Asthma – David Bradley

Meet GINA, Global INitiative for Asthma

TL:DR – Thanks to GINA I have not needed to use salbutamol to treat my asthma for three years at the time of writing.

It’s three years since my asthma nurse introduced me to GINA, the Global INitiative for Asthma. It was a phone consultation because the then new virus SARS-CoV-2, which causes what became known as COVID-19, was beginning to spread. At the time, I was very worried that it would be a killer for me given my asthma. Eventually, medical science learned that people with asthma were not necessarily at any greater risk of morbidity and mortality.

Anyway, it was nice to meet GINA. GINA contradicts some of what general practitioners (GPs) in the UK have been advising asthma patients for years, but supports what the medical evidence suggests one should do in terms of medication. The main thing is GINA told me to stop using Salbutamol (the reliever spray) and to use my Symbicort (combined preventer with reliever spray) instead. Salbutamol is an old, out-of-date drug with some unpleasant side effects in long-term use, partly because it can affect the heart but mainly because inappropriate use in the absence of proper control of the condition with a preventer can lead to scarring in the lungs.

Modern relievers are more targeted to the lungs rather than other organs. Moreover, using the preventer at a higher dose, which is what my nurse recommended, means you reduce inflammation and mucus production, which are the main issues with asthma in parallel with episodic bronchoconstriction.

For three years, I have been taking twice as much preventer each day as I was before, and only very occasionally need to take extra to get a dose of reliever. I have not used Salbutamol at all in those three years and don’t expect to have to ever again. I no longer carry Salbutamol with me.

A GP friend was concerned when I told him about GINA, he reasoned, quite sensibly that taking this approach would be increasing one’s exposure to the preventer drugs, which are corticosteroids. This is true. But asthma is mostly about inflammation and these drugs reduce inflammation and so should reduce asthma symptoms. They do. He discussed the issue with colleagues and is now persuaded that GINA is a more sensible approach to asthma control than the current NICE recommendations in the UK. Hopefully, someone will introduce NICE to GINA soon.

Coming out of Covid lockdown, I don’t think so…

Fundamentally, we are still riding (just) the first wave of the global Covid-19 pandemic. If there are sudden spikes now, that’s still part of the first wave. Nothing has changed for the virus except that some people have been avoiding contact with other people, so the rates of infection in some places have slowed giving health services a bit of space to mop up and treated those seriously ill with the virus. But, at the time of writing half a million people, at least, have died from Covid-19.

I don’t really know how I feel about this coming out of lockdown, to be honest. I suspect that having asthma and being in my 50s might make me more susceptible to being badly symptomatic with the coronavirus. Colds lay me out sometimes for weeks. But, there are far worse off people.

The infection rate is very low in our neighbourhood, and indeed in our county as a whole, 51 in a million people infected as opposed to well over 140 in a million in Leicester, where a local lockdown has been implemented to try and reduce this number before it ravages the population there.

I run a website and social media for a local pub. They’ve announced that rather than open on the 4th July when they have permission to start serving again, they will open on Monday the 6th to allow them to ease into the week. It will be incredibly busy, people will feel unleashed and gasping for a pint. But, to my mind, it only takes one infected person to cough in your face to almost guarantee that you’ll inhale virus…and so I’ll be giving the pub I love a miss, at least for the foreseeable future.

I’ve hated lockdown, hated the lack of social life, hated the fact that it’s effectively dragging us down into a serious recession. I’ve tried to jolly along with lots of silly creative ideas such as my PondWatch series, spoof/satirical phonecall videos, Rock-around-the-Wok cooking with music, writing and recording some of my own songs, and creating a VE Day 75 video with various local singers and performers (all done remotely). Getting back together with C5 The Band for a socially distanced rehearsal last week and a trip to the coast with Mrs Sciencebase were much needed tonics as were sitting at a distance drinking at and chatting with some friends in their garden. My mood is nowhere near as swing low as it was two weeks ago, thankfully. I also got hold of a Canon 7D mk ii, which has made bird photography a joy once again with a much faster focusing capacity and the virtual upgrade in zoom lens from 600mm to 900mm by virtue of moving from the 6D full-frame to 2/3 of the 7D.

There was talk this morning of a secondary type vaccine that won’t stop you becoming infected but may well keep you asymptomatic. A normal vaccine would aim to block infection, but this might not be possible for coronaviruses. If that’s developed sooner than later we could all get back to something like a new-normal situation far quicker than we otherwise might, but it’s possible it won’t be ready until next year. We’ve got the coming flu season to get through before then too! There are a couple of drugs that seem to be working for seriously ill patients, which is a good thing, but I’d rather not have to be in such a state that I’d need either, thank you very much.

