Hi
I just wanted to know do doctors diagnose severe asthma on its own or does it always come with another diagnosis?
Also, in severe asthma how can you tell if it’s uncontrolled or is just being persistent i.e. having a bad day as persistent severe asthma can mean you need reliever frequently and also everyday.
thanks
Hi, it can definitely be diagnosed on its own, though of course people can have other conditions too alongside it and often do. Part of the diagnostic process for severe asthma though involves working out if or how much other conditions are contributing and trying to treat them. If asthma symptoms for example get much better and less frequent once someone is properly treated for reflux or dysfunctional breathing, or once they're away from an environmental trigger, then they probably don't have severe asthma.
The current definition is:
-On high dose inhaled steroids and at least one other controller/preventer medication (so eg Fostair 200/6 two puffs twice daily plus Spiriva plus maybe others)
- EITHER still poorly controlled -which is defined as at least one of: needing reliever inhaler more than 2-3x/week, had at least one hospital attendance for asthma in the last year, on continuous oral steroids, or had two or more doses of oral steroids in the last year
-OR if the level of medication as above were reduced the asthma would become poorly controlled
-This applies even once other factors or conditions have been addressed ie if the criteria above apply even once someone has been to physio, or treated their reflux, or moved out of a mouldy house, or stopped being around a cat they're allergic to
You may find these pages useful if you haven't seen them:
Putting this in a separate reply because it's important and it feels like even respiratory doctors can forget this and give wrong information: *you do not need to have raised eosinophils, high FENO, or high IgE to have severe asthma. Not all severe asthma (or all asthma full stop) is eosinophilic or allergic*. Bold is not aimed at you my_fairy but I feel like people are told this a lot so wanted to add it!
I think the confusion is because most of the biologic treatments for severe asthma until very recently have been for specifically severe eosinophilic or allergic asthma, and people tend not to be tested for the type of asthma they have, under current guidelines, until they're being assessed for severe asthma and whether they can have biologics.
I've just read a research paper though that says there's not really any difference in how people with eosinophilic and non-eosinophilic asthma present when they have an exacerbation - so whether or not someone has eosinophils should not be used to say whether their asthma is severe (and to be honest if they're on pred they probably won't have any anyway because oral steroids reduce eosinophils).
Thanks for taking your time to reply. I just was wondering as severe asthma is very complex so doctors have to keep a cushion of another diagnosis i.e. dysfunctional breathing or could this be on its own. We feel that they keep saying to take inhalers as and when needed but also keep saying it’s hard to identify dysfunctional breathing 😮💨. It’s been very hard since her diagnosis as she’s continuously kept under pressure to keep these diagnoses which ignores the fact of her breathing problems severity and we feel hard to explain to new doctors each time and could delay her treatment which makes her asthma worse and prompt treatment is crucial.
It’s a constant battle needs to be sorted everytime in hospital. Thanks hope you are good though. I am glad you are so helpful on this forum each time I am stuck and especially your symptoms are so similar to my daughters and I can relate so much.
Ah I did wonder if it was something like that when I read your post, but didn't want to assume!
What I posted above is the ideal, but it's definitely true that it's not necessarily followed! From my experience, and friends with severe asthma, the reality is that it's often impossible to ditch a diagnosis of dysfunctional breathing or vocal cord dysfunction (VCD, sometimes called inducible laryngeal obstruction, or ILO). But asthma will be questioned frequently.
Dysfunctional breathing is absolutely something that happens in severe asthma (and it's not the same as anxiety which I find it often gets confused with). But it's also totally possible to get it under control, and it doesn't mean there's no asthma alongside it that needs treating. For example, it's actually a recognised part of an asthma attack to breathe faster than normal, and that can show up in arterial blood gases as low carbon dioxide. Sometimes, doctors who don't know this can see the results and the faster breathing and dismiss it all as 'hyperventilation', not recognising this is caused by the asthma and happens in attacks.
Vocal cord dysfunction is also common with asthma and also misunderstood. I've seen a research paper suggesting that upper airway/vocal cord dysfunction in severe asthma is more of a protective mechanism gone wrong than a separate condition. Not necessarily a very useful one, but the body seems to think it can protect the lower airways by closing the upper ones a bit.
