Patient guide

1-1. What happens at the first visit?

According to the NHS, the doctor usually asks about your symptoms, listens to your chest and asks about smoking, a family history of lung disease and sometimes your weight and height. Then, depending on the situation, they may ask for a breathing test, an X-ray or CT scan, a blood test or another assessment. The NHS stresses that diagnosing asthma can sometimes take time because symptoms vary over time. So if you do not get a definite answer at the first visit, that is normal. Follow-up is part of the process.

If you bring a CT result or an X-ray, the doctor reads it together with your history and decides what is missing.

1-2. What documents should you bring?

• Films and reports of CT scans or chest X-rays, old and new. Both the written report and the film or CD. The “comparison” section of a CT report measures against earlier imaging (American Lung Association), so old results are useful too.
• The result of spirometry or any earlier breathing test. The NHS writes that this test is also used to follow lung disease and the effect of treatment, so an earlier result is useful for comparison.
• Your inhalers and spacer themselves, not just their names. The American Thoracic Society recommends taking your inhaler and spacer to every visit and showing your technique.
• A list of all your medicines. Tablets, inhalers, painkillers, herbal remedies and supplements. The NHS says medicines such as aspirin and ibuprofen (and beta-blockers) set off asthma symptoms in some people, so tell the doctor about every medicine you take.
• Allergies. To medicines, foods and especially if you have ever reacted to the substance injected for a CT scan (contrast) (NHS).
• A discharge letter if you have been in hospital for breathlessness or a lung infection.
• A written asthma plan, if you have one. The NHS says to bring it to every appointment.

If you do not have some of these, do not worry. The doctor will say what is needed.

1-3. What should you write down for the doctor?

Before the visit, jot down a few lines:

• The main symptom and when it started. How long has the cough lasted? Is it dry or does it bring up phlegm? The NHS regards a cough of more than three weeks as a reason to make an appointment.
• What makes it better or worse. Activity, cold air, night, dust, pollen, smoke or infection (the CDC and NHS regard these as common asthma triggers).
• Breathlessness. What starts it? For example, how many flights of stairs or walking uphill.
• If you have a reliever inhaler, how often you need it. The NHS suggests keeping a note of how often you use it.
• Smoking, hookah and smoke history. The NHS says the doctor asks whether you smoke or have smoked. This question is to understand the cause, not to judge. The CDC reminds us that hookah is not a safe alternative to cigarettes, so if you smoke hookah, say so.
• Job and workplace. WHO regards dust, smoke and chemicals at work as risk factors for COPD. The ALA also writes that in assessing interstitial diseases, exposure at work and in hobbies is asked about. If you work with dust, paint, chemicals, birds or mould, note it down.
• Family history. Lung disease, asthma or allergy in the family (NHS).
• History of lung infections. How many times have you had pneumonia or a chest infection?
• Fever or unexplained weight loss. The NHS counts unexplained weight loss among the reasons to be seen for a cough.

1-4. What should you ask?

For reviewing a CT report the ALA suggests these questions, and most of them suit any lung condition:

• What is my problem and what could be causing it?
• What test or imaging is needed and why?
• If I have brought a report, which finding in it matters? Is it new or was it there before?
• Do I need repeat imaging or follow-up? How far apart?
• If a medicine is prescribed, what is it for, how should it be used and for how long?
• Can the correct way to use my inhaler be seen and corrected here?
• What sign means I should get in touch sooner?

Write the questions down and note the answers. If you do not understand something, ask again. The ALA also writes that you should always go over results with your doctor to understand what they mean for you.

1-5. A few points

• Do not stop a medicine on your own before a visit or a test. About spirometry the NHS writes that you will be told whether you need to stop any medicine or inhaler. So ask, and do not decide yourself. Do not stop a controller inhaler because you feel better, and do not reduce or stop steroid tablets without your doctor’s advice.
• Antibiotics only on a doctor’s advice. The NHS says antibiotics do nothing for a viral infection. If you have leftover antibiotics from before, do not take them yourself.
• If you have not tolerated CT contrast before, or you are pregnant or might be, say so before any CT scan (NHS).
• If your symptoms are on the emergency list, do not wait for a visit. See the guide “When to call urgently”.

2-1. First of all

Lung tests fall into two groups. Some take pictures (a plain X-ray and a CT scan), and some measure how the lungs work (spirometry). A picture shows what the lungs look like, and spirometry shows how they work. A lung that looks healthy may work poorly and the other way round, which is why a doctor sometimes asks for both.

