The World Health Organisation ( WHO) in its latest report released on May 11, 2022 has stated that Asthma remains a major Non Communicable Disease (NCD), affecting an estimated 262 million people ( both adults and children ) in 2019 and causing 455,000 deaths. Recent data has also revealed the disturbing fact that it is the most common chronic disease among children, prompting Asthma to be included in the WHO Global Action Plan for the Prevention and Control of NCDs and the U.N 2030 Agenda for Sustainable Development.
While many factors have been linked to an increased risk of developing asthma, and no known cure for asthma in the near future the key to preventing asthma is by minimising the modifiable risks, which according to the WHO findings are closed linked to crowded cities with smoke filled , dusty unclean environments, exposure to tobacco smoke and other sources of air pollution as well as unhealthy lifestyles leading to childhood obesity among many adverse health impacts .
The Sunday Observer spoke to Consultant Chest Physician (Acting), Chest Hospital Welisara Dr. Thanuja Tissera for more insights into how and what causes asthma and most importantly how this distressing disease can be managed and controlled using the resources freely available in most state hospitals.
Q: Childhood Asthma is on the rise worldwide and in Sri Lanka, and has been cited as a leading cause for hospital admissions . Yet many parents are still unaware as to what exactly asthma is. So tell us, what is Asthma?
A. Asthma is an inflammatory condition which affects airways or breathing tubes and this is reversible. With the inflammation there is narrowing of the major and minor airways which in turn causes asthma symptoms and difficulty in breathing. Unlike normal airways in asthmatic patients the airways are hyper responsive when they are exposed to certain triggers. When the patients are exposed to certain triggers they get asthma attacks.
Q: What are the trigger factors?
Trigger factors can be either genetic or environmental e.g. those with a family history of asthma or other allergic diseases. Studies show that the heritability of asthma is as high as 90 percent. Asthma is mainly an allergic disease when the patient is exposed to certain inhaled allergen these airways can easily become narrowed. Most common triggers are exposed to house dust mites, animal dander ( cat/dogs ), pollen, molds, cigarette smoke, mosquito coil smoke, chemical pollutants ,cold air, extreme emotional responses, physical exercise, some medications like Asprin/NSAIDs(pain killer).
Q: Which of them are the most common in Sri Lanka?
A. Indoor and outdoor air pollutants, smoke (cigarette, mosquito coils), house dust mites etc.
Q: What about allergic rhinitis?
A. Both allergic rhinitis (hay fever) and asthma are common diseases that frequently occur together. Studies have shown that the majority of patients with asthma have concomitant rhinitis and the presence of rhinitis is an increased risk factor for development of asthma. In allergic rhinitis in contrast to asthma there is inflammation of the nose. Symptoms include runny or stuffy nose, sneezing, red, itchy and watery eyes.
Q: With the onset of the rains we also have many influenza cases. If an Asthma patient had developed influenza can it endanger his/her health and worsen the attacks?
A. Yes, patients with asthma are prone to develop severe disease . So remember to take your annual influenza vaccination especially if you are an asthma patient.
Q: Who are those most at risk. Children ? Adults ?
A. You can get asthma at any age. However, it’s more common in children and adolescents than in adults.
Q: Gender wise who are more likely to develop asthma – males or females?
A. Gender wise, in children it is more commonly seen in boys than girls. However in the adults females are affected more than males.
Q: Age wise?
A. Two-thirds of asthma patients are identified before the age of 18.
Q: In the case of very young children who are unable to express their symptoms in words, how do you know that they are having a breathing problem?
A. These symptoms can vary from episode to episode in the same child. Sometimes coughing may be the only symptom. In addition they may appear more lethargic during play, may avoid sports and social activities, trouble sleeping due to cough or breathing problems, wheezing (a whistling sound when breathing in and out), feeling weak /tired.
Q: Is it a life long condition ?
A. This is one of the commonest chronic non communicable diseases. In children around 50 percent this disease will disappear around puberty. However, research has found that out of this 50 percent every one in three can get the disease again when they reach adolescence.
Q: If detected early, is Asthma curable ?
A. As I mentioned previously , this is a chronic disease, and it can be controlled by proper treatment adhering to medical advice and avoidance of trigger factors.
Q: How is asthma treated ? Medications? Inhalers?
