Original title: Working hard to keep asthma attacks at bay

When he woke up at 3am, desperately gasping for air, he knew he had to get to a doctor straightaway.

“I was like a goldfish, opening and closing my mouth,” said retiree Daniel Leong, 68, recounting his most severe asthma attack eight years ago.

“I didn’t want to wake my wife, so I took a cab. I managed to tell him in between breaths “si pai por” (a Hokkien term sometimes used to refer to Singapore General Hospital or SGH).” He was hospitalised – not the first time for such an attack.

Mr Leong was diagnosed with adult-onset asthma some 14 years ago. He has been taking medication to control it.

Asthma affects the airways of the lungs. Some attacks are severe enough to require a stay in the intensive care unit (ICU).

In some cases, it can kill.

In Singapore, the prevalence of asthma in adults is at 5 per cent, and in children, 20 per cent.

A recent study has shown that 18 per cent of university students have self-reported asthma.

Over the years, more allergies, including asthma or that of the skin, have been detected, noted Associate Professor Mariko Koh, a senior consultant at SGH’s department of respiratory and critical care medicine.

“We believe that it is because of urbanisation and living in a very hygienic environment since a young age,” she said.


A sanitised living environment can pose a problem.

“We are no longer swimming in rivers and playing with mud,” said Prof Koh. “We are not exposed to a lot of bacteria and parasites, so our immune system switches from fighting infections to allergies.

“It’s the hygiene hypothesis and it’s a global trend.”

The usual asthma triggers are infections such as flu, or environmental pollutants such as smoke and air fresheners, added Prof Koh.

Dr Jim Teo Yeow Kwan, a respiratory physician at Parkway East Hospital, said the possible triggers in tropical Singapore are those like dust mites and mould.

“We are also seeing asthma triggers by dog and cat danders.”

The most common triggers are still upper respiratory tract infections.

He said: “If you have asthma and you get a cold or flu, your risk of asthma exacerbation is very high.

“It is advisable to vaccinate the asthmatics against influenza, pneumococcus bacteria and pertussis (whooping cough).”

He also advises his asthmatic patients to do a simple 20-minute skin prick test for allergies. “From there, we can confirm allergy to dust mites, mould, grass, cats, dogs, et cetera. Once we are definite on the triggers, we can take precautions to reduce allergy exposure.”

Asthma attacks can be unpredictable and may occur even if a patient has no day-to-day symptoms, said Dr Tay Tunn Ren, a consultant at the department of respiratory and critical care medicine at Changi General Hospital (CGH).

At CGH, about 30 per cent of asthma patients have symptoms that are severe enough to require admission, he said.

Hence, asthma patients should take their preventers – inhaled corticosteroids – daily even when they feel well, Dr Tay added.


The problem is that some asthma patients are either over-reliant on relievers (commonly inhaled salbutamol) or not using their preventers daily, said Dr Tay.

Relievers are short-acting bronchodilators meant to be used on an as-needed basis to temporarily relieve asthma symptoms.

The overuse of relievers has been associated with asthma deaths. Patients often use their relievers instead of preventers, or use their relievers on a daily basis, said Dr Tay.

Many use their preventers only when they feel unwell, even though asthma is a chronic condition that requires regular use of medication to keep it under control.

As asthma symptoms can be intermittent, patients can be well in between attacks, and this can last for weeks or months, said Prof Koh.

“A lot of patients then become complacent and stop the medication on their own. But they could be exposed to an allergen and end up in ICU or die.”

Prof Koh said the preventer is to be used on a daily basis to reduce the inflammation in the lungs and the likelihood of the lungs constricting.

“It’s the most important treatment for asthma. It reduces asthma mortality and asthma attacks, and improves lung function and symptoms,” she said.

“We find that a lot of patients just use Ventolin for temporary relief and think that it is OK.”

But the reliever, like Ventolin, is only for temporary relief.

“If they have an asthma attack, we ask them to use it to open their airways,” said Prof Koh.

Those who use only relievers are at high risk of death as they are not treating the asthma, she said.

Among those who end up in ICU here, about a quarter were using only the relievers. “Some of them die on arrival or in ICU because the inflammation in the lungs is not treated,” said Prof Koh.

She shared a case of a patient in her 50s who had shortness of breath for many months but did not seek help. The woman bought overthe- counter Ventolin and also used her housemate’s Ventolin inhaler.

“She ended up with a severe attack and eventually died. Her husband wanted her to see a doctor but she was reluctant,” said Prof Koh.

Instead, she went through one or two Ventolin inhalers a month.

The use of more than one canister a month has been associated with fatalities, as this shows that the asthma is not well controlled, said Prof Koh.

There are new developments in asthma management, including bronchial thermoplasty where thermal energy is used to heat up the smooth muscles in the airways through a probe, for selected cases.

However, Dr Teo believes most asthma can be controlled without expensive medicine or procedures.

“Most importantly, patients need to be educated properly about the chronicity of their diseases, reduce their allergy triggers and be compliant with the daily inhalers that are prescribed to them.”

As Prof Koh stressed: “Don’t take asthma lightly. Patients need to take their controller medication and come back for regular followups. It is a chronic disease.”

No need to avoid any specific food: Experts

While some people believe that asthma can be controlled by avoiding food triggers, that is often not the case. There is no cure for asthma but it can be controlled by medication.

In Singapore, while it is common to hear of asthmatics avoiding food triggers such as cold drinks or spicy food, there is no conclusive evidence of the benefits of doing so, said Associate Professor Mariko Koh, a senior consultant at Singapore General Hospital’s department of respiratory and critical care medicine.

Dr Tay Tunn Ren, a consultant at Changi General Hospital’s department of respiratory and critical care medicine, said “there is generally no need for avoidance of any specific food in asthma, unless the patient has a known food allergy. Food and food additives rarely trigger asthma”.

Regular exercise can help reduce your asthma symptoms but there are no specific exercises that asthmatics can do to prevent asthma attacks.

“There is no evidence to suggest that one form of exercise is superior to another in patients with asthma,” said Dr Tay.


If you are 12 years old and above, you can take the Asthma Control Test to find out if your asthma has been kept in check over the past four weeks. You can discuss your results with your doctor.

In the past four weeks, how often did your asthma prevent you from getting as much done at work, school or home?
All of the time – 1
Most of the time – 2
Some of the time – 3
A little of the time – 4
None of the time – 5

During the past four weeks, how often have you had shortness of breath?
More than once a day – 1
Once a day – 2
Three to six times a week – 3
Once or twice a week – 4
Not at all – 5

During the past four weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?
Four or more nights a week – 1
Two to three nights a week – 2
Once a week – 3
Once or twice – 4
Not at all – 5

During the past four weeks, how often have you used your rescue inhaler or nebuliser medication (such as albuterol)?
Three or more times per day – 1
One or two times per day – 2
Two or three times per week – 3
Once a week or less – 4
Not at all – 5

How would you rate your asthma control during the past four weeks?
Not controlled at all – 1
Poorly controlled – 2
Somewhat controlled – 3
Well controlled – 4
Completely controlled – 5

Tally your scores. If your total score is 19 or less, your asthma may not be under control.