So…the long and short of it: Will I be going to the pub next Monday? No!

Does asthma drug boost athleticism?

TL:DR – Does salbutamol boost athleticism? Not really, no.

UPDATE: 2021 The GINA guidelines for healthcare workers helping people with asthma is, internationally, to avoid any use of salbutamol. If you have asthma and are still using this old drug, please speak to your doctor and mention GINA.

If you’re an athlete taking the WADA allowed 1600 micrograms of salbutamol each day that’s the equivalent of 16 doses from a standard metered dose inhaler. If you’re taking so much that it leads to you failing a drug test, then you have serious problems. Most lay people take two doses at a time to relieve symptoms, such as chest tightness, coughing, wheezing and breathlessness, so that’s still using the stuff 8 times a day.

I wonder though, whether you are an athlete or not, if you need to take that much bronchodilator each day to get relief and a decent peak flow rate, then it’s odd that you got so high up in the world of sport in the first place irrespective of how tenacious you might be. Asthma at that level of reliever need can be quite debilitating regardless of fitness.

Moreover, at that level of dosing, most GPs would’ve prescribed inhaled corticosteroid preventers to preclude the need for taking so much bronchodilator. That, of course, brings with it its own issues with respect to bone density and, of course, the World Anti-Doping Agency’s rules, even though corticosteroids are not muscle-building anabolic steroids.

So, does inhaled salbutamol actually benefit people without asthma? And thence enhance athletic performance. It’s possible. Presumably, everyone has some degree of possible expansion of their airways even if they don’t have the disorder. There was an item in the January 2016 issue of Cycling Weekly that discusses the issues in more detail and suggests that there may well be benefits. However, earlier work suggests that salbutamol does little to enhance the performance of top-level athletes. A research paper from May 2017 studying salbutamol use among professional footballers corroborated that earlier finding; that said it looked at footballers using a single therapeutic dose (2 puffs, 200 micrograms), rather than the big daily dose that represents the upper allowed limit under WADA’s rules.

Salbutamol can have a range of side effects: tremor, anxiety, headache, muscle cramps, dry mouth, heart palpitations, tachycardia, arrhythmia, flushing of the skin, myocardial ischaemia (rare), and insomnia.

Could yoga cure your asthma?

The headline is obviously a QTWTAIN, a question to which the answer is no, but there may be some benefits to yoga practice in terms of improving lung function in asthmatics, according to evidence from a new Cochrane review, possibly. The organisation’s Head of Communications and External Affairs, Julie Wood, who usually prefers to stay behind the scenes, recently stepped out from behind the curtain to write about this latest review and her own experience with asthma.

Curiously, Wood’s journey with asthma seems to mirror my own experience. Started running again in early twenties, couldn’t breathe by the end of it, diagnosed with exercise-induced bronchospasm and prescribed inhalers, symptoms emerged with other triggers, prescribed more inhalers. Don’t really want to be taking inhalers, looked for another option.

Fundamentally, however, yoga is not a panacea, it might be a useful form of exercise/stretching/relaxation for various reasons, but it’s not going to fix what ails you when it comes to bronchoconstriction and pulmonary mucus accumulation, whether that’s exercise, cold, pollen, dust, stress induced, or whatever.

In her blog post for Cochrane, Wood says:

“According to the evidence published today in the Cochrane Review, the strength of the evidence isn’t at a point where we can definitively say whether it does help people with their asthma, but the initial signs are promising.”

The NHS Choices publication “Behind the Headlines” which takes great care to critique in detail the medical headlines assesses the Cochrane systematic review of yoga-asthma research and says it was well conducted and seemed to find that “yoga may improve quality of life”, but points out that “this could be the case if you take part in many types of physical activity, not just yoga. There was no comparison with other forms of exercise.”

The NHS conclusion from its analysis of the Cochrane review is that it:

“does not produce conclusive evidence that yoga would be beneficial to people with asthma, and any negative effects were not investigated.”

For me, I’ll keep taking my meds as and when and following the medical advice from the “asthma nurse” I see once a year. I’ve tried yoga myseld and indeed still practice a little (Mrs Sciencebase is a yoga teacher, after all), but I cannot say that it does anything for my asthma, but neither does singing or anything else except the Salbutamol…

Suspending the sprays, sidestepping side-effects

UPDATE: I kind of simplified what I was actually doing for the sake of the blog post, but you’re right and maybe I should add a warning to others not to follow my example. I’ve been weaning myself off the dose for a while, my GP was happy for me to do that and I have a pending thyroid test. Last one was fine, didn’t show any depression of T etc. I have, however, noticed the side-effects I reported as diminishing somewhat over the last couple of weeks.

