Many of you may have heard the adage "all that wheezes is not asthma." As an intern, a first year physician out of medical school, a colleague came across a case of what she thought was asthma. The child was the right age, right symptoms, and a pretty typical presentation. The only problem was she did not get better with the typical treatment. She eventually underwent a bronchoscopy, a special lighted, flexible scope is inserted into the lungs, and surprisingly the lung specialist found a mardi gras bead that was not showing up on x-ray! Happy Mardi Gras.
Photo (c) Getty Images
Never Discount the Severity of an Asthma Exacerbation
Asthma exacerbations can be life threatening and can occur in anyone with mild to severe asthma. Only 33% of asthma deaths occur in the hospital which means many asthma patients who die are either not seeking care or are not being hospitalized with their worsening asthma. Patients at high risk of asthma related death require intensive education and special care. Make sure you know if you are in one of the increased risk groups discussed below.
Importantly, 80-85% who die from asthma develop progressive symptoms over anywhere from 12 hours to several weeks. Only 15 to 20% die in less than 6 hours after developing symptoms. Thus, the vast majority of patients dying from asthma developed symptoms in a time frame that would have allowed them to seek appropriate medical care.
Risk Factors for Asthma Related Death
All of the following are risk factors for asthma related death:
- Previous history of a near fatal asthma event
- Recent poorly controlled asthma with increased shortness of breath, nocturnal awakenings, and rescue inhaler use
- Prior severe asthma exacerbation where you were intubated or admitted to an intensive care unit.
- Two or more asthma related hospital admissions or three or more visits to the emergency room for asthma
- Using 2 or more canisters of your short acting bronchodilator like albuterol in a month
- If you have trouble identifying when your asthma symptoms are worsening or you are having an asthma attack
- Being poor and from the inner city
- Substance abuse
- Significant psychiatric disease
- Other significant medical problems like a heart attack and other lung diseases
What Do I Do if I am at Increased Risk?
All of the following may help you reduce your risk of an asthma related death:
- Know that you are at risk
- Know your asthma action plan
- Make sure you understand your asthma action plan
- Use your asthma action plan
- Use your peak flow meter regularly
- Do not delay seeking emergency care if your symptoms worsen
- Tell your asthma care provider that you are at increased risk of an asthma related death
- Make sure you can effectively communicate with an asthma care provider effectively
Have you ever had a near fatal asthma attack? Why not go to the forum and tell us about it what it was like and how you are preventing it from happening again.
Current asthma guidelines recommend treatment with inhaled corticosteroids to treat chronic inflammation once you need more than periodic rescue inhaler use. Currently, there are no recommendations that one inhaled steroid is better than another and the choice is often based on price and convenience. That does not mean that there is not research or other recommnendations.
A study in the Journal of Allergy and Clinical Immunology compares fluticasone and beclomethasone over a one-year period. The researchers used a patient database to compare effectiveness of these drugs based on asthma control and the number of asthma exacerbations.
The study found that beclomethasone had either a similar or better ability to achieve asthma control at a lower dose than those prescribed fluticasone. This is despite claims that fluticisone is the more potent drug. One possible explanation is that beclomethasone has been engineered to have smaller particles that may allow more of the drug to get to your lungs. This study suggests that choice of a particular inhaled corticosteroid may, in fact, alter clinical outcomes.
The Cochrane Collaboration also analyzed a number of different studies, but came to a slightly different conclusion. At the same doses, fluticasone was slightly more potent, but patients also experienced slightly more side effects such as hoarseness (but not sore throat or oral thrush).
Consumer Reports has also weighed in and made recommendations based on a number of criteria such as cost, effectiveness, and safety record. Rather than say one is better than the other they point out a number of drugs that meet certain requirements.
While it's too soon to say for sure and further long-term comparison studies are needed, you may want to discuss this with your asthma care provider at your next visit.
Do you think you might benefit from participating in an asthma medical research study?
In the past I have discussed studies such as an outpatient procedure that uses a new treatment known as bronchial thermoplasty, or radiofrequency-generated heat, that may provide relief if you have severe chronic asthma. Asthma clinical trials are an important part of furthering the discovery process related to asthma. Without trials like this with human subjects we will not make treatment advances.
The goal of asthma medical research studies is to determine if a new treatment or procedure improves asthma outcomes and is safe.
Sometimes patients worry that they are being experimented on. However, everyone who participates in a clinical trial is a volunteer. Healthy volunteers participate to feel like they are contributing to science, while people with asthma might want to participate to get access to the newest treatments and the additional attention and care that you get in a clinical trial.
Clinicaltrials.gov can help you find just about any clinical trial that is currently enrolling patients. Do you have any questions about participating in medical research? What are your concerns or experiences? Please tell me what your experience was like or let me answer your questions about clinical trials in asthma.
