If you’ve spent any time at all scrolling through the Daily Mail website, you’ll “know” that just about everything gives you cancer – whether it’s processed meat, chips, the contraceptive pill, or even having children. We live, in other words, in an age of shocking headlines, where our newspapers push scare tactics and a "can’t win" mentality that says – no matter what we do – we will find ourselves doomed to ill-health and unhappiness.

It’s with some scepticism, then, that you might find yourself approaching the asthma study carried out by the University of Liège back in March. Using mice, researchers examined how exposure to microbes could affect lung health. The findings indicated that the presence of bacterial DNA actively modified the immune environment of the lungs, which in turn helped to prevent the development of asthma. In simple terms: exposure to dirt was shown to be beneficial – and living in an environment that was too clean was shown to predispose you to asthma.

Time to Rethink Guidelines?

The reason this study is particularly frustrating is that all current guidance on asthma management stresses the importance of cleanliness. Just last year, we reported on new research that showed how "indoor pollution" – in other words dust, dirt, irritants and smoke within the home – play a worrying role in the severity of children’s asthma symptoms.

How, then, may we reconcile that knowledge with this new study? Well, the first thing to note is that this study has only been carried out on mice – although human studies have been planned. Secondly, it’s not clear from this research what constitutes "good" versus "bad" microbes. Lastly, the study seems to suggest that these findings are best applied in a preventative, as opposed to curative, manner. In other words – though this will require further consideration when more studies have been carried out – some exposure to microbes may be beneficial before, but not after, a person has developed asthma.

Going forward, asthma sufferers should not make changes to their asthma management – and parents wary of their children developing asthma shouldn’t stop vacuuming or washing their hands! For more guidance on good asthma management, read on.

Keeping Your Asthma Under Control

Many people with asthma do not consider it a serious or life-threatening condition, but that is largely because they are able to manage it well. Four simple rules for successfully managing asthma are:

• Using your inhalers and medications correctly
• Avoiding your triggers
• Having a written Asthma Action Plan
• Regular asthma reviews with your asthma doctor or nurse

Inhaler Use

If you only use a reliever inhaler, you should not be using it to treat asthma symptoms more than three times a week. Using it this frequently indicates that your asthma is not well-managed and that you probably require a preventer inhaler as well.

If you use a preventer inhaler you need to make sure you take it as directed – usually this means taking it twice a day. If you don’t use your preventer in this manner, you will not benefit from its protective effects. It’s also important to make sure you are using your inhalers correctly. You can do this by getting guidance from your doctor or nurse at your next asthma review.

To learn more about asthma medications, consult this guide from Asthma UK.

Asthma Triggers

Asthma symptoms are "set off" by certain triggers. These triggers vary from person to person; however, common ones include:

• Allergens such as dust mites, pollen, and animal dander
• Food allergies
• Airborne irritants such as cigarette smoke and pollution
• Infections of the upper airways such as the common cold
• Food additives such as sulphites
• Strong emotions such as stress or laughter
• Weather conditions such as thunderstorms
• Indoor conditions such as mould and damp
• Exercise

One of the best things you can do for your asthma is to take note of your personal triggers in your Asthma Action Plan and try to avoid them as best you can. Because it’s not always easy to avoid these triggers, it’s even more important to make sure you are taking the correct medications and using your inhalers properly.

To find out more about asthma, and the medications available to treat it, visit our Asthma page.

Around the world, concern is growing over the quality of the air that people – particularly big city dwellers – are forced to breathe. In London during January, air quality was so bad that legally mandated pollution limits for the whole of 2017 were passed in the first week of the year. The city's mayor, Sadiq Khan, spoke of what he called a "public health emergency", as toxic air hung over the central boroughs, a problem exacerbated by unusually calm weather patterns.

Everyone is at risk when conditions like these persist, but the potential health risks are even worse for anyone with respiratory or heart issues, with asthmatics often experiencing serious problems. Evidence is also mounting that cases of chronic bronchitis increase with worsening air quality. The figures for air pollution-related deaths in London alone are astonishing; every year, almost 9500 people in the city die early because of pollution-linked conditions, according to research conducted in 2015 by scientists from King's College.

Measures such as banning certain kinds of traffic in parts of a city, or restricting people from using private vehicles, can have a beneficial effect locally. But changing weather patterns or unusual conditions can result in pollution from other areas – even other countries – having a dramatic impact in distant cities. The ability of people and governments to work across borders to combat problems like this becomes immediately apparent under such conditions.

