What can be done for 'closing gaps in asthma care'

As the world is observing asthma day every hospital, Pulmonologist and every Respiratory Medicine society is busy making preparations for celebrations. I’m sitting in my Pulmonary Medicine OPD as usual, pondering over what I can do as an individual to “Closing gaps in asthma care”- as is the theme for World Asthma Day on May 3.

A well-dressed, mother- daughter duo walk in and greet me. The daughter had consulted me 2 weeks earlier with the history and symptoms typical of asthma. I enquire about her health status. “I was improving quite well initially, but when the tablets got over the symptoms came back with double the force,” said the daughter. I quizzed her about any other further triggering factors, about the correct use of prescribed medications and about the use of inhaler that I had suggested. I’m met with stone-cold stares and uncomfortable silence. “Her father is dead against inhaler use, Doctor. He’s sure that our daughter does not suffer from Asthma. None of us in the family has it!”’ says the mother. My heart sinks. The social stigma surrounding the diagnosis of ‘Asthma’ and the use of inhaled medications are ingrained within them.

Welcome to my world. Here’s a peep into what I deal with in a majority of my patients. Let me explain.

I had met them for the first time 2 weeks back when the younger of the two had reported symptoms of cough, chest tightness and wheezing since several years. Her symptoms were not permanent but recurred on and off at will. Sometimes precipitated by something as simple as a common cold, or a viral infection such as the regular flu, at other times by changes in weather, or exam tension and even at times by laughing out loud! Her parents had preferred indigenous systems of medicine and ensured a regular supply of non-descript round white pills for a while followed by strange concoctions and powders to keep their beloved daughter’s symptoms at bay, but in vain.

For every episode of symptoms she had, they somehow found out a causative reason and ensured steam inhalation, adequate number of days away from school and lots of tender loving care, explained her mother to me. In fact, they had even dared to venture out to a general physician in their locality, who had the audacity to advise tablets and inhalers! Bah! Inhalers! Who would want their beloved child to even try an inhaler and end up addicted to them! She exclaimed loudly.

I had taken time to explain to them that the girl is not suffering from simple ‘kapha kettu’ or chest congestion, as used in local parlance, but from ‘asthma’ . I had elaborated regarding the benefits of regular inhalers and tried my level best to explain away all the myths surrounding its use. My team had spent a good 20 minutes demonstrating the correct technique of using inhaler and counselled regarding avoiding allergens and triggers. But it was obvious now that we healthcare providers would have to repeat the whole cycle again in order to make patient’s understand it all.

What is asthma?
‘Asthma’ is a chronic disease of the airways that causes them to get inflamed, swell up, get narrowed constricted and produce excessive mucus.

Symptoms of asthma
Commonly an asthmatic attack begins with slight itching of the throat followed by coughing. For some people it may begin as a chest tightness which can progress on to severe difficulty in breathing, wheezing and light- headedness. Associated symptoms maybe swelling of face or lips if it is due to an allergic reaction; or sneezing and common cold symptoms if its associated with allergic rhinitis.

Coughing, wheezing and shortness of breath occurs more commonly during night or early morning. Typically, asthmatic symptoms occur intermittently over time or within the same day.

Triggers of Asthma
There are various allergic triggers for asthma. Indoor allergens, such as dust, dust mites, mold, and pet fur, feathers of hens, chicken or birds. Outdoor allergens, such as pollens and mold, dust. Emotional stress, laughing crying or anger. Exercise-induced asthma is triggered by physical activity. Infections, such as colds, influenza (flu), or COVID-19. Sometimes certain medicines, like aspirin precipitate or worsen asthma symptoms. In urban cities, poor air quality or very cold air can worsen asthma.

Diagnosis of Asthma
A proper history and physical examination followed by x rays of chest or paranasal sinuses may be required. Pulmonary function testing like spirometry, Fractional exhaled nitric oxide (FeNO) test and blood tests may be ordered in order to arrive at a diagnosis of asthma. Rarely CT scan of chest, bronchoscopy or other such tests may be required to rule out other disease that may mimic the clinical features of asthma

Management of Asthma
Allergen avoidance, keeping the home free of dampness and mold, avoiding air pollution as much as possible, and making a healthy weight a priority for you and your children are very important on the long run. Regular immunization for children and appropriate vaccinations against influenza, Pneumococcal pneumonia and COVID-19 too are a must in asthmatics

Medications can help prevent asthma attacks and also control symptoms on long term. Inhaled forms of such medications are preferred as they are given in tiny doses and are delivered directly to target site of action ie airways and lungs. Short-acting inhaled beta2-agonists (SABAs) or anticholinergics open the airways quickly so that air can flow through them during an asthma attack.  Oral corticosteroids help by reducing the inflammation swelling in your airways caused by severe asthma symptoms . Long-term controller medications and inhalers help in controlling severity of asthma and reducing frequency of asthma attacks. Newer biological or immunotherapy medications are useful in certain subset of severe eosinophilic asthma patients. Finally, newer methods such as Bronchial thermoplasty may help in severe asthma, when other treatments are not working. In this procedure, heat is applied to the muscles along the airways through a special bronchoscope .This makes them thinner and helps reducing symptoms of asthma.

Asthma is an easily diagnosed and manageable chronic lung disease, provided proper adherence to allergen avoidance and appropriate inhaler/ medications are used as per doctor’s advice.

(Dr Padmavathy R is a Consultant Pulmonologist, Meitra Hospital, Kozhikode)