The obvious answer is to prevent death due to asthma and to inhibit the development of asthma morbidity. There is an old adage, “An ounce of prevention is worth a pound of cure.” Each asthma exacerbation puts the patient at risk for death. Any measure to prevent or forestall this ominous event is well worth the endeavor. Unfortunately, we do not now have what would be equivalent to a hemoglobin A1C in diabetes mellitus for assessing and monitoring asthma.
Although exacerbations are a prominent feature of both severe and very poorly controlled asthma, an exacerbation may be experienced by patients with any level of asthma severity or control. Severe exacerbations may occur in patients with newly diagnosed asthma and even in an atopic patient with no previous asthma symptoms.
All asthma patients require repeated clinical assessments in order to ascertain their clinical disposition and to anticipate potential problems that they may encounter due to a variety of influences that may negatively impact their asthma.
Some of these influences they may be able to control, but they may have no ability to neutralize or dampen their impact of other influences. For example, if a patient knows in advance of a situation at the workplace that increases the risk for an asthma exacerbation, then a preemptive effort should be exercised to avoid the anticipated exposure or to extricate the patient from that environment. This may require a letter from a clinician to accomplish this goal.
Another example is the seasonal anticipation of increased asthma flares that can be directly linked to the circumstance of a child returning to school during the fall and the increased likelihood of contracting the rhinovirus during the same time period.
Decreasing the likelihood of deterioration of asthma and ensuring that the patient is on the minimal amount of medication necessary to maintain asthma control are not paradoxical goals. As stated in the NHLBI asthma guidelines, whenever possible, an attempt should be made to step-down therapy in order to determine the minimum therapy necessary to maintain asthma control.
This decision to step-up therapy cannot be accurately ascertained unless the following are assessed: the patient’s technique for using inhaled asthma medication; adherence to respiratory medical regimen; environmental triggers that may drive the asthma; and modifiable comorbidities. All these variables may confound the management of asthma and result in overmedication if they are not properly addressed.
Ultimately, it is important to prevent exacerbations because intermittent periods of worsening asthma inflammation are associated with accelerated lung function decline over time. After an 11-year follow-up, researchers demonstrated for the first time that asthma patients with frequent exacerbations experience excess decline in FEV1 and more severe airway obstruction.1 These findings confirmed that exacerbations represent periods of accelerated structural changes in the airway sometimes referred to as airway remodeling.
Michael B. Foggs, MD, FAAAAI, FACAAI, FCCP, is chief of allergy and immunology, Advocate Health Care, Chicago.
Reference
1. Bai TR, Vonk JM, Postma DS, Boezen HM. Severe exacerbations predict excess lung function decline in asthma. Eur Respir J. 2007;30(3):452-6.
