With no cure in sight, controlling asthma is essential

With no cure in sight, experts believe that controlling asthma is essential to ensure good quality of life for those living with it. "It is Time to Control Your Asthma" is thus the sub-theme of this year's World Asthma Day, an annual event earmarked for the first Tuesday of May, which is organised by the Global Initiative for Asthma (GINA), in collaboration with healthcare groups to raise awareness about asthma care and control globally.

What is Asthma?

Asthma is a noncommunicable chronic lung condition that is caused by the swelling and inflammation of the airways, that impairs breathing. An asthma attack is characterised by the swelling of the bronchial tubes, resulting in a reduction of the flow of air into and out of the lungs and the production of mucus, resulting in breathlessness, wheezing, and fatigue. While the mortality rate of asthma is lower than that for other chronic diseases, asthma can hinder day-to-day life by limiting activity and reducing quality of life. And yet, asthma is under-diagnosed and under-treated.

According to the Global Asthma Report 2014, an estimated 334 million are living with asthma. It is the most common non communicable chronic disease in children too. A survey done by the International Study of Asthma and Allergies in Childhood (ISAAC) found that about 14% of the world’s children were likely to have had asthmatic symptoms.

This public health issue affects high and low-income countries equally, but the burden of mortality falls most heavily on the developing world, where some 80% of asthma-related deaths occur.

Risk factors for asthma

Asthma is genetic in origin and can be affected by a host of environmental factors. The strongest risk factors for developing asthma are exposure to inhaled particles that may provoke allergic reactions or irritate the airways. In most cases, the triggers are ubiquitous and unavoidable (exercise, cold air, allergens, viruses etc). However, some triggers can, and should, be avoided (like exposure to cigarette smoke). Air pollution is also a trigger that requires community action. Urbanization too has been associated with an increase in asthma, but the exact nature of this relationship is unclear.

Asthma - hard nut to crack

Professor Guy Marks of University of Sydney, who is also a member of the Board of Directors of International Union Against Tuberculosis and Lung Disease (The Union), shared with Citizen News Service (CNS) some of the challenges that doctors face in diagnosing and treating asthma. “It is often difficult to diagnose it and in particular to decide who needs treatment. Diagnosis requires observation of an individual over time (since asthma is a recurrent problem). Often doctors see a patient only once and it can be difficult to distinguish acute respiratory illness from asthma. Only the latter requires long term treatment. Also, in most countries the main challenge is to enable patients to access (afford) regular treatment with preventer/controller medications”, he said, adding that, “There is no long term cure for asthma on the horizon. The best we can hope for in the short-term is better access to, and better targeting of, preventer/controller medications that can reduce the symptoms and disability and, mostly importantly, reduce risk of future poor outcomes (such as hospitalisation, permanent disability and/or premature death)”.

Prof Mark’s advice to prevent and control asthma in resource poor settings is to ‘avoid smoking during pregnancy and around children (prevention); and identify children and adults at risk of poor outcomes of asthma and ensure access to, and regular use of, inhaled corticosteroid medications (control)’.

Asthma in children

Dr Meenu Singh, Head of Pediatric Pulmonology, Asthma and Allergy Clinics at Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, spoke to Citizen News Service (CNS) about asthma in children. Agreeing that asthma in children is on the rise, she also emphasised that asthma is eminently controllable.

She said that, “I would like this message to go out that asthma can be managed by parents and the child with the help of doctors. As much as possible, we should give them preventative medicines, rather than just go for rescue medication that is done in acute cases. It is better to prevent the attack before it occurs and not get into the complications of asthma which would be very expensive to take care of”.

Dr Singh rued that in India it is a big challenge to make the doctors practice existing guidelines for management of asthma.

“Many of them would not know what to practice and some of them, even if they know, would rather go for therapies which are in the acute phase as that is more profitable for them. If you start giving prophylaxis to the kids then they will stop coming to the doctors and parents will be able to manage them. The strategy should be to help them get rid of inhalers and it can be done. We should train our children in doing pranayam (a breathing technique) when they are coming out of medication, as in acute cases pranayam may not be effective. In chronic phase we should encourage the children to increase the vital capacity of their lungs in order to take them off the inhalers. ‘Neti kriya' (nasal cleansing with warm salty water) is another intervention that can be used to manage childhood nasal allergy which is a prelude to respiratory allergies in later life. Parents are very important stakeholders in evidence based child healthcare, including asthma.”

Dr BP Singh, a lung health specialist pointed out that in India asthma in children is often misdiagnosed as TB. This is a matter of great concern as it involves misuse of anti-TB drugs. So, childhood asthma should be dealt with seriously and diagnosed and treated correctly. Dr Singh also echoed the thoughts of Professor Marks on giving children a clean environment to live in. “Indoor air pollution should be minimized and tobacco smoke should be stopped by all means as it is a very important risk factor for triggering asthma attacks. The kitchen must be very well ventilated. If there are pets, they must keep them away from bedroom. The house mattresses contain a lot of dust which exposes asthma patients to mites--the most important cause for allergies. In countries like India, regular sunlight exposure to pillows and mattresses can wipe out these dust mites”, he said.

“I would recommend regular controller therapy for children diagnosed with asthma. Current inhaled corticosteroids provide almost instant relief and are safe for children. They do not cause side effects because the drugs are delivered to reach the lungs directly, and, unlike oral drugs/injections, not absorbed in systemic circulation.”

Agreeing that complete avoidance of specific triggers is usually not practical, Dr Raj Kumar, Professor and Head, Department of Respiratory Allergy and Applied Immunology and National Centre of Respiratory Allergy, Asthma and Immunology (NCRAAI), at Vallabhbhai Patel Chest Institute (VPCI), advocates the use of allergen specific immunotherapy, that is effective for treating allergic bronchial asthma. According to the WHO ‘allergen immunotherapy is the administration of gradually increasing quantities of an allergen vaccine to an allergic subject, reaching a dose which is effective in ameliorating the symptoms associated with subsequent exposure to the causative allergen’.

But even as specific immunotherapy has long term preventive effects on seasonal and perennial asthma and can reduce asthma symptoms, need for medications, and risk of severe asthma attacks, it carries the risk of anaphylactic reactions and should be prescribed only by physicians adequately trainedfor treating allergy, cautions Dr Raj Kumar.

Asthma has a low profile in the health priorities of low- and middle-income countries. Avoidable asthma deaths are still occurring due to inappropriate management of asthma, including over-reliance on reliever medication rather than preventer medication. it is high time governments make asthma a lung health priority, and give it the same attention as is given to COPD, pneumonia, and TB. While there is no cure for asthma, proper treatment and routine check-ups with health professionals can provide patients with a good quality of life. Together, we can ensure that asthma is managed properly to reduce the disability, death, and economic loss associated with it.

Shobha Shukla, Citizen News Service – CNS

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