Asthma Increasing Despite Advances In Therapy

By Jan Howard

A report issued in May 2003 by the Connecticut Department of Public Health (DPH) found that in 2001 approximately 202,000 adults and 75,000 children in Connecticut have asthma.

Asthma is a chronic disease in which the airways are inflamed. It goes by many names, such as wheezy bronchitis, asthmatic bronchitis, bronchial asthma, and reactive airway disease (RAD). It is often misdiagnosed as bronchitis or pneumonia.

People with asthma have airways that are “hyper-responsive,” meaning their airways react to triggers, such as cold, cigarette smoke, and animal dander, faster and more intensely than people whose airways are clear. During an asthma episode, the lining of the airways become inflamed and produces more mucus, which makes the opening smaller, and muscles around the airways tighten, also making the opening smaller.

Dr David Oelberg, director of the Pulmonary Function Laboratory, and Dr Greg Dworkin, chief of pediatric pulmonology, of Danbury Hospital, emphasize the need to educate the patient or the patient’s parents about asthma and to have a plan to treat and control it.

In addition to education, other treatment components include monitoring the patient’s pulmonary function, minimizing exposure to substances that trigger attacks, and a medicinal regimen to control it.

“There is no cure for asthma,” Dr Oelberg, a resident of Newtown for six years, said. “There is still not a well accepted definition of asthma. Its prevalence varies around the world, but about five to eight percent of the population has the condition.”

Both doctors noted that some cases of asthma are caused by a genetic disposition toward it. “It can run in families,” Dr Dworkin noted. Upper respiratory infections are also one of the chief causes of asthma.

According to Dr Dworkin, a 15-year resident of Newtown, management of a child’s asthma requires a partnership between the parent and the doctor.

“My job is to educate and give tools to help you understand how to help yourself and your kid,” Dr Dworkin said.

Adult Asthma

According to a study, the overall prevalence of asthma among adults aged 18 and over in 2001 was 7.9 percent, with the prevalence significantly higher for women (9.6 percent) as compared to men (6 percent).

Among adults, rates were higher among the younger age groups. Racial and ethnic differences in asthma prevalence among adults were not statistically significant.

Dr Oelberg said that asthma is on the increase in adults. “It’s recognized more, but it is also increasing.”

He cited air pollution in inner cities as one possible cause. “We also live in an overly sanitized world. Our immune function doesn’t learn to deal with irritants,” he noted.

Adult asthma also can be caused by viruses and recurrent upper respiratory infections as well as exposure to second hand smoke as a child.

“It definitely runs in families,” Dr Oelberg said. “We can’t cure it but there is no excuse for daily effects” because of the effectiveness of today’s medications.

The types of drugs used in treating adult asthma are very different today, Dr Oelberg said. They are stronger and better and are almost free of side effects. Meter dosage inhalers are being replaced with ozone friendly inhalers. Dry powder inhalers are becoming the mainstay of therapy, he added.

Every asthma patient should have a rescue inhaler, he said, to relax muscles in the airway. “They should never be without it. There is no guarantee they won’t have a bad attack.”

However, he said the mortality rate from adult asthma has increased because there is too much reliance on rescue rather than control medications that are long acting, control inflammation, and prevent problems. Antibiotics are not recommended for asthma flairs.

If an asthma patient needs to use a rescue inhaler more than two times a week, he/she needs a control medication, Dr Oelberg said. “An over-reliance on albuterol alone is a sign you need to do all you can to control the asthma.”

He said a new drug, xolair, is a new class of medication. An anti-inflammatory drug, it is given by injection every two to four weeks to people with allergic asthma. A well-tolerated medicine, it takes about three months to see results. It can be very expensive, but is covered by many insurance policies, he noted.

Exercise and proper diet are important, Dr Oelberg said. Though exercise is often a trigger for asthma patients, “Do not avoid exercise. Find a way to do it, such as taking an inhaler before exercising.”

Dr Oelberg said some asthma cases are caused by a person’s occupation. If a person is unwilling or unable to change occupations, he/she must find a way to avoid the triggers through medication.

