Common causes of poor response to treatment include; wrong diagnosis, inappropriate medications or improper inhalation technique, poor adherence to medications and co-morbidity. Steroid resistant asthma is uncommon and estimated to be 1 in 1000-10000 asthmatic patients.
Full Answer
What did we not anticipate when seeking care for patients with asthma?
We did not anticipate the negative reactions from healthcare professionals that many participants described experiencing when seeking care for their asthma, or the difficulty they had in obtaining inhalers for their asthma (additional quotes are given in online supplementary tables S4 and S8 in the online supplementary appendix ).
Are self-reported asthma triggers related to physician ratings of exacerbations?
Perceived Triggers of Asthma: Measurement, Structure, and Association with Asthma Outcomes. Furthermore, a higher number of self-reported asthma triggers is correlated with physician ratings of more severe asthma [ 9, 17, 19 ], more exacerbations, and a higher frequency of oral corticosteroid use [ 9, 16 ].
Do patient experiences of asthma influence preferences for asthma management?
This qualitative study explored patient experiences of asthma and its treatment and provides an overarching narrative of the patient experience of asthma and preferences for asthma management ( table 3 ). Patient experiences of asthma influenced their preferences for the different aspects of asthma management in varying degrees.
Are we identifying asthma triggers correctly?
Adequate asthma management depends on an accurate identification of asthma triggers. A review of the literature on trigger perception in asthma shows that individuals vary in their perception of asthma triggers and that the correlation between self-reported asthma triggers and allergy tests is only modest.
What type of asthma does not respond to treatment?
Severe asthma refers to asthma that does not respond well to regular asthma treatments, such as inhaled corticosteroids and inhaled bronchodilator medications. More than 26 million people in the United States have asthma. Severe asthma is relatively uncommon, generally affecting 5–10% of people with asthma.
What happens when asthma is unresponsive to treatment?
If an attack comes on quickly and it doesn't respond to regular treatment, it can lead to status asthmaticus, If it happens, you may have to go to the hospital to get it treated. If you have a bad asthma attack and your rescue inhaler or your nebulizer doesn't help, you need medical care right away.
Why is asthma poorly controlled?
The main reasons for lack of asthma control, as declared by physicians, were comorbidities in 36.2% of patients, continued exposure to irritants/triggers in 34.0%, and inadequate adherence to treatment in 27.0%.
What are problems faced by an asthma patient?
Chest tightness or pain. Wheezing when exhaling, which is a common sign of asthma in children. Trouble sleeping caused by shortness of breath, coughing or wheezing. Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or the flu.
What happens when an inhaler doesn't help?
Your doctor can help you find what works best for you. Sometimes it can take a few tries to find the best option, so talk with your doc about what works and what doesn't. Bring your inhaler to your doctor to show how you use it. Maybe you aren't using it correctly and your doc can help with that.
What happens if steroids don't help asthma?
The study found that 55 percent of adults with severe asthma who were on regular oral corticosteroids had more airway obstruction than those with mild to moderate asthma. The patients with severe asthma still had exacerbations and severe symptoms despite chronic steroid therapy.
What makes asthma controlled vs uncontrolled?
Asthma is defined as “controlled” if the patient reports symptoms and the use of reliever medications twice per week or less, no night waking, no activity limitation or airway obstruction, and no exacerbations; “partly controlled” when symptoms or reliever use are present more than twice per week, and night waking, ...
What is the most common cause for poorly controlled asthma and exacerbations?
These patients experienced a total of 244 severe asthma exacerbations and 72 hospital admissions with 895 hospitalised days in the 12 months preceding the study. The three most prevalent contributing factors were recurrent respiratory infections, gastro-oesophageal reflux and severe sinus disease (table 3⇓).
When is asthma not under control?
Daily symptoms, such as chest tightness, shortness of breath, coughing and wheezing, are signs of uncontrolled asthma and may require the use of quick-relief medication a few times a week or even daily. In addition, you may commonly experience nighttime flare-ups and may even have to visit the emergency room.
What is the most common complication of asthma?
What are the complications of asthma?constant fatigue.frequent leave from work or school due to constant asthma flare-ups.pneumonia.increased mucus production.thickening and narrowing of bronchial tubes which can become permanent leading to respiratory failure.respiratory failure.severe chest pain.
