It has been a frustratingly intractable problem for asthma specialists. With the advent of long-acting bronchodilators, inhaled steroids, and immune system modifiers, they have the tools in hand to control this chronic, incurable disease that afflicts 20 million Americans. Yet they aren't reaching enough patients.
Asthma accounts for one-quarter of all emergency room visits, is the leading cause of school absences, and is the fourth-leading cause of work absenteeism. The disease kills 5,000 people in the U.S. each year -- 14 people a day -- even though experts say almost all these deaths are preventable. Even more worrisome, the death rate has increased by 50% since 1980 for adults and 80% for children 19 and under. Specialists mostly blame inadequate treatment, usually because patients either are unaware of or lack access to appropriate medical care.
In an effort to improve those grim statistics, the American Academy of Allergy, Asthma & Immunology and two other standard-setting groups recently issued a new set of treatment guidelines aimed at eliminating all asthma symptoms (aaaai.org). Under the old guidelines, established in 1991, patients were classified as having mild, moderate, or severe asthma and treated accordingly. The new system calls for an individualized and frequently modified treatment plan aimed at eliminating wheezing, coughing, chest tightness, and other hallmarks of asthma. "Patients should expect perfect or near-perfect control of their symptoms -- and they shouldn't settle for anything less," says Dr. James T. Li, chairman of the division of allergic diseases at the Mayo Clinic and lead author of the new guidelines.
Unfortunately, research shows that most asthmatics settle for far less, in part because they do not understand the severity of their condition. A Harris survey released last spring found that 88% of U.S. asthma sufferers believe their disease is under control. Yet 61% have to catch their breath while running upstairs, 50% have to interrupt exercising because of shortness of breath, and 48% wake during the night as a result of their asthma -- all signs of poor control.
Part of the difficulty in keeping the disease in check is that asthma is a constantly shifting target. Allergic triggers, other illnesses, exercise regimens, and stress can change the disease's severity from day to day. "A patient with mild asthma at the beginning of a month could easily have severe asthma by the middle of the month," says Dr. David Rosenstreich, director of the allergy division at Montefiore Medical Center in New York.
Asthma is characterized by overactive immune cells in the airways. When these cells are set off, often by allergic triggers such as house dust, pollen, or animal dander, they cause the air passages to become inflamed. The muscles of the airways tighten, extra mucus is produced, and it becomes increasingly difficult for the patient to breathe. Sufferers start wheezing, coughing, and gasping for breath; if untreated, a severe attack can lead to death.
To make sure the situation never gets that bad, the new guidelines emphasize treatment goals. The ideal is excellent or total control of symptoms. That means no wheezing day or night, normal lung function, full activity, no nighttime waking, and no need to use short-acting bronchodilators, also known as rescue meds, that dilate the air passages when symptoms worsen.
The first step toward this respiratory nirvana is a continual reassessment of the disease, which means regular consultations with a doctor. At each visit, the physician should get an update of symptoms, sleep disturbance, and how frequently rescue meds are used. Parents of asthmatic children -- 7% to 10% of all kids -- need to be on top of the disease since doctors increasingly think aggressive early treatment can prevent asthma from worsening.
Doctors need to consider more than their patients' words, though. Asthma sufferers should regularly check their lungs' condition at home with a peak-flow monitor. This handheld device, which costs about $25, measures the amount of air a person can expel from the lungs. If airways become narrow or blocked, peak-flow values drop. By keeping a peak-flow chart, sufferers quickly see when their condition is worsening, often before they notice symptoms.
Using this information, doctors can design a treatment plan that incorporates any number of medications. Asthma drugs fall into two groups -- those used regularly to prevent attacks by keeping the airways open, such as long-acting bronchodilators and inhaled steroids, and the more powerful rescue medications. Parents should be aware that some studies indicate that long-term use of inhaled steroids might slow a child's growth, but most specialists believe the benefits outweigh any risks.
Just as necessary as a prescription is knowing and avoiding attack triggers. "The most important thing a patient can do is make the bedroom allergen-free," says Rosenstreich. He tells his patients to use allergen-impermeable covers for pillows and mattresses and keep rugs and pets out of the bedroom.
The new guidelines do require active participation by the patient. But given that surveys have found anywhere from 40% to 60% of asthma sufferers limit activities because of their disease, a little effort could go a long way toward improving their quality of life.
By Catherine Arnst