular use of the
cromoglycate inhaler. Until the next invention comes along.

Avoidance of contact
(live a great deal of thought to this, but remember that the
asthmatic patient may need only microscopic quantities of the
offending substance to bring on even a severe attack so it is not
likely that even extremely strict measures will eliminate
trouble altogether.
16

Remember also that an asthmatic can be allergic to several
different things at once (both now and in the future) so do not
needlessly expose him to possible trouble. Feather pillows, for
instance, would be asking for it, invisibly fine organic dust
being pumped out of them every time he fidgets in bed and
going straight into his nose or mouth at the very next breath.
Remember also that emotions and nervous tension are great at
triggering off an attack, so you will only make matters worse if
you get too steamed up over all this. Calmness, sympathy, and
efficiency are required: any rousing of antagonism can undo it
all.
What then about the family cat, the horse next door, or the
incurable mould in the'basement? Before deciding upon drastic
measures with all their disadvantages, make sure in your own
mind how much of the trouble is due to these things and how
sure you are that they really bring on attacks. Do not be too
influenced by skin tests for unfortunately they are nowhere
near 100% reliable. Do not try to prove things either by getting
the patient to bury his nose in the cat’s fur and take a deep
breath: even if done in hospital, tests like this are far too
dangerous. If patient observations convince you beyond all
doubt that it is the mould in the basement that is the sole

17

culprit, then the inconvenience and expense of a house move
will be immeasurably outweighed by the great benefit gained
by the asthma sufferer. But do not go shooting innocent cats!
Difficult decisions come also with regard to allergies at work
and very often it proves remarkably difficult to pin point the
offending substance. It might be sawdust, welding fumes, or
moulds from hay and it is often something to which the patient
has been exposed for many years without trouble, his allergy to
it only developing slowly. In some of these cases the attacks
only start several hours later, in bed at night perhaps, but
cease during long weekends and holidays. This can put you off
the track for a long time. Medical scientists are steadily
finding out more and more about all this and in general it
would be best to discuss this sort of problem with doctors who
have specialised in the work.

Microscopic house mite
A very common offender indeed is the little mite one hun
dredth of an inch long that lives in our houses, in the dust of
bedrooms, in mattresses, carpets, and the like. Apparently it is
its excrement that does it, microscopic though it must be. It is
only sensible therefore to keep the bedroom as dust free as
possible. This means using a vacuum cleaner daily, wet
sponging the furniture, and using man made materials rather
than wool (animal) or cotton (plant) for sheets, blankets,
curtains, and pillows. All bedclothes should be frequently
changed, and you might encase the mattress and pillows in
plastic covers too.
To a lesser degree, the same principles apply to the rest of
the house and it is important also to try to eliminate moulds
and fungi of all sorts as their spores are common offenders. The
dry rot fungus, arch-enemy of joists and timbers, is one such.
Offending foods
Food allergies definitely occur. No doubt many people assert
they are allergic to various foods merely because they dislike
them and want a respectable reason to avoid eating them but
equally there is no doubt that some attacks of asthma are
caused by them. In this case, once identified, they can very
simply be avoided and it would be folly not to do so. A food
allergy will sometimes cause an itchy rash looking like a nettle
sting, and in fact goes by the name of nettlerash. Things that
are known to do this should be strictly avoided too, just in case
one day they provoke an asthmatic reaction:

18

Caution with drugs
Drugs can do the same and aspirin is such a common offender
that it is often considered wise for asthmatics to avoid its use
and lessen the pain of toothache, headache, or painful periods
with paracetamol. Very many headache and backache reme
dies contain aspirin and are therefore best avoided. A careful
scrutiny of the small print on the box will tell whether or not
they do; remembering that "acetyl salicylic acid” is the same
thing, being merely the chemist’s name for aspirin. Many other
drugs are occasional offenders, penicillin for instance, so it is
just as well to remain somewhat on the alert when they are
prescribed for you.
Remember that it is not the first contact that provokes an
attack, for allergy to a substance takes time to develop, so the
fact that aspirin or strawberries could safely be taken last year
does not necessarily mean that it is not the cause of trouble
now.