This page is general. The type of test, its timing and its preparation are set by your doctor and the centre doing the test. If the instructions you are given differ from this text, follow theirs.

2-2. Plain chest X-ray

What is it? The ALA and NHLBI describe it as a quick, painless test that shows the structures inside and around the chest.

What does it show? NHLBI says it helps diagnose and follow conditions such as pneumonia, heart failure, lung cancer and TB. The ALA gives a fuller list: fluid in the lung, COPD or emphysema, lung scarring and sarcoidosis. A doctor may ask for it because of a long-lasting cough, chest pain, coughing up blood, fever or breathlessness. About COPD, the NHS says a plain X-ray does not always show every problem.

Preparation: the ALA says you may be asked to take off jewellery and metal objects and wear a gown. It is done sitting, standing or lying, and you need to stay still and hold your breath for a moment so the image is not blurred.

Risk: NHLBI says the risk is low and the radiation is small. If you are pregnant or might be, tell the technician before the X-ray (ALA and NHLBI).

2-3. Chest CT scan

What is it? NHLBI describes a CT scan as a painless imaging test that takes detailed, slice-like pictures of the lungs and the inside of the chest. The NHS says it is used to diagnose a condition or follow how well treatment is working.

Preparation (NHS):

• The centre’s instructions may include not eating for some hours beforehand or taking certain medicines. Ask the centre and do not decide yourself.
• Take off jewellery, clothes with zips or buttons, and metal objects.
• Before the test, tell them if you are pregnant or might be, are breastfeeding, have asthma, kidney or thyroid disease or diabetes, or have ever had an allergic reaction to contrast.
• If you are afraid of enclosed spaces, you can ask your doctor about a calming medicine and ask someone to come with you.

What is contrast (dye)? NHLBI says that sometimes a contrast dye, often iodine-based, is injected into a vein in the arm. The NHS says you may feel warmth, a flushed face, a metallic taste or an urge to pass urine, which pass quickly. Sometimes an allergic reaction occurs. That is why you stay at the centre for up to about half an hour after the injection. Tell the radiographer if you feel unwell.

How long does it take? The NHS says usually 10 to 20 minutes, and an outpatient can usually leave soon afterwards, unless they have had contrast.

Radiation: NHLBI says the radiation from one test is usually less than what you naturally receive from the environment in about three years. It also says you should not have more CT scans than clinical guidelines recommend. Your doctor weighs the benefit and the risk for you.

The result: the NHS says a radiologist reads the images and writes a report for the doctor who sent you. The result usually takes one to two weeks and sometimes up to four weeks. If you do not understand the report, ask your doctor to explain it. There is also an article on this site about common words in the report: “What do the words in a lung CT report mean?”

2-4. CT pulmonary angiogram

Angiography means looking at the blood vessels. NHLBI describes a CT pulmonary angiogram (CTPA) as a test that takes pictures of the blood vessels of the lungs and looks for a blood clot in the lung, and calls it the main test for diagnosing a blood clot in the lung (pulmonary embolism). Warning signs that fit a clot in the lung, such as sudden breathlessness with chest pain, are an emergency and are listed in the guide “When to call urgently”.

If this test has been requested for you, ask why it is needed. The preparation, the need for contrast, kidney blood tests and precautions in pregnancy are explained by the imaging centre. The general points about contrast are in the section above.

2-5. Spirometry (lung function test)

What is it? The NHS describes it as a test that shows how much air you can breathe out in one breath and how fast. It is used to diagnose asthma, COPD and lung fibrosis, to follow treatment and sometimes to assess you before surgery.

Preparation (NHS; the centre may give different instructions):

• You may be asked not to smoke for 24 hours before, not to eat a heavy meal for at least 2 hours before and not to drink alcohol for at least 4 hours before.
• Wear comfortable clothes.
• Ask the centre whether you need to stop any medicine or inhaler before the test. Do not stop without asking.
• The NHS says the test is not safe if you have a chest infection, some heart problems, uncontrolled high blood pressure, a recent stroke or heart attack, or after some operations. So tell them before the test if you have any of these.

How is it done? (NHS and NHLBI) You sit, a clip is placed on your nose, you breathe in deeply and blow as fast and hard as you can into the tube of the machine. The NHS says you repeat the test two more times. Sometimes you are also given an airway-opening medicine and the test is repeated to see whether it changes (NHLBI). The NHS says the whole appointment usually takes no more than an hour.

