A lot is known about the causes and treatment options for asthma. However, the most important success factors for an effective treatment are the patients themselves. Particularly in the case of chronic diseases such as asthma, patient education should be an integral part of any treatment plan. Patients need to understand their condition, be able to self-monitor their therapy and know how to respond to an emergent asthma attack. As with all conditions, the more knowledge patients have about their disease, the better they can manage it.
For World Asthma Day on May 2,2023, we turned to John Harrington, who is a Respiratory Clinical Nurse Consultant at the John Hunter Hospital in New Lambton Heights, New South Wales, Australia. In addition to publishing the booklet “Fast Facts for Patients and their Supporters: Asthma” (also available in Spanish “Fast Facts para pacientes y las personas que los apoyan: asma”), he has helped in developing a summary sheet for patients about asthma. The summary sheet is available in both English and Spanish. All four resources are freely available online.
Could you please give us a basic introduction to asthma: What are the causes and how is it treated?
Asthma is a common chronic disease that affects the breathing tubes in the lungs (bronchioles), causing them to become inflamed, thus reducing the amount of air that can pass through to the part of the lung that exchanges oxygen for carbon dioxide (alveoli). Sometimes extra mucus is secreted into the airways; whilst this mucus is meant to be helpful it can block off the swollen bronchioles so no air flows to certain parts of the lung(s). That description is about the only straightforward aspect to asthma – in reality it is usually pretty complex.
There are many causative factors in asthma and new knowledge is being developed regularly on what causes some people to develop asthma. We know that whether your parents had asthma and/or smoked cigarettes can be a risk factor as can exposure to air pollution at a young age. We find some viruses can be especially problematic in both causing asthma and making asthma much worse. I explain to my patients the inflammation of the airways is due to a complex interaction between their body, its immune system and the environment they are exposed to.
On the plus side; we are able to administer medications directly to the airways to alleviate the inflammation and to prevent it from reoccurring. We can do this in the form of inhaled medications. For more than 95% of people this will take the form of a “preventer” medication that will have a small dose of steroids – like a steroid cream for a rash on the skin. Often the preventer will be mixed with another medication that is designed to open the inflamed airways up and keep them open – we call this a bronchodilator, and it is usually a long-acting one that will last for around 10 hours.
Up till recently we would give patients short-acting bronchodilators, called “relievers” as the first step of asthma treatment. We are moving away from this approach as we have found too many patients end up relying on a reliever and not taking their preventer inhaler; some of the preventer medications work as well as a reliever and can replace the reliever inhaler all together. Your doctor can discuss what the best inhaler is for you. Specialist nurses like myself are very familiar with all inhalers and can troubleshoot or advise a doctor if there are problems with your preventer inhaler.
How can a patient prevent an asthma attack?
Asthma attacks can happen at any time to any patient with asthma. We call any worsening of breathing that requires an increase in treatment an attack. This will often mean taking steroid tablets such as prednisone for 5 or more days. Attacks can be serious enough to need treatment in A&E or admission to hospital or tragically death in too many cases. We try to ensure these awful experiences do not occur and we do that by prescribing preventer inhalers – so it is very important that people with asthma take their preventer inhalers as prescribed. The preventer takes a couple of weeks to work; they do not feel instantly beneficial.
Avoiding exposures that make asthma worse is important; we call these “triggers”. Allergy testing can be beneficial in identifying some triggers such as house dust mite or animal allergies so people with asthma can avoid exposures that can cause attacks. Other triggers can be less defined but no less unpleasant such as fumes or fire-smoke; people with asthma should avoid being exposed to this.
Why is an asthma diary helpful?
The nature of asthma means it is variable day to day and it can be difficult for people to recall how bad and frequent the bad days are nor the good days. There is a lot of research showing that people with asthma underestimate their reliance on their reliever medication and regularly downplay their symptoms, especially if they experienced asthma as a child.
By keeping a diary that monitors symptoms, reliever use and medication use as well as attacks when they occur, it can help your doctor and nurse understand the severity of the asthma. There are plenty of smartphone apps that are able to record this easily. We often like to include peak flow recordings in the morning and night. Peak flow is a small cheap tool that measures how hard you can blow; it helps diagnose asthma and can be used to inform people with asthma when they need to take action to prevent further deterioration.
What is an “Asthma Action Plan” and why does every patient need one?
Having clear instructions on when to take medication is important to prevent attacks and for attacks from getting worse. Most of these plans use a “traffic light” format – “green” for when well, “orange” for when you feel you may be worsening and “red” for when you recognize you are having an attack. Action plans can reduce hospitalizations and shorten the period of bad asthma symptoms as well as help you to remember what medications to take.
What has been the best innovation in the treatment of asthma in the last ten years? What breakthroughs do you expect in the next ten years?
I would suggest two innovations:
- The recent change in guidelines to avoid reliance on reliever medication. A little boring as far as innovations go but I expect this to be very beneficial in the years ahead in preventing people’s asthma progressing to a point where it interferes with their enjoyment of life.
- The development of treatments for severe asthma (asthma that remains bad despite max-dose inhalers) such as bronchial thermoplasty – which is where a respiratory specialists uses a scope into the airways of the patient to heat them up to reduce the amount of muscle buildup. Another innovation is monoclonal antibodies which are being used for many diseases especially in immunology and rheumatology. These medications switch off very specific parts of a person’s immune system that is responsible for triggering the inflammation in their airways. It is so exciting to have patients come back and say “Now I know what feeling well is”.
Thank you very much for the interview.