Why is my asthma getting worse?
An asthma flare-up can happen even when asthma is controlled. Asthma flare-ups are also called asthma attacks or exacerbations. Triggers like allergies, respiratory infections (like a cold), cigarette smoke, exercise, or even cold air can cause a flare-up and make asthma symptoms worse.
Is asthma contagious through kissing?
Answer. To answer your first question, you can't get asthma from kissing your wife. Asthma is not contagious (in other words, it cannot be spread from person to person). It is also unlikely that kissing your wife causes her to have asthma attacks.
Why is asthma categorized according to phenotypes?
Classifying asthma according to phenotypes provides a foundation for improved understanding of disease causality and the development of more targeted and personalized approaches to management that can lead to improved asthma control [13]. Research on the classification of asthma phenotypes and the appropriate treatment of these phenotypes is ongoing.
How is bdaily PEF calculated?
bDaily diurnal PEF variability is calculated from twice daily PEF as ([day’s highest minus day’s lowest]/mean of day’s highest and lowest), and averaged over 1 week
How many deaths from asthma in 2001?
However, the survey also found that mortality due to asthma has fallen sharply since 1985. In 2001, a total of 299 deaths were attributed to asthma. Seven of these deaths occurred in persons under 19 years of age, while the majority (62%) occurred in those over 70 years of age [6].
How to control asthma in Canada?
In most patients, however, control can be achieved through the use of avoidance measures and appropriate pharmacological interventions. Inhaled corticosteroids (ICS) represent the standard of care for the majority of patients. Combination ICS/long-acting beta2-agonist inhalers are preferred for most adults who fail to achieve control with ICS therapy. Biologic therapies targeting immunoglobulin E or interleukin-5 are recent additions to the asthma treatment armamentarium and may be useful in select cases of difficult to control asthma. Allergen-specific immunotherapy represents a potentially disease-modifying therapy for many patients with asthma, but should only be prescribed by physicians with appropriate training in allergy. In addition to avoidance measures and pharmacotherapy, essential components of asthma management include: regular monitoring of asthma control using objective testing measures such as spirometry, whenever feasible; creation of written asthma action plans; assessing barriers to treatment and adherence to therapy; and reviewing inhaler device technique. This article provides a review of current literature and guidelines for the appropriate diagnosis and management of asthma in adults and children.
What is the most common respiratory disease in Canada?
Background. Asthma remains the most common chronic respiratory disease in Canada, affecting approximately 10% of the population [1]. It is also the most common chronic disease of childhood [2].
What happens to the airway during the early phase of asthma?
The mediators and cytokines released during the early phase of an immune response to an inciting trigger further propagate the inflammatory response (late-phase asthmatic response) that leads to progressive airway inflammation and bronchial hyperreactivity [9]. Over time, the airway remodeling that occurs with frequent asthma exacerbations leads to greater lung function decline and more severe airway obstruction [10]. This highlights the importance of frequent assessment of asthma control and the prevention of exacerbations.
When is PEF measured?
PEF is usually measured in the morning and in the evening. A diurnal variation in PEF of more than 20% or an improvement of at least 60 L/min or at least 20% after inhalation of a rapid-acting bronchodilator suggests asthma [15].
Do authors have competing interests?
Competing interests: The authors declare that they have no competing interests.
Is asthma a type 2 immune system?
Dysregulated type II immune responses are seen in a large proportion of asthmatics, especially those with childhood-onset disease. The mechanisms of impaired IFN responses and how they relate to the type II inflammatory responses typically seen in asthmatics is also of considerable interest in the current literature.
Does rhinovirus cause interferons?
The asthmatic airway is suggested to be deficient in the production of interferons in response to rhinovirus infection. This contributes to increased viral replication. The type II immune cytokines interleukin (IL)-4 and IL-13 have been shown to dampen interferon responses, possibly through the induction of suppressor of cytokine signaling 1 (SOCS1). IL-33 is induced by rhinovirus infection and activates type 2 innate lymphoid cells (ILC2s), which in turn release type II cytokines and pro-inflammatory cytokines such as IL-6 and granulocyte macrophage colony-stimulating factor (GM-CSF). Recent findings demonstrate the ability of type I interferons to suppress IL-33-stimulated ILC2 responses.
