Brittle asthma: what the term means, severe asthma and getting specialist help

The phrase brittle asthma is still used by some people and in some older writing. Asthma + Lung UK says that if you hear the term used to describe your asthma, it is an old-fashioned name for difficult asthma and severe asthma. In practice, UK health teams now talk about whether asthma is well controlled, difficult to control or severe, and then look for the reasons behind it.

Asthma itself is a condition in which, in the NHS's description, the airways become swollen and narrower, causing breathing problems. The main symptoms are wheezing, coughing, shortness of breath and a tight chest, which usually come and go and may be worse at night and early in the morning. For most people the NHS says inhalers work well to reduce or prevent symptoms, but some people have more severe symptoms that are harder to control and need other treatment.

Asthma + Lung UK separates asthma that is hard to control from true severe asthma. Your GP may say you have difficult or hard to control asthma if, in the last 12 months, you needed two or more courses of steroid tablets, went to hospital or A&E at least once for your asthma, were prescribed six blue reliever inhalers, have had lots of symptoms even on high-dose treatment, or have been on maintenance steroid tablets.

Severe asthma is described as a type of asthma that is hard to control with the usual asthma medicines, is the most serious type of asthma and needs specialist treatments. Asthma + Lung UK stresses that having these symptoms does not always mean you have severe asthma, and a very bad asthma attack does not on its own mean you have it. There can be many reasons why asthma is difficult to control, including allergies, stress or other medical conditions.

Asthma + Lung UK says that not taking your inhaler regularly and incorrect inhaler technique are common causes of uncontrolled Type 2 inflammation. When someone with difficult asthma sees their GP, the review covers problems like forgetting to take inhalers or avoiding medicines because of side effects, whether the inhaler is used the right way, avoiding triggers such as smoking or vaping or triggers at work like dust or chemicals, and mental wellbeing, because stress, anxiety and depression can make symptoms worse.

The GP will also consider allergies, including seasonal allergies like hay fever, and other conditions such as obstructive sleep apnoea, obesity, acid reflux, allergies and anxiety and depression, which can all make asthma difficult to control. If asthma improves with support and a good medicine routine, you do not have severe asthma. But your GP should refer you to a specialist asthma team if symptoms are still not well controlled after a review.

Asthma + Lung UK describes the signs of severe asthma as lots of symptoms like coughing, wheezing, a tight chest and breathlessness most days, frequent asthma attacks that can happen without warning, and difficulty controlling symptoms even with higher doses of medicine. It advises seeing your GP or nurse if you get lots of symptoms a lot of the time, need your reliever a lot, wake at night because of your asthma, find daily activities difficult or have frequent attacks.

The NHS says to see a GP if treatments are not helping, you are needing your inhaler more often or your symptoms are stopping you doing your usual activities or waking you at night. After an asthma attack that you have recovered from, it says to ask for an urgent GP appointment and be seen within 2 days to discuss treatment, even if you feel better.

The NHS says that if you are having an asthma attack you should sit up straight and try to stay calm, and use your reliever inhaler. With a blue reliever inhaler, take 1 puff every 30 to 60 seconds until you feel better, up to a maximum of 10 puffs, using a spacer if you have one. With an AIR or MART inhaler, take 1 puff every 1 to 3 minutes until you feel better, up to a maximum of 6 puffs. If your personal asthma action plan gives a different maximum, follow that.

Call 999 if you or someone else is having an asthma attack and starts to feel worse at any time, does not feel better after taking the maximum dose of reliever, or does not have an inhaler. If symptoms are no better after 10 minutes and an ambulance has not arrived, the NHS says to use the inhaler again, up to the same maximum dose. Do not drive yourself to A&E. The NHS says hospital treatment for a severe attack that does not get better may include oxygen through a mask, a nebuliser with high doses of medicine, and steroid tablets or injections.

Asthma + Lung UK says that specialist teams arrange tests to confirm or rule out severe asthma and to show what type you have, and that some tests may need to be repeated because results can differ with the time of day, with oral steroids or with smoking. Doctors may say your asthma is difficult to control for some time before confirming severe asthma, so specialists can be sure that the usual treatments have been tried and that other causes have been treated.

• Asthma Control Test: five questions about how well controlled your asthma has been over the last four weeks

• FeNO (fractional exhaled nitric oxide): if levels go down after regular use of a steroid preventer inhaler with good technique, you do not have severe asthma

• Blood tests: to check for inflammation or allergies and for levels of a blood cell called an eosinophil, which can help show which biologic therapies might suit you

• Allergy blood test (IgE): for people with allergy signs or symptoms

• Spirometry with a bronchodilator reversibility test: measures how much air you can breathe out in a set time and how well medicines are working

• Sputum test: a phlegm sample tested for eosinophils

• CT scan: gives more detail than a chest X-ray and can show what may be causing difficult symptoms

Asthma + Lung UK says you may be referred to specialist asthma care if your asthma diagnosis is unclear, your symptoms could be caused by another condition, or your GP thinks you have work-related asthma. A GP may also refer you if symptoms are hard to control even though you use your inhalers and medicines correctly, for example if in the last 12 months you needed two or more courses of steroid tablets or went to hospital or A&E at least once. It says very few people are referred to specialist asthma centres and that only a small number exist across the UK.

A specialist asthma centre must have access to a team of respiratory and other specialists, be able to offer specialist tests and treatments such as biologic therapies and bronchial thermoplasty, and be led by at least two consultant respiratory physicians with a specific interest in severe asthma. Asthma + Lung UK says its aims include confirming your diagnosis and type of asthma, identifying work-related triggers, treating linked conditions such as sleep apnoea and finding ways to avoid long-term use of high-dose oral steroids. To prepare, it suggests keeping a peak flow diary, a diary showing you have been taking your medicines and using your written asthma action plan, and a diary of symptoms, triggers and reliever use.

The NHS says that if you have severe asthma that is not controlled by inhalers and tablets you may be offered other treatments such as medicines that you inject, called biological therapies. Asthma + Lung UK says type 2 inflammation, linked to allergies or higher levels of eosinophils, is the target for some of these treatments, and that types of severe asthma include severe eosinophilic asthma, severe allergic asthma and non-eosinophilic severe asthma.

Asthma + Lung UK says specialist treatments like biologics are making a big difference to many people with severe asthma, but that living with severe asthma is linked to some risks and complications and can be linked to lower life expectancy. It says airway remodelling, where long-term inflammation and asthma attacks cause the airways to become narrower, scarred and inflamed, is more likely, and some people who have had severe asthma for a long time can develop COPD alongside it. Lower life expectancy is linked to getting older, poor living conditions, whether you smoke and how well your symptoms are managed, and it recommends talking to your specialist team about any concerns.

Asthma + Lung UK also notes that severe asthma may be considered a disability under the Equality Act 2010, which means you may be able to get financial support and benefits and ask your employer for adjustments. The NHS says you should have check-ups at least once a year, including checking your inhaler technique and that your asthma action plan is up to date.