What do you know about asthma and the Affordable Care Act?
When I first started writing about asthma and the Affordable Care Act, most asthma patients believed the law was good for their asthma. Interest groups such as the Allergy & Asthma Network Mothers of Asthmatics, a leading patient education organization, have lobbied to affect how the national healthcare law impacts allergy and asthma patients.
"Under ACA, many people with allergies or asthma will breathe easier," said Tonya Winders, AANMA chief operating officer, in a press release. "They are more likely to obtain cost-effective and much-needed preventive, primary and specialty care services."
Asthma patients on inhaled steroids and also taking a statin, a cholesterol lowering medication, may be as much as 33% less likely to be hospitalized or visit an emergency room in the next year based on analysis of insurance claims according to research that has bee presented at the American Academy of Allergy, Asthma, and Immunology. Additionally, hospitalization costs and ER costs were 18 and 43 percent lower, respectively.
A second study, however, did not find any benefit of statins related to asthma.
The relationship of statins and asthma remains an area of active research. Since these reports have been released, a number of other studies have been released with some supporting the idea that statins may improve asthma, while others have shown that asthma may become slightly worse.
We will keep an active eye on this innovative research area and keep you informed.
Other Asthma Research
- Do Asthma Specialists Improve Quality Care in Asthma?
- Can One Asthma Inhaler Treat My Asthma?
- What Is the Relationship Between Asthma and GERD?
Over the last several years, custodial/ cleaning staff have been noted to have an occupational risk because of increased reports of asthma and other respiratory illnesses. A study published online in Environmental Health has found that cleaning staff in hospitals are at risk for a number of different occupational exposures and that because of the properties of some the agents used by cleaning staff, other employees and even patients nay be at risk because of the duration of how long some of the agents remain in the local environment.
Anila Bello and colleagues preformed workplace interviews, reviewed product Materials Safety Data Sheets, reviewed the chemical properties of cleaning ingredients, and preformed occupational hygiene observational analyses in order to determine the occupational exposures of cleaning products used for common cleaning tasks in hospitals.
The investigators found a variety of different chemical compounds used for different tasks in the hospitals. Importantly, the authors concluded "There is evidence of exposures to respiratory and dermal irritants and sensitizers from cleaning products" and that "Hazardous exposures related to cleaning products are an important public health concern because these exposures impact not only cleaning workers, but also other occupants in the building."
Have you ever wondered why your asthma flares when in a certain building? It may be that while with good intentions, some sort of cleaning product is making your asthma worse.
What do you think? Have you ever noticed that your asthma tends to flare in certain building or that you have to use your rescue inhaler more? Leave a comment or go to the forum to join the discussion.
Studies of asthma have revealed that as may as 74% of asthmatics have nighttime awakenings at least awoke at least once per week, while as many as 64% may have nocturnal symptoms 3 or more times per week. Importantly, as many as 40% asthmatics experience symptoms nightly.
Asthmatics may under appreciate nocturnal symptoms as a sign of poor asthma control. In another study, 26% of patients who rated their asthma as "mild" reported experiencing asthma symptoms like cough, wheezing, and shortness of breath nightly.
It is important to recognize these nighttime symptoms as poor control because a significant proportion of fatal asthma in adults and children from respiratory arrest and sudden death occurs between midnight and 8 a.m.
Sutherland ER. Nocturnal asthma. J Allergy Clin Immunol. 2005 Dec;116(6):1179-86.
In addition to a number of other chronic diseases, Beethoven had significant asthma. According to the Faces of Asthma, while Beethoven was composing his musical masterpieces, the "bumbling doctors" of Vienna were unable to give him any relief from his asthma. Despite this, he was one of the world's most masterful composers.
Photo © Wikipedia user Kokin
A friend recently asked me if I thought their weight was impacting their asthma and would weight loss improve their symptoms. Not really knowing the answer, I said possibly and then went to review the issue in more detail. In the article "Does weight Affect Asthma" I discuss some of what we know. What I learned most is that there is very little research on the topic of weight loss and asthma outcomes. Unfortunately, we do not have any definitive answers on the impact of weight loss on asthma outcomes.
According to a study published in Annals of Allergy, Asthma & Immunology, the scientific journal of the American College of Allergy, Asthma and Immunology (ACAAI), rapid weight loss following bariatric surgery decreased prescription breathing medications by 50%.
The retrospective study examined pharmacy fill rates of asthma medication using insurance data before and on year after the 320 patients had bariatric surgery at Henry Ford Hospital in Detroit. While 324 prescriptions were filled before surgery, only 154 were filled one year after surgery.
A few smaller trials have shown improved asthma outcomes with more lifestyle modifications.