In both cases you can treat the issues though, but they seem incredibly hard to ditch as a diagnosis and a reason to question asthma. To be honest, I find it a bit ridiculous that doctors treating asthma, especially specialists, are saying it's hard to identify dysfunctional breathing. I've never met a respiratory physio who can't, and they're usually better at being sensible and not stating things in black and white eg everything must be either all asthma or all dysfunctional breathing. (I find respiratory doctors prone to that kind of black and white thinking).
Has your daughter seen a respiratory physio, and were they helpful? If not, it may be helpful for her to clear up any lingering issues and also so that the physio could perhaps help with telling doctors 'I've seen her, we've worked on this, I'm happy she's got it under control', or 'I don't feel this is an issue that's affecting things currently'. It's not a guarantee but it may be one thing you can point out, that she's worked on that and still not magically cured so maybe it's not the main problem.
I can't remember if I shared this post with you before but it might be helpful if not, just so you and your daughter can point out the differences if needed: healthunlocked.com/asthmauk...
I'd also point out that anxiety, if they're saying that's an issue, is natural in this situation. Plenty of people are naturally anxious when they can't breathe. That part doesn't make me anxious personally, but I still get anxious around medical people when I have asthma and need treatment, because they have been so awful in the past and dismissive when I needed help and I never know what I'm going to get.
Such a well informed,balanced reply Lysistrata.
Thank you 
Yes she’s seen many physios they don’t see a problem with her breathing but consultant level bureaucracy is unbearable… I’m trying to sort the medical side fingers crossed we find a good doctor who can actually listen to us … thanks
Yeah it doesn't always help sadly! I've also found an attitude among some doctors that they don't actually respect the opinions or expertise of nurses or allied health professionals if they dare to disagree with doctors.
If the physio had said once that your daughter did have dysfunctional breathing then that would come out to make a point, even if they'd worked on it with her. But if the physio says it's not an issue or has been resolved now, the message often seems to get lost. I got a doctor laying into me once for not trying at physio, and the physio was actually pretty annoyed with him because he hadn't actually bothered to ask her how I was doing before saying that. She felt I'd done as much as I could with her and she definitely felt I was doing the best I could, but it hadn't fixed things and the consultant (RBH adult) didn't like that.
I must sound very cynical to others reading this not familiar with the system and it doesn't always happen, but let's just say it happens a lot more than it should!
I do hope you get somewhere and find a better team for your daughter soon.
We have a physiotherapist in the family and to underline your statement on doctors not respecting other health professionals, I've heard their frustration with consultants and doctors who look on physio as nothing more that folk healing. Patients are referred quite late on in the process and physio reports to doctors aren't always given any weight in the treatment package for the patient. Doesn't help when management also take this view.
When I read the online blurb for my hospital respiratory team, it boasted of a respiratory physiotherapist, but getting a referral is nigh on impossible. Fortunately, a young team doctor thought it a good idea and it really helped me in my asthma self care in addition to the medication.
I just have severe poorly controlled asthma at present.
Bless you same with my daughter … it’s hard all the symptoms of tightness, wheeze and especially when she’s pain in attacks … please look into natural remedies along with your meds as they often seem to help … complimentary meds are promoted by nhs and asthma uk … do your own research and really see what makes a difference for you…
The approach depends on the season. Last night my wife turned on the central heating for the first time this autumn, so lots of dust. Never noticed this correlation before
So immediate severe asthma attack, but within an hour the air purifiers had got it back to tolerable limits.
Just adding my usual warning to anyone else reading to be careful with natural remedies, even if you're taking them alongside your asthma medication. They can interact with other medications (not necessarily for asthma) and have side effects and dangers of their own, including potentially being a trigger for asthma.
As with anything involving medication (or even things like opening the window at night or inhaling steam), the fact it's ok for someone else or seemed to work for them doesn't mean it will be the same for you (a general you to anyone reading).
I feel I need to say this because people tend to try natural remedies without necessarily asking for medical advice on it, whereas most people don't have easy access to prescription medication.
Anyone interested in looking into this may find this page from ALUK helpful, as it summarises the various different options and whether there's any good quality evidence for them (ie properly done research, not taken only from reviews from people who tried it or from poorly done trials with low numbers): asthmaandlung.org.uk/sympto...
For me it came with another diagnosis
But I don't think that's always the case but it does appear to be ridiculously common
Any advice on explaining severe asthma to doctors and nurses?
Adrenal Insufficiency - it is possible to recover with severe asthma? 
Severe infrequent asthma attack
