The answer is: people of all ages. 180,000 people across the world die from asthma each year.1 The United States records about 70 deaths a week2, most of them preventable. In the United Kingdom, 20 persons die each week3. The question hence arises: why were these deaths not prevented?
A study by the British Thoracic Association4 of 90 asthma deaths found that 74% occurred because patients underestimated the severity of the disease. In 36 instances, the patients saw a health care provider prior to death, but in 25 of those cases, the physician under-estimated the severity of the disease. The deaths resulted from inadequate assessment, inadequate emergency treatment and delay in referring or sending the patient to the hospital. Only 10% were managed satisfactorily.
Despite new guidelines, a 2014 examination of 195 confirmed asthma deaths3 in Britain found that
- 45% died without seeking medical help
- 10% died within four weeks of discharge from hospital
- 21% had been to Emergency in the previous year
- 23% had an asthma action plan
Referring to the 2014 British report, Dr Levy in his article titled “Asthma still kills: little change over five decades”5, pointed out that the recommendations in the guidelines for the treatment of asthma had not been applied, and previously identified preventable factors ignored. Excessive use of relievers together with inadequate controller medications played a role in these deaths. Further, 68% of the deaths in Britain were from patients who had been discharged from hospital without any follow-up; and 21% had been to Emergency for an acute asthma exacerbation in the year prior to their death. Healthcare providers also failed to discuss the asthma when seeing asthma patients for other medical problems. In another article he also noted that “over half of those who died from asthma were prescribed more than six salbutamol (albuterol) inhalers in the 12 months before death.”6
Asthma death knows no boundaries. In Denmark, 49 individuals who suffered from uncontrolled asthma had their cause of death confirmed.7 In 63% of cases, death was due to sudden cardiac death while 27% had a fatal asthma attack. Of the asthma deaths:
- 84% reported symptoms prior to death
- 69% had symptoms more than 24 hours before death
- 57% had symptoms within the 24 hours preceding death
- 57% sought medical advice from a physician or in Emergency due to their symptoms.
Children with asthma also die needlessly. Despite guidelines that recommend inhaled corticosteroids, of 12 fatal asthma cases studied, only five were on inhaled steroids.8 In children and adolescents, fatal asthma was associated with eosinophils and mucus plugs in the small airways.
Asthma mortality shows a high correlation with race and low socioeconomic status. 9 It is surmised that because impoverished patients lack access to continuous medical care, they neglect their illness until an acute exacerbation forces a visit to anEmergency Room. 10 The result is partial recovery before the next exacerbation. This unrelenting cycle can deplete the patient's physical resources and increase the impact of the disease. Most deaths occur in patients who have severe asthma and whose disease has been inadequately controlled over a long period. 11,12 While some deaths are related to overwhelming and sudden allergen exposure, this is not common.
A number of detailed studies have been done on the cause of the deaths and the life circumstances of those who die. 13 Deaths in asthma have been associated with depression, denial of the disease, anxiety, family conflicts, life crises and social isolation. Many deaths were found to be related to poor patient adherence and also to poor physician understanding of the disease. 14 In short, they were preventable.
As far as physicians are concerned, there was a failure of management 15 in that:
- deterioration was often not recognized early enough
- clinical status was not adequately assessed
- objective measures of severity were not used
- the use of both inhaled and systemic corticosteroids was not begun soon enough.
The Global Initiative on Asthma (GINA) 16 states that under-diagnosis and inappropriate treatment were major factors contributing to asthma mortality and morbidity. Thus, both under-treatment and under-assessment can be fatal. Patients very often
- did not understand the use of medications and preventive medication 17
- failed to recognize symptoms of deterioration 11
- ignored advice on changes in their environment
- relied on symptomatic treatments such as bronchodilators
- avoided preventative treatment with inhaled steroids or similar medications 12
- delayed getting medical help. 14,18
The Guidelines15 state that even patients with mild or well-controlled asthma are at risk of life-threatening asthma attacks. Patients most at risk are those who have been found to exhibit the following characteristics:15,16,19-21
- a high threshold of perception and a corresponding low sensitivity to their asthma symptoms. This risk is heightened if patients are unable to perceive, measure and follow changes as they occur in worsening asthma.
