Respiratory physicians and asthma specialists across the world last week (May 2) came together to pool their resources and knowledge to improve the quality of life of all Asthma patients, especially those in low and middle income countries who bear the main burden of this Chronic disease.
The Sunday Observer spoke to Assistant Editor of Sri Lanka College of Pulmonologists and Consultant Respiratory Physician, District General Hospital and District Chest Clinic, Trincomalee, Dr Upul Pathirana to give better insights into this common condition that affects both young and old alike. We also asked what advice he could offer to asthma patients on how to manage their symptoms better so that they may be able to lead normal lives.
Dr. Upul Pathirana
Q: Although Asthma is a very common condition not many still know much about this condition. So tell us, what is Asthma?
A. We have two lungs in our body, which oxygenates the blood and removes waste gas, Carbon Dioxide (CO2) from the blood. To maintain the optimum level of Oxygen (O2) and CO2 in the blood, the required amount of air should reach the alveoli (Alveoli are tiny air sacs connected to the terminal part of the airways). The branched system of airways enables air to pass to the alveoli. The symptoms of asthma are associated with difficulty in breathing air out of the lungs due to airway narrowing, airway wall thickening and increased production of phlegm.
Q: Why is a special day set aside for this common health problem?
A. Asthma is a serious global health problem affecting all age groups, with an estimated 262 million people in 2019 and 455 000 deaths. Over time, chronic inflammation can damage healthy cells, tissues, and organs. Yet in spite of its wide prevalence and serious outcomes if neglected, many health sectors are yet to give Asthma a high priority in their list of chronic diseases. It is to fill this gap and raise more awareness both among the public, patients, health sectors and policymakers that World Asthma Day is organised each year by the Global Initiative for Asthma, (GINA),
Q: What are the main symptoms to look out for?
A. Cardinal symptoms of asthma are the cough, wheezing, shortness of breath, and chest tightness, which occur in isolation or in combination. Isolated cough might be the only symptom in asthma, for instance: a child coughing after cycling suggests exercise induced asthma. On the other hand, asthma may present with severe devastating symptoms like extreme breathlessness.
Q: How do you distinguish between an ordinary cold and the onset of an asthma attack?
A. The distinction of the above two common health problems is quite significant. Usually, the person who already has asthma will probably know to distinguish an asthma attack from a common cold. However, this may be difficult for those who develop an asthma attack for the first time. The common cold is an acute illness caused by viruses and it is characterised by soreness of your throat, runny nose, sneezing and cough. You may experience body pain and fever. For treating a common cold all you need is simple symptomatic treatment. In the case of an asthma attack or acute asthma the symptoms are more aggressive like breathlessness due to wheezing and chest tightness in addition to a simple cough. The important lesson here is that one should keep in mind that viral illnesses can precipitate asthma attacks or make your asthma uncontrolled.
Q: What kinds of conditions are usually associated with asthma in Sri Lanka especially? Over crowded urban areas? Polluted air? Allergens?
The correct technique for using an inhaler with a spacer
A. Air pollution can make asthma symptoms worse and trigger asthma attacks. Viral infections, allergens (house dust mite and pollen), tobacco smoke, stress and exercise can also trigger or worsen asthma symptoms. In addition some medications like aspirin can also induce or trigger asthma attacks in some individuals.
Q: What about stress? Many studies have shown that children and adults with asthma often develop an attack before an exam, or job interview or due to overwork. Is this correct?
A. Yes. Stress is a trigger rather than a cause of asthma. If you have asthma, keep an eye on your stress levels - approximately 40% of people with asthma tell their doctors that stress triggers their symptoms.
Q: The theme chosen for this year (2023) by the Global Initiative for Asthma, (GINA) is “Asthma care for ALL” How relevant is it especially for Lankan patients?
A. Availability and access to effective, quality assured asthma medications to all persons especially in low and middle income countries such as we are, is the cornerstone to battle this burden. Hence GINA encourages health care leaders to ensure the availability and access to asthma treatment for all and the “Asthma care for ALL” message promotes the development and implementation of effective asthma management programs in all resource countries.
Q: What are the gaps you see in meeting the target of this year’s goal challenge in Sri Lanka?
A. The Sri Lankan health care system has been accomplishing a wonderful job to overcome the asthma related burden. However, there is a lot more room for improvement. It is to this end that in collaboration with the Ministry of Health, the Respiratory Physicians and Sri Lanka College of Pulmonologists have organised many awareness raising activities targeting the public and health care workers.
