Trying To Knock The Wind Out Of Asthma

"Asthma feels like a monster is sitting on me."

--A 5-year-old child

Anyone who thinks asthma is psychosomatic or mainly an excuse geeky kids use to avoid gym class need only ask a sufferer what an attack feels like. It shouldn't be hard to find a victim. Asthma is the most common chronic disease in the industrialized world, afflicting 4% to 6% of adults and 20% of children. There are 12 million asthmatics in the U.S. alone, and it costs about $6.5 billion a year to treat them.

The good news is, treatment keeps getting better. Asthma sufferers who can't get a good night's sleep can now take a long-acting inhaled bronchodilator, salmeterol, that was just approved for sale by Glaxo Pharmaceuticals under the brand name Serevent. A study published in May in the Journal of the American Medical Assn. found that salmeterol inhaled twice daily is more effective in preventing attacks than albuterol, a commonly used treatment that can be inhaled as much as four times a day. Plus, inhaled corticosteroids are becoming increasingly common in relieving the underlying inflammation that causes asthma attacks.

Still, the incidence, severity, and death rate from asthma have been rising steadily for a decade. According to the American Lung Assn., there was a 36% jump in the number of Americans with asthma from 1982 to 1991. Even more disturbing, the number of deaths each year has grown 66% since 1980, to well over 4,000. The rising numbers are not strictly a U.S. phenomenon: At least 14 other countries have experienced the same trends, to the mystification of the medical community.

Granted, several studies have suggested links between asthma and greater air pollution, poverty, and exposure to cigarette smoke. But even in places where the air is clean and the people not poor, such as remote Scottish islands, many are suffering more than ever. Besides, given a spectacular leap in the scientific understanding of asthma and the advent of safer, more effective drugs, virtually no one should die of asthma if treated properly.

"TWITCHY." And there may be the heart of the problem: Patients aren't being treated properly. That may be because they are not educated about their condition, or their doctors are unaware of its severity. Also, doctors worry that many of the drugs address only the symptoms and could be masking the disease's underlying severity. "Many, many people still don't understand asthma, including a lot of doctors, and that's why it's mistreated," says Nancy Sander, president and founder of the Allergy & Asthma Network/Mothers of Asthmatics, a nonprofit health association.

The definition of asthma has changed dramatically over the past decade, but specialists say the change has not yet trickled down to all the general practitioners who treat the bulk of sufferers. For many years, asthma was defined as a reversible obstructive airway disease, and doctors focused only on the bronchospasm, or attack. But the medical community now considers it a chronic inflammatory disease, and specialists treat the inflammation in the airway linings that causes the attack. Since 1991 the National Institutes of Health has recommended a course that grades asthmatics from mild to severe and calls for anti-inflammatory drugs once the disease moves beyond the mild stage.

Despite the changed approach to treatment, there is still no cure. That's because researchers have yet to figure out what causes asthma. The disease hits people with hypersensitive or "twitchy" lungs and can occur after prolonged exposure to irritants such as pollution or dust, a bout of pneumonia, or even a severe cold. Asthma can also be induced by exercise and allergies, come on only at night, or get triggered for no obvious reason. Patients having an attack feel as if they are drowning and experience coughing, chest tightness, wheezing, and shortness of breath. Some sufferers are born with the disease, and some children find the symptoms abate as they reach their teens. About 25% of patients develop it after the age of 40. Researchers are fairly certain that there is a genetic component but have no idea what it is.

While scientists search for a cause, patients only want relief. Virtually every sufferer uses bronchodilators, the most commonly prescribed class of drugs in the world. These open the airway by relaxing the muscles that line the walls of the bronchial passage, making it easier for air to move through. They can come in pill, suppository, or injectable form, but the most popular by far is an inhalant, administered with the puffer most asthmatics carry around.

The most effective bronchodilators today are beta-2 agonists, sold under the names Brethaire, Maxair, Proventil, or Ventolin. They can relieve an attack in minutes by going directly to the swollen air passages. But several studies over the last few years have linked the heavy use of beta-2 agonists to increased risk of death.

TOO EFFECTIVE? Although there is some concern that the drug itself may be contributing to a worsening of the disease, many specialists believe the real problem is that the drugs are too effective. Users take a puff and relieve their symptoms, but they don't bother to get away from the cause of the attack, such as cat hair or tobacco smoke. And by opening the airways with the puffer, they are more exposed than ever to continued irritation. So the condition keeps worsening, and instead of moving to an anti-inflammatory treatment, they just take more puffs. Patients suffering fatal or near-fatal attacks have been known to take 20 puffs a day, although they would certainly balk at swallowing 20 pills. Instead, severe asthmatics should be seeking help at a hospital, where they could get oxygen and injected steroids.

People with mild asthma are fine with bronchodilators, but patients who are using them more than four times a day, or every day, are considered to have moderate asthma and should be given a regular, preventive anti-inflammatory medication. Even salmeterol, though it can prevent an attack for up to 12 hours with one puff, should be used in conjunction with an anti-inflammatory treatment, not in place of one.

This is where many doctors fail their asthma patients, say specialists. The most effective anti-inflammatories are inhaled corticosteroids, sold under the brand names Aerobid, Azmacort, Beclovent, and Vanceril. But whereas sales of bronchodilators rose some 30% from 1983 to 1990, sales of inhaled steroids increased only 3%. The reason, says Dr. Thomas Casale, director of the division of allergies and immunology at the University of Iowa Hospitals and Clinic, is a misplaced fear of steroids, which can have severe side effects when taken orally. Inhaled steroids, however, go directly to the bronchial passage and are considered extremely safe, even for children. "Both physicians and patients have concerns about safety when the word steroid is used," says Casale. "Old ideas change slowly, but physicians who have gone through the training process recently will be treating patients differently."

Beyond all the medications available, perhaps the most important factor in treating asthma is the patient's own behavior. Sufferers should work out a treatment plan with a specialist--and then stick with it religiously. Such a plan includes an understanding of what brings on an attack, what drugs should be taken when, and how to tell when the condition is worsening. For that reason, a $25 handheld device known as a peak-flow meter can be as crucial as any medication. Patients should check their breathing regularly with the meter, keep a record of the readings, and notify their doctor if their lung power deteriorates. With careful monitoring, asthma sufferers can go a long way toward getting that monster off their chest.



All patients should have a written asthma management plan, a peak-flow meter to monitor breathing, awareness of early warning signals of an attack, knowledge of how and when to increase medications, and a plan to remove as many allergic factors as possible from the home.

MILD ASTHMA Inhaled bronchodilators, such as theophylline or beta-2 agonists, are taken to relieve symptoms or before exercise. If used daily, or more than four times in one day, additional therapy may be needed.

MODERATE ASTHMA Anti-inflammatory medications, such as inhaled corticosteroids or inhaled cromolyn sodium, are taken daily to avoid symptoms. Oral corticosteroids are used on a short-term basis to treat serious attacks. Bronchodilators relieve symptoms, and, if necessary, a long-acting oral beta-2 agonist can prevent attacks during the night.

SEVERE ASTHMA If problems cannot be controlled with maximum doses of inhaled anti-inflammatory or bronchodilator medications, an oral corticosteroid may be required under the direction of an asthma specialist. Condition may also require supplemental oxygen, intensified treatment, and hospitalization.


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