Smoking
Many people with asthma continue to smoke even when'the
condition is quite bad, feeling that it helps them to cough up
their phlegm. This it undoubtedly does, for the simple reason
that the smoke itself speeds up the manufacture of mucus in

19

the bronchial tubes, and it is this extra mucus that then comes
up in the form of phlegm.
At the same time the smoke by irritating the bronchi makes
them narrow down and their walls thicken just as happens in
asthma anyway. It therefore in fact worsens the situation. But,
worse still, it paralyses and then destroys those marvellous
little ciliary hairs that are so useful in wafting the mucus up
out of the depths of the lungs and up to the larynx. Much of the
extra mucus, caused by smoking, is therefore unable to get
away and stays put in the bronchi. Lying there, inert and
stagnant, it soon gets colonised by all sorts of invading germs,
brought to it by every breath. In it these germs multiply
happily, and the bad ones amongst them quickly set up infec
tions which the body has lost the ability to eliminate. These
infections slowly damage the walls of the bronchial tubes,
spread into the real lung tissues itself where the gas-exchang
ing alveoli are and damage them too. Damage of this sort
cannot be repaired by the body and therefore stays there for
ever.
The next step is that the damaged lung in turn cannot defend
itself against germ infections either, nor when they develop
can i; get rid of them, so the damage worsens, permanent

20

again. Stepwise in this way the lungs deteriorate ever more
and more, particularly in the winter when chest colds are rife.
Many different germs can make trouble like this once the
lungs are damaged, some of them normally fairly harmless and
resistant to the action of antibiotics. It is dreadful then to
watch the progressive downhill slide of these people, with their
breathing difficulties relentlessly increasing, their phlegm
copious and dirty, and their weight, strength, and general
vitality steadily sapped. Medical treatment at this stage is
powerless to do any more than prolong an increasingly miser
able existence for them.

No smoking and no smoke
This is the reason why asthmatics are told not to smoke at all.
In contrast with the position with respect to lung cancer, it
takes very little tobacco smoke indeed to harm an asthmatic,
for the very fact of being asthmatic means that their bronchial
tubes are far more sensitive to any form of irritation than are
those of healthy people. So much so that there is no point in
their just cutting down on the smoking a bit and feeling
virtuous about it: it has to be cut out altogether and for
ever. Even their companions have to stop smoking in their
presence or else put up with a healthy cross draught of fresh
air in the room. Give the poor fellow’s bronchial tubes a
chance!

Asthma in children
It is common for asthma to start about the age of 3, perhaps
after a warning period of infantile eczema or after the general
warning of asthma, hay fever, and eczema being in the family.
At first all that is noticed is that the child catches coughs very
easily, coughing especially at night and being rather dis
tressed by it.
A doctor’s stethoscope would pick up the wheezes in the
chest at such times "wheezy bronchitis” but one attack of
that would not necessarily mean that the child (usually a boy
and therefore referred to henceforth as "him”) is doomed to
become an asthmatic. Nor even would two attacks. It has to

keep on recurring for such a diagnosis to be made. If it does so,
however, it will be found that bronchodilator drugs —salbuta
mol etc - are very helpful and take away not only the wheeze
but the cough. Children with asthma cough much more than
adults do.
Most of them will grow out of the condition before their
teens but a few may have trouble again many years later.
Perhaps it is their increasing immunity to the viruses of
ordinary coughs and colds that help them to shake it off, for it
would appear that the allergic basis to the trouble usually only
becomes important several years later. Nevertheless it is
obviously wise to be closely on the watch for allergies straight
away and to institute anti-dust, anti-wool, anti-cotton, and to
some extent anti-pollen and anti-animal measures too.
All this is a great test of wise parenthood for though the
child needs this special care and needs special support when
asthma strikes he must not be overprotected or turned into too
much of a special case or his emotional development will be at
risk, and among all the problems that this can bring even the
asthma itself can be worsened.
It is most important that nobody be allowed to smoke in the
child’s bedroom and it would be more than shameful if any
member of the family continued to smoke in the same house
anyway. It takes very little tobacco smoke in the atmosphere
to harm an asthmatic child.
Aim for normality
The aim of management of the child will be to try to achieve a
normal upbringing, both at home and at school. What altera
tions have to be made depend on the nature and severity of his
condition. Far more often than not it is all very mild and
remains so; a nasty fright for the parents perhaps, and that is
all. There may be a dozen wheezy attacks altogether during
which the child will need companionship at night and a long
sleep-in in the morning, losing perhaps a day at school.
Naturally the parents will not leave his side when the attack is
on: crying and coughing worsen things so their presence is
much needed. Furthermore, any unexpected worsening of the
condition demands a doctor’s help immediately, so the child
needs watching all the time. On the other hand he must not be
alarmed, so you must appear casual (but don't be!).
Children of 5 years and older might well be able to manage
the salbutamol inhaler and as this works quicker than tablets
]t is clearly preferable. Make sure he is using it properly, so

