Enough asthma deaths; adopt the MART as treatment approach
Many of us know one or more people who died from asthma. The usual story of asthma death is that an individual known to have asthma begins to experience an asthma attack, attempts self-treatment but the illness only gets worse in spite of the self-treatment. The individual tries to seek health care but dies before arrival at a hospital. Most asthma deaths occur before arrival at a health facility.
That was the unfortunate situation I witnessed at a hospital, only a few weeks ago. An elderly man was rushed to a hospital when he had an asthma attack. Unfortunately, he was found dead on arrival at the hospital. The shock and wailing of his relatives were heart-breaking as they never expected their father and uncle, who only a few days ago was quite well, to die.
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Many of us are unaware of the havoc asthma causes in Ghana and other parts of the world. Many people who have asthma, are unaware that the condition can kill. In Ghana, though data is not robust, an estimated three to five individuals die each day from asthma. Globally, more than 1,000 individuals die each day from the disease.
Besides death, asthma causes enormous discomfort for the individuals who get it and impairs their ability to work or participate in school work. Asthma robs affected individuals and their families of quality sleep because the main symptoms of the disease; shortness of breath, cough, wheezing and chest tightness, tend to be worse at night. Sports people who have asthma are particularly apprehensive of experiencing flares of the symptoms during physical exertion. Many have had to quit jobs and sports because of the disease.
Research has amply shown that most deaths and suffering from asthma are preventable. Among the main causes of asthma deaths and suffering are misconceptions about the disease and its treatment. That is why this year’s world asthma day marked on 5th May focused on addressing misconceptions about the disease. As the Bible says, for lack of knowledge, my people perish. It can be argued that much of suffering and deaths due to asthma are attributable to lack of knowledge or misconceptions. A study done in the United Kingdom to unravel the reasons for asthma deaths, dubbed Why Asthma Still Kills in the United Kingdom, revealed that misconceptions on the part of both people who have asthma and health care providers contribute significantly to asthma deaths.
A major misconception about asthma relates to how it is treated. Asthma is a chronic disease of the airway in which the airway is constantly under the attack of a disorder of the immune system. The airway is the passage from our throats down our necks into the chest through which air enters and leaves our lungs. In asthma, the immune system goes awry and attacks the airway resulting in injury of the airway known as inflammation. This injury is persistent though its intensity varies from time to time. Therefore, it is described as chronic airway inflammation. This chronic airway inflammation is the cardinal problem in asthma.
As a result of the chronic airway inflammation, the airway becomes narrow and hyper-responsive from time to time resulting in the symptoms people with asthma experience. The four main symptoms of asthma are shortness of breath, wheezing, chest tightness and cough. A major problem about asthma is the lack of understanding that the main problem of the person who has asthma is the chronic airway inflammation. Rather, focus is on symptoms. Asthma is not curable. Effective treatment is the major way to curb the disease and the suffering and deaths it causes.
The main misconception about asthma is treatment which focuses on relieving symptoms. This is one of the main causes of asthma deaths. Effective treatment rather focuses on controlling the underlying airway inflammation. If there is going to be a change in the current situation regarding suffering and deaths from asthma, there will have to be significant changes in policy and practice regarding the treatment of asthma. Japan adopted a paradigm shift in asthma management from focus on relief of symptoms to treating underlying chronic inflammation. The result was a dramatic drop in asthma deaths.
There are two types of asthma medicines: relievers and controllers. Relievers only alleviate the symptoms but do not deal with the underlying chronic airway inflammation. The most popular of these is salbutamol which is in the form of tablets and inhalers. The second group of drugs, controllers deal with the underlying airway inflammation. The second group are the most important asthma medicines. The regular use of controllers is the most effective way of treating asthma. Unfortunately, many people who have asthma rather use the relievers alone and do not use controllers. This is a major reason people with asthma experience frequent symptoms.
However, using two separate medicines- reliever inhalers and controller inhalers is cumbersome. Due to this, a recent approach has been recommended by the Global Initiative of Asthma (GINA), the global outfit which recommends best asthma treatment approaches. This recommendation is the use of inhalers which contain both relievers and controllers in the same device. The reliever component of these inhalers is a drug called formoterol which has a unique property of providing quick relief within 3 minutes and has the advantage of keeping the airway open for up to 12 hours, compared with the popular salbutamol which keeps the airway open for only 4 hours. These inhalers significantly simplify asthma treatment and make treatment highly effective.
This treatment approach is known as Maintenance and Reliever Therapy using the same device (MART). This approach involves asthma patients using inhalers which contain both formoterol and controllers in the same inhaler device both for relief of symptoms and daily use to control the chronic airway inflammation. From my experience in treating asthma patients, this is the most effective way of treating asthma. When people who have asthma use MART, they soon become free of symptoms and are able to have normal quality lives. This can be used by children 4 years and older and adults.
The inhalers used for MART are available in Ghana and provided on the National Health Insurance. However, due to limited knowledge about best practices in asthma management by both health care providers and asthma patients, it is underutilized. A shift from reliance on salbutamol to relying on MART as the main treatment is the way to go to curb suffering and deaths from asthma.
As a country, adopting MART as the main approach in managing asthma as policy and practice will simplify asthma treatment and bring tremendous relief to people with asthma as well as potentially reduce asthma deaths significantly. In this month that the world is considering asthma, I recommend that the country adopts the MART approach and discourage the reliance on salbutamol to minimize suffering and curb deaths from asthma. I recommend that health providers adopt this recommendation by the Global Initiative for Asthma.
Dr. Allen Steele-Dadzie
Asthma Specialist
Family Medicine/Polyclinic Department
Korle Bu Teaching Hospital
Member, Ghana Thoracic Society