Side effects: the NHS and NHLBI say you may feel light-headed or tired during or just after the test, which passes quickly.

The result: the NHS says a specialist reviews the result and sends it to your doctor, and you usually get it within a few weeks. If you hear nothing, get in touch. The result only has meaning when the doctor sees it together with your symptoms and examination, not on its own.

2-6. Other tests you may hear about

• Peak flow meter. NHLBI describes it as a small handheld device that shows how fast you can blow air out. The NHS says in asthma it is sometimes given to a patient to use at home for a few weeks for monitoring.
• Finger pulse oximetry. NHLBI describes it as a painless test with a sensor on the fingertip that estimates the oxygen in your blood.
• Allergy tests and blood tests. NHLBI says that if you have a history of allergy they are requested to find what you react to.
• FeNO. NHLBI describes it as a test that measures nitric oxide in the air you breathe out; a high level may be a sign of inflammation in the airways, and it does not need forceful breathing.

Do not be frightened of any of these. The aim of all of them is only to clarify the cause, and most of these tests carry little risk.

3-1. What is an inhaler for?

An inhaler delivers medicine straight into the airways. The NHS says that if the technique is not right, very little of the medicine reaches the lungs. The American Thoracic Society also says that even with the best technique about a quarter of the medicine may reach the lungs, and many people get less than 15 percent. This amount is often enough for treatment, but it shows why technique matters and why a spacer helps.

There are two main roles. The names and colours of devices vary. If you are not sure which is which, ask your doctor or pharmacist.

3-2. Controller and reliever inhalers

Controller (preventer). It calms inflammation in the airways. About beclometasone inhalers (a steroid inhaler), the NHS says it is a “preventer”, does not work immediately and must be used every day, even if you have no symptoms. Its full effect can take a few weeks. On its own this inhaler does not relieve an asthma attack that has already started.

Reliever. It relaxes the muscles around the airways for a short time and eases symptoms. NHLBI says it does not treat the underlying inflammation. The NHS says a blue reliever (such as salbutamol) should not be given on its own for asthma. If you need it a lot, control is not good enough.

Combination inhaler. The NHS says some patients have an inhaler that is used both daily to prevent symptoms and when symptoms appear, and others have an anti-inflammatory reliever that is used only when symptoms appear. Which one suits you is for your doctor to decide.

In COPD the NHS also says the first treatment is usually short-acting bronchodilator inhalers, and a steroid inhaler is usually given as a combination inhaler with a long-acting medicine.

3-2-1. When should you raise it with your doctor?

• The NHS says that if you need your reliever inhaler more than four times in 24 hours, or on three or more days a week, or at least one night a week, you may be getting worse and need different treatment. Raise this, non-urgently, at an appointment. If your need for it has suddenly gone up, see the guide “When to call urgently”.
• The NHS and CDC both say that if you need your reliever more and more, you should talk to your doctor.
• For beclometasone inhalers the NHS says to tell your doctor or nurse soon if symptoms have not improved after a week or get worse.

3-2-2. An attack and emergencies

If you have used your reliever as set out in your written plan and your breathing has not improved, or you have no written plan and the reliever has not helped, or your inhaler is not with you, or you cannot finish a sentence, call 115 (Iran’s emergency number). The full list is in the guide “When to call urgently”. How much and how often to use the inhaler in an attack is written by your doctor in your written plan, and this page does not change it.

3-3. A pressurised inhaler (MDI): step by step

This is the general method. Always read the leaflet that came with your inhaler too. These steps come from NHLBI and the ATS:

1. Take off the cap and shake the inhaler. If the device is new or has not been used for a while, prime it as the leaflet says (spray a few puffs into the air). The leaflet for that medicine says how many puffs.
2. Sit up straight or stand.
3. Breathe out fully, away from the mouthpiece.
4. Put the mouthpiece in your mouth and close your lips firmly around it.
5. As you start to breathe in, press the canister once and breathe in slowly and deeply. NHLBI says to keep breathing in for 3 to 5 seconds.
6. Hold your breath and count to 10 (ATS: 5 to 10 seconds). Then breathe out slowly.
7. If your plan says more than one puff, wait between puffs (sources differ: the ATS says 15 to 30 seconds and NHLBI says one minute, so follow what your doctor or the leaflet says).
8. Put the cap back on.
9. If it is a steroid inhaler, rinse your mouth with water and spit it out.

