When caring for a patient experiencing an asthma exacerbation a nurse should place the patient in which of the following positions?

Reliever inhalers – usually blue – are taken to relieve asthma symptoms quickly.

The inhaler usually contains a medicine called a short-acting beta2-agonist, which works by relaxing the muscles surrounding the narrowed airways. This allows the airways to open wider, making it easier to breathe again.

Reliever inhalers do not reduce the inflammation in the airways, so they do not make asthma better in the long term – they are intended only for the relief of symptoms.

Examples of reliever medicines include salbutamol and terbutaline. They are generally safe medicines with few side effects, unless overused.

However, they should rarely, if ever, be necessary if asthma is well controlled, and anyone needing to use them three or more times a week should have their treatment reviewed.

Everyone with asthma should be given a reliever inhaler, also known simply as a 'reliever'.

Read further information:

Preventer inhalers

Preventer inhalers – usually brown, red or orange – work over time to reduce the amount of inflammation and sensitivity of the airways, and reduce the chances of asthma attacks occurring.

They must be used regularly (typically twice or occasionally once daily) and indefinitely to keep asthma under control.

You will need to use the preventer inhaler daily for some time before you gain the full benefit. You may still occasionally need the blue reliever inhaler to relieve your symptoms, but your treatment should be reviewed if you continue to need them often.

The preventer inhaler usually contains a medicine called an inhaled corticosteroid. Examples of preventer medicines include beclometasone, budesonide, fluticasone, ciclesonide and mometasone.

Preventer treatment should be taken regularly if you have anything more than occasional symptoms from your asthma, and certainly if you feel the need to use a reliever inhaler more than twice a week.

Some inhaled corticosteroids can occasionally cause a mild fungal infection (oral thrush) in the mouth and throat, so make sure you rinse your mouth thoroughly after inhaling a dose. The use of a spacer device also reduces this risk.

Smoking can reduce the effects of preventer inhalers.

Read further information:

• Asthma UK: preventer inhalers

Other treatments and 'add-on' therapy

Long-acting reliever inhalers

If your asthma does not respond to initial treatment, the dose of preventer inhaler you take may be increased in agreement with your healthcare team.

If this does not control your asthma symptoms, you may be given an inhaler containing a medicine called a long-acting reliever (long-acting bronchodilator/long-acting beta2-agonist, or LABA) to take as well.

These work in the same way as short-acting relievers. Although they take slightly longer to work, their effects can last for up to 12 hours. This means that taking them regularly twice a day provides 24-hour cover.

Regular use of long-acting relievers can also help reduce the dosage of preventer medication needed to control asthma. Examples of long-acting relievers include formoterol and salmeterol, and recently vilanterol, which may last up to 24 hours.

However, like short-acting relievers, long-acting relievers do not reduce the inflammation in the airways. If they are taken without a preventer, this may allow the condition to get worse while masking the symptoms, increasing the chance of a sudden and potentially life-threatening severe asthma attack.

You should therefore always use a long-acting reliever inhaler in combination with a preventer inhaler, and never by itself.

In view of this, most long-acting relievers are prescribed in a 'combination' inhaler, which contains both an inhaled steroid (as a preventer) and a long-acting bronchodilator in the one device.

Examples of combination inhalers include Seretide, Symbicort, Fostair, Flutiform and Relvar. These are usually (but not always) purple, red and white, or maroon.

Other preventer medicines

If regular efficient administration of treatment with a preventer and a long-acting reliever still fails to control asthma symptoms, additional medicines may be tried. Two possible alternatives include:

• leukotriene receptor antagonists – tablets that block part of the chemical reaction involved in the swelling (inflammation) of the airways
• theophyllines – tablets that help widen the airways by relaxing the muscles around them, and are also relatively weak anti-inflammatory agents

Oral steroids

If your asthma is still not under control, you may be prescribed regular steroid tablets. This treatment is usually monitored by a respiratory specialist (an asthma specialist).