EU takes action

Around six weeks after the January pollution spike in London, the EEB (European Environmental Bureau) announced that five EU countries were consistently breaching air pollution limits. The UK, Germany, France, Spain and Italy were, the EEB claimed, failing in their duty to protect people's health, and legal proceedings would follow. Furthermore, the EEB statement pointed out that this was not a new issue; the situation had been going on for years.

One particular pollutant, nitrogen dioxide, was singled out for its likely effect on young children with asthma, and its probable contribution to increased cases of bronchitis and other lung infections. It is the job of the European Commission to ensure that EU laws regarding air quality are upheld, and recent EU legislation includes new and more stringent emissions targets. The EEB's senior air pollution policy officer, Louise Duprez, said there was "no excuse" for not meeting the targets, and that children "deserved better" than to grow up inhaling toxic air.

Bronchitis: causes and treatment

Bronchitis is frequently mentioned as one of the effects of air pollution, though of course poor environmental air quality is not the only risk factor. Bronchitis, like pneumonia, is an infection of the airways and/or lungs, and can be a mild and relatively short-lived condition – acute bronchitis – experienced by people who have simply caught a cold. When the condition becomes a long-term, more serious health problem, it's known as chronic bronchitis.

The chances of developing bronchitis are increased by a number of factors, smoking being one of the most common. Chronic bronchitis can vary in intensity throughout the year, and environmental factors can have a causative effect, and can also make the condition worse. The main symptoms of both the acute and chronic varieties of the infection are a persistent cough with chest/lung discomfort or pain, and possible breathing problems. In emphysema sufferers, chronic bronchitis can lead to COPD, which can cause permanent lung damage in the long term.

There are a number of recommended ways to avoid contracting bronchitis, and stopping smoking is, unsurprisingly, at the top of the list. Not only does smoking cause lung damage, it lowers the body's resistance to infection. Staying within alcohol consumption guidelines – currently 14 units or fewer per week – and eating a healthy diet can help the immune system to fight infections.

It's important to be aware that bronchitis can be caused by both viruses and bacteria. Viral infections are not treatable with antibiotics. Mild cases of acute bronchitis may not require treatment, and in fact, using cough medicines is generally not recommended, as the body needs to expel phlegm by coughing. You should see a GP if your symptoms get worse or the condition doesn't clear up relatively quickly. In cases where antibiotics are appropriate, you may be able to order them from The Online Clinic – see the Free Online Assessment at the link.

According to Asthma UK, there are 5.4 million people living with asthma in the UK, 1.1 million of whom are children. That adds up to 1 in every 11 children, meaning that on average there are three with asthma in every classroom in the country.

At first glance, asthma might not seem like the worst health condition to live with, but the reality can be scary. For adults and children coping with severe asthma, living a normal life can be a daily struggle.

The good news is that asthma medications and the techniques for managing the condition effectively are constantly improving. Recent research from the American Academy of Pediatrics also looks set to make a significant contribution to the health of asthmatic children and adults.

According to the experts, the indoor environment of asthma sufferers’ homes plays a crucial role in respiratory health. In fact, controlling this environment could be as vital to asthma management as the use of medication. This discovery is particularly important for parents of asthmatic children, because air-borne pollutants can disrupt the development of young airways. Children are also more likely to be exposed to irritants and pollutants than adults because they spend more time on the floor.

Keeping your Home Safe

The new guidance recommends that parents with asthmatic children take the following precautions in their home:

• Reduce your child’s exposure to cigarette smoke

• Dust and clean regularly to avoid exposure to dust mites

• Address any mould or damp issues

• Address any issues with pests or vermin

Ultimately, the best thing you can do for your child is to keep your home very clean, dust-free and regularly vacuumed – particularly the rooms they spend the most time in.

Pets & Asthma

The report also discussed the role that family pets can play in children’s asthma. Animal dander is a common asthma trigger and it’s not always easy to control – even if you have a so-called "hypoallergenic" pet.

Giving up your dog or cat is not necessarily the only option if your child has asthma. This is because animal dander is only a problem if your child has an allergy to it – not all asthma sufferers are automatically allergic.

You’ll be able to tell if your child is allergic by monitoring their symptoms when they are around your pets. When the allergy is severe, a reaction will be instant, causing coughing, wheezing, shortness of breath and sometimes even a rash. When the allergy is only mild, a reaction may take a few days to develop.