The ATS says the biggest mistake is not being able to breathe in at the same time as the puff. A spacer solves exactly this problem.

3-4. A spacer (holding chamber)

A spacer is a tube that holds the puff for a few seconds so you do not have to time the puff and the breath exactly. The ATS says that with correct use the amount of medicine that reaches the lungs can rise to about a quarter, and the risk of side effects such as a hoarse voice and thrush in the mouth is lower. The NHS says it is very helpful for young children.

Steps with a spacer (ATS and ALA):

1. Shake the inhaler, fit it into the opening of the spacer, and take the caps off both.
2. Breathe out, away from the device.
3. Hold the spacer mouthpiece in your mouth and close your lips (or place the mask over your nose and mouth).
4. Press once and breathe in slowly and deeply.
5. If the spacer whistles, you are breathing in too fast. Slow down.
6. Hold your breath for 5 to 10 seconds and breathe out slowly.
7. If another puff is needed, repeat.
8. If it is a steroid, rinse your mouth and spit the water out.

Looking after a spacer (ATS and NHLBI):

• Do not wipe the inside of the spacer with a brush or cloth.
• Do not put the canister under water.
• Replace the spacer when the rubber valve becomes stiff or brittle.
• Read the washing method on the leaflet, because some spacers pick up static charge and the medicine sticks to the walls.

3-5. Dry powder inhalers

Dry powder inhalers differ from pressurised ones. NHLBI says all of them need a fast, deep breath in, and each brand has its own way of loading (sliding a lever, pressing a button, twisting or inserting a capsule). Safety points:

• Do not shake it. The dose can fall out.
• Do not use it with a spacer.
• Do not breathe out into it. Breathe out away from the device.
• Do not keep it in the bathroom, because humidity makes it clog.
• Do not clean it with water. Wipe the mouthpiece with a dry cloth.
• Get a new device before the counter reaches zero.

After breathing in, hold your breath for about 10 seconds and then breathe out. If it is a steroid, rinse your mouth.

3-6. Rinsing your mouth after a steroid inhaler

The NHS says to rinse your mouth or brush your teeth after a steroid inhaler to prevent infection and soreness in the mouth. The ATS and NHLBI say the same. Do not swallow the water; spit it out.

3-7. Do not stop your medicines

• Do not stop a controller inhaler because you feel better. The NHS says it must be used every day even when you have improved and must not be stopped without talking to your doctor or nurse, because symptoms may come back. If you think you no longer need it, discuss it with your doctor. The decision is theirs.
• Do not reduce or stop steroid tablets on your own. The NHS warns that stopping suddenly can cause severe tiredness, nausea, dizziness and a return of symptoms.
• Antibiotics only on a doctor’s advice. In COPD the NHS also says a doctor prescribes them when there are signs of a chest infection.
• Steroid inhalers are not addictive. NHLBI says inhaled steroids are not addictive and are different from the steroids athletes use (anabolic). About the reliever, the NHS says there is no evidence that even years of use cause lasting harm to the body.
• If you are worried about side effects, raise it with your doctor instead of quietly setting the medicine aside. The NHS says that with correct use lasting side effects are unlikely and an inhaler delivers a smaller amount to the rest of the body. In children and teenagers on a high dose, height and weight should be monitored.

3-8. Storage and checking your technique

• Keep your inhaler with you (NHS: “always carry your inhaler”).
• Check the expiry date and the dose counter. The ATS says do not drop the canister in water or rely on the sound of shaking it, because neither is a correct way to know how much medicine is left.
• Return empty or out-of-date devices to the pharmacy (NHS).
• The NHS says if you are not sure, or it has been a year since anyone watched your technique, ask your doctor, nurse or pharmacist to watch. NHLBI also suggests reviewing your technique at every follow-up visit.
• A written asthma plan. The ALA describes it as a written sheet that you write with your doctor and that contains your medicines, warning signs and what to do. Always bring it with you.

4-1. What is a trigger?

Asthma means the airways are sensitive. The CDC says asthma is always there, but an attack happens only when something irritates the lungs. These things are called “triggers”. Triggers differ from person to person and you do not need to know them all. Treat the list below only as a guide for working out your own.

The CDC and NHS name these as common triggers: smoke (especially cigarette smoke), dust, mould, pollen, pets, cockroaches and pests, air pollution, cold and dry air, exercise, viral infections, acid reflux, some chemicals and perfumes, and some foods or medicines in sensitive people.