Oral steroids are powerful anti-inflammatory preventers, which are generally used in two ways:

• to regain control of asthma when it is temporarily upset – for example, by a lapse in regular medication or an unexpected chest infection; in these cases, they are typically given for one or two weeks, then stopped
• when long-term control of asthma remains a problem, despite maximal dosages of inhaled and other medications – in these cases, oral steroids may be given for prolonged periods, or even indefinitely, while maintaining maximum treatment with inhalers as this maximises the chance of being able to stop the oral steroids again in the future

Long-term use of oral steroids has serious possible side effects, so they are only used once other treatment options have been tried, and after discussing the risks and benefits with your healthcare team.

Omalizumab (Xolair)

Omalizumab, also known as Xolair, is the first of a new category of medication that binds to one of the proteins involved in the immune response and reduces its level in the blood. This lowers the chance of an immune reaction happening and causing an asthma attack.

It is licensed for use in adults and children over six years of age with asthma.

The National Institute for Heath and Care Excellence (NICE) recommends that omalizumab can be used in people with allergy-related asthma who need continuous or frequent treatment with oral corticosteroids.

Omalizumab is given as an injection every two to four weeks. It should only be prescribed in a specialist centre. If omalizumab does not control asthma symptoms within 16 weeks, the treatment should be stopped.

Read further information:

Bronchial thermoplasty

Bronchial thermoplasty is a relatively new procedure that can be used in some cases of severe asthma. It works by destroying some of the muscles surrounding the airways in the lungs, which can reduce their ability to narrow the airways.

The procedure is carried out either with sedation or under general anaesthetic. A bronchoscope (a long, flexible tube) containing a probe is inserted into the lungs through the mouth or nose so it touches the airways.

The probe then uses controlled heat to damage the muscles around the airways. Three treatment sessions are usually needed, with at least three weeks between each session.

There is some evidence to show this procedure may reduce asthma attacks and improve the quality of life of someone with severe asthma.

However, the long-term risks and benefits are not yet fully understood. There is a small risk it will trigger an asthma attack, which sometimes requires hospital admission.

You should discuss this procedure fully with your clinician if the treatment is offered.

Read further information:

• NICE: bronchial thermoplasty for severe asthma

Side effects of treatments

Side effects of relievers and preventers

Relievers are a safe and effective medicine, and have few side effects as long as they are not used too much. The main side effects include a mild shaking of the hands (tremors), headaches and muscle cramps. These usually only happen with high doses of reliever inhaler and usually only last for a few minutes.

Preventers are very safe at usual doses, although they can cause a range of side effects at high doses, especially with long-term use.

The main side effect of preventer inhalers is a fungal infection of the mouth or throat (oral candidiasis). You may also develop a hoarse voice and sore throat.

Using a spacer can help prevent these side effects, as can rinsing your mouth or cleaning your teeth after using your preventer inhaler.

Your doctor or nurse will discuss with you the need to balance control of your asthma with the risk of side effects, and how to keep side effects to a minimum.

Side effects of add-on therapy

Long-acting relievers may cause similar side effects to short-acting relievers. You should be monitored at the beginning of your treatment and reviewed regularly. If you find there is no benefit to using the long-acting reliever, it should be stopped.

Theophylline tablets have been known to cause side effects in some people, including nausea, vomiting, tremors and noticeable heartbeats (palpitations). These can usually be avoided by adjusting the dose according to periodic measurement of the theophylline concentration in the blood.

Side effects of leukotriene receptor agonists can include tummy (abdominal) pain and headaches.

Side effects of steroid tablets

Oral steroids carry a risk if they are taken for more than three months or if they are taken frequently (more than three or four courses of steroids a year). Side effects can include:

With the exception of increased appetite, which is very commonly experienced by people taking oral steroids, most of these unwanted effects are uncommon.