How does asthma affect perception?
The perception of asthma symptoms occurs when changes in somatosensory information are detected and matched to mental models of asthma symptoms [34, 35]. In this process, several factors have been identified that may cause a divergence between the level of bronchoconstriction and the level of perceived asthma symptoms. For example, a person may be unable to detect changes in respiratory resistance, and the resulting absence of asthma symptoms increases the risk of near-fatal asthma [36] and may also hinder a person to perceive a contingency between airway obstruction and environmental factors that triggers the obstruction. Furthermore, concurrent affect or contextual information may also interfere with the accurate perception of asthma symptoms [37–41]. Experimental studies have shown that contextual information that is related to previous experience with asthma triggers can lead to the perception of asthma symptoms in absence of the original asthma trigger [42], whereas being in a situation that is perceived as unrelated to asthma may also reduce the perception of asthma symptoms [43]. Also, other factors such as memory, personality, gender, and cultural norms have been shown to influence perception and report of asthma symptoms [35, 44, 45]. Similar to perception of asthma symptoms, perception of other physical symptom, such as symptoms linked to upper respiratory tract infections, is also correlated with personality characteristics and may also lack accordance with objective disease criteria [46, 47]. However, information about the role of perception of upper respiratory tract infections in asthma management is currently lacking.
How many asthma triggers are there?
The number of asthma triggers that is reported by patients in different studies varies widely, ranging from 4–12 [15–17]. Differences in the number of triggers reported across studies may be a function of the questions that are used to elicit personal trigger reports, with the number of triggers being evaluated ranging from 9–32 [9, 15–17]. In order to assess asthma triggers in a standardized form, studies have attempted to develop measures to probe patients’ trigger perceptions. An earlier instrument, the Asthma Trigger Index, [18] was specifically developed to evaluate emotional triggers of asthma. It consisted of a list of potential triggers and a series of situation vignettes linked to emotional experiences.. Although the instrument was reported to have a high test-retest reliability and good content validity, results of a psychometric evaluation have never been published. More recently, the Asthma Trigger Inventory (ATI) [9] has been developed to assess a broad spectrum of asthma triggers in a standardized way. It is a 32-item questionnaire, consisting of 7 subscales measuring trigger domains of pollen allergens, animal allergens, physical activity, air pollution/irritants, infections, and psychological factors. All domain scales have a high internal consistency and test-retest reliability.
What is asthma trigger identification?
Asthma trigger identification is a complex task. It requires perception of asthma symptoms, perception of potential asthma triggers, and perception of a contingency or causal relationship between potential asthma triggers and symptoms (cf. Figure 1).
How long does it take for an allergic reaction to occur?
Allergic reactions consist of both an acute (within minutes after exposure) as well as a late phase response (4–24 hours after initial exposure)[64], which means that by the time the late response occurs it may not be easy to determine what triggered the response originally. Indeed, a decrease in lung function during the late phase response is perceived as less intense compared to a similar decrease in lung function during the acute phase [65]. In contrast, the airway constriction to emotional triggers happens while exposed to the trigger, thus providing a much better condition for perceiving trigger-symptom contingencies [66]. Consequently, reports of psychological asthma triggers in daily life have been linked to stronger bronchoconstriction to emotionally aversive laboratory stimuli [9, 66, 67] Furthermore, allergic reactions to specific triggers have been known to change during the lifetime response in later life [68]. This implies that previous knowledge about individually relevant asthma triggers may become inaccurate when the sensitivity to specific triggers changes.
What are the triggers for asthma?
house dust mite, pollen). In asthma, non-allergic triggers such as air pollution, cigarette smoke, perfume, stress, negative emotions or physical activity may also trigger asthma symptoms [4].
Why is contingency perception important?
In asthma and allergies, contingency perception is used to predict and avoid onset of asthma symptoms. However, contingency perception is often biased.
Why is trigger avoidance so successful?