WARNING: This post does not constitute medical advice, please talk to your GP before setting out on any self-revised prescription…

People rarely read the patient information leaflets that come with their medicine…well, I say that, I have no evidence for it other than anecdote and the fact that I don’t. Well, I have occasionally, but hadn’t for my asthma meds (a combined reliever, preventer called Symbicort that contains formoterol (long-acting beta-agonist, LABA, reliever) and the corticosteroid budesonide (the preventer). I’ve been on this medication for a couple of years because my previous preventer (beclomethasone) was giving me a really dry throat and adding far too much huskiness to my singing voice.

It’s only recently, however, that I’ve been wondering whether some symptoms I’ve been experiencing this last year or two might be down to the inhaler. So, I checked out the list of side-effects for the Rx and sure enough there are probably 4 or 5 things listed from which I suffer sporadically and with no apparent pattern. I had started to put some of them down to the morning-after-the-night-before type effects and more painfully, simply getting on a bit, I am soon to depart my fifth decade after all, but now I’m half worried that I’ve been poisoning myself all this time with my asthma treatment.

I wonder whether these various problems are due to my regular daily dose of corticosteroid and I’ve decided to stop taking the preventer/reliever for a few days to see whether any of the “side-effects” dissipate. Of course, it’s the worst time to do a personal clinical trial as Xmas is almost upon us, I will hopefully not be spending much time at my desk and may even have a few glasses of the hard stuff, as well as being exposed to at least a couple of relatives’ cats. So, it’s always going to be personal anecdotal evidence,and not double-blinded and certainly not controlled.

But, I’ve had enough of my extraneous, idiopathic symptoms, which could be due to the reliever or the preventer, or both, or neither (who knows?) and having read that there are growing concerns about long-acting beta agonists, even when used in parallel with a preventer, I’m going to take a leap of faith. The ENT specialist who checked out my vocal cords (more properly known as vocal folds) when I was getting all husky suggested I should wean myself off the corticosteroids anyway, so here goes. If I don’t end up being hospitalised having had a serious bronchospasm episode, I’ll let you know how I get on. Breathe easy…

Don’t die of asthma

Every breath you (don’t) take…

A report that hit the headlines in the UK this week should be something of a wake-up call to anyone with asthma and the people who care for them. The study revealed that current healthcare guidelines for asthma are not being used properly in some cases and that this can put lives at risk.

Asthma symptom-relieving medications (such as the common blue inhaler (Ventolin) are being over-prescribed by some doctors while patients that ought to be on asthma-preventing inhalers (usually corticosteroids, not to be confused with bodybuilding steroids) are not always being prescribed those inhalers despite having poorly controlled symptoms – coughing, breathlessness, wheezing, tight-chestedness. More detail on the report and the NHS critique of media coverage here.

Vocal cords and asthma

A diagnosis of exercise-induced bronchospasm – asthma – is commonly given to patients who present with cough, breathlessness and wheeziness after exertion despite being otherwise physically fit. An alternative explanation to bronchial (airways) constriction was discussed on BBC Radio 4’s Inside Health this week on which they suggested that vocal cord dysfunction might be to blame as the vocal folds close over the airway in susceptible individuals.

Thus, physiotherapy and breathing exercises rather than asthma medication might be a better intervention for many sufferers (unless they also have underlying asthma). It does rather suggest that asthma might be being over-diagnosed. It also hints that yoga, singing and other techniques that teach better posture and breathing may actually have a genuine mode of action if they can control the constriction of one’s vocal folds.

Intriguingly, a quick PubMed search turned up a paper from 1996 on seven elite athletes with psychogenic vocal cord dysfunction who presented with apparent exercise-induced asthma that was nothing of the sort. The study’s conclusion is that “The mere association of exercise and airway obstruction is not sufficient to establish the diagnosis of asthma.”

That was 1996…why are we only now [six years later at the time of writing] learning about this issue and the potential differential diagnosis for exercise-induced breathing difficulties. If you or your child’s physician offers asthma meds for those after-sport symptoms ask whether vocal cord dysfunction might be to blame.

There is actually no real, definitive test for asthma, peak flow meter before and after inhaled salbutamol seems to be the usual way. However, there is a way to diagnose exercise-induced vocal cord dysfunction using trans-nasal endoscopy.

Vocal cord dysfunction masqueradin… [Am J Respir Crit Care Med. 1996] – PubMed – NCBI.