22

check yourself from the instruction sheet and check again
with your doctor. If there is any trouble with the inhaler or for
any reason you suspect the attack might become a bad one use
the salbutamol tablets as well, and use them immediately. Do
not be frightened of using them unnecessarily.

Perseverance pays off
If attacks come at all frequently, whether throughout the year
or not, a cromoglycate inhaler may well be prescribed. If so be
sure to give it a really good try as it takes time to do its work in
preventing attacks.
Don’t underestimate the problem
Attacks are made worse by fear, tension, and anxiety. If the
attack is bad even your approach to the bedside can worsen it
so you could easily be misled into thinking that the child is
putting it on. NEVER THINK THIS. Such worsening is com
monly a sign of danger. It can mean that he has not got much
reserve left. He is, as it were, labouring uphill and is in bottom
gear already. He maybe ought to be in hospital by now.
It is more dangerous still if the child finds it difficult to talk.
This is a reliable sign of a severe attack, with all its fearsome
possibilities, and it means that immediate emergency action is
absolutely essential.

Avoid emotional upsets
Emotional tensions at home make an asthmatic worse but do
not be deceived into thinking it is at heart a psychological
illness. Modern research indicates ever more clearly that it is
not. Because tension is bad for it, anything that relieves this
will do good. Yoga, faith healing, acupuncture, hypnosis, will
all do it for some people. No doubt the best of all though is a
happy household, with the right mixture of the three basic
ingredients of affection, security, and discipline and thus the
avoidance of tension in the first place. This is at once the best
and the cheapest method. Tranquillisers are usually no good
and indeed are nearly always harmful before long. Their use is
very much a doctor’s decision, reached only after careful
professional assessment of the individual case.
Keep cool and calm
Asthma itself is of course a cause of emotional tension, not
only in the child who is suffering the attacks but in his parents
and household too. It is all too easy therefore for a vicious
23

circle to develop, nervous tension worsening the asthma and
asthma worsening the nervous tension. It is not surprising that
it is all too easy to take fright and imagine an attack to be
much worse than it is. This makes life unnecessarily difficult
for everybody and the best way to avoid making the mistake is
to take actual measurements of how bad the attack is by using
a peak flow meter, described later.
On the other hand —and the value of measurement comes in
again here—it is far worse, and much more dangerous, to
overlook the severity of an attack and to think things are
better than they really are. The child bravely puts up with
grave and worsening distress, danger signs are ignored, and
fatalities result.
Peak flow meters
The difficulty is that it is not at all as easy as you might think
to be sure whether an attack is getting worse or how it
compares with previous ones. Simple tests like blowing out a
match with your mouth wide open give a fairly good idea but it
is far better to have more precise measurements and for this
purpose a gadget has been developed, called a mini flow meter.
You blow into it as hard as you can and it measures how fast
you do so, giving the answer in litres per minute. Ordinarily

24

you might manage a flow of 500 or 600 litres per minute, just for
a fraction of a second; a mild attack of asthma might bring this
down to 250 and a severe one to as low as 100 or less. With it
you can watch how things are going and can tell for sure
whether improvement has started or not. whether your inhaler
is still giving you benefit, or whether you might need an
injection. Instruments of this sort are much relied upon in
hospitals and they can be very helpful in the home too. Most
asthma clinics and many family doctors will supply patients
with these meters. They are not all that expensive and it might
be well worth buying one.

