Asthma: symptoms, triggers and inhaler treatment
Asthma is a condition of the airways that narrows them in episodes, so the symptoms come and go: wheeze, cough, a tight chest and breathlessness, often worse at night or with exercise. It is controlled rather than cured, and the way it is controlled is unusual in medicine, because the medicine that makes you feel better immediately is not the one that keeps you well. This page covers the symptoms and triggers, how the diagnosis is made, what the two kinds of inhaler do, how to tell when control is slipping, and which signs mean an emergency.
What are the symptoms?
Four symptoms make up the usual picture: a wheeze, a dry cough, tightness across the chest and breathlessness. What points to asthma is not any one of them but the pattern. Symptoms vary from day to day, are often worse in the early morning or at night, and are set off by particular things.
A cough alone can be the whole presentation, particularly in children and particularly at night, and it is often mistaken for one infection after another. Breathlessness on exercise that settles with rest is another common form.
Symptoms that are constant and unchanging, or that came on suddenly in an older adult who has never had them, point away from asthma and towards other causes that need a different assessment. Breathlessness with swollen ankles, with chest pain, or that wakes you gasping is not a reason to reach for an inhaler; it is a reason to be examined.
What triggers it?
Triggers differ from person to person, and the useful ones to know are your own. The common ones are house dust mite, animal dander, pollen, mould, cold air, exercise, cigarette smoke, strong smells and air pollution.
Respiratory infections are the most frequent reason for a flare, which is why a cold can turn into a fortnight of poor control. Some medicines can provoke symptoms, including aspirin and other anti-inflammatory painkillers in a minority of people, and beta blockers, so tell any prescriber that you have asthma.
In Malta three local factors come up repeatedly. Dust carried in on southerly winds raises airborne particle levels for days at a time. Damp and mould in older buildings over the winter months affect some people markedly. And humidity combined with summer heat makes exertion harder for everyone, which can be mistaken for worsening asthma.
Reflux, obesity and untreated hay fever all make asthma harder to control, and treating them often does more than changing an inhaler.
How is asthma diagnosed?
The diagnosis starts with the history, because the pattern of symptoms carries most of the weight: what brings them on, when they are worst, whether they respond to a reliever, and whether there is eczema, hay fever or asthma in the family.
Breathing tests support it. The usual measurement looks at how fast and how much air you can blow out, before and after a reliever inhaler, to show that the narrowing is reversible. A peak flow meter used at home over a couple of weeks can show the day-to-day variation that is characteristic of asthma. Tests that look at airway inflammation or at allergy may be added.
Two cautions. Normal breathing tests between episodes do not exclude asthma, because the abnormality is intermittent by nature; and a good response to a reliever does not by itself confirm it. This is why a first diagnosis needs a doctor who can examine you and arrange the tests, and cannot be made from a questionnaire.
Reliever and preventer inhalers: what each one does
A reliever opens the airways within minutes and wears off within hours. Salbutamol is the usual one, authorised in Malta and marketed here under brand names including Ventolin, and our page on /medicines/ventolin/ describes it in more detail. It treats the symptom and does nothing to the underlying inflammation.
A preventer works on the inflammation that makes the airways twitchy in the first place. It is usually an inhaled steroid, sometimes combined with a long-acting bronchodilator in one device. It does nothing for you in the moment, which is exactly why it gets abandoned, and it is the part of treatment that keeps people out of hospital.
The consequence is counterintuitive and worth stating plainly: needing the reliever more and more often is not a sign that it is working well, it is a sign that control is slipping and that the preventer side of the treatment needs reviewing. Relying on a reliever alone is the pattern most strongly associated with severe attacks.
Which regimen suits you is a decision for a doctor, and it has changed in recent years for some groups of patients. Do not copy someone else's inhaler routine.
Inhaler technique, spacers and the things that quietly go wrong
An inhaler that is used poorly delivers a fraction of the dose, and poor technique is common even after years of use. The medicine is not the variable here; the delivery is. Ask a pharmacist to watch you use your device, which takes a minute and is the highest-value minute in asthma care.