If you think your symptoms are not from asthma, or you are not sure, this page does not replace an assessment by a doctor.

4-2. Cigarette smoke, hookah and heaters

• Cigarette smoke. The CDC says if you have asthma nobody should smoke near you. The NHS also counts smoke among the triggers.

• Hookah. The CDC stresses that hookah is not a safe alternative to cigarettes, its smoke contains the harmful substances found in cigarette smoke, and the water in a hookah does not filter out the toxins. Hookah smoke is a risk to people around you too.

• If you smoke cigarettes or hookah yourself, there is no blame here. About COPD, the NHS regards stopping as the most effective way to prevent the disease getting worse and says even people with more advanced disease benefit from stopping. You can talk to your doctor about help with stopping.

• Heaters and water heaters. The NHS says carbon monoxide is colourless and odourless and comes from gas, oil, wood and charcoal appliances that are badly installed or not serviced. To prevent it:

  • Have heaters, fireplaces, water heaters and stoves serviced regularly by a professional.
  • Keep flues and vents open and in good condition.
  • Fit a carbon monoxide alarm.
  • Do not light a barbecue or a portable gas stove indoors or in a tent.
  • Do not leave a car running in an enclosed space.

  If you have a headache, dizziness, nausea, weakness or confusion that gets worse in a room with a gas-burning appliance, switch the appliance off and leave the house. Details are in the guide “When to call urgently”.

• Indoor air pollution. WHO says cooking and heating with biomass fuels (wood, animal dung, crop waste) or coal produces a lot of smoke and is a cause of COPD. If you heat your home this way, vents and ventilation matter.

4-3. Dust and mites

For dust mites the CDC suggests:

• Special allergen-proof covers for the mattress and pillows.
• Avoid feather pillows and duvets.
• Wash bedding every week and dry it completely.
• Use a vacuum cleaner with a HEPA filter regularly.
• Keep the humidity in your home low, about 30 to 50 percent.

For pollen allergy the NHS also says to wipe dust with a damp cloth and to vacuum.

4-4. Damp and mould

The CDC says breathing in mould can bring on an attack, even if you are not allergic to it. Advice:

• Dry wet things within 24 to 48 hours.
• Fix leaks quickly.
• If a ceiling or carpet has mould, replace it.
• Keep humidity below 50 percent. An air conditioner or a dehumidifier helps.
• Clean mould from hard surfaces with detergent and water and dry them completely.
• When you shower, turn on the bathroom fan or leave a window open.

4-5. Pests, pets and sprays

• Cockroaches and mice. The CDC advises removing sources of food and water, keeping food in sealed containers, putting rubbish in a lidded bin and sealing cracks. Avoid insect sprays and foggers, because they can themselves cause an attack.
• Pets. If you are allergic to an animal, the CDC says you may need to find it another home. If you do not want to or cannot: keep it out of the bedroom, wash it regularly, and use a HEPA filter and allergen-proof covers. The CDC reminds us the allergy is not to the fur itself, so cutting its hair does not help.
• Perfumes, detergents and cleaning products. The CDC counts chemicals and strong smells among the triggers. If a smell makes your symptoms worse, ventilate the room and stop using it.

4-6. Pollen and the seasons

For hay fever (pollen allergy) the NHS recommends:

• Keep doors and windows closed as far as possible.
• Shower and change your clothes when you come in from outside to wash off the pollen.
• Do not dry washing outdoors, because it catches pollen.
• Vacuum and dust with a damp cloth regularly.
• Do not bring fresh flowers into the house and, as far as possible, keep pets from coming in, because they bring pollen in with them.

The pollen season differs from one area to another. Ask your doctor when it is worst in your city. If allergy symptoms do not improve, or get worse, with medicines you can get without a prescription, the NHS says to see a doctor.

4-7. Air pollution and cold air

The CDC’s only specific advice about air pollution is to follow the air quality forecast. If your symptoms get worse on polluted days, ask your doctor what your plan should be on those days. The NHS counts cold air and pollution among the triggers.

4-8. Exercise, food and medicines

• The NHS recommends regular physical activity, and says if exercise brings on symptoms, talk to your doctor, who will tell you how to do it safely.
• Some medicines are triggers. The NHS says aspirin, ibuprofen and beta-blockers can bring on asthma symptoms in some people. Do not start another medicine without asking your doctor or pharmacist, and do not stop your other medicines without your doctor’s advice either.
• The CDC counts food and medicines as triggers in people sensitive to them. If you suspect a food, make a note and raise it with your doctor.
• Viruses such as influenza make asthma symptoms worse (NHS). Ask your doctor which vaccines suit you.

