Vol. 21 • Issue 24 • Page 20
When I taught asthma education classes in middle and high schools, I often found that as the age of the students increased, more girls than boys appeared in my classes. It also became apparent that younger boys and older girls had the greater number of problems with asthma.
People often asked me, “Is this normal?” Not only do individuals with asthma and their parents want to know but so do school nurses and administrators, teachers and others.
This type of information can help when developing action plans, watching for symptom development or exacerbation, monitoring medication compliance, using medical resources and all aspects of asthma care.
How do we start to explain these differences in age and gender so that we can be aware of when and whom to monitor? Let’s first look at males. They usually are diagnosed in the first decade of life-a fact often attributed to boys having smaller airway diameters relative to lung volume and more allergen sensitivities.
With women, it seems the pubertal changes in sex hormones coincide with the adolescent increase of asthma. This suggests that estrogen or progesterone may influence the disease. The hypothesis is still under investigation.
Other people believe women have underdiagnosised and undertreated asthma. Another theory for the later diagnosis suggests that because women are in the home environment and indoor businesses more often than men, women have an increased likelihood of indoor environmental exposures and greater atopy prevalence.1
Most recently, a study published in August analyzed airway responsiveness in more than 1,000 children with mild-to-moderate asthma over a nine-year period.2Researchers from Brigham and Women’s Hospital and Harvard Medical School performed annual spirometry and methacholine challenges to examine the natural history of sex differences in asthma.
They discovered a pattern that showed boys became increasingly tolerant to greater amounts of methacholine, suggesting a possible decrease in disease severity. Meanwhile, the girls’ reactivity did not change over the years. The differences in gender began at the time of transition to early puberty.
These findings suggest that boys may outgrow asthma more often than girls. In addition, this study’s results could influence how clinicians handle dosage adjustments when young boys and girls become teens.
Achieving Best Outcomes
With more certainty, we can say the gender and age gap affects emergency room visits and hospitalizations. In children up to age 10, males are twice as likely to be seen in and admitted to the hospital for asthma.
As the age range approaches adolescence, differences start to even out with girls “taking the lead” in their teens. After age 20, female asthma patients are two to 2.5 times as likely as males to be seen or admitted to a hospital.3 Education for patients and staff is the best way to correct these gender disparities and keep people out of the hospital. We need to be aware of how the two sexes perceive their breathing and symptoms, the different times when they are likely to have problems, and subtleties in their peak flow rates. We must then incorporate this information into their asthma action plans.
Here are some things to consider about gender’s role in asthma treatment:1,4• When looking at a peak flow rate or FEV1(especially in the ER or at a doctor’s visit), make sure to use the patient’s known best peak flow or the value that is adjusted for male or female. Using a male value for female (or vice versa) can cause you to think patients are doing better or worse than they actually are, leading to a wrong treatment plan.
• Women are more likely to be insured than men, so they are more likely to have a primary care provider. This also correlates with an increased likelihood of using inhaled corticosteroids because they are often prescribed by a PCP.
• Women perceive mild symptoms more rapidly than men, so they will react and seek care quicker, and this equates to higher rates of health care usage.
• Women appear to have more known asthma triggers, with psychosocial factors especially common.
• Men are more likely to have problems in the early morning hours and women in the evening.
• Women often report longer periods of exacerbation and time to recover and a greater chance of relapse. This may be due to their perception of symptoms-the fact that women are “more aware” of mild symptoms than men.
We also need to teach the physicians and nurses in the ER and hospital about what questions to ask and what to monitor when treating asthma patients so they can care for their patients more effectively and quickly. If we are more aware of gender differences when patients report their asthma symptoms or are having an exacerbation, we can begin to treat all patients using treatment plans developed to fit them individually.
That way, we can achieve the best outcomes possible, and we may be able to help erase the “differences” in asthma.
Kay Stiffler is the treasurer for the Association of Asthma Educators.
1. Singh AK, Cydulka RK, Stahmer SA, Woodruff PG, Carmargo CA Jr. Sex differences among adults presenting to the emergency department with acute asthma. Multicenter Asthma Research Collaboration Investigators. Arch Intern Med. (1999; 159, 11: 1237-43).
2. Tantisira K, Colvin R, Tonascia J, Strunk R, Weiss S, Fuhlbrigge A. Airway responsiveness in mild to moderate childhood asthma: sex influences on the natural history. Am J Respir Crit Care Med. (2008; 178, 4: 325-31).
3. Trawick DR, Holm C, Wirth J. Influence of gender on rates of hospitalization, hospital course, and hypercapnea in high-risk patients admitted for asthma: a 10-year retrospective study at Yale-New Haven Hospital. Chest. (2001; 119, 1: 115-9).
4. Schatz M. Clark S, Carmargo CA Jr. Sex differences in the presentation and course of asthma hospitalizations. Chest. (2006; 129, 1: 50-5).