What Is Asthma?:

Asthma is a chronic inflammatory disease of the lungs and airways that involves swelling and irritation.[12] Individuals with asthma may experience periods of airway obstruction and compromised breathing caused by a number of factors, including airborne allergens (e.g., pollen), animal dander, colds or viruses, and environmental triggers (e.g., changes in the weather).

In susceptible individuals, the inflammation causes repeated episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and in the early morning.

The symptoms may be intermittent (less than weekly), mildly persistent (weekly to daily), moderately persistent (daily), or severely persistent (continuous).

These episodes are usually associated with obstruction of airflow that is reversible either spontaneously or with treatment.

Interview #1:

'The Goal Is Normal Functioning'

Noreen M. Clark, PhD, is dean of the University of Michigan School of Public Health and the Marshall H. Becker Professor of Public Health there. She is a leading voice in behavioral and educational approaches to the control and treatment of asthma. She developed the Open Airways programs for school children in Detroit, New York City, and other school systems. Currently she heads Allies Against Asthma, sponsored by the Robert Wood Johnson Foundation, a new effort to show how diverse groups in a community can work together to reduce the burden of asthma.

Q: First, what’s the good news about asthma?

A: There’s been terrific movement forward in the last 20 years. One of the most important advances is the use of anti-inflammatory medicines as a standard part of the practice. Their use is now part of the guidelines for diagnosis and treatment of asthma.

Secondly, we’ve recognized the tremendous benefit of educating people to be self-managers. When people manage their asthma they stay out of emergency rooms -- they stay out of hospitals. This has brought enormous personal benefit to the individual with asthma and that person’s family. But it has benefited the health care system as well, because treating asthma in the emergency room of hospitals is a very expensive proposition.

Q: How effective is good asthma management? Can people with asthma lead normal lives?

A: Absolutely, that’s the goal, and that’s what people have to understand. The goal is normal functioning -- no symptoms that interfere with daily life, very few asthma episodes and symptoms, and not ending up in the hospital or emergency room when symptoms do occur. That means the ability to function fully in whatever kinds of physical activities -- recreational, sports activities -- the person wants to engage in so that the disease doesn’t interrupt normal functioning in any way.

Q: Can a person with moderate or even severe asthma achieve that?

A: Yes, but the person must have a partnership with a good clinician who knows how to treat asthma, including prescribing medicines to get at the underlying inflammation.

Asthma can’t be cured. The best line of defense is managing it with the right medicine. But it’s a dynamic situation: the person is changing physically, particularly if he or she is a child. The environment is always changing. Day-to-day situations in which people find themselves change. Stressful situations come and go. And what works effectively for one set of circumstances may not be effective to control asthma in another set. So the person and the clinician have to realize they’re in this for the long haul, that they’re partners in controlling the disease. Working together they negotiate a medical regimen that has to be tailored over time. It’s unlikely that they’ll arrive at the ideal regimen the first time out, and over time the person needs to become smarter about what particular strategies work to keep his or her asthma under control.

Q: What does this involve?

A: First, knowing what to do to prevent the onset of symptoms and how to remove asthma triggers from the environment. Second, it requires knowing how to manage an attack -- how to keep the symptoms at bay and get control over them quickly. Third, it requires developing skills in negotiating within the health care system. Unfortunately, the health care system is complex and difficult to negotiate. People have to learn how to do this. Fourth, people with asthma need to be able to communicate with family members because they are part of the management team. In addition, children and their parents have to be able to communicate with teachers, counselors, and the principal in the child’s school, who will all need to help the child be a good manager of his or her asthma.

Adults need to communicate effectively to get help from people in their work setting when needed and to find the information about asthma medicines and potential triggers to asthma, which for individuals can change. They need to be able to set up the social and information networks that allow them to get the kind of data they may need to try a new strategy for managing their asthma. They need to create an information flow with the help of other people in their social environment and develop the social support needed to manage their symptoms.