For children with only a mild allergy, it may be possible to keep pets as long as they are not allowed into bedrooms or communal living areas. Keeping your pets well groomed and clean is also important, as is regularly cleaning and vacuuming.

For children with a severe allergy, it’s worth getting a definitive allergy test before you consider giving up your pet. It may be that your child is allergic to something else in your home.

Other Management Techniques

Keeping your home clean and safe is very important when it comes to asthma management, but there are other important techniques to keep in mind.

The first is having a written asthma action plan. This is a document which details all the vital information related to your child’s condition. It will include a list of your child’s triggers, medications, and what to do in the event of an asthma attack. To establish a comprehensive asthma action plan for your child you will need to take some time monitoring their condition, and working out what their asthma triggers are.

It’s also crucial to make sure your child is using the correct asthma medication. If they are only using a blue reliever inhaler (usually Ventolin) but experiencing symptoms more than three times a week, then it is likely that will need a preventer inhaler.

However, frequent flare-ups of symptoms could also be a sign of an unidentified trigger in the home – whether it’s cigarette smoke, animal dander, dust mites, food additives or mould. In this situation, an allergy test is recommended.

You can read more about asthma and the various medications available to treat it at The Online Clinic. Click here to view our inhalers and learn more about asthma management.

A key issue with most asthma inhalers is that a large part of the medication stays in a patient’s throat rather than reaching their lungs. However, this may be about to change as a team at Monash University has developed a new method of making ultra-fine particles, which would pass easier to the lungs.

The team, which is currently sponsored by the Australian Research Council, presented its findings in China last year and has attracted significant interest from the pharmaceutical industry. Initially the team had been researching dairy production, with the purpose of attempting to produce lactose crystals using nitrogen laced with ethanol vapour. This led to the development of tiny and uniform lactose particles. Having investigated this unexpected outcome, the researchers concluded that the alcohol absorbed into the initial droplets led to the development of the uniform lactose particles.

It is now hoped that the method described above could be harnessed to develop ultra-fine and uniform particles of the asthma medications so that they would be able to reach the lungs. As a result of this, it is hoped that it could increase the efficacy and accuracy of inhalers. Moreover, it means it would affect the manufacturing process and potentially make the production of inhalers more cost effective.

It is still too early to say whether this method is viable in the manufacturing process of asthma inhalers. However, if this were to produce the expected outcomes then we would be keen to see what clinical implications it would have in terms of prescribed dosages in the inhalers.

You can read more about this discovery at Fierce Drug Delivery.

When it comes to treatment of various illnesses it is not always the case that one size fits all. Instead, it is not uncommon for individual treatment plans to be developed to suit the affected person. A good example of that can be seen in how individuals who have asthma often need to find what is right for them. Yet, despite the many options available, there are still some individuals who do not respond well to traditional treatments for asthma. Although this is a long-standing problem, no large-scale studies have addressed the issue to date. However, this is about to change.

Researchers from University of Adelaide School of Medicine recently announced that they are recruiting participants for a five-year study in Australia. The key purpose of the research is to consider the benefits of macrolide antibiotics in the lungs of asthmatics, who (despite taking medications), are still symptomatic. In addition to that, the same team will conduct clinical trials on an alternative treatment for this population.

According to the researchers the current treatments target so called eosinophil cells (white bloods cells). However, they postulate that targeting neutrophil cells (also white blood cells) may be more suitable for some individuals as many asthma sufferers have normal levels of eosinophil cells. It is their hope that their research and clinical trials will illuminate this relationship for further research to be done and new treatments to be developed.

It is important to point out that the proposed treatment therapy is not only appropriate where there is an infection present. Macrolide antibiotics have anti-inflammatory properties and the use in asthma has been postulated before in a study dating back to 2004.

We are always a bit weary of researchers’ claims before seeing the results of any trial. However, the scope of this project is substantial, not only in terms of length of time but also in terms of funding. As such, it is our hope that the research will at the very least help clarify unanswered questions regarding cell biology in the process of asthma development and treatment. You can read more about this study here.

