Asthma attack: The “heat” is on!
BACKGROUND: Asthma is a chronic lung disease that inflames and narrows the airways. It causes recurring periods of wheezing, chest tightness, shortness of breath and coughing. The inflammation can be trigged by a number of internal and external factors, but the exact cause is not known. The airways then swell and fill with mucus, making it difficult to breathe. Because asthma causes resistance, or obstruction, to exhaled air, it is called an obstructive lung disease.
Asthma is one of the most common and most costly diseases in the world, and presently, it has no cure. More than 20 million American have asthma, and managing asthma costs as much as $18 billion each year. In the U.S. each year, asthma attacks result in almost 10 million outpatient visits and 2 million emergency room visits. It also accounts for 500,000 hospitalizations and 4,000 deaths each year.
TREATMENTS: Treatments for asthma can be divided into long-term control and quick-relief medications. There are two major groups of medications used in controlling asthma: anti-inflammatories and bronchodilators. Anti-inflammatories reduce the number of inflammatory cells in the airways and prevent blood vessels from leaking fluid into the airway tissues. Bronchodilators work by increasing the diameter of the air passages and easing the flow of gases to and from the lungs. Regular follow-up visits (at least every six months) are important to maintain asthma control and to reassess medication requirements.
BRONCHIAL THERMOPLASTY: Bronchial thermoplasty is the first device-based asthma treatment approved by the FDA. It's performed through the working channel of a standard flexible bronchoscope that is passed through a patient's nose or mouth, into their lungs. The tip of the small catheter is expanded to contract the walls of targeted airways. The thermal energy is then delivered to the airway walls to reduce the presence of excess airway smooth muscle that narrows the airways in patients with asthma. By decreasing the ability of the airways to constrict, this new treatment has been shown to help patients with severe asthma gain substantially better control over their disease.
According to a study in the American Journal of Respiratory and Critical Care Medicine, the patients treated with bronchial thermoplasty saw their quality of life improve. They saw a 32-percent drop in asthma attacks, an 84-percent reduction in emergency room visits for respiratory symptoms, a 73-percent drop in hospitalizations for respiratory symptoms and a 66-percent reduction in days lost from work or school or other daily activities due to asthma. Doctors stressed that this device does not cure asthma, but it helps improve the patient’s quality of life. There’s little risk since there is no incision, but patients may suffer from worse asthma symptoms the days immediately following the procedure. (Source: American Journal of respiratory and Critical medicine)
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Sumita B. Khatri, MD, MS, Co-Director Asthma Center at the Cleveland Clinic Respiratory Institute, talks about the new weapon to help people attack the annoying symptoms of asthma.
Have you been seeing a lot of cases right now?
Dr. Khatri: asthma is funny that way-sometimes one can anticipate a trend and at other times it is unpredictable. There was a pronounced seasonal component for many people with asthma this spring because it was a warmer spring. it seems the allergies came out with a bang and I noticed that more patients were feeling those symptoms more strongly and earlier in the year.
What do you normally do for patients when they come in?
Dr. Khatri: It depends on if I’m seeing them for the first time or if they’re seeing me in follow up. For the first visit it’s a longer visit where we talk about how they’ve been feeling since they noticed their asthma. We talk about when they were first diagnosed and what have they done for their treatment. Then we figure out what are the barriers to keeping them under good asthma control. The main goal of therapy is to make sure that there’s nothing getting in the way of doing what they want to do. If it’s a follow-up visit, we make sure to understand whether their asthma is in control and if not, how to improve control be it with medication or other measures. If asthma is and has been under control, we consider reducing some of the asthma medications, ie ‘stepping down’ their asthma regimen.
Are there any other symptoms besides having hard time breathing?