Q: Family, teachers, coworkers – they’re part of the partnership, too?

A: Yes, and they’re extremely important. Mother, father, spouse, teacher, close friends, and coworkers are all very important to helping an individual manage asthma effectively. They are often the ones who encourage the patient to use medicines regularly and to talk with the clinician if things don’t seem to be going well. They are people who may step in on behalf of the parent to assist a child when the parent is not around or to help with an emergency.

Q: What roles do stress and emotional events play in asthma?

A: Stress in any form is going to take a toll on a person with asthma, as it does with any chronic disease. Some people think that emotions somehow cause the disease. Asthma is definitely a physical condition. In my view, it’s more realistic to think that people in stressful circumstances find it more difficult to manage the disease, and there’s probably an interaction between those stressful situations and the physical manifestation of the disease.

Q: So the good news is that asthma needn’t interfere with normal everyday functioning. What’s the bad news?

A: Asthma increased by 42 percent in the decade from 1982-92 in the United States, and it has risen more since then. It’s a worldwide phenomenon, rising fastest in developed countries. The estimates are that asthma affects about 17 million persons in the United States. At least two-thirds are children and youths under age 18. Asthma is the leading cause of hospital visits for children, except for accidents. A 50-percent increase in hospitalization for children with asthma occurred from 1980-90. Asthma care costs in this country are estimated at $6 billion a year. That doesn’t include indirect costs: days lost from school or work and day-to-day costs to the family trying to manage the disease. It’s a ubiquitous and expensive disease.

Interview #2:

'Identifying and Treating Those at High Risk'

Marielena Lara, MD, is director of the UCLA-RAND program on Latino children with asthma and assistant professor of pediatrics at UCLA. She started her work in pediatric asthma as a Robert Wood Johnson Foundation Clinical Scholar four years ago. She continues to treat children with asthma at The Olive-View/UCLA Medical Center -- a Los Angeles County hospital whose mission is to serve underserved populations.

Q: Is the asthma situation really getting worse?

A: We know the figures have been going up in terms of how many people have asthma. At first we thought this could be an "awareness" issue, that people were becoming more aware of asthma and doctors were making more diagnoses. But now we see it’s going up all around the world, even more in developed countries than in the underdeveloped ones.

Q: Are there some bright spots?

A: Among the aspects that have improved, the most important is that now we have medications and treatments that can control asthma very effectively. That has happened in the last 10 years, starting with the development of inhaled steroids and currently the leukotriene receptor antagonists (a new class of oral asthma medications).

Anti-inflammatories started to be used in the last 10 years, leukotrienes in the last two or three years. We now have more medical capacity to control asthma. We know that it’s an inflammatory process, and we know we have to treat that inflammatory process to make patients get better.

Another area that has improved is that we now have greater awareness of what the gaps in access to services are and know more about how these gaps may be worse in some ethnic groups.

Q: New medications work, but asthma is still sharply on the rise. Why are we making so little headway?

A: We know how to control asthma. But patients have to use the medication properly. And compliance isn’t just the patient deciding to take the medication, but also taking it right and being taught how to take it. The patient has to have the medication and the equipment to use it. Compliance is a very broad issue, the area where I think we’re weakest, and it’s very complex. It involves reducing barriers to care, improving financing of care, and communicating with patients in ways they can understand.

Q: How do you tackle such massive problems?

A: First we have to find a way to do a better job of finding out who has asthma in the population at large, instead of depending on people coming to the emergency room when they’re really sick. Most important, we have to figure out who is at the highest risk and focus on those people. Because an individual who has mild asthma and doesn’t take his or her medications correctly is not the same as an individual with severe asthma who isn’t taking the medication correctly. This second person may be at risk for death or may have had a life-threatening event earlier in his or her asthma history, and therefore it’s crucial that he or she receive the appropriate medication. So the strategy would be to focus on those with the highest need and try to use resources most efficiently to get to the meat of the matter.

