How Is Severe Asthma Diagnosed
More steps are taken to arrive at a diagnosis of Severe Asthma compared to mild-to-moderate asthma. As in mild-to-moderate asthma, healthcare providers will take a detailed medical history, listen for wheezing on examination of the chest, and assess for underlying allergic and non-allergic triggers. Underlying diseases such as eczema or allergic rhinitis may be clues that allergy is present. Allergy skin testing may be performed to evaluate if specific allergic triggers are present that can result in asthma attacks.
In addition, healthcare professionals will likely also conduct objective examinations of lung function including spirometry, or peak expiratory flow , and in some cases, sputum cell counts, which indicate the presence, type, and extent of inflammation in the airways. These objective tests in addition to history will help determine if a patient has Severe Asthma, and will inform treatment choices for patients.
Healthcare providers should refer patients with Severe Asthma to a specialist to confirm their diagnosis and assist in management.
Can You Answer These 6 Questions About Severe Uncontrolled Asthma
Most people know someonemaybe a friend or family memberwho lives with asthma, a chronic disease marked by inflammation of the airway that makes it hard to breathe. At the heart of it all, asthma is not the same for everyone. It can have different triggers, attack in different forms, and may sometimes require specialized treatment.
May is Asthma and Allergy Awareness Month, a peak season for the millions of Americans living with asthma and allergies. Here are the six most important questions you need to know about severe, uncontrolled asthma.
How Many People Seek Medical Care For Asthma
- In 2018, asthma accounted for 5.8 million doctors office visits.5
- In 2018, asthma accounted for 178,530 discharges from hospital inpatient care and 1.6 million emergency department visits.6,7
- Black people in the U.S. are nearly five times more likely than white people in the U.S. to visit the emergency department due to asthma.7
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What Happens When Asthma Isnt Controlled
If your asthma is mild to moderate but isnât under control, you may:
- Feel like something is tightening around your chest
- Have a hard time breathing
- Make a whistling sound when you inhale and exhale
In children, unmanaged asthma can slow growth or delay puberty.
Some peopleâs lungs change when the tubes that bring air in and out of them are always swollen. The airways get narrower, your lungs have scars, and itâs tough to breathe. This is called airway remodeling. Doctors need to learn more about this condition. But they do know that medication often stops the swelling. Airway remodeling can make asthma medications less effective, so itâs important that you start asthma treatment as soon as possible.
Your lungs are vulnerable to infections like pneumonia too. They also may not work as well when you age. Some loss of function is normal when youâre older, but asthma that isnât treated can speed up the process. Be sure to let your doctor know if you have trouble breathing as an adult. They can determine if itâs from aging, asthma, or something else.
Future Risk Of Exacerbations In Severe Asthmatics
Exacerbation is a defining feature of severe asthma, which is defined by a worsening of symptoms requiring the use of SCS or an increase in the SCS doses in patients on a stable maintenance dose, to prevent serious outcomes.25 In a cross-sectional assessment of the TENOR II cohort participants with severe or difficult-to-treat asthma, 48.2% of the cases experienced exacerbation in the recent 12 months and 21.3% had severe exacerbations .19 In the Australian Severe Asthma Web-Based Database, severe asthmatic patients experienced a median of 2 exacerbations during the 2-year follow-up.26
In a 5-year prospective longitudinal follow-up study of 177 patients with problematic asthma from Singapore, there were 3 distinct trajectories described in terms of severe exacerbation rates: infrequent exacerbators , non-persistently frequent exacerbators , and persistently frequent exacerbators .17 The most unfavourable trajectory group had an annual mean incidence of severe exacerbation of around 4 person-years, whereas the other 2 groups showed a less than 1 person-year incidence at 5 years. The unfavourable group characteristics included a higher body mass index, more frequent history of near-fatal asthma or severe exacerbation as well as more frequent gastroesophageal reflux disease , obstructive sleep apnoea, and depression than the other 2 trajectory groups.17 However, no longitudinal correlations with asthma control status were presented.
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Is Controlled Severe Asthma Completely Being Controlled
As reviewed above, the future risks of adverse outcomes in patients with controlled severe asthma have not been completely studied. These patients may belong to a grey zone, because their future health risk is not readily measurable but is also poorly perceived by this group. For this reason, there is an important question as to whether controlled severe asthma is completely being controlled. At the very least, the answer is No in terms of the future risk of drug side effects. The risk of drug side effects increases even at low-dose SCS exposure. In addition, it is likely that chronic corticosteroid therapy will not prevent future asthma progression. Lung function decline was not prevented in severe asthmatics despite improvements in asthma control with higher-intensity treatments.49
Know The Major Dangers Of Untreated Asthma
It is known that a person treated for asthma can lead a normal life. So what happens to those patients who are untreated? Luckily many of them do not suffer from severe asthma but end up visiting the hospitals frequently when asthma flares. However, in rare cases, you can suffer serious medical problems making it even more difficult to control asthma. The dangers of untreated asthma are troublesome both in terms of health and financial perspective. They can range from lifestyle disruptions to even long hospital stays and deaths. The following are the worst case scenarios.
