Justines Asthma pages

Mild asthma, which responds well to treatments, may be a completely different disease than severe asthma. A first ever investigation in Europe, found that people with severe asthma where 15-20 times more likely to need emergency care than those with mild to moderate asthma. Severe asthma has a huge impact on health care costs. The five- year survival of people with very severe asthma is as poor as in several forms of cancer, researchers say. They conducted a trial of 163 patients with severe asthma and compared them with 158 people whos mild to moderate asthma was controlled by inhaled steroids. The patients with severe asthma were much more likely to have asthma attacks and a poor quality of life despite the fact that they were on large doses of oral steroids and inhaled steroids. The severe asthma patients had different levels of chemicals in their blood, suggesting that severe asthma is a distinctly different form of asthma, rather than simply more severe asthma symptoms. This shows that there are as yet undiscovered mechcanisms that cause severe asthma and more research is needed for doctors to improve diagnosis.

                  Asthma rules the lives of severe asthmatics.

                         Asthma symptoms are continuous.     

                           Frequent night time symptoms.         

                        Level of activity  extremely limited.        

Type one brittle asthma is patients who consistantly show wide variations of peak flow readings despite maximun medical theraphy. These patients are typically female aged fifteen to fiftyfive. Type two brittle asthma seems to be well controlled between attacks which are often very sudden in onset and are associated with loss of or disturbed consciousness on at least one occasion. These patients are very likely to exhibit a severe respiratory acidosis in an attack. This type of brittle asthma occurs equally in men and women. Type one brittle asthma is a cause of considerable morbidity and hospital admissions and results in high doses of medication. Side effects of this medication are very common and include osteoporosis, weight gain and oesophageal reflux. In addition, this can result in obstructive sleep apnoea which may remain unsuspected because poor quality tends to be attributed to asthma, even though the symptom pattern is exactly the same in these patients compaired to associated sleep apnoea. Sleep apnoea is treated with positive continuous airway pressure.

Risk factor: Atophy: Over 90% of patients with the type one brittle asthma are strongly atopic despite which over two-thirds keep pets at home, so continuing exposure to allergens may be inportant in maintaining symptoms in this group, especially as they spend more time at home and indoors. Food intolerence: Over 60% of type one brittle asthmatics report one food or drink that makes their asthma worse. Food allergies are as common as in 50% of brittle asthmatics with wheat and dairy products the main triggers. Psychosocial factors are also important in type one brittle asthma. Reports of high depression, broken relationships and physical abuse are among these. Just as common are abnormal coping strategies for managing deteriorating asthma (YES THIS IS HARD TO COPE WITH). However it is difficult to be certain whether brittle asthma is associated primarily with personality desorder, or whether severe asthma induces psychological instability (I think this is more likely).

These patients are, by definition, extremely difficult to manage. Many of them have fallen out with their doctor, prehaps, understandably, has run out of ideas, and, often patience. Managment should be holistic, trying to approach all areas which impact on an individuals symptoms. This involves identifying all the factors before attempting to wrestle all the medicine. Group theraphy might be a help to these patients as I feel that no one cares and speaking to others in the same boat may help these patients cope. Removal of animals from some patients is a must and to identify allergens and food intolerence. The most important factor is none compliance of treatment. This it's self does not cause severe asthma but lots of asthmatics opt not to take treatments because of the side effects and usually because they do not make much difference to their condition. Many asthmatics take too much inhaled medications, especially ventolin. This is usually because they are extremely breathless much of the time and often at night. This can also cause side effects. It is written and said this is too avoid steroid medications, but I know for a fact that it is because I am breathless. Yes thats a fact. Infusions of long term continuous terbutaline is usually helpful in these patients.

Managment of type two brittle asthma is less difficult. In view of a rapid attack each patient should be given a medical alert bracelet. Again identification of triggers is crucial but the mainstream theraphy for these attacks is adrenaline. These patients seen to be symptom free between attacks. Adrenaline may have advantages for these patients it reduces airway oedema in acute airway narrowing. Ana pen should be provided for emergencey treatment. Rapid recovery is usually the response with adrenoline.

Conclusion: Patients with either type one or two brittle asthma pose difficult and complex managment problems. helping to determain these patients will provide a framework for beginning to unravel aetiology and treatment for this high morbidity group.

Studies from asthma deaths of and people with near fatal asthma have concluded that there are factors associated with the disease. Enquiries from 200 asthma deaths  shows that medical management and the patients behavior or psychosocial status that contributed to the deaths. Most of the patients that died had chronically severe asthma. In very few with mild asthma the attack happened very sudden. Some of the deaths occurred in patients that had received inadequate treatment or inadequate monitoring or their asthma. Some of these patients were not even under care of a specialist. Heavy or increased use of beta 2 agonists therapy was associated with the asthma deaths. Deaths have continued to be reported following inappropriate prescription of beta blockers (asthmatics should not really be given these) or heavy sedation. A small number of patients were sensitive to non-steroidal anti-inflammatory agents, all asthma patients should be asked if any past reactions to drugs etc.

Behavioural and adverse psychosocial factors were recorded in the majority of patients who died of asthma. Below shows a table of patients at risk.

Previous near fatal asthma.

Admission to hospital in last year.

Requiring three of more asthma medications.

Heavy use of inhaled beta 2 agonists.

Brittle asthma.

Non compliance of treatment or monitoring.

Failure to attend appointments.

Self discharge from hospital.

Psychosis and depression.

Recent tranquilliser use.

Denial.

Alcohol or drug abuse.

Obesity.

Learning difficulty.

Income and social problems.

Marital or legal stress.

Compared with controlled asthmatics, patients who died had the more severe disease. Health care professionals must be aware that patients with severe asthma and one or more risk factors are at risk from death. Compared with those who die, those with near fatal asthma are significantly younger. All patients with severe and near fatal asthma must be kept under specialist care. In the uk asthma deaths peak in younger people in July and August and in December and January in older people. In one study asthma attacks in 80% of patients happened slowly over 48 hrs. There are very many similarities in people who die from asthma and patients with near fatal asthma.