By Dr. W. Gifford Jones
June 28, 1992
Why are more asthmatics with "twitchy airways" dying in this country? Is it that the severity of asthma has changed? Are patients doing something wrong? Or are some doctors inadvertently killing their patients? To find out I recently talked to Dr. Graham K. Crompton, a specialist in respiratory medicine at Edinburgh University.
It's estimated that 10 million North Americans suffer from difficult, breathing or what's called "reversible bronchospasm". During such an attack the airway constricts, impairing the normal exchange of air. Bronchial constriction is the result of tightened bronchial muscles, swollen bronchial tissues and the accumulation of mucus plugs in bronchial tubes.
Dr. Crompton says that what worries doctors is the changing pattern of asthma. For instance, Sir William Osler, one of this nations most respected clinicians, remarked at the turn of this century that, "Death during an asthmatic attack is unknown. The patient pants into old age". Today too many asthmatics are dying rather than wheezing happily into their latter years.
What has gone wrong? Some argue that in addition to the usual house dust, pollen and animal dander the bronchi are also exposed to more allergic substances in the environment such as food additives, atmospheric pollution, and drugs.
Crompton claims there's another major problem. Patients have become too used to the "little puff". Bronchodilator drugs called "beta-agonists" quickly relax the constricted airway and remove the terror that's often associated with this disease. So who wouldn't want to use the "little puff" again and again to restore normal breathing? Surely, patients reason, if a drug provides such sudden relief it must be good for you.
But that's the hitch. In the past, doctors believed that the primary problem of asthma was bronchial spasm. And that relief of the spasm was the be-all-and-end-all of treatment. But in some countries researchers began to worry about an increase in asthmatic deaths. For instance, studies done in New Zealand and Canada showed that the excessive use of bronchodilators was associated with increased risk of death from asthma.
It appears that the chronic and excessive use of bronchodilators has the same effect as whipping a tired horse. The horse eventually drops dead from exhaustion. In the case of the asthmatic patient the bronchial tubes eventually fail to respond to excessive stimulation by beta-agonists. So what was initially a blessing becomes an ominous after-effect.
Patients using bronchodilators should always keep the tired horse in mind when using this medication. If beta-agonists are used two or three times a week, or once a day, there's a good chance the asthma is under control. But if several puffs a day are necessary there's a good possibility the asthma is getting out of control.
Dr. Crompton suggests this scenario does not have to happen for what appears to be a sound reason. Biopsies of the airway reveal that virtually all asthmatic patients show an underlying inflammation throughout the bronchial tubes. It's this chronic inflammation that triggers asthmatic attacks. And bronchodilator drugs have no effect on this underlying problem.
So how do patients break this vicious cycle of needing more and more bronchodilators? Crompton and many other researchers say the key is the use of inhaled steroids which attack the underlying inflammation. This in turn decreases the hyperactivity of the air passages and the frequency of asthmatic attacks.
Crompton advises doctors to prescribe inhaled steroids initially four times a day. Then once the steroids have soothed the inflamed tubes the dosage can be decreased to twice a day. The aim is to get the asthmatic attack under control so that it does not require bronchodilators more than once a day.
The message is quite clear. Patients must be educated on how to use the "little puff" with greater discretion. They must be made to realize that although steroids do not provide the immediate relief from difficult breathing they do fight the underlying pathology that keeps the asthmatic fire burning.
Can some asthmatic patients use bronchodilators without the use of inhaled steroids? Dr. Crompton says the answer is "yes" once the inflammation has been treated and the patient requires a puff of the bronchodilator only two to three times a week. But he adds that doctors must be sure that these patients are not avoiding exercise, smokey atmospheres and hiding from other allergic substances to do so.
Next week, how some parents are helping to kill their asthmatic child due to their own lack of common sense.