The severe attack
Relatively few asthmatic people ever get a really severe attack;
for most the condition remains very mild. Asthma is so com
mon, however, that most doctors have to deal with bad attacks
at times and in hospital emergency departments these are
quite common. Asthma causes about 1700 deaths in Britain
each year, mostly in young people. This is in fact as much as a
quarter of the number of people killed on the roads and like car
accidents these fatal attacks do not have to happen.
Undoubtedly many would have been prevented if the patient
had been given and had heeded advice about the danger signs
and what to do about them. What often happens is that he
courageously tries to stick the bad attack out, just as he has
stuck quite nasty ones out in the past, and by the time he
realises that he cannot do so after all he is so short of breath
that he can no longer do anything about it. He can hardly get
downstairs and into a car. By now insufficient oxygen is
getting into his system, and the whole situation puts so much
strain on his heart that it may suddenly fail and he is dead—
beyond recall by the "kiss of life” as even the best rescuers
cannot blow any air into his asthmatic lungs for him.

To hospital—with all speed
If he had got to hospital in time, continuous intravenous
injections of drugs like aminophylline and steroids would have
had a good chance of saving his life; and if they should fail
other methods are nevertheless available there such as oxygen
25

forced under pressure into the lungs. Unfortunately the setting
up of all this takes quite a time and there is very little time
available if the condition is worsening badly. The remedy
therefore is that patients developing a bad attack need early
and urgent hospital admission.
How to achieve this varies from district to district but your
general practitioner is the one to advise you. Many hospitals
nowadays actively encourage their asthmatic patients to feel
free to demand emergency admission whenever they think it
necessary: they can soon be discharged again if it all turns out
to have been a false alarm.

Warning signs
It is often impossible to tell why a severe attack occurs but
sometimes the reason is a nasty chest cold or perhaps pneu
monia, so be on guard if such things start up. Use of the flow
meter will tell you how things are going, but if you have not
got one or have left it at home, seek medical help or get to
hospital if talking becomes difficult, you become pale, sweat, or
your pulse rate rises above 100 beats per minute. Signs of
desperate urgency are menial confusion, total inability to talk,
a definite blue tinge to lips and tongue (a much better guide
than the cheeks), and a pulse rate above 120.
Such patients must do nothing at all for themselves or they
may drop down dead. The standard emergency treatment is the
drug aminophylline, given by desperately slow intravenous
injection, but first aid with oxygen, giving it as pure as
possible, right close up to the face, and with the tap turned well
on can save lives. (DANGEROUS STUFF! A smouldering
cigarette will burst into flames, BE CAREFUL!)

Asthma that goes on and
on . . .
Asthma can take on rather a different form, when instead of
just consisting of sudden attacks (mild or severe) with long
periods of complete freedom in between it is present all the
time. It still varies a good deal, being much worse at some
times than at others but it never goes away completely. This is
26

obviously much nastier for the patient than the usual sort. It is
very similar to chronic bronchitis except that it is more
wheezy, there is less phlegm, and though smoking undoubtedly
makes it ten times worse you do not have to be a smoker to
develop it. The same thing is going on in the small bronchi and
bronchioles as goes on in the ordinary attack of asthma
described earlier.
Scientists believe that this sort of asthma is again the result
of an allergic process but of a different sort and they do not
know what it is all about. It is called "intrinsic” asthma as it
seems to be due more to something wrong with the patient
himself and much less to the effects of animal and vegetable
matter in his environment. The patient is not atopic like the
eczema-asthma-hay fever sufferer, has nothing that he is
clearly allergic to, and may derive little or no benefit from the
usual anti-allergic measures like the avoidance of cats, or from
desensitising injections, or even from cromoglycate. Broncho
dilators still work, though not usually all that well and regular
steroids are often necessary.
In this form of asthma steroids may have to be taken for
months or years on end, in which case the only way to avoid a
steady build up of ever worsening side effects is to keep their
dose as low as possible. The best way of achieving this is by
taking them by inhaler, the only side effect of which is a
tendency to get mild thrush infections in the throat, easily
cured by appropriate treatment from your doctor. If tablets
have to be taken in addition, their dosage can be kept down by
concentrating greatly on the other treatment measures and in
particular on the complete avoidance of all irritant fumes or
gases and of tobacco smoke of any sort at all. If this is not done
and tablets of steroid drugs like prednisone or prednisolone
have to be taken several times every day, after a year or so the
side effects from the treatment become a good deal more
dangerous, disabling, and even more painful than the disease
itself.