4-9. A written asthma action plan

The ALA describes it as a personal, written sheet that you and your doctor write. It usually contains:

• Your triggers.
• Your medicines, by name.
• The symptoms or peak flow number that show your asthma is getting worse.
• What to do in each situation.
• Signs that mean urgent help.
• Contact numbers for emergency help, your doctor and the hospital.

The ALA names three “zones”: green (no symptoms, carry on with your daily medicine), yellow (you have symptoms, use your reliever as set out in the plan) and red (severe symptoms or an attack, act as your plan says and, if you do not improve, get help immediately). The amount and type of medicine are written in the plan by your doctor, and this page does not change them.

Bring the plan with you, give a copy to your family and keep a note of how often you use your reliever. If you do not have a written plan, ask your doctor to write one at your next visit.

One reminder: do not stop a controller medicine because you feel better. Do not reduce or stop steroid tablets on your own either. Agree any change with your doctor.

5-1. Recovery takes time

After a lung infection the fever and feeling unwell usually go sooner, but the cough and tiredness take longer. This is normal and does not necessarily mean the treatment has not worked.

• About pneumonia, the NHS says most people feel better in 2 to 4 weeks, and about chest infection it says most symptoms ease in around 7 to 10 days but a cough and phlegm can last up to 3 weeks. For bronchitis the NHS also regards about 3 weeks as normal.
• The American Lung Association (ALA) says some people return to normal activity within a week and others need a month or more, and it may take weeks or even months to feel the way you did before. Cough, tiredness and breathlessness may continue while you recover. The ALA puts this down to inflammation, fluid and cell debris in the airways, which take time to clear.

If you have reached these time frames and the cough is still there, or you are worried, go to the section “When to see a doctor again” below.

5-2. What helps?

• Rest. The ALA and NHS both recommend resting at home until you feel better and slowly building activity back up. The ALA says to avoid doing too much and to ask when you can return to your usual routine.
• Fluids. The NHS and ALA recommend drinking fluids. The ALA says a warm drink or a steamy shower may make breathing easier.
• Cough medicine. For pneumonia the NHS does not recommend anti-cough medicine, because coughing helps the body clear the infection. The ALA also says not to take cough medicine without asking your doctor. On its cough page the NHS says cough syrups and medicines do not stop a cough and may only help a little. Honey and lemon have limited evidence and are not suitable for a baby under one year.
• Smoke. The ALA advises staying away from smoke (cigarettes, second-hand smoke, wood smoke) while recovering so the lungs have a chance to heal, and says this is a good time to think about stopping. The NHS also says that stopping smoking lowers the risk of pneumonia. This is not blame; every step helps, and your doctor can support you in stopping.

5-3. Antibiotics: only on a doctor’s advice

• The NHS says antibiotics are only for bacterial infections and do nothing for viruses (such as flu or viral bronchitis). So do not start antibiotics without a doctor’s advice, and do not use leftover medicine.
• If your doctor prescribes antibiotics, finish the course, even if you feel better quickly. The NHS and ALA both say this. The ALA says stopping early may let the infection come back and make the germ more resistant to later medicines.
• The NHS says if you are no better after 2 to 3 days of antibiotics, contact your doctor.

5-4. When to see a doctor again

The same day (NHS on pneumonia and cough): the fever has come back, chest pain when breathing or coughing, breathlessness, yellow or green phlegm, a very bad or quickly worsening cough, a few streaks of blood in the phlegm if you do not have pneumonia. The ALA says if your breathing is getting worse instead of better, get in touch right away. If you have bronchiectasis and develop signs of infection such as a fever, the NHS says to contact your doctor soon.

Urgent, call 115 (Iran’s emergency number): you cannot finish a sentence, your lips or skin have turned blue or grey, you are coughing up a lot of blood (or any blood if you have pneumonia, NHS), or you suddenly feel confused. The full list is in the guide “When to call urgently”.

Within this week: a cough of more than three weeks or unexplained weight loss (NHS). The NHS also says that if you are pregnant, over 65, have a weakened immune system or long-term heart, lung or kidney disease, you should speak to a doctor sooner with a chest infection.