- previous severe attacks with sudden onset
- large diurnal variation in PEFR or recent discharge from hospital
- in hospital but just out of Intensive Care. These patients need special attention and care in follow-up.
- recent or current use of oral corticosteroids
- two or more hospitalisations in the last year
- use of more than 2 canisters of short-acting beta-agonist per month
- a history of exacerbations requiring intubation and mechanical ventilation not using inhaled corticosteroids
- poor adherence with asthma medications
- poor adherence to an asthma action plan
- lack of a written asthma action plan
- food allergy in an individual with asthma
- current psychiatric disease or psychosocial problems
- sensitivity to alternaria
- co-morbidity (cardiovascular or lung disease)
- use of illicit drugs
- low socioeconomic status combined with urban residence
Adolescents who have asthma and are depressed are at high risk of dying from asthma.
Preventable factors15,16,22 that have been identified include:
- lack of education in recognizing risk
- inaccuracy in diagnosis
- poor assessment of severity
- use of sedation during an asthma exacerbation
- inadequate treatment and poor prescribing
- failure to use inhaled corticosteroids for uncontrolled asthma symptoms
- failure to provide personal asthma action plans
- failure to identify and act on risk factors for asthma exacerbations and asthma deaths
The only hope for changing these factors is by educating patients about their symptoms, and teaching them how to manage the disease through environmental control and appropriate medication usage.15 Primary care-based interventions, such as health education, can be effective in teaching patients to achieve guided self-management which would, in turn, lead to a reduction in costs23-28 of this troublesome disease that can unnecessarily end in death.
Lack of education is one of the main reasons patients do not understand asthma and hence cannot manage it. Patients need to be taught the very basics of asthma including
- the symptoms of worsening asthma (chest tightness, fatigue, cough, shortness of breath, wheeze)
- how to monitor their asthma by recognising symptoms or using peak flow readings
- how to use and record readings from a peak flow meter
- the medical terms used in asthma, such as wheeze and shortness of breath
- how to interpret a written asthma action plan
- how to use their inhalers
- the names and dosage of their medications
- the expiry date of their medications
- how to keep track of the medication used
- to note any change in their activity levels
- when to seek medical help
Patients are required to learn a lot, do a lot, remember everything pertaining to asthma, and constantly monitor how they feel and to note any symptoms and changes in the degree of symptoms. This is a large burden and patients cannot do this on their own without guidance. They need to be taught, and the teaching should be done by someone trained to do so – such as a certified asthma educator. Since there is a natural tendency to forget, repetition is essential to ensure that inhaler technique is correct and that patients understand the role of controller medications in the treatment of asthma. Frequent repetition enhances learning. This is the job of the asthma educator. This education then is essential for guided self-management. Death from asthma is preventable. Education of both providers and patients is the requirement.
- Nunes C, Pereira AM, Morais-Almeida M. Asthma costs and social impact. Asthma Res Pract. 2017 Jan 6;3:1. doi: 10.1186/s40733-016-0029-3. eCollection 2017.
- FastStats - Asthma. www.cdc.gov/nchs/fastats/asthma.htm. Accessed May 15, 2017
- Griffiths C, Levy ML. Preventing avoidable asthma deaths. Practitioner. 2014 Sep;258(1774):27-31, 3.
- Death from asthma in two regions of England. British Thoracic Association. Br Med J (Clin Res Ed). 1982 Oct 30;285(6350):1251-1255.
- Levy M. Asthma still kills: little change over five decades. NPJ Prim Care Respir Med. 2014; 24: 14029. doi: 10.1038 /npjpcrm.2014.29
- Levy M. Preventing asthma deaths: what can GPs do? Br J Gen Pract. 2014 Jul; 64(624): 329–330. doi: 10.3399/bjgp14X680389
- Gullach AJ, Risgaard B et al. Sudden death in young persons with uncontrolled asthma--a nationwide cohort study in Denmark. BMC Pulm Med. 2015 Apr 14;15:35. doi: 10.1186/s12890-015-0033-z.
