The first line medicine for asthma is inhaled salbutamol. So salbutamol is a chemical that helps to open up the airways, to relax the muscles that can make the airways be narrow. So this is breathed in into the lungs and it helps you, helps relax the airways. Some people only need to have this. It’s called salbutamol. It’s also known as Ventolin or the blue inhaler. And people take this when they are wheezy and it has an effect within about 15 or 20 minutes. And some people also take it if they are about to do something they know will make them wheezy so before they exercise for example.

Now if you only very, very occasionally get wheezy so less than two times a week in the day time or less than once a week at night then you probably only need a blue inhaler but if you’ve had more severe asthma in the last couple of years or if you are finding you need your blue inhaler frequently then it is suggested you should also have a preventer. So this is inhaled corticosteroids, the brown inhaler. The most common one until recently was something called, Becotide. The most common one in the UK now is Clenil (Clenil Modulite) but the names change quite frequently. This inhaler is not used as and when, it is used regularly every day in the morning and in the evening and it stabilises the airways. It stops them being reactive. It stops them tightening up when you meet a trigger for your asthma. And for most people they will have this pattern of having their preventer morning and night and their treatment inhaler when they need it.

There are other sorts of inhalers as well. There are long-acting treatment ones that get taken twice a day and there are also combination inhalers which are usually combination of the steroids and the long-acting treatment and that’s quite useful because it means you only have to have one inhaler a day. When people have much more severe asthma, when they have an exacerbation sometimes they have to have added in treatments particularly tablets and steroid tablets usually in the form of prednisolone are used when people have a severe attack.

I find mainly with my asthma that during winter periods, especially when theres colds flying around, I’ve got one right now, especially when theres colds flying around, you find that its more prevalent. And it comes about more quickly. So I think, I mainly use my inhalers during the winter months, and during the summer it’s not that much of a necessity, especially if I’m at a stage where I’m doing lots of sport and just maintaining myself. I don’t find I need it as much. Its only when you come to the winter times when you get, you’ve got a cold. It, it depends. It really becomes more dominant then, than at any other time.

But having said that, I’ve found, it hasn’t been that restrictive in sport I play rugby for a profession through schooldays, I played for England under18s, and all the way through [name of team] and things like that, and I didn’t find it much of a hindrance.

So do you have a preventer and a reliever, preventer is the brown one isn’t it?

Yes. I’ve actually got them with me. Do you want to have a look?

Yes please.

This is God I don’t know, I mean you take the blue initially so it opens the airways and the brown is the preventer. So that stops.

So how often do you take each of those then?

At the minute twice a day, once in the morning and once in the evening.

The brown one yes?

The blue and the brown. And then say for instance, I’m not at the moment, but if I have a condition session or a fitness session should I need to take the blue, I always have it with me just in case, but if I do need it during that, which I haven’t for the last couple of months. So, touch wood. But yes, yes, I always have the blue with me during sport but yes, I try and take them twice a day during winter.

I went on Ventolin for a short while and he then asked to see me again, the normal follow up, and prescribed that I should take this treatment as and when was necessary. And prescribed the brown inhaler which I know as Becotide, but it’s probably called something different now, to help prevent occurrence of the problem in the future.

And since that time I’ve been on two puffs or sometimes varying from two to six puffs a day of Becotide, depending on how things are progressing and Ventolin as and when required.

Now when initially I had to take Ventolin for wheezing, it was probably fairly regular in the sense that I probably took a puff, a couple of puffs every night. Probably not outside that. But over a period of time and years that dropped to now I probably only take a puff of Ventolin about once a month or once every other month.

But I’ve always got a Ventolin inhaler with me just in case, because certain things can set it off with me and over the period of time I find that certain wines, especially white wine, especially German white wines, ones with a sort of a flowery aroma to them will set me off, and I experience quite a chest constriction and sort of wheezing, and I have to take Ventolin then to relieve it.

And certain plants can set me off. I know Golden Rod, the sort of, whether it’s the seeds or whatever it is from it, spores from it, can activate it as well. So I have to normally when I go out on garden visits I take a Ventolin inhaler just in case I need one. Very seldom these days. I mean the Becotide seems to work.

