Dr. Qaadri

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Medical Post Asthma Interview

By Dr. Shafiq Qaadri, MD

She wheezes regularly, feels breathless easily, wakes up at night with coughing spells and almost feels disabled by her weak lungs. "My asthma's fine, doc," says the 45-year-old patient. What she means is she hasn't recently visited an emergency room for an asthma attack.

Like too many other asthma patients, she just muddles through with treatable symptoms: According to the Asthma in Canada Survey, 57 per cent of the country's two million asthma sufferers find their conditions poorly controlled.

"There's still a gap between what doctors are prescribing, what patients are using and where we need to go," says Dr. Ron Grossman, a leading respiratory specialist, and chief of medicine at Credit Valley Hospital in Mississauga, Ont.

So why do people settle for such poor control of their asthma?

There are several reasons: Many people don't know they have asthma, thinking they're destined to have recurrent chest colds. Others resist the diagnosis and seek relief with cough syrups, lozenges and home remedies. Still others don't take their medications as directed, or their doctors haven't prescribed the most suitable inhalers at the right dosage.

"Many Canadians tolerate serious asthma symptoms because they have come to accept them as normal," says the Asthma Society of Canada. "They suffer needlessly."

Thus asthma remains a major health problem affecting quality of life and is one of the leading causes of emergency-room visits in Canada, with 500 people a day seeking urgent care.

What is asthma? Normal breathing allows air to flow in and out of the lungs freely, about 16 times a minute. With asthma, however, each breath can be a struggle, as the windpipe tightens and the lungs start filling with phlegm. And it's these two processes -- narrowing of the airway (broncho-constriction), and filling with mucus (inflammation) -- that lead to persistent asthma symptoms.

How is it diagnosed? Ideally, a doctor assessing a patient for asthma should do a full history, physical examination, lung function tests, disease education and continuing monitoring -- preferably early in the course of the disease.

The reality, however, is different.

"So how long has your son been wheezing?" I ask the mother of a three-year-old.

"Oh, doctor, since he was born," she says tearfully. "He's always been chesty -- his cough never seems to go away."

Mothers of young children with asthma are tough customers, and dread the prospect that their child may have asthma. Often their child has had frequent antibiotics from several doctors, but still remains chronically undiagnosed.

And research is revealing that the longer appropriate treatment is delayed, the worse the lungs can get, sometimes with irreversible damage -- what doctors call lung remodelling.

But it's not just mothers of asthmatic children who resist therapy.

"Why should I use a puffer at all?" asks 80-year-old Walter Olkovich, an asthma patient who coughs regularly because of chest phlegm, but is too scared to use an inhaler because of possible side effects, which tend to be mild and dose-dependent.

Counselling patients about environmental hygiene and allergies is another important aspect of asthma care, but the advice is not easily implemented. "Doc, I'll get rid of my husband before I get rid of my cat," says a 51-year-old woman whose cat allergy triggers her sneezing episodes, sinus congestion and asthma.
Indeed, the list of potential asthma triggers is expanding daily: dust, pollens, moulds, first or secondhand smoking, furry or feathered pets, carpeting, strong perfumes, spices and cleaners, pollution -- and even an unwashed teddy bear. For those whose workplace has provoked their breathing symptoms, a whole new diagnosis -- occupational asthma -- has been created. Asthma can even be set off by exercise, stress, viral infections and anxiety -- so it is not surprising that asthma is so troublesome for patients, caregivers and the health-care system.

What are the best available treatments for asthma?
There are several categories of puffers: wheezing relievers are short-acting windpipe dilators; anti-inflammatory steroid inhalers are the mainstays of therapy and dry chest phlegm, and newer long-acting windpipe dilators.

Doctors want patients who have persistent asthma symptoms to use the anti-inflammatory inhalers, as these puffers modify the source of the problem, the chronic inflammation. Patients, on the other hand, rely too frequently on windpipe dilators, which gives them temporary but immediate relief. The battle between the two methods has been one of the major barriers to effective asthma management for 15 years.