The future
What comes next? Something for the "intrinsic” asthma suf
ferer perhaps: something that is greatly needed. Research
continues in several centres, aimed at unravelling the myster
ies that surround the dreadful obstinacy of the bronchial
irritation in this condition. It might well be that it is some
thing rather fundamental that has gone wrong with the
patient’s immunity and defence mechanism, something that
27

might be tremendously important to know about in connection
with all sorts of other diseases quite apart from asthma. This
often happens in medical research.
Maybe there will be a solution soon, but if I could persuade a
modern Nuffield to sponsor medical research in any chosen
subject, this would be the one I should choose. Perhaps you
know someone? Or perhaps you might like to make a contribu
tion yourself, big or small? It would be lovely if you did. The
organisation concerned with research is The Asthma Research
Council, St Thomas’ Hospital, Lambeth Palace Road, London,
SEI (01-928 3099).

Your questions answered
Q Is asthma an hereditary condition?
A Yes, but not in a straightforward way as is the case with red
hair or blue eyes. It is a constitutional sort of illness, and the
sort of constitution that is prone to it is carried down in
families by inheritance rather than by environment.
Q When my asthmatic child starts at school, should he
be excused PE and games?
A Almost certainly not, as it would be much to his disadvan
tage. If exemption proves necessary, then it must be accepted,
but the aim of treatment of a school age asthmatic is to secure
him a completely normal upbringing in all respects.
If his asthma is brought on by exercise, a puff of cromogly
cate or other treatment may prevent it completely. But. if not,
then it would be foolish to risk bad attacks developing this
way, and sadly PE and games would have to be restricted.
Fight hard to make him safe for them!
Q Why should my asthmatic attacks be specially bad just
before I start my period?
A I would love to know. One can speculate that it might have
something to do with premenstrual.tension itself a vague and
difficult subject when one comes to try to investigate it. One
can also generalise: sex hormones affect the personality and
the personality affects asthma; sex hormones are chemical

28

relations of steroid drugs and steroid drugs affect asthma; sex
hormones affect the body’s power to retain fluid and it might
well be that fluid retention could have some effect on ordinary
asthma, though I rather doubt it. Ask again in 10 years’ time.
Q Will a child with asthma continue to have it as an
adult?
A Probably not. Most of them stop having attacks when they
reach about 12 but if I had an asthmatic child 1 would work
hard to try and ensure that he belonged to that lucky majority
group. This would mean doing everything sensible to help him
avoid contact with whatever he is allergic to and at the same
time getting him going on cromoglycate and keeping him at it
regularly. There is no proof but the hope would be that if
attacks can be totally prevented for a few years his bronchi
would get out of the habit of having them and would then stay
that way for ever after.
Q Is it true that asthma "burns itself out” as you get
older?
A Yes it usually does, by about the age of 12 but unfortunately
not always. And the nasty persistent sort of asthma, the
intrinsic variety that commonly starts in middle-age, is far less
likely to do so. If you are going to have it at all, have it young
and get over it: if you start it later on, you might well get
saddled with it for the rest of your life.
Q What is the difference between asthma and bronchitis?
A Asthma is wheeze and bronchitis is cough and spit, but
many asthmatics cough and bronchitics wheeze so it is not
always easy to tell. The basic difference is that asthma is due to
allergy, and bronchitis is due to atmospheric pollution. The
conditions are closely linked, however, for an asthmatic per
son is extra susceptible to atmospheric pollution and if
exposed to it is very likely indeed to develop genuine bronchi
tis and then come to have both conditions at once. And on the
other hand the wheezing that most bronchitics are subject to is
the result of bronchospasm, very similar indeed to that of
asthma but differing by being irreversible, and not improved,
or hardly at all, by the bronchodilator drugs.