Although it may be hard to generalize findings from the wide variety of trigger avoidance interventions that have been evaluated [8], we argue that one reason for the mixed success of trigger avoidance may be that individuals have difficulty identifying their personal triggers. In patients with asthma, agreement between reported asthma triggers and actual tests of physical or psychological trigger impact is only moderate [9]. Although this discrepancy could be due to a lack of accuracy of the allergy test, this finding suggests that patients may be unaware of all or some of their triggers, which may leave them uncertain about what the exacerbating factors of their disease are and about which specific triggers to avoid, and could leave them exposed to critical triggers repeatedly without protection. This way, they are presented with recurrent aversive somatic experiences that appear unpredictable and uncontrollable [10, 11]. Alternatively, patients with asthma may attribute their respiratory symptoms to a specific trigger despite the absence of a relationship between the trigger and actual airway obstruction. In other allergic conditions, such as food allergy, the discordance between perceived allergic triggers and triggers identified by atopy tests or provocation tests is even worse [12, 13]. Misidentification of asthma triggers can lead to unnecessary avoidance of perceived triggers and thus restrictions in daily functioning and impairments in quality of life. In asthma, a discrepancy between the perception of symptoms and actual lung function effects of benign daily life physical activity [14] could be associated with the long term risk of forgoing the protective effect of exercise.
What is the best asthma control for a patient with fewer than two symptoms/month?
In Step 1 of the stepwise approach to adjusting asthma treatment, the preferred controller option for patients with fewer than two symptoms/month and no exacerbation risk factors is low-dose ICS/formoterol as needed. This strategy is indirectly supported by the results of the SYGMA 1 study which evaluated the efficacy and safety of budesonide/formoterol as needed, compared with as-needed terbutaline and budesonide bid plus as-needed terbutaline (see above). In patients with mild asthma, the use of an ICS/LABA (budesonide/formoterol) combination as needed provided superior symptom control to as-needed SABA, resulting in a 64% lower rate of exacerbations (p = 0.07) with a lower steroid dose (17% of the budesonide maintenance dose) [ 34 ]. The changes extend to the other controller options as well. In the 2017 GINA guidelines, the preferred treatment was as-needed SABA with the option to consider adding a regular low-dose ICS to the reliever. In order to overcome the poor adherence with the ICS regimen, and with the aim to reduce the risk of severe exacerbations, the 2019 GINA document recommends taking low-dose ICS whenever SABA is taken, with the daily ICS option no longer listed.
What is asthma treatment?
Asthma treatment is based on a stepwise and control-based approach that involves an iterative cycle of assessment, adjustment of the treatment and review of the response aimed to minimize symptom burden and risk of exacerbations. Anti-inflammatory treatment is the mainstay of asthma management.
What is the difference between asthma control and quick relief?
Evolution of a concept. Asthma control medications reduce airway inflammation and help to prevent asthma symptoms; among these, inhaled corticosteroids (ICS) are the mainstay in the treatment of asthma, whereas quick-relief (reliever) or rescue medicines quickly ease symptoms that may arise acutely.
What are some examples of asthma exacerbations?
A typical example of this mechanism is given by viral infections, the most frequent triggers of asthma exacerbations. Rhinoviruses, the most common viruses found in patients with asthma exacerbations, interfere with the mechanism of action of corticosteroids making the anti-inflammatory treatment transiently ineffective.
How many people are affected by asthma?
Background. Asthma, a major global health problem affecting as many as 235 million people worldwide [ 1 ], is a common, non-communicable, and variable chronic disease that can result in episodic or persistent respiratory symptoms (e.g. shortness of breath, wheezing, chest tightness, cough) and airflow limitation, ...
Can asthma patients overuse SABA?
Controversies (1) and (2) can both establish an early over-dependence on SABAs. Indeed, asthma patients freely use (and possibly overuse) SABAs as rescue medication. UK registry data have recently suggested SABA overuse or overreliance may be linked to asthma-related deaths: among 165 patients on short-acting relievers at the time of death, 56%, 39%, and 4% had been prescribed > 6, > 12, and > 50 SABA inhalers respectively in the previous year [ 21 ]. Registry studies have shown the number of SABA canisters used per year to be directly related to the risk of death in patients with asthma. Conversely, the number of ICS canisters used per year is inversely related to the rate of death from asthma, when compared with non-users of ICS [ 8, 22 ]. Furthermore, low-dose ICS used regularly are associated with a decreased risk of asthma death, with discontinuation of these agents possibly detrimental [ 22 ].
Is ICS a maintenance and reliever?