Q: Have you figured out how to get high-risk people to follow their regimens?

A: In my clinical practice I’ve found patients are most receptive to being compliant with their medication after they’ve had a severe event. When you start a child on medication and the parents and child see how much difference it makes -- the kid starts running again, stops coughing at night, goes to school regularly -- that does wonders for compliance. These are key moments when you can motivate patients to do preventive therapy.

Q: But do you sometimes have to push the patient or parents harder?

A: Sometimes you use not just the carrot but also the stick. For instance, you tell the parent: "Your kid is going to die if you don’t stop smoking because that’s a key environmental trigger in your home." Most parents respond to that. It rings a lot of bells, and they are motivated to stop smoking, at least at home.

But we really don’t want anyone to reach that level of severity. We want to manage the disease early on to prevent hospitalizations and lost school days as well as improve child and family quality of life.

Q: How do you identify children with asthma early on?

A: School screenings for asthma are being investigated across the country. They’ve raised some interesting issues. One proposal may be that every child should be screened for asthma before he or she gets into school and referred for treatment if asthma is found. This type of measure would be similar to immunization programs for communicable diseases.

The problem with asthma, however, is that though it is life-threatening it is not communicable or contagious. It affects the health of the individual but not the health of the population at large. Thus it is harder to justify screening the whole population for asthma, particularly when the screening may be associated with incorrect "labeling" of some children as having asthma when they don’t really have it.

Q: What are you doing in your role as head of the pediatric program of the UCLA-RAND program for Latino children with asthma?

A: We’re working on several projects. One, funded by the Robert Wood Johnson Foundation, involves developing an outline of options to improve policy at the national level for pediatric asthma, looking at issues such as: how can you create better surveillance programs to track the population, how can you improve financing or coverage policies, and what screening and referral policies can improve outcomes. We’re going to go through an expert group process to focus on the steps we think are most beneficial at the federal, state, and school levels and for health care providers.

We’re also continuing to analyze factors associated with emergency department care for asthma in a population here in Los Angeles. We’re focusing on the kinds of barriers to care this population experiences, the factors associated with hospitalization after the child comes to the emergency room, and factors associated with relapses. As part of this work we’ve developed a bilingual measure for asthma symptom control that was just published in the March issue of Medical Care.

Q: How well does the partnership concept for asthma management work in these settings?

A: It’s very important to promote close relationships between the patient, the health care provider, the family, and the school. That’s necessary for the child with asthma to get better. However, these relationships cannot occur in a vacuum. They have to occur in an infrastructure of care that we currently don’t have.

Q: That we don’t have at all?

A: We have a safety net for underserved populations. However, partnership depends not just on the ties between participants but also on other elements. For instance, if there are some problems at school, and school policies don’t promote the use of medications in school or emphasize that school nurses should be knowledgeable about the issue, or don’t allow the children access to school nurses -- positive school policies need to be in place to change that situation and then make good things occur. So I think partnership is a great idea and a necessary one, but we have to do some reality testing about what kind of environment it will thrive in and what kinds of collaborative relationships need to exist, for instance, between schools and the health care system.

Q: Why do you think there has been this drastic increase in how many people have asthma?

A: One of the hypotheses is that there’s something in our indoor environment that has changed. And the fact that we mostly now live indoors instead of outdoors -- as more people did in the past -- because of changes in housing and lifestyles. Some of this indoor living is driven by the fear of being outside because of violence in the streets, especially in inner cities.

My impression is that the rise of asthma is due probably to a combination of factors, with some genetic predisposition to it, and some propensity based on environmental exposures early on in life. This shows up in the Hispanic populations I’m studying, where Puerto Ricans have much higher prevalence of asthma than Mexican Americans, for instance, or Cubans. I participated in a CDC study that showed that mortality rates were two to three times higher for persons of Puerto Rican ethnicity living in the United States than for non-Hispanic whites and about the same or higher than for African-Americans living in some high-risk areas of the country. The rate is higher for Puerto Ricans in all areas of the U.S. This suggests there is probably a genetic component and/or something about what Puerto Ricans are exposed to early in life that would lead to higher risk of developing asthma.