In the UK, most individuals with asthma are well aware of the possibility to use an inhaler that contains a combination of corticosteroids and so-called LABA. In fact, in the UK the treatment (which is commonly called SMART) appears to have been widely available for adults for nearly ten years. Yet, two trials that were recently published in The Lancet Respiratory Medicine recently appear to have met some resistance in the US, with some sources claiming that recommending the use of SMART inhalers would go against national and international medical guidelines, that clinicians’ perceptions of the efficacy of SMART are not the same as patients perceptions and that the promotion of SMART inhalers reflects financial interests rather than a concern for patients well-being. In this blog post, we consider whether there is any foundation behind those statements and whether the findings from the two studies warrant a serious consideration of SMART treatments.

The first study, conducted by Patel et al, was a 24 week trial that included a total of 301 patients. The participants, who were between the ages of 16 and 65 were randomly put into groups that either used SMART inhalers or used standard inhalers. The key findings indicate that individuals in the SMART group had fewer severe asthma exacerbations, leading the researchers to conclude that SMART is a particularly suitable treatment for adults that are at risk of having severe asthma exacerbations.

In addition to standardising the treatments so that they were comparable between the groups, the researchers also used an electronic device to ensure that the measurement of actuations was more precise than it had been in past studies. This study also differed from past studies, as the researchers did not use dry powdered inhaler and as it was the first study that had not received funding from a pharmaceutical company.

The second study, conducted by Papi et al, was a double blind trial that was conducted between a total of 14 European countries (183 centres) over the course of 48 weeks. The 1714 participants, who were over the age of 18, were randomly put into groups that either used a combination of corticosteroids and LABA or only relied on LABA. After controlling for factors such as lung function, symptoms scores and asthma exacerbation, the findings suggested that the latter group had severe exacerbations earlier than the former group. Moreover, individuals in the former group also had fewer mild asthma exacerbations. Based on this the researchers concluded that the using a combination of corticosteroids and LABA would be useful for patients with moderate to severe asthma.

Given that this trial controlled for many aspects that previous studies did not address sufficiently, it is unlikely that the findings from this large-scale trial are random. The sheer size of the trial, in combination with the blind design, makes it challenging to question the findings.

It is clear that both of the aforementioned trials are robust and unique in many ways. However, despite the fact that these studies corroborate findings of past trials and testimonies of clinicians, it also appears that patients’ perception of their symptoms improving or being better controlled as a result of using SMART inhalers is not always a given. This of course, should not be taken lightly. However, some likely explanations for this incongruence could be attributed to variations in diagnosis severity, triggers and medication compliance.

To our knowledge there are no studies to address this, but it does seem like a feasible explanation for the incongruence between clinicians and some patients’ perceptions. We believe that rather than considering negative patient testimonies as noise, it would be valuable to understand the difference between patients who find SMART useful and patients who do not. This of course, is less extreme than suggesting that SMART treatments are breaching medical guidelines.

In conclusion, we find it abundantly clear that the two studies are extremely valuable in further supporting the use of SMART inhalers. We see little support for the argument of financial motivation, especially when considering the Patel et al trial and hope that future research efforts are put into optimising the use of SMART inhalers for relevant patient groups.

The bulk of past research into asthma has considered how the outer environment may affect individuals’ lungs. However, recently published research now suggests that both healthy and unhealthy individuals present with microbiota in their lungs.

The study, which was published in BMC Infectious Diseases, was a case-control study of a total of 96 participants between the ages of 21-62. Of those, 54 had asthma. All the participants received isotonic saline through an ultrasonic nebuliser and were required to cough up globules of sputum. These were then examined using a microscope. Researchers also used these samples to extract DNA. The key results indicated that both cases and controls had a larger than expected amount of fungi in their lungs and asthmatic patients had the fungi Malassezia pachydermatis. In total, 136 different species of fungi were found among the groups. Of those, there were 46 that were more common among asthmatic patients and 90 that were more common among healthy controls. This led the researchers to conclude that fungi in the lungs is common among healthy individuals and that there is a need for further studies to consider whether the pattern of lung fungi varies between patients and controls.

Although this study was well designed, there are a few areas that are worth improving. For instance, it is clear that this study needs to be replicated using a larger and more representative sample. It is also clear that using a fresh sputum sample would have been more beneficial than delaying the analysis and subjecting the sample to potential contamination from spores in the air. Lastly, if Malassezia pachydermatis were to be a replicated finding, then it would be valuable to know whether any of those participants also had pet dogs, as this is a type of fungi often found on their skin.