Oilspill, asthma, melamine, peer review

These are the latest science news links and snippets from Sciencebase:

That underwater hydrocarbon plume is still there – Things in the Gulf of Mexico may not be cleaning themselves up quite as fast as some had claimed and many had hoped. Surprise, surprise
Paracetamol use and risk of asthma in teenagers studied – NHS Choices – Health News – It is not possible in a study of this design to determine whether the positive association observed was causal.
Piped David Bradley – My main science blogs, going down the tubes? Yahoo Pipes pulls in all the feeds from Sciencebase (science), Sciencetext (tech), ReactiveReports (chemistry), SciScoop (forum), and ImagingStorm (scientific photos)
New colour-change test for melamine contamination of milk products – First pets died in the US, then babies in China succumbed to the scurrilous practice of artificially boosting protein readings in milk products by adding the nitrogen-rich industrial chemical melamine to milk products. Now, researchers in China have published details of a simple test for melamine contamination, in the peer-reviewed journal Talanta.
Good God! Can’t a Journal Author Have Any Fun Anymore? – Jesus cures case of influenza, gets retracted by scholarly journal
Drug testing – A simple analytical approach to identifying drugs of abuse would be a boon to forensic scientists and law enforcement agencies. A collaboration between researchers in the US and Europe demonstrates how an assessment of different methods using chromatography coupled to mass spectrometry reveals that multivariate selectivity can take into account the degree of resolution between nominally unresolved peaks due to the presence of various drugs in a forensic sample and so allow quicker identification.

Asthma sufferers, don’t hold your breath

TL:DR – If you have asthma, do not fall for quackery, seek professional medical advice and adhere to the qualified recommendations for prescribed medication. By quackery I mean various therapies, crystal healing, homeopathy, chiropractic, osteopathy, acupuncture etc. None of it has any medical validity whatsoever.

As someone who developed exercise-induced bronchospasm (mild asthma) only after coming up to Cambridge in the late 1980s and having never suffered in childhood, I was rather disappointed to find myself on first one inhaler (a reliever) and then a second (preventer). UPDATE: 2020 – The GINA guidelines recommend nobody use Salbutamol these days, much better to be on a preventer with a combined reliever.

Anyway, asthma sufferers everywhere could benefit from breathing exercises that allow them to regain control of their breath, reduce wheezing and breathlessness, and in time cut down on their reliance on inhaled medication. When I mentioned these techniques to my GP during a general checkup, he confessed that before inhalers were available, breathing exercises were all that he and his fellow practitioners could prescribe for mild attacks. What goes around, comes around it seems.

Breathing exercises could be something of a breath of fresh air. Although saying that cold, fresh air is one of the triggers for an asthma episode as fellow sufferers will know.

Across the UK more than 5 million people suffer the potentially debilitating effects of asthma and many millions more around the world. Diagnosis is usually straightforward and most sufferers are prescribed one or both of two kinds of inhaler – an inhaler to reduce symptoms (Salbutamol, for instance, known as a reliever) and another to reduce the underlying inflammation in the lungs (a corticosteroid such as beclomethasone).

Learning to control one’s breath and to breathe through the nose is important for asthma sufferers and something many fail to do, especially when asleep.

Five golden rules for reducing your asthma symptoms:

Breathe through your nose when you can, but never tape up your mouth
Take control of your breathing
Try to avoid nervous or unnecessary coughing
Look after yourself in general
Most importantly, use your prescribed medication properly

You are best advised to talk to your GP about the potential of breathing techniques for you and at the very least to adhere strictly to Rule 5. Whatever you do, do not abandon your medication. Recently, there has been a lot of talk about the Buteyko Method. This is based on a false premise about carbon dioxide levels in the blood being the problem. Don’t follow that route. Breathing exercises may well help you cope, but they will not cure your asthma.

Smoking ban

Geordie Boffin Asthma sufferers, non-smokers, and those who really just don’t care for passive-smoking-induced lung cancer can breathe a long sigh of relief as England follows other enlightened states and places a ban on smoking in enclosed public places, such as pubs, clubs, and restaurants, from July 1, 2007.

There’s sure to be an enormous backlash from those addicted to the Nicotiana vapours, but it can only be good for the rest of us who prefer not to partake of the various chemical congeners that accompany tobacco smoke: carcinogenic polyaromatic hydrocarbons, arsenic, carbon monoxide, hydrogen cyanide, lead, formaldehyde, phenol, butadiene, etc etc etc.

The ban in England will follow those in the Irish Republic and Scotland. Wales ban begins April 2, 2007.

Anyway, for those who simply cannot resist, there’s always those little patches, chewing tobacco, or what about the Victorians’ favourite, snuff? All the artificial benefits with none of the smoke. Oh, but regular use will increase your risk of nasal, oral, or throat cancer. You may even want to consider getting an e-cig with an Aspire tank for sale as these can reduce your nicotine intake and do not contain vapors that are as harmful.

UPDATE: 2021-12-20 Who knew that “vaping” would be such a big thing so many years later?