Dr. Khatri: Yes. The usual signs are episodes of shortness of breath, chest tightness, wheezing and cough. However, sometimes I’ve noticed that people complain that they just don’t have energy. When you really drill down deeper you realize is because they have asthma. For instance this may be because they are just noticing that they’re not catching enough air or they just don’t have the endurance or they don’t have the tolerance. In those cases, the traditional symptoms of chest tightness and wheezing are not always there. Another thing people don’t realize is the most common symptom of asthma is a cough. You might think, ‘Oh I just have this cold that’s not going away’ or ‘It’s just allergies’ or ‘How come everyone is moving away from me because they think I’m contagious?’. It’s because probably their main symptom is a cough. Cough and lack of energy are the two less understood symptoms of asthma.
Do a lot of people mistake asthma for allergies or is it interchangeable?
Dr. Khatri: I think a lot of people might mistake only allergies as asthma and vice versa. One of the main triggers for asthma is allergies. People will notice they’re sneezing and that they have a runny nose and may think they are short of breath from being congested. But the key is to see if when the allergy season is over, whether these symptoms are better or whether they persist.
What do you do to treat it?
Dr. Khatri: One of the main pillars of treatment of asthma is to control the factors that make asthma worse. What you do is, you try and figure what is their baseline asthma and then figure out what is the things that make it worse. If they notice that they have more problems when it’s allergy season you treat the allergies with anti-allergy medication or nasal sprays or just avoiding the things that make them worse. Managing those symptoms will by default, make asthma better, but then on the other hand you have to treat the asthma individually not just through anti-allergy medications.
What if it gets worse?
Dr. Khatri: One of the major barriers for improving asthma symptoms is people don’t really understand how to use their medications and when to use them. Most people with asthma if they’re treated properly and if they take their medications appropriately, will have very few limitations to their day. But the issue is people think that, especially with asthma, when they have good days and bad days they fail to realize that they need their medication every day to maintain control. It’s just like treating high blood pressure. Even if you think your blood pressure is under control you still have to take the medications to keep it under control.
How do you get to the point where you need something like bronchial thermoplasty?
Dr. Khatri: That is reserved for those individuals who are in that ten percent who don’t seem to get better regardless of what you do from the standpoint of maximizing their medical therapy. Caregivers really have to make sure they’re on the right medications and that they’re avoiding the triggers that make them worse. If you’re managing the other conditions that make asthma worse like depression, sleep apnea, gastro-esophageal reflux, sinus disease, and they’re still having daily symptoms and asthma is interfering with their lives that’s when you think about newer, novel procedures or therapies such as bronchial thermoplasty.
Tell me about the thermoplasty.
Dr. Khatri: Bronchial Thermoplasty uses technology that’s used in other conditions as well. It uses radio frequency energy, which converts electrical energy into thermal energy or heat in the airway so that there is a reduction in the smooth muscle thickness in the airways.
Is it a different type of sinuplasty?
Dr. Khatri: Sinuplasty is probably opening up of the sinuses so that you don’t have as much inflammation or sinus blockage. Bronchial thermoplasty means the reduction of the smooth muscle so it does open up some of the lower or lung airways as well, but we believe that the therapeutic improvement happens because the spasming that happens as part of asthma is less pronounced.
How does this work?
Dr. Khatri: Individuals who are well managed with their asthma medications are eligible. They have to be well enough to tolerate the procedure, but sick enough to qualify for the procedure. It’s a narrow window of patients.
Is it an outpatient procedure?
Dr. Khatri: Yes, it’s an outpatient procedure performed in three different sessions separated at least three weeks apart. Most of the time you treat one part of the right lung first then you wait three weeks and you treat the lower part of the left lung. After at least another 3 weeks, the third procedure treats the upper parts of both lungs.
Can you walk through the procedure?