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Spirometry And Symptom Control
We measured forced expiratory volume in the first second , forced vital capacity and peak expiratory flow from spirometry according to ERS standardizations.12
We defined asthma control based on European Respiratory Society/American Thoracic Society guidelines.2 Asthma control was assessed by the asthma control test , asthma control questionnaire and the annualized number of severe exacerbations 12 months prior to study visit, defined as a burst of systemic corticosteroids for 3 days. Uncontrolled asthma was defined as either ACQ 1.5 or ACT < 20, or two or more severe exacerbations or one serious exacerbation with hospitalization, ICU stay or mechanical ventilation in the previous year.2
To study the long-term changes in body composition and its relation to asthma control, we compared the changes in body composition between patients with persistent uncontrolled asthma and patients with controlled or temporarily uncontrolled asthma. Persistent uncontrolled defines patients who had uncontrolled symptoms at baseline and at follow-up, while the rest of the patients had controlled asthma at both study visits or had uncontrolled symptoms at only one of the study visits.
Sometimes Asthma Can Cause Long
Airway Remodeling If you have asthma, your airways become inflamed, which causes them to swell and produce extra mucus. Unless youre able to control this inflammation with medication, it can ultimately lead to a permanent narrowing or other structural changes in the lungs bronchial tubes, Dr. Rosenstreich says.
This airway remodeling is irreversible and can affect how well you breathe. Some people may ultimately need to use an assistive device, like an oxygen machine, to breathe.
Its believed that everyone who has asthma experiences airway modeling to some degree, however, severe airway remodeling is rare. When inflammation in the lungs isnt properly controlled by therapy with corticosteroids or bronchodilators, scar tissue can form and the airways are no longer able to open up, even after using an inhaler, Rosenstreich says. It can begin shortly after the onset of asthma, which is why we encourage people to stick to their prescribed therapy.
Anxiety and Depression As with some other chronic diseases, asthma may increase your risk for anxiety and depression. Some research has found that people with asthma are nearly twice as likely to develop depression as those without asthma.
Some research suggests the psychological stress and negative emotions associated with asthma are what put individuals with asthma at higher risk for these mood disorders. Sleep disturbances and inflammatory factors associated with asthma may also contribute.
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Uncontrolled Asthma: Assessment And Management
www.sciencephoto.com
- CPD module
- After reading this article, test your knowledge by completing the CPD questions and receive a certificate as a record of your learning.
After reading this CPD article, adapted from Pharmacy Management of Long-term Medical Conditions, published by Pharmaceutical Press, you should be able to:
- Identify when signs and symptoms are indicative of a patients asthma not being well-controlled
- Assess patients and undertake an asthma review
- Understand how to effectively manage patients, including the process of stepping up treatment and related considerations.
Asthma is a common chronic condition that affects around 5.4 million people in the UK, including 1.1 million children, and 1 in 5 of these people will suffer from severe asthma. It contributes to a large burden on the NHS, including 77,124 UK hospital admissions in 2016/2017, 75% of which were thought to be avoidable, and 1,484 deaths in 2017, two-thirds of which were thought to be preventable.
Asthma is a reversible obstruction of the airways, characterised by intermittent inflammation that causes narrowing of the airways and limits airflow. Asthma also causes damage to the nerve endings in the airways, making them hypersensitive and easily irritated. People with asthma typically experience periods of chest tightness, shortness of breath and wheeze in between periods of normal lung function.
Outlook For People With Severe Asthma
Because severe asthma is so unpredictable in the treatments it responds to, and the course it takes, the long-term outlook is different for everyone, says Dr Andy.
There are lots of treatments around for people with severe asthma and your team of healthcare professionals will work with you to find the right ones for you so you can have the best quality of life possible in the long term.
Airway remodelling
One of the possible long-term effects of severe asthma is something called airway remodelling.
This is where your airways become thicker over time, so the airway itself is narrower, making it harder to breathe.
Airway remodelling can happen if people have frequent asthma attacks. If you have severe asthma, your risk increases because youll probably have asthma attacks more often. Long-term exposure to pollutants including tobacco smoke can play a part too.
Whatever the reason, if youre continually having lots of symptoms over a long period of time then theres a risk your airways will become permanently narrowed, scarred and inflamed, which can mean your symptoms get worse.
For most people, changes to the structure of your airways can be avoided with good asthma management.
Airway remodelling can be treated with bronchial thermoplasty, but this treatment is not recommended for everyone with severe asthma.
COPD and Asthma-COPD overlap syndrome
Long term severe asthma can sometimes lead to a chronic lung condition called COPD or ACO .
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Poor Adherence To Medication
Suboptimal adherence to medication use is the most common reason for treatment failure in asthma and has several known drivers . Firstly, patients overestimate their asthma control, and accept poor control as part of living with asthma. In a UK qualitative analysis of 42 adults with asthma, patients often did not think daily treatments preventing inflammation were needed if their asthma was not bothersome . In a study of the perception of control among 329 adults in Trinidad, uncontrolled asthma correlated with routine work limitation, night-time disturbances, work absenteeism, exacerbations and rescue inhalation however, 65% believed that they had to live with their symptoms . In an online survey of 2467 adults with asthma from eight Asian countries/regions , 50% of patients had diagnosed uncontrolled asthma however, approximately 90% of respondents felt their asthma was under control. Patients consistently overestimated their asthma control and considered control as the management of exacerbations .
