News-Sentinel.com

Thursday, 05/04/2000

ASTHMA: THE BATTLE TO BREATHE

Proper medication regimens help keep disease in check

By Jennifer L. Boen of The News-Sentinel

Kelly Lloyd remembers the days and years when her asthma was out of control.

"I wasn't getting any rest. My parents weren't getting any rest. I coughed and wheezed a lot at night. I felt like an elephant was sitting on my chest. I felt like I was being smothered," she recalled.

It wasn't until Lloyd was in the eighth grade that she finally got her asthma under control with the help of an Indianapolis pulmonologist and a medication regimen.

"I started to understand my allergies, and all the triggers. Cats, dogs, horses, dust, tree mold — I'm allergic to them all. Going outside after someone has mowed the grass was a problem. The fastest way for me to go into an asthma attack was a quick temperature change."

In high school, she ran track well enough to earn a college scholarship. Now, the 23-year-old is Miss Indiana. She travels the state, speaking on behalf of the American Lung Association.

"You want to know what an asthma attack feels like? I tell people, `Go run around the block several times, then come in, plug your nose and breath through a cocktail straw,' " said Lloyd. "That's asthma.

"I worked hard to learn about the disease so I could participate in the same things as other kids," Lloyd said.

Within just the last decade, more knowledge about asthma has benefited thousands of asthmatics such as Lloyd. In 1991, as national health officials began seeing a rise in asthma cases and deaths, the National Institutes of Health convened a panel of scientists and clinicians who set the stage for new treatment guidelines.

Researchers determined that the primary occurrence of asthma involves inflammation, and the secondary occurrence related to airway muscle constriction.

"The whole paradigm changed," said Dr. William Smits, a Fort Wayne pulmonologist and asthma/allergy specialist. "Prior to that, the focus was geared to just treating the muscles."

In an asthmatic, a trigger — cold air, pet dander, pollen or other irritant — causes hyper-responsiveness in the breathing tubes of the lungs. The lining of the airways swells, and mucus clogs the tiniest tubes, preventing air from flowing freely in and out. The muscles surrounding the tubes begin to spasm, further constricting the flow of air.

Once the process of asthma was better understood, researchers were challenged to develop new asthma medications, particularly ones aimed at treating inflammation. What experts now know, and what NIH guidelines explain, is that anti-inflammatories — the controllers — are the key asthma medication, yet they won't stop an attack that has already started.

Conversely, bronchodilators — the rescuers — help stop attacks once they've started. They are quick-fix medicines that treat symptoms, with few or no long-term, anti-asthma effects.

Which medications, their dosage and length of time used can make the difference in whether an asthmatic's illness is under control. Yet researchers have learned that treatment guidelines, which were updated in 1997, are not being widely followed.

"There are things that we know should be done that aren't being done," said Dr. Stephen Redd, of the Centers for Disease Control and Prevention. "The guidelines are not being followed as they should."

Smits agrees. "Increasing deaths are due to lack of appropriate treatment. Overall, I think the medical community is doing a better job of understanding and treating the inflammatory process, but it could always be better."

Much of the undertreatment, particularly for children, centers around fears about the use of corticosteroids, the most potent of the drugs that treat inflammation. These are not the same as anabolic steroids bodybuilders sometimes use.

"The concern of pediatricians and family physicians is inhaled steroids may inhibit growth in children," said Dr. William Martin II of Indiana University's Asthma Clinical Research Center in Indianapolis.

Inhaled steroids, which are recommended by the federal Asthma Education and Prevention Program, are safer than oral steroids, Martin said. Inhaled steroids stop inflammation at the cellular level, Smits said, delivering medication to the site of the problem and preventing inflammation.

"The data indicate low-dose, inhaled steroids are absolutely safe for children and can have positive effects over long periods of time," Martin said.

Oral steroids are prescribed for seven- to 10-day regimens, after which the medication is usually tapered off. They can depress the immune system, and cause blurred vision, frequent urination, mood changes, nervousness, stomach upset and restlessness, said Fort Wayne pediatrician Dr. Chris Tallo.

Jennifer Littleford says putting her son, Elijah, 21 months, on an oral steroid enabled him to gain weight and begin talking. He was born premature and has a condition called bronchopulmonary dysplasia (BPD), due to spending 10 weeks on a ventilator. Children with BPD often develop asthma.

"He's a different child now," Littleford said. "He wants to eat now, and we hope when he's taken off the oral steroid, he'll want to continue to eat."

Dr. Terry Gaff, an emergency room doctor and former family physician, believes the problem of underutilization of steroids lies more with the patient than the physician.

"The steroid medicine tastes horrible," he said. "And the steroid medicines don't work right away. The rescue medicines give immediate relief, so that's what people begin depending on."

Temporary relief provided by rescue inhalers may allow asthmatics to delay more effective treatment, the physician said.

"The key here is education — to teach patients and parents how to manage the disease."

Gaff likens out-of-control asthmatics to diabetics who assume they know what their blood sugar is by how they are feeling at the time.

Gaff's 18-year-old son has asthma. "Just like my son says, `I don't need to use my inhaler. I know how I feel.' The situation is his condition may be worsening, but he does not yet recognize the symptoms.

"In my opinion," Gaff added, "we have enough knowledge and treatment of this disorder to create a problem. You know, it's like the adage `A little knowledge is a dangerous thing.' We allow people to treat mild disease on their own without helping them realize what can happen."

Now, Miss Indiana's asthma is even better controlled, thanks to newer, more effective medications.

"Asthma never goes away," Lloyd cautioned. "You may be symptom-free, but it is still there."

Her advice to others is, "Learn all you can, and take your medicines."

Costs of asthma

Direct expenses (In millions)

Hospital care

Inpatient $3,215.58 Emergency room 608.23 Outpatient 392.36

Physician services

Inpatient 301.02 Outpatient 715.44

Medications 2,267.36

Direct expense total 7,499.99

Indirect Costs (In millions)

School days lost 1,234.58

Loss of work

Men (outside the home) 184.97Women (outside the home) 290.22 Housekeeping 690.22

Mortality

Men 666.76 Women 733.24

Indirect expense total 3,799.99

Source: New England Journal of Medicine, National Center for Health Statistics, Health Care Financing Administration, U.S. Bureau of the Census.