I went to the doctor that day and I said to him, This isn’t how I felt asthma would be. You know, I thought, I didn’t think I’d have trouble breathing every day and sometimes it would be worse. I thought I’d be OK every day and sometimes it would be worse. And he agreed that that was how it should be. So they referred me to the respiratory clinic. And I went to the respiratory clinic at the hospital and had to wait two or three months for that appointment. So by this time were into early 2006. And I went first and did some tests with, on a bicycle and blowing into a thing that looks like a, the, the extractor tube from a, a tumble dryer and riding a bike with a clip on my nose and things like this. And then I went to see the, the doctor and they did a whole series of tests. And I came home that evening with a new inhaler, a different one again, red and white this time. And some tablets.

And then a month later I had to go back to see the consultant and I was beginning to feel better for the first time. And, and he felt that he felt that I didn’t need the tablets but that I should stay on this red and white inhaler. And I’ve been on that ever since. I don’t take it all the time

Over the years I’ve seen my GP less and less. I hardly see him at all these days really, only if I’ve got you know, if it’s really bad. But I have at least annual contact with the asthma nurse at the surgery. And two or three years ago she told me that I could manage this red and white inhaler myself. So at, at most I take four puffs in the morning and four puffs in the evening but my goal is always to get it down to nothing. And because it’s a steroid I have to do that very slowly. So I, you know, I start three puffs in the morning, four in the evening. And then three in the morning, three in the evening. And, and it will take me anything up to four to six months to get off it completely. So a typical kind of cycle will be I, I have some sort of viral infection, a cold for example, I end up with a really bad chest. I might be off work then for, when I was working, for four weeks or so, it would be really, you know, it was quite debilitating

And I now feel that I’ve reached a stage where for the most part, 95% of the time, I am in control of my asthma. I have, I have my inhaler and I choose when I use it. And I’ve got two inhalers. I’ve got the blue one which obviously I have to use in an emergency but I’ve got the red and white one and I choose whether I think I need to use that morning and evening, just morning, just evening and how many puffs I have. And I know once I start on that I’ve, to reduce it I’ve got to do it slowly. So I manage how I reduce it.

And it took about a year to get it properly under control. And I had to try lots of different inhalers and I found that really, really hard going, because I just, I was struggling with the fact that I had been told that there was something wrong with me in the first place and then to try and adapt and take the inhalers and get used to taking them and when I take them and how you take them, and so that was sort of like another thing I was battling with, and then even when I did take them they didn’t work. So I’d then get upset because they weren’t working and I didn’t know why they weren’t working and was it because it was me not taking them right? Or was it just? They just weren’t working. So that was, that was really hard and I struggled for about two years I’d say, just coming to terms with it, dealing with it, and accepting that was the way life was going to be.

And I was backwards and forwards to the doctors a lot, just trying to get the right inhalers that actually worked.

My message to somebody who’d just been diagnosed would be always ask if you don’t know. I never did I was so scared, so frightened and I felt so alone and blamed myself. And nowadays with the support that there is out there, there isn’t any reason to really feel like that I don’t think now. Because the doctors and the nurses they will never not answer your questions. They will always make sure if you need to know something that you know it. And if you’re not sure on taking your inhalers always say to them, I’m really not sure, could we just go through that again please. Because yet again I didn’t and I, I do feel that at the beginning for me that was part of my problem that I just didn’t know.

Didn’t have the right technique?

Didn’t have the right technique. It wasn’t, I didn’t know if I was doing it right. So yes, always make sure you’ve got enough information to be able to feel satisfied and happy before you walk away.

So the sorts of treatments wed start somebody on would be inhaled treatments and one of the key things with inhaled treatments is getting good inhaler technique. So we may start somebody on an inhaler and they are not perhaps responding as well as wed expect and the first thing we would then look at is: Have they got good inhaler technique? Have they been taught to use the inhaler correctly? If they have and they’re still not getting full response, they are getting some benefit but still getting some symptoms then we may need to step the treatment up adding in different drugs or increasing the dose of the treatments in the inhalers. So for some people you might hit on the right dose straight away for other people you might need to increase doses over a few times before you get to the right dose to get the asthma under control.

And does that involve patients returning to see you at different intervals to check up how that is going?

Yes and we would expect that we would see a patient perhaps every six weeks or so depending on how symptomatic they are. If somebody came to see us straight away with a very severe attack then we might want to see them within a few days to make sure that is settling down and perhaps see them a little more frequently until they are a bit more stable but for somebody who is stepping up treatment wed normally try a treatment for about six to eight weeks and then get them to come back to see how they have responded to the treatment and if they are still having symptoms then try a new inhaler or an increase in dose and then bring them back again, again about 6 to 8 weeks later until weve got the condition stable.