Key reasons for poor adherence to asthma medication. SABA: short-acting beta-agonist.
What Is Severe Uncontrolled Asthma
Asthma is an inflammatory disease that causes the airways in the lungs to become swollen or inflamed and over-reactive to triggers like pollen, dust, or smoke. An asthma attack can make it hard to breathe, and in many cases, people dont recognize their asthma as severe.
Severe asthma requires medium- to high-dose inhaled corticosteroids plus another asthma controller medication and may require the addition of oral corticosteroids. However, despite using high-dose medicines, reducing risks, and following a treatment plan, many times asthma remains uncontrolled1.
According to the American Lung Association, people with uncontrolled asthma experience at least three of the following2:
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You Think Your Asthma Is Under Control
Most of the asthmatic patients do not realize that their condition has worsened unless they are admitted to the emergency ward. They think that they are alright as long as they are regularly using their rescue medication when needed. In reality, even if the asthma is silent, i.e. without any coughing or wheezing, or breathing difficulty, there can be the presence of lung inflammation. Asthma patients get used to the breathing difficulty and stop focusing on it over a period.
If you have persistent asthma, but you treat it only during the attacks, then you are not controlling it properly. Taking controller medication is important to reduce the inflammation and mucus production, thereby healing the lungs which is highly important so that you wont suffer from untreated asthma. Controller medication opens up the airways making it easy for you to breath. Just 60 seconds of inhalation with asthma pump can provide you relief for several hours or even days.
How To Treat Severe Asthma
Once your asthma specialist has determined the type of severe asthma you are suffering from, they can tailor treatment based on your specific type. Basic treatment for severe persistent asthma consists of inhaled corticosteroids. Additional long-term controller medicines, such as long-acting beta 2 agonists , montelukast or theophylline, are added if asthma is still uncontrolled. Oral corticosteroids can be added on to treatment if patients are still experiencing symptoms and flare-ups.
A personalized treatment plan may include:
Macrolide AntibioticsMacrolide antibiotics are used to help the body fight infection. These medicines control the number of white blood cells found in your airways. One study showed positive results using macrolide antibiotics in people with high counts of neutrophils in blood or sputum samples. Doctors dont suggest these medications be used long term though because side effects, such as antibiotic resistance, can be very serious.
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How Many People Live With Severe Uncontrolled Asthma
Around 5%10% of asthma cases are diagnosed as severe. About 20%50% of those are considered to have severe, uncontrolled asthma, which means they are unable to effectively control their condition with currently available medications. Its estimated that about 1 million people in the U.S. and about 2.5 million people globally live with severe, uncontrolled asthma3,4.
“Asthma is among the most common chronic diseases in the world, says Darryl Sleep, M.D., senior vice president, Global Medical, and chief medical officer at Amgen. And those living with severe, uncontrolled asthma continue to face significant unmet needs.
What Are The Long
A long-term complication of uncontrolled asthma is airway remodeling, which is permanent narrowing of the bronchial tubes. 4 If you dont get good control over your asthma, this conditionwhich mimics chronic obstructive pulmonary diseases can develop over many years.
Is asthma long-term or short term?
Asthma is a long-term condition for many people, particularly if it first develops when youre an adult. In children, it sometimes goes away or improves during the teenage years, but can come back later in life. The symptoms can usually be controlled with treatment.
How long do the effects of asthma last?
An asthma episode, also called an asthma flare-up or asthma attack, can happen at any time. Mild symptoms may only last a few minutes while more severe asthma symptoms can last hours or days.
What is the cause and effect of asthma?
Asthma is a chronic condition that affects the airways. It causes wheezing and can make it hard to breathe. Some triggers include exposure to an allergen or irritant, viruses, exercise, emotional stress, and other factors.
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Why Do Males And Females Have Different Rates Of Asthma
- Male children are more likely to have asthma than female children. This trend reverses in adulthood, where female adults are more likely to have asthma than male adults.11
- Some studies suggest this trend reverses because of the effects of testosterone on lung cells. Testosterone, a male sex hormone, has been found to decrease the swelling of the airways in asthma.11
Medical Review February 2018, updated April 2022 by Sarah Goff, MD, PhD
References
1. Centers for Disease Control and Prevention. . 2019 National Health Interview Survey Data. U.S. Department of Health & Human Services.
2. Ferrante, G., & La Grutta, S. . The Burden of Pediatric Asthma. Frontiers in Pediatrics, 6.
3. Centers for Disease Control and Prevention. . Asthma Data Visualizations.
4. Centers for Disease Control and Prevention. . AsthmaStats: Uncontrolled Asthma Among Children, 20122014. U.S. Department of Health and Human Services.
5. National Center for Health Statistics. . National Ambulatory Medical Care Survey: 2018 Summary Tables. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.