Q: According to most Asthma specialists, the best option for asthma is to control and manage the symptoms .How do we do this?
A. To answer the above question, we should look into what is happening inside lungs in patients with asthma. First of all we will look into the term inflammation.
Inflammation occurs when the body releases chemicals that trigger an immune response to fight off infection or other injurious agents. Once the injury or infection is healed, the inflammatory process ends.
Chronic inflammation is an abnormal immune response in which the inflammatory process does not end when it should or may begin when there is no infection or injury (that is for harmless environmental material and it is called allergy or hypersensitivity reactions). Over time, chronic inflammation can damage healthy cells, tissues, and organs.
Q: Treatment- how do you treat asthma? tell us the procedure.
A. I will put this simply to the umbrella term of asthma pathology that is inflammation.
We prescribe medications to overcome the inflammation. These are called anti-inflammatory medications (Preventers), which is the mainstay of treatment. However, medications to dilate the airways called bronchodilators (Relievers) are used to treat breakthrough symptoms and to manage asthma in acute situations.
Q: How is this done? Through pills? Inhalers? If so, which method is better?
A. There are 2 glands above both kidneys called suprarenal or adrenal glands. These glands secrete a hormone called corticosteroids, which possesses a good anti-inflammatory action. These natural hormones can be synthesised in a laboratory for treatment purposes. The biggest drawback of oral corticosteroid (example, prednisolone) is its adverse effects (such as diabetes, high blood pressure, osteoporosis and infections) with long-term use. The technology has been applied to overcome the adverse effects by converting tablets of corticosteroids into inhaled formulations.
Q: Does that mean inhalers are better?
A. The dose is very minimal in the form of inhalers (microgram) in contrast to tablets (milligram).
You should swallow the tablets and therefore, it gets absorbed into the blood resulting in more systemic side effects.
Inhaler devices directly deposit the medication to the target site of airways. Therefore, there are no systemic adverse effects with low to moderate doses of inhalers.
We use a short course of pills to treat initial uncontrolled or severe symptoms followed by maintenance treatment with inhalers.
Your physician may add some other tablets; these are most of the time non-corticosteroids tablets, but with weak efficacy.
Q: If patients, once treated, feel better with good control of symptoms, is it necessary to continue asthma medication on long term as a maintenance treatment?
A. Yes. This is very important. One natural tendency of patients for some chronic disease is to discontinue medications without medical advice when they are asymptomatic. Asthma is a chronic disease, therefore the inflammation is going on despite you not feeling any symptoms until they come to a head. A new attack while not on treatment could be life threatening putting your life at risk, besides consuming a significant health care cost. The chronic inflammation is also not healthy. The end result could be permanent changes within your airways and ultimately it behaves like chronic obstructive pulmonary disease (COPD). The symptom control might be partial at this stage irrespective of multiple medications in high doses. So don’t stop without consulting a physician. Once your asthma is well controlled, we will reduce the treatment to the lowest possible maintenance dose of medications.
Q: I understand that many people also misuse these devices, which often leads to health complications. How are they misused? Give us some examples?
A. We have two types of inhalers: preventers and relievers. Preventers help induce and maintain remission. Relievers are there to treat breakthrough symptoms. Some patients get confused with these two and administer relievers regularly without using preventers. They are the patients with poor adherence to regular maintenance therapy, who end up with asthma related complications. Medication misuse is mainly observed in oral corticosteroids and not the inhalers.
Q: We have seen an array of inhaler devices in the pharmacies. What are the differences and how do you choose what is best for your patient?
A. We can divide all the inhaler devices into two groups: dry powder (DPI) and pressurised metered dose inhalers (pMDI). DPI contains small particles in the form of powder form, therefore; you have to have good inhalation force to take the medication into your lungs. In comparison to DPI, pMDI has the capacity to generate the mist, therefore; you should inspire slowly for optimum drug deposition. Those who are unable to have good coordination with inspiration, we may add a spacer device to the pMDI. The physician will choose one that will suit his individual patient after discussing the matter with the patient.
Q: Do you have a message to our readers who are vulnerable to asthma on managing their symptoms effectively?
A. Asthma is a chronic disease, therefore; the treatment is long term. We can achieve a state of remission of your asthma which is near- normal to cure. Inhaler devices are the development and technology, and it is a few steps beyond pills.
You must not be scared about inhalers and good adherence to the prescribed medication will keep you in a normal, active life.