Running on Empty: The Crisis in Asthma Control

in Asthma, Features
Published: July 2, 2010

Asthmatics are living half lives, shunning exercise, medications and coughing their way through the night. It doesn’t have to be this way. Article from the Canadian edition of Allergic Living.

Adrienne Smith has been battling with her asthma since she was diagnosed at the age of 13. For Smith, high school gym class was particulary difficult: she would often get a crushing feeling in her chest when she started to run, and it would take her 25 minutes to recover. “It was humiliating,” she says.

Now, at 30, Smith’s asthma is still a big part of her life. She doesn’t play competitive sports any more, something she used to enjoy. And when she works out, she tends to walk, rather than run. When her asthma is at its worst, it keeps her up at night. During these bouts, she finds ordinary household chores arduous, such as carrying laundry up the stairs.

Still, Smith, who lives in Victoria, B.C., feels she’s doing fairly well. “I haven’t been to the hospital this year,” she says. “So that’s a good sign.” While she finds her limitations frustrating, she accepts them as a part of who she is. “I don’t think I’m sickly. It’s just that sometimes I have these episodes.”

About three million Canadians have asthma – one of the highest incidences in the world – and the majority of those affected share Smith’s conception of the disease.

“They think it’s normal to be short of breath, waking up at night, or not being able to perform exercise,” says Dr. Louis-Philippe Boulet, a respirologist and asthma researcher at Laval University in Quebec City. “I saw a patient recently who had stopped exercising; he started playing chess. He almost couldn’t do anything. But it was normal for him.

“Research shows 28 per cent of Canadians with asthma have symptoms of their disease every day, while 67 per cent have symptoms every week. But the experts agree that this should not be the case; that asthma is completely controllable. In the right environment and with the right medications, even those with severe asthma should have relatively few symptoms.

That’s because the medications available today can prevent the inflammation of the lungs, and the resulting constriction of the bronchial tubes and mucus build-up.

It’s possible to develop an asthma action plan in which, by reducing bronchial inflammation with medication and avoiding asthma triggers, the patient should rarely have to stop to catch a breath. And that blue “rescue” inhaler that many asthmatics depend on to treat frequent symptoms? It should only be used occasionally.

However, this ideal is far from reality. Instead, the majority of Canadian asthmatics are living half-lives. They aren’t exercising, which can lead to a host of other health problems, like obesity, diabetes and heart disease. They are missing school and work, and giving up activities they enjoy.

They see their doctors, but these visits are often marked by poor communication. They end up in the hospital after days of worsening symptoms. They are Canada’s “walking wounded,” and they’re slipping through the cracks of our health-care system. Amazingly, most of them don’t even realize they have a problem.

Statistics Tell the Story

The statistics show just how bad it is. Six years ago, the Asthma Society of Canada announced that 57 per cent of Canadians with asthma did not have their disease under control. The society’s latest research, released in September 2006, shows no sign of improvement; more than half of asthmatics are still living with symptoms above what are considered acceptable levels.

Earlier findings showed 10 per cent of them had landed in the emergency room at least once in the previous year because of an asthma attack, and 12 per cent reported missing school or work.

In Ontario alone, hospital statistics show that asthmatics made more than 73,000 emergency room visits in the past year. National statistics are not available, but the numbers are known to be uniformly high.

“Certainly for children, we know that it is one of the most common reasons for emergency visits,” says Jan Haffner, vice-president of health initiatives for the Lung Association of Saskatchewan.

There is also rampant “presenteeism” in the workplace, says Dr. Kenneth Chapman, the director of the Asthma and Airway Centre of the University Health Network in Toronto. This refers to asthmatics who show up to work but aren’t functioning at full capacity because they’re experiencing symptoms, or they were up all night wheezing and coughing.

Defining Asthma Control

Asthma “control” is defined by how often a person has symptoms. The Canadian Asthma Consensus Guidelines say that if a patient coughs, wheezes or has tightness in his chest three or more times a week, the asthma is out of control. If asthma keeps the person up at night once or more a week, that is unacceptable.

If asthma has made the person stop exercising once in the last three months, or he uses a reliever puffer more than three times per week, again, the asthma is out of control.

Poor asthma management begins where most asthma patients seek treatment: the family doctor’s office. Often, a physician will diagnose a patient after he or she complains of wheezing or shortness of breath. In many instances, spirometry, a lung-function test, is not done, and medication needs are estimated.

“They will say, ‘this is asthma’ based on the fact we’re wheezing and we have a cough, and here’s a treatment,” says Dr. Alan Kaplan, a doctor in Richmond Hill, Ont. who chairs the Family Physician Airways Group of Canada. “They just try therapy, rather than doing a definitive test.”

Also, the doctor isn’t always able to explain fully to the patient how the medications work, and what kind of results to expect. “Physicians obviously give good information to the patient, but are limited by the time and resources they have,” says Haffner of the Lung Association.

Because the patient doesn’t really know any better, the next time the doctor sees him and asks how his asthma is, he’ll invariably answer that ‘it’s fine.’

Understanding Asthma Meds

Studies show, and experts agree, that there is a great deal of patient confusion about asthma medication, primarily how it works and whether it’s safe. There are two types of medication to treat asthma: controller and reliever.

Controller medications, usually inhaled corticosteroids, are meant to be taken every day to prevent inflammation in the lungs. Reliever medications shouldn’t be needed on a regular basis, but will open the lungs in the event of an asthma flare-up.

All too often, patients don’t take their controller medication, the corticosteroid, at all. “They’re afraid of the steroid word,” says Kaplan. But corticosteroids aren’t like the muscle-building steroids that are known to harm your body.

And Boulet says any legitimate long-term side effects, such as loss of bone density, should not occur at the doses usually prescribed. (Canadian guidelines stress that doctors should prescribe the lowest dose necessary to control the condition.)

“Corticosteroids are extremely safe,” he says. Yet, according to the Asthma Society, more than a third of those prescribed an inhaled corticosteroid don’t have any intention of even filling the prescription. Another 20 per cent fill it, but don’t take the medicine.

Next page: Why you should take daily asthma medication