However, it is a good idea to keep an eye out for them regularly, especially side effects that are not immediately obvious, such as high blood pressure, thinning of the bones, diabetes and glaucoma.

You will need regular appointments to check for these.

Read further information:

• Asthma UK: side effects of asthma medicines

Asthma attacks

A personal asthma action plan will help you recognise the initial symptoms of an asthma attack, know how to respond, and when to seek medical attention.

In most cases, the following actions will be recommended:

1. Take one to two puffs of your reliever inhaler (usually blue) immediately.
2. Sit down and try to take slow, steady breaths.
3. If you do not start to feel better, take two puffs of your reliever inhaler (one puff at a time) every two minutes (you can take up to 10 puffs) – this is easier using a spacer, if you have one.
4. If you do not feel better after taking your inhaler as above or if you are worried at any time, phone 999.
5. If an ambulance does not arrive within 10 minutes and you are still feeling unwell, repeat step three.

If your symptoms improve and you do not need to phone 999, you still need to see a doctor or asthma nurse within 24 hours.

If you are admitted to hospital, you will be given a combination of oxygen, reliever and preventer medicines to bring your asthma under control.

Your personal asthma action plan will need to be reviewed after an asthma attack, so reasons for the attack can be identified and avoided in future.

Read further information:

• Asthma UK: what to do in an asthma attack

Personal asthma action plan

As part of your initial assessment, you should be encouraged to draw up a personal asthma action plan with your GP or asthma nurse.

If you've been admitted to hospital because of an asthma attack, you should be offered an action plan (or the opportunity to review an existing action plan) before you go home.

The action plan should include information about your asthma medicines, and will help you recognise when your symptoms are getting worse and what steps to take. You should also be given information about what to do if you have an asthma attack.

Your personal asthma action plan should be reviewed with your GP or asthma nurse at least once a year, or more frequently if your symptoms are severe.

As part of your asthma plan, you may be given a peak flow meter. This will give you another way of monitoring your asthma, rather than relying only on symptoms, so you can recognise deterioration earlier and take appropriate steps.

Read further information:

• Asthma UK: personal asthma action plan

What is good asthma care?

Your doctor or nurse will tailor your asthma treatment to your symptoms. Sometimes you may need to be on higher levels of medication than at others.

You should be offered:

• care at your GP surgery provided by doctors and nurses trained in asthma management
• full information about your condition and how to control it
• involvement in making decisions about your treatment
• regular checks to ensure your asthma is under control and your treatment is right for you (this should be at least once a year)
• a written personal asthma action plan agreed with your doctor or nurse

It is also important that your GP or pharmacist teaches you how to properly use your inhaler, as this is an important part of good asthma care.

Occupational asthma

If it is possible you have asthma associated with your job (occupational asthma), you will be referred to a respiratory specialist to confirm the diagnosis.

If your employer has an occupational health service, they should also be informed, along with your health and safety officer.

Your employer has a responsibility to protect you from the causes of occupational asthma. It may sometimes be possible to substitute or remove the substance triggering your occupational asthma from your workplace, to redeploy you to another role within the company, or to wear protective breathing equipment.

However, you may need to consider changing your job or relocating away from your work environment, ideally within 12 months of your symptoms developing.

Some people with occupational asthma may be entitled to Industrial Injuries Disablement Benefit.

Read further information:

Complementary therapies

A number of complementary therapies have been suggested for the treatment of asthma, including:

• breathing exercises
• traditional Chinese herbal medicine
• acupuncture
• ionisers – devices that use an electric current to charge (ionise) molecules of air
• manual therapies – such as chiropractic
• hypnosis
• homoeopathy
• dietary supplements

However, there is little evidence that any of these treatments, other than breathing exercises, are effective.

There is some evidence that breathing exercises can improve symptoms and reduce the need for reliever medicines in some people. These include breathing exercises taught by a physiotherapist, yoga and the Buteyko method (a technique involving slowed, controlled breathing).

Read further information:

• Asthma UK: complementary therapies