"Intelligent" Non-Adherence Is Not So Smart

Good asthma management banishes most symptoms that interfere with fully-functioning daily life. That’s a promise that asthma therapy today can deliver in practically every case.

Yet about half of all persons being treated for asthma do not follow the management programs their doctors recommend, according to Cynthia S. Rand, PhD, associate professor and researcher with the Asthma and Allergy Center of Johns Hopkins University.

Three types of non-adherence to doctors’ orders are most prevalent, she says:

• Erratic non-adherence is when the person forgets to take the medicine, skips doses, and then goes back on for a while, or takes "drug holidays" away from the medications. The more complex the regimen, the poorer the patient’s compliance may be. People in chaotic families, adults with complicated work schedules, and children with multiple caregivers tend to have high rates of erratic non-adherence. The solution lies in simplifying the therapy and helping the patient utilize behavioral strategies that prompt and support regular adherence.

• Unwitting non-adherence is a hidden form of non-compliance when the patients think they are doing what they’re supposed to do and the doctor thinks so too, when in fact the doctor and patient are not communicating and there are significant misunderstandings between them. Studies have shown that patients may forget 50 percent of what their doctors tell them when they get home from the doctor’s office. The solution here is improved doctor-patient communication. Health care providers should evaluate patient understanding of the regimen with direct queries, such as, "Show me what medicines you are taking and exactly how you’re taking them."

• "Intelligent" or deliberate noncompliance is when patients alter or discontinue therapy based on their own health beliefs, fears, and lifestyles. The patient decides, "I just don’t need it any more." Yet for the majority of people with moderate to severe asthma, controller medications must be taken every day in order to prevent an asthma flare up.

"But let’s not focus only on patients in this equation," says Rand. "Part of the problem lies in the physician’s recognition of what appropriate therapy is -- the physician’s adherence to national guidelines for treatment of asthma."

It takes an "active medical consumer" to determine whether a clinician is actually following the guidelines, Rand says. She recommends the Internet as a first step toward getting information on asthma (http://www.nhlbi.nih.gov/health/public/lung/asthma), or phoning the American Lung Association (202-682-5864) and the Asthma Information Line of the U.S. Department of Health and Human Services (1-800-822-2762).

One-Tenth of Asthma in Adults Linked to Workplace:

Roughly 6 million adults in the United States have asthma.

About a third of the adults with asthma have had the disease continuously since childhood. Another third had asthma in childhood, but it became quiescent and then reappeared in adulthood. The final third of adults with asthma suffered onset without any previous history of the disease, according to Paul Blanc, MD, a specialist in occupational medicine at the University of California at San Francisco.

Worldwide, about one-tenth of all adult asthma is associated with work factors such as exposure to chemical sensitizers, irritants, and naturally occurring sensitizers, Blanc’s investigations have shown.

"For example, a very common asthma trigger is natural latex particles from powdered latex gloves used by health care providers," says Blanc. "The powder itself is not latex but it carries particles of the latex sensitizer."

People who work in the bakery industry have long been at risk for asthma, Blanc also points out, from flour dust, mites that contaminate the flour, and chemical additives.

"Once someone has asthma, he or she may have exacerbations that are hard to predict. So there are issues of job flexibility and schedules, physical demands of the work, and exposure on the job -- not only to irritants but also to changes in temperature -- that can aggravate the condition. Relations between work and asthma are quite complicated, and work disability with asthma is a common and costly problem," Blanc says.

It’s typically not a disabling condition, however, and people with asthma can remain active in the workforce and in their non-work lives, according to Blanc.

