EXPERT PATIENTS (asthma)
Asthma is a reversible reduction in the diameter of small air tubes in the lungs. When severe, the shortness of breath can be extreme or even fatal. The difficulty moving air is more obvious while breathing out rather than when inhaling. People who are susceptible to asthma have hyper-reactive airways, which go into spasm and resist airflow from minor amounts of irritation or inflammation which does not affect the rest of us. Examples of irritants are allergens such as ragweed, pollen, cat dander, house pets, and non-allergic irritants such as smoke and chemical fumes. Even cold air and severe exercise occasionally causes airway constriction and can produce asthma in some individuals.
The goal in treatment is to control the asthma completely. This is illustrated by the occasional expert asthma patient who is also capable of Olympic athletic performance. This requires the athlete to learn to completely control the irritable airways throughout training to permit a competitive performance. Too many non-expert asthmatic patients believe that the treatment is habit forming. Compare with a diabetic patient trying to wean off insulin. Gradually, we are training non-athletic asthma patients in the fine points of control, a large health benefit even though they will never care to compete athletically.
The medications, which control asthma immediately, are related to adrenalin. To avoid serious side effects, the dose must be limited to quantities not much greater than occurs from the normal function of the adrenal glands, which produce adrenalin to improve our ability to fight or run regardless of asthma. Many patients who do not dream of taking a handful of pills, of which the dose is one or two, don’t think twice about similar overdose of medicine inhaled as a spray, especially since the instantaneous benefit is so obvious.
We do have long acting medications, which reduce the need for quick acting sprays to emergencies or in anticipation of an athletic workout in people subject to asthma induced by strenuous exercise. It is easy to stop taking these long-acting remedies. Some of them are even administered by spray. Most of these are cortisone derivatives which act locally in the bronchial tree to reduce inflammation and the irritability previously mentioned. It takes sophistication to use a spray which seems useless for acute attacks. My directions for these medications frequently state “inhale two puffs twice daily for three weeks after all asthma”. In other words, if you have asthma more than every three weeks, you use these long acting sprays all of the time. We also have long-acting medicine taken in pill form. These are easy to stop taking because of no immediate consequences, and because of expense, and in the case of one long-acting available medicine the need for occasional blood tests to avoid overdose.
Our expert asthma patient almost never visits the hospital emergency room because of uncontrolled asthma. This is because his careful use of the long-acting remedies leaves him with an “ace in the hole”, the additional quantity of immediate acting spray, which he is entitled to use without the risk of overdose. This gets him through a long weekend permitting him to see his regular physician, a convenience for all concerned. Our expert asthma patient also has a peak flow meter into which he blows occasionally to detect traces of asthma before any symptoms. This permits him to adjust his medication to be absolutely free of asthma almost all of the time.
Ten or fifteen years ago in an effort to help asthma patients be more self sufficient, Great Britain permitted the sale of the adrenalin type of sprays without a doctor’s prescription. This permission was revoked after a year or so because of an increase in the mortality rate for asthma noticeable in the statistics for the entire country. With more opportunities to be educated when refilling their medications, the public’s use of the long-acting remedies became more appropriate and the excess mortality ceased.
I have written this not primarily as a handbook for asthma patients but for the general public. Asthma is a common disease already, and its incidence is increasing. Widespread knowledge of the principles of treatment of asthma will enhance its effective control in subtle ways such as tactful admonishment by friends and relatives of patients. High blood pressure and its treatment is now much better understood by the general public than was the case a decade or so ago resulting in more affective treatment. There is no sharp line dividing expert patients from an expert public.
John A. Frantz, M.D.
Chairman, Monroe Board of Health
July 4, 2002