Dr. Khatri: When a patient is eligible for the procedure, you have to make sure that they’ve not had any major flair ups. One of the main side effects of the procedure is to have a flair up of asthma. You have to be stable from the asthma standpoint enough to tolerate the procedure and patients are also prescribed higher dose steroids around the time of the procedure. Patients are treated in a bronchoscopy suite as an outpatient procedure. After they are given some sedation, a bronchoscope, which is similar to other scopes people are familiar with, is introduced through the nose or the mouth and passed through their vocal cords into the airway. You look at the airways, make sure everything is okay, and then you put a small catheter through the bronchoscope, which has these struts. It looks a little bit like a basket and that basket is what delivers the heat to the airway walls.
Why does it work?
Dr. Khatri: We’re still trying to figure out why it works, but we do know that from a change in pathology standpoint, that areas that have been treated from previous studies show that the thickness of the muscle wall is reduced. If you think about the fact that you need a full circle of muscle to spasm and narrow a breathing tube, consequently if you reduce the thickness in certain areas it’s less strong. You don’t want overly strong muscles in your lung, you want them to be cooperative. We think that that’s the main mode of how it’s helpful. However, the body is interesting in the sense that there are signals that come from all cells in the body. We think that perhaps there’s inflammatory reduction just by the fact that the muscle cells in certain areas after thermoplasty are not there to send inflammatory signals. It’s important to note that thermoplasty is not a cure for asthma. Asthma is still a very multifactorial spectrum of disease. There are a lot of things that can make it worse and we have to treat it in different ways. Thermoplasty addresses the smooth muscle, which is one of the first therapies addressing the muscle in the lungs.
If you do it once will you ever have to do it again?
Dr. Khatri: Studies so far have demonstrated that you’re really only supposed to go through the session once. There are outcomes of people who had the treatment about five to eight years previously who have still some benefit and no changes in their spasm. But this is a new procedure. There’s a lot to be learned from it. Just because it’s available it doesn’t mean it’s for everybody, so you have to figure out who’s the right patient.
Can you talk about Karen?
Dr. Khatri: Karen is a very special person. She’s somebody who doesn’t let anything get in her way. However, no matter what she was doing for her asthma she felt that her breath was taken away. She was very sensitive to her environment. Just being around someone who was wearing any perfume or being around any aromas would trigger her asthma. It’s important to note even before the thermoplasty, her lung function tests, where you check how good somebody is at blowing out their breath, looked fairly reasonable. It’s interesting that it’s day to day changes and what she was around is what affected her asthma. It’s not just the numbers, it’s their symptoms and what triggers them.
She seems to be doing well.
Dr. Khatri: I would say she’s changed her life because she did what she needed to do and she was never afraid of trying what was necessary. We’re glad to have this in our tool box. I view very much as we are sort of navigators for our patients and that we will give them what they need to feel better whether or not it’s thermoplasty.
In the people you have treated, has it not worked for some?
Dr. Khatri: Everybody is different. It’s still early but overwhelmingly people are pleased with their changes. Again they still need their asthma medications because this isn’t a cure. Some people do better than others.
Treatments frequently result in flare-ups of their asthma. So that is the biggest hurdle.
Is there any danger to the procedure?
Dr. Khatri: There’s always risk to any procedure. Luckily throughout all the clinical trials there have been no extremely bad outcomes such as death. But there have been pneumonia and admissions to the hospital. In some cases bleeding in airways due to inflammation.
When it comes to asthma or allergies, is there any other (alternative) things that you try first?
Dr. Khatri: I’m not closed-minded to adjunctive therapies. If you are willing to consider other therapies that are out there while not ignoring the fact that really you need to treat inflammation in asthma. As long as it’s not harmful I’m usually okay with that. I think what’s also important is that patient should be comfortable to bring up different things they’re trying or want to try with their caregivers and it’s our responsibility to be open minded about it. I think acupuncture and relaxation therapy are good. Stress is a major trigger for asthma. There are some new breathing techniques that seem to help some patients. I’m okay with all of that as long as you really continue to keep your therapeutic relationship with your physician.
FOR MORE INFORMATION, PLEASE CONTACT:
Kelynn Brewer, RN BSN
The Asthma Center, Cleveland Clinic Respiratory Institute
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