Asthma and Indoor Air:

Asthma episodes may be caused by a variety of indoor and outdoor allergens. A recent study, released January 19, 2000, by the National Academy of Sciences’ Institute of Medicine (IOM) identified cats, cockroaches, dust mites, and tobacco smoke as several of the most potent indoor triggers of asthma. Dogs and exposure to fungus were also found to be associated with asthma exacerbation in certain individuals.

The only allergen clearly identified in the study as causally related to the development of asthma in susceptible children is house dust mite allergen.

This does not mean that dust mite allergen is the sole factor determining whether a person will develop the illness, cautioned the IOM, an agency of the National Research Council. Most scientists believe that some persons have a predisposition to asthma that depends on a complex and poorly understood combination of inherited factors and factors acquired later in life, the report stated.

For a copy of Clearing the Air: Asthma and Indoor Air Exposures or its executive summary, contact: Office of News and Public Information, (202) 334-2138.

Triggers and Treatments:

Asthma management involves avoiding asthma triggers whenever possible, monitoring the condition, tailoring a medication regimen to prevent and cope with attacks when they occur, and establishing partnerships with health care providers and family members.

Many environmental and emotional irritants can bring on an asthma attack by causing the muscles around the airways to tighten or spasm, and by producing swelling and narrowing of the airways in the lungs. Triggers can include inhaled allergens from house dust mites, pollens of grasses and trees, molds, and cat and horse secretions. Cold air, dust, strong fumes, emotional upsets, and tobacco smoke, both first- and second-hand, also can trigger attacks, as can viral infections such as colds and influenza. Episodes of intense emotions such as excessive crying or laughing can also trigger asthma episodes by drying and irritating the airways.

Exercise can trigger symptoms in adults and children with asthma. Exercise-induced asthma can be controlled through the use of preventive medications and broncholdilators prior to physical exertion. Other strategies for preventing exercise-induced symptoms include warming up and taking breaks during strenuous exercise.

The peak flow meter, a simple device that measures how well air is flowing out of the lungs, is an important tool that persons with moderate to severe asthma can use to track their ups and downs and determine whether their personal asthma plan is working well. Peak flow meters are used to check asthma the way that blood pressure cuffs are used to monitor high blood pressure. The peak flow meter can show if there is a narrowing of the airways many hours before there are any outward symptoms of asthma. Using this information, people with asthma can avoid a serious attack by taking medicine early, before symptoms occur.

Patients can work with their health care provider to establish a tailored medication regimen to help manage their asthma. Asthma medications typically fall into two categories, anti-inflammatory medications taken every day to prevent symptoms and bronchodilator medications used only when symptoms occur. Some bronchodilator medications are inhalers; others are tablets. The provider and patient work together to determine what set of medications works for the patient. Ongoing adjustment is required to accommodate changes in the patient’s life and environment.

The management of asthma is enhanced when people with asthma establish partnerships with their physicians, family, teachers, friends, co-workers, and others to help them manage their condition. Patients can work with this support network to identify warning signs, remove potential triggers, and administer medication when necessary.

Steps to Collaborative Management of Chronic Conditions:

Once a chronic condition has been identified, patients do best if there is on-going commitment by patients, their families, and their health care providers to work together over time. There is strong evidence that the following simple steps taken by providers and patients can significantly improve health and well-being.

1. Define the problem jointly: Providers often define problems in terms of medical diagnoses and treatments, while patients define them in terms of the impact that symptoms have on their lives. Patients are more likely to benefit when these two perspectives are harmonized in a shared definition of the problem.

2. Develop common action plan: Managing chronic conditions is more successful when providers and patients focus on a few specific concerns, identify realistic goals, and commit to a joint plan of action in which the responsibilities of both parties are clear.

3. Explore possible programs and services: Many chronic conditions are better managed when patients are referred by providers to special support services or behavior change programs tailored to their priorities, needs, and preferences.

