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Monday, February 16, 2009

Is it possible pure asthma is NOT a fatal disease?

When I was a child asthmatic rarely did I think of the disease as something that could kill me. Yes it can be a very stressful and hard to deal with at times, but even during the worse asthma attacks I never thought I would die.

My doctors, and my parents, on the other hand thought otherwise. They feared for my life so much that, on January 9, 1985, they had me admitted to an asthma hospital in Denver Colorado. While there I was faced with the notion that, if I don't take better care of myself, and if my doctors don't get my asthma under better control, I might of an asthma attack.

I even had a friend while there who was discharged to home and later died. I also met another boy while there who had a brother die of asthma just months before I met him. Since then, however, I have never heard of any asthmatic die from his disease. I work as an RT, and I have never had an asthmatic die while in my care nor in the care of my hospital.

I'm not saying that asthma doesn't present some serious complications, but I do wish to propose a theory by this post which may not be common but has been brought up by prominent physicians of the past: that pure asthma in itself is not a deadly disease.  Even prominent physicians such as Henry Hyde Salter and William Henry Osler made such an observation.

How shocking does that sound? Think of it this way. As postulated by Albert Sheffler in his book "Fatal Asthma," which was published around 1995, who explained that famous asthma physicians and authors starting throughout the 19th century wrote that pure asthma does not kill.  It may be extremely uncomfortable, but it doesn't (or rarely does) kill.  Various other authors have noted the same.

Sheffler explains in his book that Henry Hyde Salter, in his book, "On Asthma"that was first published in 1860, wrote, "Asthma never kills; at least I have never seen a case in which the paroxysm proved fatal." You have to note here that Salter was the prominent figure on asthma in the 19th century.

Yes it is true that the number of asthma related deaths had doubled since 1985 (to about 5,000 per year), however, upon further analysis, is it possible that those deaths were not caused by asthma per se, but the person taking care of the asthmatic or other ailments coupled with asthma, such as pneumonia or -- as might be caused by the unsteady and untrained eye -- a collapsed lung from artificial respiration.  Or perhaps the asthma was coupled with emphysema, bronchitis or heart failure, and it was this that caused the death and not asthma.

I have had many bad attacks. Fortunately I have never needed artificial respiration. However, I have taken care of a few asthmatics who required intubation and artificial respiration on a ventilator.  Yet all of those cases were complicated by a smoking history, obesity, pneumonia, or other such ailment.

And, as my colleague Jane Sage brought to my attention, an asthmatic kid she took care of before I became an RT died of asthma.  However, Jane told me, post mortem x-ay showed a massive pneumothorax (collapsed lung).  Jane believed that this asthmatic did not die of asthma more so than because the doctor tried to pump too much air into the patient's lungs. She said this may not have been so much panic, but a bad medical practice at that time.  If not for modern medical intervention, this asthmatic, Sage postulated, would have survived.

Modern intervention, panic, the feeling you have to do something right now may be the cause of many cases of asthma related death.   My theory is that a well trained and educated hand may save the asthmatic from dying an untimely death. In fact, I'm almost sure of this.  Plus patience is required.

Consider in the 1800s and all the way up to the 1960s books have been published where the authors, prominent physicians, wrote that asthma does not kill, as did Salter. Leffler writes that a textbook in 1935 wrote that "life of an asthmatic is not endangered."

Thus, wrote Lefler, , "In 1935 Dr. H. L. Alexander of St. Louis concluded that, prior to 1930, 'death during an asthma attack was almost unknown."

However, this wasn't always the case?  Epinephrine was discovered in 1900 and first used on an asthmatic in 1903.  After this time it became a readily available option to immediately end a fit of asthma.  Yet statistics show that asthma related deaths spiked at this time.