- Malmström K, Lohi J, et al. Immunohistology and remodeling in fatal pediatric and adolescent asthma. Respiratory Research 2017; 18:94. DOI: 10.1186/s12931-017-0575-0
- Asthma: a concern for minority populations. National Institute of Allergy and Infectious Diseases fact sheet. NIH August 1996:1-4
- Haire-Joshu D, Fisher EB, Munro J, Wedner HJ. A comparison of patient attitudes toward asthma self-management among acute and preventive care settings. J Asthma 1993; 30(5): 359-71
- McFadden ER, Warren EL. Observations on asthma mortality. Ann Int Med 1997; 127 (2): 142-7
- Targonski PV, Persky VW, Ramakrishnan V. Effect of environmental molds on risk of death from asthma during the pollen season. J Allergy Clin Immunol 1995; 95: 955-61
- Sly RM. Changing asthma mortality. Ann Allergy 1994; 7: 259-68
- Patterson R, Greenberger PA, Patterson DA. Potentially fatal asthma: the problem of noncompliance. Ann All 1991;67 (2 Pt 1): 138-42.
- National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung and Blood Institute, National Institutes of Health: U.S. Department of Health and Human Services; 2007 Aug 28. Report No.: NIH Publication No.07-4051.
- Global Strategy for Asthma Management and Prevention (2017 update) www.ginasthma.org. Accessed April 2017.
- Bucknall CE, Robertson C, Moran F, Stevenson RD. Management of asthma in hospital: a prospective audit. BMJ 1988; 296: 1637-9
- Levy M. The national review of asthma deaths: what did we learn and what needs to change? Breathe (Sheff). 2015 Mar; 11(1): 14–24. doi: 10.1183/20734735.008914.
- Roberts G, Patel N, et al. Food allergy as a risk factor for life-threatening asthma in childhood: a case-controlled study. J Allergy Clin Immunol. 2003;112:168–74.
- Denning DW, O'Driscoll BR, et al. The link between fungi and severe asthma: a summary of the evidence. Eur Respir J. 2006;27:615–26.
- Sturdy PM, Victor et al. Psychological, social and health behaviour risk factors for deaths certified as asthma: a national cast-control study. Thorax 2002; 57:1034-39. doi: 10.1136/thorax.57.12.1034
- D’Amato G, Vitale C, et al. Asthma-related deaths. Multidisciplinary Respiratory Medicine. 201611:37. DOI: 10.1186/s40248-016-0073-0
- Nurmagambetov TA, Barnett SB, et al. Task Force on Community Preventive Services. Economic value of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity a community guide systematic review. Am J Prev Med. 2011 Aug;41(2 Suppl 1):S33-47. doi: 10.1016/j.amepre. 2011.05.011.
- Coffman JM, Cabana MD, Halpin HA, Yelin EH. Effects of asthma education on children's use of acute care services: a meta-analysis. Pediatrics. 2008 Mar;121(3):575-86. doi: 10.1542/peds.2007-0113.
- Suh DC, Sjom SK, et al. Impact of a targeted asthma intervention program on treatment costs in patients with asthma. Am J Managed Care 2001; 7:897-906
- Castro M, Zimmermann NA et al. Asthma intervention program prevents re-admissions in high healthcare users. Am J Respir Crit Care Med 2003; 168(9):1095-99
- Sadatsafavo M, Chen w ET AL. Economic Burden of Asthma Study Group. Saving in medical costs by achieving guideline-based asthma symptom control; a population-based study. Allergy 2016; 71(3):371-7. Doi 10.0000éall.12803
- Karnick P, Margellos-Anast H, et al. The pediatric asthma intervention: a comprehensive cost-effective approach to asthma management in a disadvantaged inner-city community. J Asthma 2007; 44(10): 39-44