Deaths associated with asthma attacks have decreased over the last decade but the number of people having severe asthma attacks and missing school or work because of it, has changed very little. New medications have aided doctors in tailoring treatment to the particular needs of the patient. So why haven’t asthma flare-ups and hospitalizations decreased, you might ask?
Asthma management goals have been better defined over the last decade but many obstacles to optimal care continue to plague primary doctors and asthma specialists. Although asthma controller inhalers are very effective in clinical trials, real-world experience with them hardly ever reflects their success. Here are five reasons why:
1) Many people that volunteer for asthma research studies are not as sick as some of the patients seen in an asthma specialty clinic. Some patients are eliminated from studies because of severe asthma at the time or near the time of the study period.
2) Study patients are often screened for other conditions that might complicate the interpretation of results. Examples include: present or previous tobacco smoking; history of GERD (gastro-esophageal reflux disease); psychiatric problems; sleep apnea; heart conditions.
3) Study patients are most often paid to participate and are therefore highly motivated.
4) Study patients are frequently monitored either by phone or office visits resulting in quick address of developing problems.
5) Inhaler technique is thoroughly reviewed at orientation and follow-up appointments in order to assure the patient is getting regular doses of the medication.
Since many clinical studies publish high rates of success with asthma medications, is there a way doctors can increase the rate of improvement in the office setting by adopting some of the strategies utilized in clinical trials? I think so.
The last three points (3, 4, and 5 above) represent pathways which may be explored to improve better outcomes of asthma control.
Of course, paying a patient, as done in clinical research studies, would not be popular (with the doctors) but developing ways to motivate them would be great. I’ve provided information to parents and patients that illustrate the cost-savings associated with good asthma control. By taking controllers, daily, for treatment of persistent asthma, the need for urgent care (and Emergency Department visits) may be avoided, which may reduce health expenses. Having an Asthma Action Plan empowers patients and family to self-treat and avoid the additional expenses of urgent doctor visits and additional medications. Patients/parents oriented in this way, are often more motivated to follow established treatment guidelines.
Monitoring patients more closely, by phone calls, or more frequent office visits, helps to identify warning signs of poor control. Patients who have required oral steroid, an ED visit or missed work or school because of asthma should be followed more closely.
I make it a point to review inhaler technique almost every office visit because proper inhaler use is difficult. There are several steps to proper inhaler use which if not correctly followed, may considerably reduce the effectiveness of the medication. Impeccable inhaler technique is essential to good asthma control.
The majority of patients, young and old, have flaws in inhaler technique which develop between office visits. Here are some flaws I most often encounter:
1) Failure to completely exhale (blow all the air out of the lungs) before inhaling the medication.
2) Simultaneously pressing the canister to expel the inhalant, and inhaling it in, is frequently flawed. Many people press, and then a fraction of a second later breathe in, allowing the inhalant to bounce out of the mouth, and as well, coat the tongue and throat (which mean less medicine gets to the lungs).
3) Many people breathe the inhalant in too fast, such that medication gets slammed against the throat instead of flowing down into the lungs.
4) Although many people know to hold their breath for 10 seconds after inhaling, they often count too fast.
5) Some patients fail to re-prime their asthma inhalers. The relievers often need re-priming if they haven’t been used for more than 2 weeks (some require re-priming after 3 days if not used).
Consistent use of your controller inhaler and proper inhaler technique may greatly improve asthma control.