4. Track progress and anticipate course corrections: Scheduled, on-going communication between providers and patients is critical to tracking progress in achieving goals, identifying potential barriers and complications, and making needed adjustments in the joint plan of action.

For more information on the Behavior Change in Managed Care Settings project, visit our Web site http://www.cfah.org

The Research:

1. Blanc PD & Toren K. (1999). How much adult asthma can be attributed to occupational factors? American Journal of Medicine, 107:580-7.
   
   
2. Blanc PD, et al. (1996). Asthma, employment status, and disability among adults treated by pulmonary and allergy specialists. Chest, 109:688-96.
   
   
3. Centers for Disease Control and Prevention. (1998). Forecasted state-specific estimates of self-reported asthma prevalence—United States, 1998. Morbidity and Mortality Weekly Report, 47(47):1022-5.
   
   
4. Centers for Disease Control and Prevention. (1996). Asthma mortality and hospitalization among children and young adults—United States, 1980-1993. Morbidity and Mortality Weekly Report, 45(17):350-3.
   
   
5. Centers for Disease Control and Prevention & National Center for Environmental Health. (1999). Asthma Prevention Program of the National Center for Environmental Health, Centers for Disease Control and Prevention: At a Glance. Atlanta, GA. http://www.cdc.gov/nceh/programs/asthma/ataglance/asthmaag2.htm
   
   
6. Clark NM & Nothwehr F. (1997). Self-management of asthma by adult patients. Patient Education and Counseling, 32:S5-20.
   
   
7. Clark NM, Bailey WC, & Rand CS. (1998). Advances in prevention and education in lung disease. American Journal of Respiratory and Critical Care Medicine, 157:S155-67.
   
   
8. Homa DM, Mannino DM, & Lara M. (2000). Asthma mortality in U.S. Hispanics of Mexican, Puerto Rican, and Cuban heritage, 1990-1995. American Journal of Respiratory and Critical Care Medicine, 161:504-9.
   
   
9. Lara M, et al. (1999). Elevated asthma morbidity in Puerto Rican children: A review of possible risk and prognostic factors. Western Journal of Medicine, 170:75-84.
   
   
10. Lara M, et al. (1998). Differences between child and parent reports of symptoms among Latino children with asthma. Pediatrics, 102(6):1-8.
    
    
11. Lara, M, et al. (1999). Physician perceptions of barriers to care for inner-city Latino children with asthma. Health Care for the Poor and Underserved, 10(1):27-44.
    
    
12. Lemanske, RF & Busse, WW. (1997). Asthma. The Journal of the American Medical Association, 278(22):1855-73.
    
    
13. National Heart, Lung, and Blood Institute. (1998). Data Fact Sheet: Asthma Statistics #55-798. Bethesda, MD. http://www.nhlbi.nih.gov/health/prof/lung/asthma/am_fa99/asthfcts.htm
    
    
14. Rand CS, Malveaux FJ, et al. (2000). Emergency department visits by urban African-American children with asthma. Journal of Allergy & Clinical Immunology, 106(1):83-90.

Facts of Life is prepared with assistance from:

Academy of Behavioral Medicine Research
Academy of Psychosomatic Medicine
American Academy of Nursing
American College of Neuropsychopharmacology
American Psychiatric Association
American Psychological Association
American Psychological Association-Division 38
American Psychosomatic Society
American Society of Psychiatric Oncology
American Sociological Association
Association for Applied Psychophysiology and Biofeedback
College on Problems of Drug Dependence
Institute for the Advancement of Social Work Research
International Psycho-Oncology Society
International Society for Traumatic Stress Studies
Society of Behavioral Medicine
Society for Developmental and Behavioral Pediatrics
Society for Public Health Education
Society for Research on Nicotine and Tobacco

The Center for the Advancement of Health, a nonprofit organization, promotes the science underlying the relationship between mental and physical states that influence health and illness, and works to turn that knowledge into practical health care solutions. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

For more information contact:
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