Ask The Doctor

• By Nikolay Voutchkov, Melissa Jackson
• Nov 01, 2000

The following questions were posed to Dr. John Winder, MD, chairman of public education committee and national chair of the asthma screening program for the American College of Allergy, Asthma and Immunology and a board-certified allergist. Winder has a private practice in Toledo, Ohio. For further information, visit: http://allergy.mcg.edu/.

*Why does the number of people with asthma continue to grow each year?

We don't know why it continues to grow each year, but we do know that it is a world wide problem that has been increasing steadily for the past 20 years. There are a number of risk factors that we feel may be contributing. A recently recognized significant allergen is cockroach exposure and other causes include lack of access to medical care, poverty, increasing air pollution and inadequate medical treatment. Whatever the reason for the increase in prevalence, it's increasing in spite of the fact that we have an excellent understanding into what is going on in the lung with asthma and have very effective treatments for it as well. We have seen a decrease in the death rate in asthma (a 4 percent decrease in 1997 -- the latest available year for statistics), but it is still a major problem.

*What can be done to decrease the growth?

To decrease this growth, efforts in better distribution, acceptance and utilization of the National Asthma Education and Prevention Program (NAEPP) asthma guidelines are very important. Raising the level of physical awareness of these guidelines and then having them followed by the treating doctor would certainly contribute positively.

*What are the common treatments for people with asthma?

The common treatments for asthma fall into two categories: treatment of the acute episode and the prevention or long term control of asthma. A reliever or rescue medication for the acute attack is a rapid onset bronchodilator (often a prescription inhaler). The preventative, long term medications, of which there are several classes, work to decrease the chronic inflammation which is now recognized to be a central facet of asthma. The treatment will vary for individual persons depending on the level of severity of the asthma and even will vary in the individual patient over time as asthma waxes and wanes. The NAEPP Guidelines spell out very clearly and succinctly the treatment modalities for different levels of severity.

A mainstay of long-term control is treating the chronic inflammation in the airways. The most effective anti-inflammatory medications we have for this are the inhaled steroids, yet they are grossly underused in asthma treatment, particularly at the primary care physician level. Eighty to 85 percent of asthma is treated by primary care physicians who don't follow the guidelines and under-utilize the most effective treatment we have, the inhaled steroids.

*What steps can be taken to decrease mortality due to asthma?

We now have tools and the understanding to deal effectively with asthma, but a major problem is getting their acceptance, utilization into the front ranks -- those who are treating asthma on a daily basis. There are recognized risk factors for fatal asthma. These include underestimation of the severity of asthma, poor compliance with medical treatment, and what I refer to as mismatched asthma treatment, in other words, the person's level of asthma severity is greater than the treatment regimen he/she is placed on by the treating physician, add psychosocial situations and socio-economic factors and you have a recipe for trouble.

*How important is it for asthmatics to have a written action plan for emergency attacks or to better control their asthma?

A written action plan for acute treatment is very important and a critical piece in the NAEPP Guidelines. By recognizing the early signs and symptoms of increasing asthma, the person with asthma can implement what I call ET or early treatment. The earlier one treats increased acute asthma, the easier it is to treat. The action plan provides pre-set cues, parameters and timelines to use and follow during an attack.

*What do health care providers and asthmatics need to know that they may not be aware of?

If there is just one important facet for the person with asthma to possess, is patient education and self management, learning about his or her disease and how it should be treated. If the person with asthma becomes knowledgeable about it and its appropriate treatment, he or she will know if the asthma is being effectively matched to treatment or not.

*Are there any myths or misconceptions about asthma?

There have been a number of myths/misconceptions about asthma that have been around for a number of years such as: asthma can be outgrown, it is not serious, no one ever dies from it, it's an emotional or parenting problem. With the growing awareness of asthma in the more recent past, I am not sure if these old beliefs are still around. Rather, I wonder if their impact has not been replaced by the ignorance of the role of chronic inflammation and the need for early treatment in asthma.

*Is compliance a problem?

Compliance has been recognized as a critical issue in effective asthma treatment, but the problem is ingrained or inherent in the treatment modalities for asthma. Some treatment regimens for asthma are as or even more complex than those for treating HIV, so the KISS principle (keep it simple stupid) doubly applies to asthma. The health care provider needs to recognize that it is not nature's way for a person to have to swallow, inhale, or aerosolize something several times daily, day in and day out.

This article originally appeared in the November 2000 issue of HME Business.