You were talking about inhaler technique earlier can you just say a little bit about because there are difference devices at the moment. There are different types of inhalers.

Yes. We use lots of different devices for people with asthma. Ideally we should be checking whether somebody can use the particular device that we are recommending but also if possible offering a choice of different devices that might be more suitable to the patient’s lifestyle. So vaguely the two different types of devices we have are either devices that are what we call, the metered dose inhalers’ or puffers which are where the patient compresses the inhaler down and a spray or mist of inhaler comes out and the patient has to breathe that down into their lungs. With those sorts of devices the patient often has to co-ordinate being able to press and breathe in at the same time and should breathe in with slow gentle breaths so that they carry that mist or that spray as far down into the lungs as possible. And they can be quite difficult devices to use because of getting the co-ordination right and getting the timing right. We can use those devices in spacers as we mentioned earlier and that can help with co-ordination because you don’t have to press and breathe at exactly the right time with the spacer device and so that can make it a little bit easier to use.

The other devices we have are called, dry powder devices. There are lots of different dry powder devices. Weve got turbohalers and accuhalers and clickhalers that are different types of devices that have powder in them and the patient twists or primes the device and then has to breathe in quite forcibly to take the powder down into the lungs. The different devices suit different people. Some people prefer one device over another. Sometimes it’s that a particular drug comes in a particular device and that’s the particular drug that is better for that person’s asthma. So there are lots of different reasons why we might choose one device over another.

Certainly if somebody had difficulty in operating one particular type there are options for them to have.

Yes there are lots of different devices and we mustn’t forget that there are people. We often think of asthma in younger people but there are older people with asthma who perhaps don’t have the dexterity to be able to press an inhaler. So somebody may have arthritis or rheumatism and not be able to press an inhaler down. And we have devices that we can put on inhalers to adapt them to make them easier to press the inhaler or we have different devices that we can use. It may be that somebody is younger and has poorer co-ordination or just somebody who wants something that fits better with their lifestyle. So lots of different devices that we can choose, so not always having to stick to the device that has been the first one that has been chosen.

I know from talking to asthma nurses, specialist asthma nurse and asthma professionals that they could spend all day and every day teaching people how to actually take the drugs properly. A lot of people have the medication and they think they’re taking it but they’re swallowing it or losing it into the air or whatever but they’re not actually getting it into the lungs.

Would you maybe describe how you should take it?

Well, I think a lot of people find it very unnatural at the beginning, when they’ve got like say, the salbutimol inhaler and sometimes if people are struggling with that, their GP or their clinic would give them a spacer or a…

Is that that tube?

What’s the other word for it? A spacer or a volumetric is it? I think it’s called, but that basically, dis allows the dose to be dispersed into a chamber and then you’re able to actually suck the air from that chamber down into the lungs. But I think what people find to be unnatural is you need to artificially force the air out of your lungs, to empty your lungs, to create a vacuum in order to receive the medication in a single inhale and that’s not something you do day in daily. It feels awkward. It looks awkward. It’s an effort [laughs]. It’s not pleasant, yeah. So I think maybe people get given the medication and without somebody standing and almost like coaching them. It’s a skill and without coaching the skill you could be out there with your medication thinking that you’re taking it and getting a bit of it and not all of it. So any of the clinics that I’ve been aware of over the years, I think they put a tremendous amount of effort into it all of that, of making sure people, and maybe children are easier than adults. I don’t know. Maybe adult onset is worse because were not as good at learning new skills or maybe or maybe it’s easier for younger people but I think there could be quite a lot of asthmatics running around who are using their inhalers but not getting the dose.

Although I was compliant and taking my inhaled steroid every night, I don’t think my technique was correct. And consequently you know, years later I realised that I wasn’t getting the, you know, steroid down me, as much as I should.

I’m part of sort of a group that you know, talks, you know, sort of shares common experiences, I realised oh only in a couple of years ago when a nurse, who has asthma, came and was part of the group and she was demonstrating her inhaler technique and I thought I’m still not doing it quite right. And its, so I thought, I took that away and I thought this is what I do. And it has helped, because I’m starting to reduce the amount of medication I need.

So when you weren’t doing it right, were you not getting the right measured dose?