Whether a follow-up X-ray or blood test is needed after pneumonia is for your doctor to decide. In their texts, the NHS and ALA do not give a set time for a follow-up visit.

5-5. Other reasons a cough lingers

If the cough is still there after a few weeks, the cause may not be the infection itself. The NHS names these causes of cough: smoking, acid reflux, allergy such as hay fever, infections such as bronchitis and mucus dripping from the back of the nose. The NHS says a cough is rarely a sign of something serious such as lung cancer, but a cough of more than 3 weeks should be shown to a doctor. The NHS and CDC also write that viral infections can make asthma symptoms worse. So if after a cold you have wheezing or a cough at night, tell your doctor. More is in the article “How long is a cough normal after a cold or infection?”.

5-6. If infections keep coming back

Several episodes of pneumonia or chest infection in a year are a reason for assessment, not something to put up with. About bronchiectasis the NHS writes that a lot of phlegm can lead to repeated chest infections, and that it is diagnosed with tests such as an X-ray, a breathing test, a phlegm sample and then a CT scan. What the reason is in your case is for your doctor to decide. Bring your records (films, reports, a list of the antibiotics you have taken) to the visit.

5-7. Vaccines to ask your doctor about

• Flu. The NHS says an annual vaccine is recommended for people with a long-term breathing condition, because flu can be serious, and it needs repeating every year.
• Pneumococcal. The NHS recommends it for people at higher risk, including those with a long-term breathing condition, and says it protects against serious bacterial infections such as pneumonia and meningitis. The ALA recommends it for all adults aged 50 and over and for those aged 19 to 49 with a long-term condition such as asthma, COPD, diabetes and heart disease.
• These recommendations come from other countries and the vaccine schedule differs from place to place. Ask your doctor which vaccine, at what age and at what interval suits you.

5-8. If your doctor says it is TB

TB is treated with antibiotics. The NHS says medicine is usually needed for at least 6 months and you must finish the treatment even when you feel better, because if it is stopped early the TB may come back. The NHS stresses that anyone can get TB. So there is no need to hide the symptoms or give up treatment out of fear of other people’s judgement. Ask your doctor or TB treatment centre anything you want to know about the medicine and follow-up.

6-0. First of all

Most of the time a worsening cough or breathing problem can be assessed by your doctor at an ordinary appointment. But there are a few situations where you should not wait. This list does not cover everything and does not replace seeing a doctor. If you are worried or not sure, call. It is better to call without need than too late.

In Iran the emergency number is 115. If you are unwell, do not drive yourself. Take the medicines and inhalers you use with you.

There are three groups. The first means call 115 now, the second means be seen the same day, and the third means speak to a doctor this week.

6-1. Call 115 now

If you have any of these, or someone with you does, call. Do not wait for your own doctor to reply or for an appointment.

6-1-1. You cannot finish a sentence

The NHS says if breathing has become very hard, you are gasping or you cannot speak, you should call emergency services at once. If you have to stop for breath after a few words, do not wait.

6-1-2. Lips or nails have turned blue, grey or very pale

The NHS regards a blue, grey or very pale colour of the lips and skin as an emergency sign and says that on brown or black skin this change may be easier to see on the palms. Look under the nails and inside the lips too.

6-1-3. The reliever inhaler is not working

If you have used your reliever as set out in the written plan your doctor gave you and your breathing has not improved or is getting worse, or you have no written plan and the reliever has not helped, or your inhaler is not with you, call. The NHS says the same in an asthma attack. Until help arrives:

• Sit upright and try to stay calm.
• If you have a spacer, use it with your inhaler and follow your written plan.
• If ten minutes have passed, help has not arrived and you are not better, the NHS says to use the inhaler again. The amount is the one in your written plan.

6-1-4. Sudden breathlessness with chest pain, or with swelling and pain in one leg

The NHS says sudden breathlessness, chest pain or pain in the upper back, a very fast heartbeat or fainting can be a sign of a blood clot in the lung and needs urgent treatment. If one leg (usually the calf) is swollen and painful, warm or red, and you have become breathless or your chest hurts, a clot may have travelled from the leg to the lung. This should not be managed at home. Also call if you are breathless and your chest feels tight or heavy, or you have pain that spreads to your arms, back, neck or jaw (NHS).