A spacer improves delivery from a pressurised inhaler substantially, particularly for children and during a flare. Rinsing your mouth after an inhaled steroid reduces hoarseness and oral thrush. Keeping track of how much is left in the device avoids the classic problem of an empty reliever during an attack.
Two more quiet failures. A reliever left in a hot car degrades, and cars in Malta get very hot. And a written action plan, agreed with a doctor, that says what to do when symptoms worsen is worth more than any extra medicine, because it turns a frightening episode into a sequence of steps.
Signs that control is slipping, and signs of an emergency
Control is slipping when you are using the reliever more often than you used to, waking at night with symptoms, finding that ordinary activity brings on a wheeze, or noticing that your peak flow readings are lower or more variable. That is the moment for a review, not for using more reliever.
Seek help the same day if symptoms do not respond to the reliever as they normally do, if you need it again within a few hours, or if a flare has been going on for days with no improvement.
Call 112 or go straight to an accident and emergency department if you are too breathless to speak in full sentences, if your lips or fingers look blue, if the reliever is not working at all, if you are exhausted by the effort of breathing, or if a child is drowsy or struggling to feed. A silent chest, meaning that the wheeze has disappeared while breathlessness is worse, is a serious sign rather than an improvement.
Do not drive yourself to hospital during a severe attack.
Living with asthma
Most people with asthma live without restriction, and the aim of treatment is exactly that: no symptoms limiting what you do, no night waking, and a reliever that sits unused for long stretches.
The habits that get people there are unglamorous. Take the preventer every day, including when you feel well, because that is when it is working. Have your technique checked. Keep a spare reliever and check the counter. Treat hay fever properly if you have it. Stop smoking and avoid smoky environments, including vaping around you. Keep to a reasonable weight, because it changes how much breathlessness a given degree of narrowing produces.
Exercise is to be encouraged rather than avoided; if exertion reliably brings on symptoms, that is a treatable problem, not a reason to stop. Vaccination against influenza and other respiratory infections is worth discussing, since infection is the commonest trigger of a flare.
Finally, keep your own record: the inhalers you use, the doses, your best peak flow and the dates of flares. It makes any future assessment faster and better.
Can asthma be diagnosed online?
No. A first diagnosis needs a doctor who can examine you, listen to your chest and arrange breathing tests, because the pattern has to be distinguished from other causes of cough and breathlessness. An assessment on paper can review a treatment that has already been established and monitored; it cannot open the question of whether you have asthma.
Why do I need a preventer if the reliever works?
Because they do different jobs. The reliever opens the airways for a few hours and leaves the underlying inflammation untouched; the preventer treats that inflammation and is what reduces the risk of a severe attack. Feeling nothing from the preventer is normal and is not a reason to stop it. Needing the reliever more often is a signal to have the treatment reviewed.
How often is it acceptable to use a reliever inhaler?
There is no single figure that we can responsibly put on it, because the threshold depends on your treatment and your history and belongs in the action plan your doctor agrees with you. What is clear is the direction: if your use is rising, if you wake at night, or if ordinary activity sets symptoms off, control needs reviewing rather than more reliever.
What are the signs of an asthma attack that needs emergency help?
Being too breathless to speak in full sentences, blue lips or fingers, a reliever that is not working, exhaustion from the effort of breathing, or a child who is drowsy or cannot feed. A chest that has gone quiet while breathlessness is worse is a serious sign. Call 112 or go to an accident and emergency department, and do not drive yourself.
Does the weather in Malta affect asthma?
For some people, noticeably. Dust carried on southerly winds raises airborne particle levels for days, damp and mould in older buildings can matter over the winter, and summer humidity makes exertion harder. None of that changes the treatment, but knowing your own triggers lets you take the preventer seriously before the season rather than after it.
My inhaler prescription has run out. Can it be continued without an appointment?
Where the diagnosis is established, the regimen is unchanged and your control is stable, a doctor can often assess a request to continue from your answers and your records. Where control is poor, where the dose or device needs changing, where you have had a recent flare, or where the diagnosis itself is uncertain, you need to be seen.