But research and a new generation of combination inhalers may offer an elegant solution, helping to optimize asthma management. Chest physician Dr. Andrew Greening, a world authority on asthma at the University of Edinburgh, instructs doctors that asthma patients will achieve better control with inhalers that contain both types of medications -- the long-acting windpipe dilators and the drying steroids -- in one device. He notes: "We have shown that the combination inhalers give better outcomes in terms of lung function and symptom control." And this two-in-one treatment is beginning to prove to be a major advance in asthma care.

For those who can afford them, the new combination inhalers may represent the best compromise solution to the battle of the competing inhalers.

But even if patients have been prescribed state-of-the-art medications, they still have to use them correctly -- an issue doctors call compliance. The Canadian Journal of Diagnosis estimates that 40 per cent of asthma patients have poor inhaler technique, and this is a major reason for suboptimal treatment.

"Was I supposed to take the cap off?" asked a patient who was wondering why his asthma wasn't getting any better. All doctors have seen incorrect but creative inhaler techniques, limited only by our patients' ingenuity. One man even sprayed the medication onto his chest, like a cologne. "You did say it goes directly into the lungs, doctor." Yes, but not quite that directly.

"Improved education for people with asthma is critically important," says Michael McDonald, director of health initiatives at the Lung Association. "Canadians with asthma should speak to their doctor, frankly and openly, and doctors should let their patients know . . . [they] can live normal, active and symptom-free lives if their condition is managed properly."

Dr. Grossman, also a professor of medicine at the University of Toronto, agrees. But he believes that doctors themselves should enhance their asthma management skills so that patients can benefit from the latest findings. Addressing an international asthma conference held recently in Toronto, he noted: "A more aggressive education effort is needed, especially for primary care physicians."

The ingredients for optimal asthma management are all in place: public awareness campaigns (today is World Asthma Day, a global initiative in asthma education), physician training, new research and medication delivery systems, treatment guidelines and patient trends toward taking an active role in their own asthma management.

A team approach that capitalizes on the synergy of all these elements will best help asthmatics -- and their caregivers -- breathe more easily.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education (CME) lecturer. www.doctorQ.ca

All about asthma

SYMPTOMS
You regularly cough, wheeze, get breathless and feel your chest tighten.
You get short of breath when climbing a couple of flights of stairs.
During physical activity, it takes you longer than most people to catch your breath.
You avoid exercise since your breathing gets too difficult.
You experience breathing symptoms after being around a common trigger.
You get a cold and it tends to go to your lungs and lasts longer than 10 days.
You wake up during the night with coughing or shortness of breath.
You feel that your chest is congested.
You have to clear your throat constantly.
-- Adapted from the Global Initiative in Asthma

TRIGGERS
Acid reflux (nighttime heartburn)
Allergies (cigarette smoke, cats and dogs, cooking fumes, dust, pollen, moulds, smog, strong perfumes, spices, cleaners, etc.)
Aspirin-sensitivity
Blood-pressure pills known as beta-blockers
Cold winter air
Environmental pollution
Exercise
Missed asthma medications
Sinus congestion (phlegm dripping down at the back of the throat, known as postnasal drip)
Stress & anxiety
Workplace chemicals & fumes
Viral infections (especially in children)

WHAT TO DISCUSS WITH YOUR DOCTOR
Working as partners for better asthma management.
Medications for long-term control.
Managing your asthma attacks.
Regular follow-up care.
Your concerns about possible side effects (throat irritation, throat fungus infections, glaucoma, bone effects).

A new generation of inhalers
The problem: Asthma inhalers like the one this child is holding are difficult for most patients to use:
They require some co-ordination to push the top of the inhaler to release the medicine while breathing in at the same time.
Some patients can't tell when the inhaler is empty and needs to be replaced.
Some solutions: These two new-generations puffers are easier to use:
They are breath activated; Pre-measured doses are released when the patient inhales.
Most have dose counters to keep track of usage and let patients know when to get a replacement.

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