Well I probably, you know, the dose, you click the bottom and, of your inhaler and so it’s there ready to be inhaled. But if you, if you’ve got to take two doses and you, you, you breathe in and then you think oh click and you know, life, you know, you rush around and you think oh right get that done, you know, sort of tick that one off for this morning. And of course you aren’t allowing the, the sort of powder to go down and, and to settle as I think of it. And you sort of, you know, the second dose probably wasn’t terribly effective and now the nurse literally she, she showed how she took hers. She breathed in and then she literally counted her fingers slowly to ten, holding her breath in and then breathed out very gently before taking the second dose. And just that improvement and the technique was just useful to learn.

I think the spacers are kind of, they’re good but they are still quite bulky.

The big spacers, I’ve never been given a big spacer by, I’ve got friends that have them and if anybody gave me one I wouldn’t use it.

Because it’s just too huge. And you couldn’t carry it around. Sorry.

And but the little one is quite good but it is still, it is quite bulky and I know it’s a lot better when you take the Ventolin through it. I mean, you can feel it’s a lot better but it’s kind of, you can have a Ventolin thrown in the bottom of your bag and nobody kind of looks askance because lots of people have asthma and just have a Ventolin thrown in the bottom of their bag. If you’ve got a Ventolin and a spacerit’s kind of, theres kind of this, because not everybody has spacers, and they tend to just give spacers to people who really need it so everybody’s like, What’s that? Why do you need that? And

And it makes you a bit more conspicuous?

Yeah. And when you take it people, people aren’t, I think people are just still not used to seeing spacers being used and so when you take it it’s like, Whoa, that’s some weird device you’re using.

And then you feel you have to explain.

And then you have to explain it when you’re still breathless which is not ideal [laughs].

Is that relatively new then, these, the spacer

I think the little ones are.

I mean, the big ones I know they, they’ve had for quite a long time

If you’re having a really bad attack, I mean, certainly for me, if I’m having a really bad attack I can’t breathe in very far. And so the drug doesn’t get far enough down.Whereas with the spacer you, because you don’t have to take that really deep fast breath, which is what I struggle with when I’m really tight.

You can kind of, you can take a number of smaller breaths and it doesn’t, or you can take like one slow deep breath.

Sure you have to take your inhalers from time to time, and sometimes, I guess when you go to a new place for instance you join a new club or you’re with a new group of people there is a factor where you don’t want them to see you blowing on the inhaler, because it looks quite geeky. It looks, it doesn’t look too, too cool. But theres not too much stigma about it, I think so. I haven’t found it too much of an issue. And I have been able to cope with it and excel with it, so, yes I guess it’s part of my life, but it hasn’t been too much of a hindrance.

I don’t think many people who don’t have it know a lot about it. I think they know people have to take inhalers before they do sport or if they’re struggling to breathe, but no, I don’t think people know a lot about it to be honest. But then again, I don’t think people in day to day life, know about many diseases or stuff like that. So I guess no, not a lot is, known about it. Especially from people who don’t have all this stuff come into their lives. But yes, if they did thered be a lot more understanding and you might get away with a lot more stuff. So, yes

I don’t know. I like to think people in general would know what was going on if someone was breathing in an inhaler. I don’t think they were doing drugs or something like that. So I think people know always associate inhalers with asthma. It is, so they know what’s going on, but no it’s not seen a lot in public.

There are side effects. The blue inhalers can cause people to have a little bit of the shakes if they use too much of them. They can feel their hearts racing a bit. These are not dangerous. It’s just a physiological response to the drug. And it tends to settle down in time.

As far as inhaled steroids are concerned there is some evidence that, that very high doses over long periods of time, it can cause problems with contributing, particularly in older people, contributing to osteoporosis (decalcification of the bones), but that’s a very much less an effect. More common is a dry mouth. Occasionally thrush in the mouth. The, the fungal infection in the mouth can occur in about 2 or 3 per cent of people. But those are the, the symptoms you get from inhaled steroids.

I’ve had some people who’ve I’ve spoken to who have talked about things like skin thinning. Is that something that you’re familiar with?

Yes. In older people with high dose inhaled steroids you can get, not so much thinning but easy bruising and so you get these rather purplish patches on the, on the skin and when they fade then the skin does look a bit thinner, where that has been.

Clearly any side effect of any treatment needs to be made clear to the patient what they are. From my point of view the benefits of inhaled steroids are so strong, it was the most dramatic arrival on the scene in the late 1960s when inhaled steroids first arrived. It transformed the life of many people with asthma. They’d never had anything like it. It is a tremendously effective treatment. It controls symptoms. It reduces asthma attacks. And when you balance that against some of the long term side effects then I think, yes, you need to understand what those benefits are, but the benefits in my view, way outweigh the risks.