THE HEART OF THE MATTER
a special program of the National Emergency Medicine Association (NEMA) 

Week 620.6

Guest Chris Fanta, Clinical Director, Partners Asthma Ctr. Boston, MA

Topic Asthma education & treatment

Host/Producer Steve Girard

NEMA More people die, or are hospitalized because of asthma than ever before...despite the fact that treatments are better than ever. Asthma still carries a lot of question marks, but Dr. Chris Fanta, the clinical director of the Partners Asthma Center in Boston, is here us to bring us up to speed on what we know about the disease and ways to lessen it's impact...

FANTA I think the best way to understand asthma is as abnormal sensitivity of the bronchial tubes. The asthma leaves the airways, the air passageways of the lungs, vulnerable to stimulation from triggers in the world around... whether they're allergic triggers or irritants...and when breathed into the lungs, the bronchial tubes will narrow, making it difficult getting air in and out of the lungs. And so persons experience cough and wheeze, and a tightness in the chest, and shortness of breath....symptoms reflecting narrowing of the bronchial tubes. And what's unique about asthma is that persistent sensitivity of the bronchial tubes. At one moment the airways are perfectly normal, wide open. Air passes freely. And in another moment, stimulated by something breathed in, triggering narrowing of the airways, the person has difficulty breathing, maybe rushed to the emergency room, gasping for air. So, the vulnerability, or the sensitivity of the bronchial tubes is persistent, it's chronic...but intermittently, the airways may be caused to narrow.

NEMA It seems that we refer to what happens to asthma sufferers is an attack...and we don't think as much of the chronic sensitivity...

FANTA It may be also milder, more persistent symptoms, that cough that won't go away, the colds that linger all winter long with cough and congestion, the night time awakening cough, short of breath in the middle of the night...can't quite get your air - they may all be manifestations of asthma. And for many people, thinking of asthma as allergy of the bronchial tubes is not a bad way to look at it.

NEMA Statistics show a big increase of asthma cases over the last 15 years...is this because we're diagnosing more people, or are there simply more people becoming asthmatic?

FANTA Almost surely part of it is that persons with respiratory symptoms are more aware that this may be asthma. And part of it is that physicians are more aware of just how common asthma is, and are making the diagnosis of asthma among their patients more often. International statistics suggest that the prevalence of asthma is increasing worldwide, and there's a great deal of interest to sort out why this might be so. Here's one theory. So much of what we understand about the allergic reaction of the bronchial tubes has to do with allergens...breathed in in the home environment. Persons are allergic not just to cat dander and dog dander, but house dust mites...you may have heard of...and cockroach antigen and mice and rats, and all sorts of things in the indoor environment, together with second hand smoke exposures, fumes from cooking, and gases and the like. So, people spend more time indoors, and there was a big push toward tighter, fuel efficient homes...and that may mean that There's less circulation of fresh air through the home environment, and more exposure to these allergens.

NEMA How has diagnosing asthma changed over the last 15 or 20 years...?

FANTA I think the diagnosis of asthma is very much like it was years ago, and it's most often a physician listening to the story a person tells about episodes of coughs and tightness in the chest...and wheeze and shortness of breath, that come and go. In asthma, there are periods where a person may be symptomatic and troubled by asthmatic symptoms, and another period where he or she feels perfectly well. And as you know can compete in Olympic athletic events. Very often we confirm it by measuring breathing capacity...those techniques haven't much changed. I think what has changed, in terms of treatment...is a focus away from medicines that just relax the muscles that surround the bronchial tubes. The new emphasis in the last decade or so, is the other part of asthma we already talked about...the inflammation, the allergic reaction of the bronchial tubes. And now, we have effective treatment that can reduce the basic problem, the basic allergic irritation of the bronchial tubes.

NEMA Some of the figures show that African Americans and Hispanics are hit particularly hard by asthma...more get it, and more have serious complications...