Another spike in asthma related deaths occured after the 1957 invention of the rescue inhaler.  This spike was determined to be caused by lack of education regarding the medicine, not so much that asthma got worse at this time.  This started a debate that continues to this day:

  1. Are asthma related deaths caused by asthma rescue medicine?  
  2. Are asthma related deaths caused due to poor education about asthma rescue medicines?
One the inhalers were made to not be so readily available to asthmatics, and once a warning label was placed on the boxes, asthma related deaths associated with the inhalers declined. This, in my opinion, shows the spike in asthma deaths following the introduction of epi and the epi inhalers was due to poor education.

It is my opinion that asthmatics are so happy to have the rescue medicine when they are having a fit of asthma, that they overuse it.  So, instead of seeking help, they stay home until it is too late.  Hence, they are found with the inhaler clutched in their grasp, and the blame for the death goes to the inhaler rather than the lack of patient education.

A similar event happened in 1976 when the long acting beta adrenergic Fenoterol was introduced to the market in New Zealand.  Deaths from asthma spiked, and this resulted in a panic that had experts wondering if the medicine was the cause.  Ultimately a warning was included with the product on how to properly use the mediicne, and the death rate declined.

A longer acting beta adrenergic called Salmeterol was introduced to the market in 1994, and has since been combined with the medicine fluticasone in Advair.  Yet Salmeterol was blamed for many asthma related deaths.  Once again the reason was credited to the inhaler and many experts tried to have the medicine removed from the shelves.

Yet, once again, asthmatics wanted the medicine to continue to be available because, like rescue inhalers, salmeterol helped many asthmatics control their asthma.

To encourage proper use of the medicine, the FDA now recommends serevent never be used by itself for asthmatics, and instead be given in combination with an inhaled corticosteroid to control the underlying inflammation of the air passages.  Advair has since become the most popular asthma controller medicine.  Advair also comes with a black box warning so patients know of the dangers of abusing this medicine.  I wrote about this in more detail here.

So while rescue medicine and LABAs can work to make life better for asthmatics, abuse of these medicine, which usually results from lack of education, can kill.  So this is just another long history of examples of why it's important for asthmatics to stay educated.  


Anne said...

When I was a child, there was far less you could do about asthma than there is now. My mom was very worried about my asthma, but somehow she avoided burdening me with that fear, and I grew up seeing my asthma as a huge nuisance and inconvenience, but not something that terrified me.

Years later, when I was grown, she told me that she had once asked our doctor about what if the asthma got so bad that I could no longer breathe. He told her that I would then lose consciousness, and that my autonomic nervous system would start me breathing again.

I have no idea if he had any experiential or theoretical basis for this belief, or if he simply thought that patients and their parents were all better off not having to deal with the fear that the patient's asthma might prove fatal.

This advice would have been given in the early 1940's, as I was born in 1939, and Dr. Rieke died when the ship he was on was torpedoed not long before the war ended.

Shannon said...

A nurse that I used to work with lost her daughter to an asthma attack. At the time I was not yet educated to a great extent about asthma (I'm now in my 2nd year of RT school) but from what I remember, her daughter was at cheer leading practice and it was a hot and humid summer day. She was not taking her meds and she developed a severe attack. It was so bad that the coach called 911 because she "stopped breathing".
I found out that she died on the way to the hospital because the Ambulance Technicians could not intubate her. I live in Quebec, Canada and we don't have paramedics in the ambulances. We only have what they call "Ambulance Technicians" and one they things they are not permitted/trained to do is intubate patients (even with a combitube).
From what I now know about asthma, I'm guessing that this was a severe attack that deteriorated into status asthmaticus. Because she could not be intubated (and I'm guessing adequately ventilated with a bagging until she could be intubated?), she died. I always thought that it took a while before things got to that point. Can you educate me a little more about this? Does this make sense to you?

Freadom said...

Anne: Thanks for the story. Your doctor may have been right. We still don't know for sure.

Shannon: I too lost a friend to asthma when I was a kid, and it's a very difficult thing to understand let alone accept.

Asthma remains a mysterious disease to even the worlds most renowned doctors and scientists. As I learn more, I will definitely report it here on this blog.