Q Why is eczema often linked with asthma?
A Eczema and asthma are basically very similar conditions,
differing mainly in the parts of the body they affect. They are
both due to allergy, the one in the skin and the other in the
29

bronchi, as a result of which inflammatory reactions are liable
to occur when there is exposure to whatever the child is
allergic to. If it is the skin that is allergic, eczema develops; if
the bronchi, asthma. In both conditions the affected part will
thereafter be very susceptible to minor irritants, so the skin of
a child with eczema will for instance be made much worse if
scrubbed with soap, just as the asthmatic’s bronchi will go into
a fury if exposed to atmospheric pollution like cigarette smoke.
Both conditions may co-exist in the same child, poor thing,
but eczema commonly starts younger and may have cleared
away before the asthma starts. In some families both con
ditions are quite common, with an obvious hereditary element,
and the word "atopy” is then applied —atopic eczema and
atopic asthma.
Q Must I always carry my inhaler around with me? What
should I do if I have an attack and I have left it at home?
A It is a good idea to have it with you if attacks are at all
frequent or you have any reason to suspect one might come on
while you are away But if the condition is mild and attacks are
rare you hardly need bother.
If an attack starts and you need your inhaler but have left it
at home, get hold of one from a chemist’s shop- even at
weekends there will be one open somewhere —but you will of
course first see a doctor and he will be able to advise you.
Q Are you born with a tendency to asthma—or is it
something that is acquired?
A Mostly you are born with the tendency, though it may not
show itself for a long while. But if you are born with just a bit
of a tendency to it it is likely that you could make things much
worse for yourself by being unkind to your bronchi and
exposing them to unnecessary atmospheric pollution. Cigar
ettes, for instance!
Q Is it dangerous to fly with asthma?
A If you have severe persistent "intrinsic” asthma, flying may
well be quite out of the question: your doctor will advise you.
Otherwise it should present no problems. Oxygen is available
of course, but it should not be needed and all I should do would
be to make sure I had tablets and inhalers with me.
Q Is asthma affected by diet or alcohol?
A Not usually, though alcohol has a strange ability to find out
one’s weak spots, and certainly affects some people adversely.
30

It is fairly obvious if it, or if any article of food, does affect one
in an undesirable way. If it does not do so then there is no need
to restrict oneself in any way (good news!).

Q Is smoking harmful to an asthmatic?
A Yes, unbelievably and disastrously so. It is the irritant
effect of the smoke itself that matters, nothing to do with
whatever ingredients there are that promote heart disease,
arterial disease and lung cancers. Even very small quantities
are harmful, and most asthmatics are detectably harmed if
they just breathe the air of a smoke laden room, without ever
doing the actual smoking themselves.
Q My asthma has been diagnosed as being due to house
dust. Can you tell me whether one of the air purifiers now
on the market is likely to be beneficial?
A I should not put much faith, or money, into air purifiers.
What one needs is regular and frequent room cleaning, paying
particular attention to carpets, bedclothes, curtains, and any
other fabrics that might hold the dust.
Q Are inhalers dangerous if they are used too often?
A Not in themselves, but if you are needing to use them every
half hour or so they cannot be working. If you are using them
correctly, the container is npt empty, and your asthma is
genuinely getting worse you may well be in urgent need of
some different treatment and therefore you need your doctor's
help without delay.
Q Does a severe attack of asthma need immediate atten
tion from a doctor?
A Yes, it may and do not be timid about calling him out or
about getting yourself quickly to a hospital accident and
emergency department, it is what they are there for. That is
not to suggest you should do this with every single nasty
attack but it is certainly recommended that you should do so if
the attack is in any way at all worse than the usual nasty ones.

Normally our breathing is quite effortless and not even
noticed. On a crisp bright morning it is even a delight. But
with asthma it becomes an effort to breathe in and out
again. Frightening too, if the asthma is bad, not knowing if
you are going to get enough breath to recover. The author
of this booklet, Dr H. Wykenham Balme, outlines the risks,
warning signs, and what action to take. Most major
attacks of asthma are preventable. The aim of this booklet
is to improve the quality of life of the asthmatic which
need not be nearly as restrictive as many people imagine.
Some of our top athletes and sportsmen and women suffer
from, but cope with, asthma.
J-579

Rs. 15/-

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