Nevertheless, this study is interesting because it changes the way we may imagine the lungs. Rather than assuming that we are all born with clean lungs that get attacked from our environment, it seems as if we already have microbiota in our system. This opens up the possibility to see whether some microbiota are better at combating harmful substances than others, and also whether some microbiotas make individuals vulnerable to get certain infections if they are exposed to particular kinds of environment. Moreover, understanding what specific microbiota are involved in developing and maintaining asthma means there are possibilities to develop more precise and efficient treatments.

A woman’s menstrual cycle is known to affect many health issues, now it appears that respiratory symptoms can be added to that list. A recent Norwegian study suggests that a women’s menstrual cycle may have an impact on the severity of respiratory symptoms, which in turn may affect conditions such as asthma.

The study, which was published in American Journal of Respiratory and Critical Care Medicine, included a total of 4000 women that had a 28 day cycle and did not use contraceptives. Overall 28% of the individuals were smokers, and 8% had asthma. The key findings indicated that wheezing symptoms worsened between day 10 and 22 during the menstruation cycle. In addition to that, shortness of breath appeared to worsen between day 7 and 21. This led the authors to conclude that there potentially may be both a direct and indirect relationship between a woman’s menstruation cycle and respiratory symptoms.

Generally, during a woman’s cycle her hormones fluctuate and the body temperature rises during ovulation. The findings from the current study would suggest that this may directly influence airways and indirectly influence inflammatory responses to infection.

This of course is valuable news when it comes to the management and treatment of respiratory conditions. For instance, women with asthma may note if there is a particular time during their cycle that symptoms worsen which can help them take preventive measures and tailor treatments accordingly. However, as a mere 8% of the participants had asthma the findings would need to be replicated specifically in this population.

The National Institute for Health and Clinical Excellence has published a review where it rejects the use of Xolair as treatment for severe asthma. The reasoning behind this recommendation is said to be based on recent evidence primarily regarding mortality and cost-effectiveness of the treatment. At the moment, the recommendation is not final. But if the review is finalised, then the decision is likely to affect individuals England and Wales.

Xolair is a treatment most commonly prescribed for individuals with moderate to severe allergic asthma, which is caused by constant allergens in the air. The treatment, which works by blocking immunogloin antibodies, can cost between £1665 and £26640 per patient per year depending on the dosage required. Currently, it is estimated that 7000 individuals in England are eligible for the treatment.

Although Sir Andrew Dillon (chief executive of NICE) has recognized that Xolair is an effective treatment, new evidence has come to light and he has stated that the cost of treatment now outweighs its benefits. However, Neil Churchill (the chief executive of Asthma UK) has expressed disappointment over this recommendation and urged the manufacturers to collaborate with NICE in order to attempt to make the treatment affordable for NHS patients.

The review is due to be finalised in 2013 and it is likely to first affect patients in England and Wales, and then be put through a review in Scotland and Northern Ireland. Patients who are currently being treated with Xolair will be allowed to continue to do so.

Over the years a number of studies in various countries have been considering the relationship between indoor dampness, mould and asthma. However, to date the results have been inconclusive. Now a recently published systematic review claims that dampness and mould poses a significant risk for developing asthma.

The systematic review, which was published in PlosOne, considered a total of 16 studies that had been published between 1990 and March 2012. Combining the studies allowed for a total of 35857 participants. In order for the studies to be included in the review, they needed to have been cohort or longitudinal studies or incident case-control studies. Moreover, a key requirement was that the studies did not report asthmatics at baseline as the purpose of the review was to establish the development of asthma. In addition to critically evaluating those studies, the authors also carried out separate meta-analyses to see whether the relationships investigated differed depending on the type of exposure. The types of exposure included; visible mould, mould odour, water damage and dampness. The key findings indicated that the presence of dampness and mould increased the risk for developing asthma by 31- 50%. However, the risk was not increased by the presence of water damage. Based on this, the authors concluded that their findings support the need for preventative and remediation actions against indoor dampness and mould.

Overall, this review benefitted from including only the most methodologically robust studies that assessed the risk prior to the onset of asthma. However, as with any secondary analysis, the findings can only be as strong as the initial studies considered. Therefore a limitation of the current review is that the emphasis on quantitative analysis does not permit room for discussion of limitations in the primary studies that may have affected their results. Still, this may not be necessary as the study complements a recent qualitative review which is comparable to these findings’.

Although, we are not surprised to hear that the associations between these factors are significant, we do believe that the findings are valuable and should not be disregarded in future studies.