Despite multiple treatment modalities why is asthma still a dilemma

Another World Asthma Day is here and it is the time to ponder more on Asthma. Despite being a disease described for a long time and various disciplines of medicine offering multiple treatment modalities, it remains a significant global burden. According to the global burden of disease (GBD, 1990-2019), the total Asthma burden in the world is 262 million with India contributing a major 13.09%, i.e., 34.3 million. Asthma takes up a huge proportion of 27.9% of disability-adjusted life years (DALYs) in the Indian population. The picture is more alarming when we realize the fact that India has three times higher mortality and more than two times higher DALYs compared to the global proportion of asthma burden. And, these statistics pressurize the need for more discussion on Asthma.

Asthma is one of the most underdiagnosed diseases in this part of the world. Recognizing asthma symptoms early is a crucial step in management. A lot of asthma patients are overloaded with unnecessary treatments including antibiotics. The prime reason for this is the fact that acute symptoms of asthma are always misinterpreted as chest infections leading to the inadvertent use of antibiotics. The cardinal symptoms of Asthma are cough, wheezing, shortness of breath and chest tightness.

These symptoms usually vary over time and in intensity and are worsened by triggers. There are thousands of triggers mentioned in studies, out of which common ones are house dust, mite, pests, cold, pets, mold, viral infections, pollen, smoke, dust, etc. Even a strong emotion like laughter or cry, exercise, some medicines, humid weather, food additives, and fragrances can also trigger an asthma attack. Triggers vary from person to person, too. Asthma being a reversible airflow obstruction condition, those affected can have intermittent symptom-free periods.

In the post covid era, many presents to physicians with coughs. Many coughs which are tagged as long-haul Covid-19 are in fact, underdiagnosed Asthma. Covid19 is well known to unmask allergic symptoms, leading to more asthma attacks after covid19. Like any viral infection, asthma can be triggered by covid19. Consulting a pulmonologist at the right time can prevent unnecessary investigations and treatment. Spirometry, peak flow meter and chest X Ray are common armamentarium for pulmonologists to diagnose or rule out Asthma.

The general public often considers only continuous severe breathlessness as Asthma, whereas recurrent dry cough or intermittent chest tightness are ignored which leads to the progression of the disease.  Hence, a tag of “Asthma” is not accepted, when a chest physician diagnoses it. The above-mentioned study found that only 71% of doctors refer to “Asthma” as the name of their disease and 29% use other terminology. When it comes to the patient level- only 23% of asthmatic patients mention their disease as asthma while rest of them use terms like infection, swas, dama or cold, cough or respective terms for cough in their regional language.

Inhaler therapy is the best evidence-based asthma treatment modality. Inhaler phobia, especially in the Indian population is considered as one of the reasons for the high morbidity and mortality. Asthma is often considered a stigma and many parents/subjects are reluctant to reveal the disease. It leads to avoidance of medications and/or medications are taken only when a patient is severely symptomatic. Unscientific public notions such as inhalers are harmful and habit forming also play a major role in treatment non-adherence.

Improper inhaler technique is yet another unmet problem in asthma management. With a lot of inhaler devices in the market, patients may get confused with the devices and its technique. There should be “Know your inhaler” counters manned by respiratory therapists or nurses in all Respiratory Outpatient clinics. Improper technique is in fact the most common cause of uncontrolled asthma. Overuse of emergency reliever medications like salbutamol (commonly known as Asthalin) is also a headache for pulmonologists. It is aggravated by the practice of sos nebulisations as well as over-the-counter buying of emergency asthma medications.

Overuse of emergency medications via an inhaler or Nebuliser increases allergic responses and airway inflammation and reduces bronchodilator response when it is needed. Studies reveal that use of more than 12 canisters of 200 doses of Salbutamol is associated with an increased risk of Asthma-related death. Non-adherence to medications is a pitfall in the management that can only be prevented by proper patient counseling. Frequent exacerbations despite proper medications and adherence are common in clinical practice. Addressing modifiable risk factors for exacerbation is a major step. Concomitant allergic rhinitis, obesity, gastroesophageal reflux disease, food allergy, anxiety and depression are the major culprits responsible for uncontrolled symptoms.

(Dr Sujith Varghese Abraham is pulmonologist, Department of Respiratory Medicine, KIMSHEALTH, Thiruvananthapuram)