FANTA What's most dramatic about persons of color in general is the greater severity of their disease...a greater percentage of hospitalizations, and a disproportionate number of asthmatic deaths...there are about 5 thousand deaths in the United States each year. But each death is tragic, for sure, because this is a preventable disease. I think the evidence points more and more to poverty as the main culprit. And you can imagine the ways in which that might be true... whether it's the housing in which you live...you're more exposed to those allergens...you have less control about modifying it...you have less chance of having air conditioning to filter out pollens from the outside. You have more exposure to cockroaches in the inner city, urban environments, and that's been clearly demonstrated as a risk factor for severe asthma. And then partly it's difficulty getting the good health care that is effective in prevention of severe asthma...whether it's difficulty finding a physician, or difficulty getting to the physician because there are so many barriers in the way.

NEMA The reason I'm talking to you was I heard about a conference on asthma and its effects on the Hispanic community, and so there must be some movement, some strategy being developed that may get the message out to the people hardest hit by it....

FANTA There are national efforts...the National Institutes of Health sponsors a national asthma education and prevention program that has provided guidelines for care of persons with asthma. The National Institutes of Health sponsors a number of research efforts to sort out just what it is that makes asthma such a severe burden on the poor and persons of color. We're involved in program called the Community Asthma Program, which targets specifically persons in the inner city. These are adults receiving their care at several neighborhood health centers. And whether an asthma education effort directed at those persons with asthma, and at the primary care physicians who are treating them, can improve outcomes - fewer sever attacks, fewer hospitalizations, less risk of that potentially fatal attack.

NEMA What can an asthma sufferer do to lessen the frequency of attacks...I mean beside drugs...some tips to make the home environment safer, I guess?

FANTA I think some are pretty simple and straightforward....like getting rid of the pet cat, to which you are allergic. If you feel you are clearly allergic to that animal, and there it is sleeping in the bedroom night after night. Not a good idea. The issue of dust mites...it turns out that as many as half the asthmatic persons in this country, and probably worldwide, are allergic to a component of this microscopic creature that live in dust....and you might know that because every time you dust or vacuum, you'd start having asthmatic symptoms, or because you've had testing. And if you are one of those persons, there are in fact practically things that can be done. Wrap the mattress with an allergy proof, zippered plastic wrapping....and wrap the pillow with a similar allergy proof wrap. Then the mite that is trapped won't be aerosolized every time you put your head on the pillow or your body on the mattress, and you won't breath it in all night. And some will accumulate on the sheets and the pillowcase, but that can be washed.....the mite is killed by hot water, so practical measures that reduce the exposure to those things that fuel the fire of asthma can make a difference. Fewer symptoms, less need for medications.

NEMA What's the treatment like....? And what's coming in the near future?

FANTA Let me just emphasize that the therapies we have now, already in place, are highly effective. When used regularly, they prevent the severe attacks, reduce the risk of hospitalizations, and reduce the risk of death from asthma. And so, we don't need to look toward the future, I think, as much as we need to implement the therapies that we have. And it's a matter of getting these treatments to those people who most need them, who are at greatest risk. On the horizon, I think are very exciting new therapies...some are involving, even as we speak, in the last year or two a whole new category of medicines for asthma...medications that block one of the chemicals released onto the bronchial tubes as part of the allergic reactions, never available before. So, that's a new therapy that's just emerged in the last two years. Looking to the future, I think the more we learn about that sequence and all the steps and communication between cells that occurs in the body, the better we'll be able to identify novel places to interrupt that sequence. And that's ongoing...that research is ongoing, and I think probably in the next decade, we'll see emerging, very exciting new therapies that get at the heart of the allergic reaction in the bronchial tubes.

NEMA Our thanks to Dr. Chris Fanta, director of the Partners Asthma center, a joint effort of the Brigham and Women's Hospital and Massachusetts General Hospital in Boston.

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NEMA Thanks for joining us for today's program. If you have any comments or suggestions, contact this station. Or visit our home page at

www.nemahealth.org/

...for a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I'm Steve Girard at The Heart of the Matter.