The concomitant administration of an as-needed bronchodilator and ICS would provide rapid relief while administering anti-inflammatory therapy. This concept is not new: in the maintenance and reliever approach, patients are treated with ICS/formoterol (fast-acting, long-acting bronchodilator) combinations for both maintenance and reliever therapy. An effective example of this therapeutic approach is provided in the SMILE study in which symptomatic patients with moderate to severe asthma and treated with budesonide/formoterol as maintenance therapy were exposed to three different as-needed options: SABA (terbutaline), rapid-onset LABA (formoterol) and a combination of LABA and ICS (budesonide/formoterol) [ 28 ]. When compared with formoterol, budesonide/formoterol as reliever therapy significantly reduced the risk of severe exacerbations, indicating the efficacy of ICS as rescue medication and the importance of the as-needed use of the anti-inflammatory reliever.
Why are dose counters important?
They wanted their inhalers to contain more doses and last longer. A dose counter (not included on some preventer and reliever inhalers in New Zealand) was important for all participants because it allowed them to plan when to get another inhaler and avoid using empty inhalers.
Why was Routine important to asthma?
They developed their own strategies to feel in control. Routine was a positive strategy, which promoted regular use of preventers whereas lack of routine and forgetfulness contributed to erratic use of preventer inhalers. Access to inhalers and control over inhaler supplies were important to participants’ management strategies, and included stockpiling inhalers, using out-of-date inhalers, or borrowing them from others.
What is the objective of asthma management?
Objective Preference for asthma management and the use of medications is motivated by the interplay between lived experiences of asthma and patients’ attitudes towards medications . Many previous studies have focused on individual aspects of asthma management, such as the use of preventer and reliever inhalers. The aim of this qualitative study was to explore the preferences of patients with mild-moderate asthma for asthma management as a whole and factors that influenced these preferences.
How did asthma affect the participants?
Asthma had far-reaching effects on participants’ lives. Physical experiences of asthma symptoms were forefront in all participants’ narratives. Breathlessness was the most common symptom and had the greatest impact. Night waking due to asthma and cough had a greater impact on participant’s lives than other asthma symptoms such as wheeze, chest tightness and sputum. Asthma frequently limited physical exertion such as walking up inclines and restricted participation in sports.
Why didn't people like metered dose inhalers?
Many didn’t like the noise of metered dose inhalers because it drew attention to them taking the inhaler. Participants had environmental concerns about inhaler devices, particularly the quantity of plastic generated and wanted inhalers to be recycled or refillable.
What is descriptive statistics?
Descriptive statistics summarise information on demographics, asthma control and medication use. NVivo V.12 was used for management and coding of the qualitative data. Thematic analysis was used to analyse the data, 28 themes were derived from the data. Initial coding was done on a line-by-line basis with an iterative process of reading, reviewing and refining themes and subthemes to develop overarching concepts. All the data were coded by CB with AC peer coding 20% of the data. Emerging themes and concepts were discussed and iterated following each focus group between CB, AC and WL with MH providing the Kaupapa Māori research oversight. 26 The supplement includes additional quotes in ( online supplementary tables S1–S8 ).
What is a broad approach to exploring the patient experience of asthma, its management and preferences for management?
A broad approach to exploring the patient experience of asthma, its management and preferences for management enabled a novel analysis of patient preferences and patient experiences of asthma that influence their preferences.
How does bronchial thermoplasty help with asthma?
This results in reduction in smooth airways muscle and improvement in asthma control. It is unclear whether the mechanism of action for this therapy is through reduction of the ability of smooth muscle to cause bronchoconstriction or via the reduction in potential reservoir of inflammatory cells. The therapy has been established as effective and safe in both the short and longer term [ 12, 13 ]. The main downside of this therapy is the need for three bronchoscopies and the short-term risk of exacerbation peri-procedure.
Is asthma one disease?
Over the years as our understanding of asthma has changed, we now appreciate that asthma is not one disease, but the condition can be subdivided into different forms or phenotypes of asthma [ 4 ]. This understanding of the different forms of asthma is critical as we can now start to understand that different people’s asthma responds to different asthma therapies and we need to be focused on ensuring our patients get the right therapies, so we can aim for optimal control of symptoms whilst minimizing the risk of side effects.