Connecticut General Statutes require that all physicians report any known or suspected cases of occupational disease. According to the report, it is estimated that up to 15 percent of adult onset asthma is because of work-related exposures. Occupational asthma and RADS account for approximately one-third of all respiratory diseases and disorders.

In Connecticut, the most commonly identified reported cause of occupational asthma/RADS is poor indoor air quality, which includes mold, dust, bio-aerosols, cigar/cigarette smoke, poor ventilation, and renovation activities.

Pediatric Asthma

Dr Dworkin said that while asthma in children is being better diagnosed, there has also been “a true increase” in the number of cases.

Why it is increasing is not fully understood, he noted. “It would be nice to say here are the seven reasons.” However, he noted, one reason might be that energy consciousness has brought about houses that are better sealed, thus retaining air pollutants that previously would have filtered out.

Allergies often cause asthmatic reactions. “You can’t always avoid the triggers,” Dr Dworkin said. When avoiding triggers fails, medication comes into play, he added.

Second hand smoke is a major issue, he said. Parents need to give up smoking if they have a child with asthma.

He said children under age 5 often have an asthma-related illness, with wheezing, that they outgrow by the time they are 5 years old. There are, however, other illnesses that might make them prone to get asthma, he noted.

“Not all infants that wheeze have true asthma,” he said, noting the treatment approach is similar to asthma, while recognizing that the condition is not asthma. “True asthmatics don’t grow out of it by 5 years old,” Dr Dworkin said.

He said with today’s medications, there is no reason to restrict children with asthma from participating in athletics. “Taking medications makes it possible for children to participate in sports and keeps them out of the hospital and the emergency room,” he said.

Dr Dworkin said in order to manage childhood asthma, parents must address the fact the child has a problem, identify the triggers, avoid the triggers, use preventative medicines, and approach the problem as a partnership with the health care professional.

“We need input from them and they need advice from us,” he said. “We educate them to make informed choices.”

While there are new drugs currently being tested, Dr Dworkin said, “The ones we have are pretty effective. We’re very optimistic about new medications, but we are all from Missouri in relation to kids. What we’re doing is very effective in children.”

According to the DPH report, the prevalence of asthma among children under age 18 years (8.9 percent) was greater than the prevalence among adults age 18 years and over (7.9 percent.)

The asthma hospitalization rate for children in Connecticut was lower than that for children in the United States as a whole. However, the asthma hospitalization rate for children in the state’s five largest cities — Bridgeport, Hartford, New Haven, Stamford, and Waterbury — was higher than the rate for the entire state and the United States.

From 1992 to 2000, asthma hospitalization rates for black and Hispanic children were consistently higher than the rate for white children, about five times higher during the same time period. Most hospitalizations occurred in the fall, with the fewest during the summer months.

Children in the state’s five largest cities accounted for nearly 45 percent of all hospitalizations and emergency room visits in the 0 to 14-year age group.

According to the report, from 1999 to 2000, there were 30 asthma related emergency room visits for children age 0 to 14 from Newtown. There were 11 asthma related hospitalizations from Newtown during the same time period.

Danbury Hospital recently received the 2004 Connecticut Hospital Association Community Service Award for its Pediatric Asthma Management Program, which was developed in 1996 by Dr Dworkin in response to an increase in the number of children being diagnosed with asthma in the hospital’s service area.

The award, sponsored each year by the Connecticut Hospital Association and the Department of Public Health, recognizes a Connecticut hospital that has made an outstanding contribution to the health of its community.

Danbury Hospital debuted the American Lung Association’s “Open Airways for Schools” program to educate children, parents, school personnel, and pediatricians on asthma and medication management.

The program, open to all school districts and pediatricians in the hospital’s service area, has seen significant results since the program was initiated eight years ago. Asthma-related school absences are down 50 percent since the program started, while asthma-related hospital admissions and asthma-related emergency department visits declined by 72 percent and 25 percent respectively.