HYDERABAD: Over the last few years, there is a rise in asthma cases in respiratory clinics. Of every 100 patients who walk in, about 30% to 40% have varying severities of asthma. Amongst these, close to 5% have severe asthma, a number that appears to be increasing. I believe this is because of changes in lifestyle and the increase in pollution levels, both in the cities as well as the villages.
India has a large population of 18 – 20 million people suffering from asthma. Symptoms of asthma include cough and sputum production, difficulty in breathing, chest tightness and wheezing (a whistle like sound produced while breathing). The airways in people with asthma are narrower than normal which makes it difficult for the air to pass freely through them and this leads to feeling of breathlessness or chest tightness. The airways in asthma patients are hyper responsive to various stimuli in the atmosphere and these triggers provoke asthma symptoms. The mainstay of treatment for asthma is inhalation therapy and most asthmatics are prescribed inhalers for regular use.
What is severe asthma?
Upto 5 % of the asthmatics have ‘Severe Asthma’. In such patients, the symptoms persist despite using maximal dosages of inhalers. These patients are at a higher risk of repeated hospitalisations when they get an asthma attack. There are at least 1.6 lakh[ Soured from BSC press release on Alair launch in India] asthma patients in India who suffer from severe asthma. I am most concerned for the 5% patients with severe asthma because the condition impacts them physically as well as psychologically. They come in with a high level of frustration and simply want to ‘give up’, accepting that their condition has no treatment or cure. This is because medicines that are normally given for asthma relief do not do much for those with severe asthma, leaving them in deep fear of their next attack.
There is no one-shot approach to managing patients with severe asthma. We need to look at a combination of ‘interventions’ at multiple levels. In my view, in addition to prescribing medicines, the key interventions that doctors and patients must consider are as follows:
1) Avoid the trigger: Every asthmatic is well aware that exposure to certain triggers can bring on an asthma attack. These triggers range from common allergens such as dust and pollen to lesser known ones such as household mold or domestic pets. Knowing your triggers and avoiding them are absolutely critical for asthma control. Since these vary from person to person, doctors must urge patients to do an in-depth investigation to identify triggers that affect each individual.
2) Proper use of inhalers: The introduction of inhalers has entirely changed our approach to managing asthma, allowing better control of symptoms. Although inhalers are considered the first line treatment in asthma management, many patients are not shown the correct way to use them. This negates the impact of this treatment and increases the risk of uncontrolled asthma. This simple intervention of learning the correct technique can be a life-long boon for asthmatics.
3) Understand the emotional triggers: The psychosomatic aspect of asthma is a real but often ignored aspect of the condition. ‘Beliefs Can Trigger Asthma Attacks’ article shows that simply believing that a certain activity will trigger an asthma attack is sometimes all it takes to induce real physical symptoms! Doctors must encourage patients to examine and identify emotional triggers and report any instances of anxiety, depression and stress. There is now no doubt that treating the psychosomatic aspect of asthma can improve symptoms and enable better asthma control.
4) Identify and treat asthma co-morbidities: Many patients with asthma also have other co-existing medical conditions that can influence asthma control and response to treatment. This includes conditions such as allergic rhinitis, gastro-intestinal esophageal reflux disease (GERD), obstructive sleep apnea (OSA) and obesity. Identification and treatment of these co-morbidities is crucial to ensure proper asthma management and prevent worsening of symptoms.
Newer therapies for Severe asthma:
With the advent of newer modalities of therapies, the outlook for the patients with severe asthma has changed and is very encouraging. With these newer modalities, even the severest of asthma patients can be made to live a completely normal lifestyle.
Biologic therapies: These are newer drugs which control specific pathways of inflammation in asthma patients. Not all patients are eligible for such therapies. Patients are chosen if they have elevated blood levels of certain molecules (Ig E, Eosinophils). One such drug, Omalizumab, is available and is being used in India. Several other biologics are also planned to be launched in our market in the coming years.
Bronchial thermoplasty: This is latest treatment which has been approved by all the International Societies for the treatment of severe asthma. It is a minimally invasive bronchoscopic procedure performed on an out-patient basis, which uses heat energy to open up the asthmatic airways. The excessive smooth muscle in the airways which narrows the airway is reduced by this procedure. As a result, the air flows much easily and the symptoms improve significantly. All severe patients are eligible for this procedure and patient who fail biologic therapies may also be candidates for bronchial thermoplasty. There is a significant improvement in the quality of life and the effects of the procedure last for several years after the therapy.
(The author is a consultant pulmonologist, Yashoda Hospital)