A. Management of the disease can be broadly divided into two parts - pharmacological and nonpharmacological. Patient education, identification and avoidance of triggers are the main non pharmacological options. Asthma is treated with inhalers and medications. There are various type of inhalers are available in the market and these can be either dry powder inhalers (where you have to use medicated capsules and release the medicine when you take a deep breath) or metered dose inhaler (uses a small aerosol canister to push out a short burst of medication through a plastic mouthpiece). Metered dose inhalers can be taken directly or with a spacer device which facilitates the delivery of medications to the lung. Spacer devices are usually given for children and elderly people. Proper inhaler techniques are paramount for good delivery of medications into the lung and in turn good asthma control.
Q: What are the medications that are used in these inhalers ?
A. Medications that are used in inhalers can be of two types. That is reliever medications and preventer medications. Asthma preventer or controller medications are used to control asthma and lower the risk of disease exacerbations. Relievers contain fast acting medications like Salbutamol.
Preventers are given for long term control and these medications will help to reduce the inflammation and narrowing of the airway. Preventers need to be taken regularly in order to control the disease. Preventers contain steroids which helps to reduce airway inflammation and narrowing.
Q: Any advice as to how these should be taken?
A. You should always follow your doctor’s instructions as techniques are different from device to device. It is very important to rinse your mouth after taking inhalers as otherwise medications that are deposited in your throat can cause hoarseness of voice and fungal infections (oral thrush). Remember to spit and not to swallow after rinsing the mouth.
Remember to take your inhaler device with you every time when you go to meet your doctor to assess your technique.
Q: With medical advances moving forward, what are the new therapies that have recently surfaced for Asthma treatment? Are they available in Sri Lanka?
A. Newer therapies for asthma include biologic medications which come as injections. Some patients with poorly controlled asthma despite maximum inhaler therapy and oral medications will benefit from these. However, currently these are not yet available in Sri Lanka
Q: What do you need for proper control of the disease?
A. Asthma is associated with several comorbid conditions that require treatment at the same time to achieve proper asthma control. These are obesity, obstructive sleep apnea, gastro esophageal reflux disease, vocal cord dysfunction, allergic rhinitis and post nasal drip.
Q: Is treatment tailored to the age, physical and mental health condition of the patient ?
A. Yes, always it should be a personalized approach. Medications and types of the inhalers will be different according to the age. At the extreme of age inhaler techniques are the main issues. Your inhaler technique from time to time should be assessed by a healthcare worker (doctor/nurse) in order to make sure that you are taking your medicine correctly and you are getting the correct treatment. Poor inhaler technique may cause suboptimal delivery of the medications into the lungs.
Q: Can those with asthma, marry, have children, work and lead an active life
A. Yes of course, that’s what these medications are for. This is true for everyone, especially children and adolescents who are entitled to enjoy their childhood. With proper medications they should be able to eat what they like, do any sport (swimming) without fear or an attack..
Q. How safe and effective are these medications? Can they be used by all asthma patients?
A. Most of the asthma medications are safe to be used during pregnancy and breastfeeding. However, you should consult your doctor before starting any medications if you are pregnant or breastfeeding. In addition there is a risk of getting asthma attacks during pregnancy so you should not stop your inhaler during this period. You can perform your normal work with asthma but be vigilant and avoid being exposed to triggers such as dust or chemicals in your working place which can exacerbate your asthma.
Q: How can they protect themselves from pollutants that trigger an attack in their workplace?
A. It is important to wear protective measures (proper face masks) during these situations to avoid exposure. While on medications if you can’t live a normal life that means you are undertreated and you need to consult your doctor for assessment of your disease.
Q: Asthma has been linked to air pollution. Do you agree?
A. Evidence suggests that air pollution has a negative impact on asthma outcomes in both the adult and pediatric population. Traffic related air pollution, nitrogen dioxide, second hand smoking exposure are the significant risk factors for development of asthma in children. Exposure to outdoor pollutants can induce asthma symptoms and asthma attacks. Both active smoking and second hand exposure adversely affect the development and control of asthma. Indoor air pollutants such as heating sources and moulds also negatively impact on the course of asthma. Measures to reduce exposure to air pollutants are needed to improve the outcome of asthma control.
Q: Do you have a message to our readers on preventing and reducing the complications of asthma?
A. Asthma can be fully controlled with proper medications following medical advice. If your asthma is well controlled you can live a normal life. If not you need to consult your doctor and check if your medications are adequate and your inhaler technique is correct. Every medication has side effects so this is true for asthma too but these side effects are very mild and negligible. With regard to myths surrounding inhalers, I wish to emphasise that there is no danger that you will get addicted to inhalers. In fact with time when your asthma is controlled we can reduce the dosage of your inhaler. Most of the asthma medications are safe to be used during pregnancy and breastfeeding so you should not stop your medications.