6-1-5. Coughing up a lot of blood

About bronchiectasis, the NHS says if you cough up more than a few spots or streaks of blood, emergency services should be called. If there is a lot of blood, or it comes with breathlessness and chest pain, call 115. The NHS also lists coughing up blood among the emergency signs of pneumonia, so if you have pneumonia, call 115 even for a small amount. (Otherwise, a few small streaks of blood in phlegm belong in the second group.)

6-1-6. Sudden confusion or severe drowsiness

If you suddenly feel confused, or the person with you is hard to wake and does not answer properly, call 115. The NHS counts sudden confusion as an emergency sign in pneumonia, breathlessness and carbon monoxide poisoning. The NHS reminds us that confusion is common in older people with pneumonia.

6-1-7. Suspected carbon monoxide poisoning (gas from a heater, water heater or fireplace)

The NHS says carbon monoxide has no colour or smell. Headache, dizziness, nausea, weakness, confusion, chest pain and breathlessness are among the signs, and they may get worse in a room with a gas-burning appliance. A heater, fireplace, water heater or gas heater that is not properly installed or serviced is a source.

• If you can, switch off the suspect appliance and leave the room or the house right now. Do not go back until you have been advised.
• If you have breathlessness, confusion, fainting, weakness or chest pain, or someone in the house does, call 115.
• If the signs are mild but you suspect poisoning, a doctor should see you the same day.

6-1-8. Fever and severe breathlessness

A fever with breathlessness that is there even at rest, or blue lips, confusion or being unable to speak, means severe pneumonia is possible. Call 115. (A fever with milder breathlessness belongs in the next group.)

6-2. Be seen the same day

These are usually not a matter of minutes, but they should not wait until tomorrow. Go the same day to a doctor, a clinic or a hospital emergency department. If any of the signs above appear on the way or at any moment, call 115.

• Fever and breathlessness, even mild. For pneumonia the NHS says a cough of a few weeks, yellow or green phlegm, pain that comes with breathing and coughing, and a feeling of breathlessness should be seen soon.
• A few streaks of blood in the phlegm. The NHS puts this in the urgent group, but not 115. The same goes for TB, in which coughing up blood is one of the main symptoms.
• A cough that is severe or quickly getting worse, a constant cough that will not stop, or chest pain (NHS, cough).
• More breathlessness than usual in someone with asthma, COPD or bronchiectasis, or signs of a chest infection such as a fever (NHS).
• Pain and swelling in one leg without breathlessness. For this the NHS advises being seen the same day, because a blood clot needs to be assessed quickly. If breathlessness or chest pain develops too, call 115.
• Suddenly needing your reliever more than usual, or newly waking at night with a cough and wheeze. The NHS says to see your doctor when you need the inhaler more often or symptoms wake you at night. If the change is sudden, do not leave it to another day.

6-3. Speak to a doctor this week

• A cough that has lasted more than three weeks. The NHS says a cough usually clears up by itself in three to four weeks. If it has not, whatever the cause (allergy, reflux, smoking or something else), it needs assessment.
• Unexplained weight loss, fever and night sweats, or tiredness that has no explanation.
• Breathlessness with activity that has gradually increased, or gets worse when lying down.
• Repeated wheezing or night-time cough, or symptoms that stop you doing your usual activities.
• Swollen ankles with breathlessness (NHS).
• After any asthma attack, even if you have recovered. The NHS says to see a doctor within two days so your treatment and the risk of another attack can be reviewed.

6-4. If you cannot reach your own doctor

This happens most often at night, on holidays, or when the number does not answer.

• For the signs in the first group, do not wait for your doctor to reply. Call 115.
• For the signs in the second group, go the same day to the emergency department of the nearest hospital. Your own doctor does not need to be there.
• If you do not know which group your signs fall in, choose the more cautious side and go to the emergency department.
• Take with you: all your inhalers and medicines, reports and imaging films, your written asthma plan, and a list of your medicines and allergies.
• If your doctor replies later, tell them the result.

6-5. A few points to remember in a crisis

• Do not stop a controller medicine on your own, and if you take steroid tablets, do not reduce or stop them without your doctor’s advice. The NHS warns that stopping steroid tablets suddenly has side effects.
• Start or stop antibiotics only on a doctor’s advice. The NHS says antibiotics do nothing for a viral infection and, if a doctor prescribes them, the course must be finished.
• If you have TB or suspect it, there is no need to hide symptoms out of fear of stigma. The NHS says anyone can get TB and it is treated with antibiotics, as long as the course is completed.