Transcription:
Diagnosing and Treating Asthma

Scott Webb (Host): Many of us have a sense of what asthma is, what happens during an asthma attack, for example; but it's actually often under and overdiagnosed, and really requires the expertise of someone like my guest today to properly diagnose and treat it. And I'm joined today by Dr. Craig Thurm. He's the Director of Pulmonary Medicine and Respiratory Therapy at the Jamaica Hospital Medical Center.

This is Jamaica Hospital Med Talk, the podcast from Jamaica Hospital Medical Center. I'm Scott Webb. So doctor, thanks so much for your time today. We're going to talk about asthma, whether it's under or over-diagnosed treatment options and so on. So as we get rolling here, what is asthma, like what happens during an asthma attack?

Craig Thurm, MD (Guest): Asthma is an inflammatory disease, which is really important to keep in mind. There's inflammation. It's an inflammatory disease of the airways, which leads to people at times, having narrowing or constriction of the airways, which can get better and get worse. And that causes the symptoms that people are aware of. The shortness of breath, the wheezing, cough, not being able to walk because of shortness of breath.

And sometimes, you could have what you mentioned, an exacerbation and an asthma attack where you get really tight. And sometimes people have to go to the emergency room of the hospital and asthma still causes death. So those exacerbations can still be a quite serious thing.

Host: Yeah, they definitely can. And you know, it's interesting, you mentioned that people unfortunately still pass away from asthma because I have it in my mind. I'm 53 that, oh, we checked asthma off the list years ago that that's not really a thing so much anymore, but, interesting and maybe a little alarming to know that it really is still a concern. Something that people still suffer from and it needs to be diagnosed, obviously. So.

Dr. Thurm: Even people with mild asthma can end up with a serious exacerbation. It's not just this severe asthmatic who's terrible all the time. Who's on you know, multiple medications who's not doing well, ends up in the hospital. You could have people with milder asthma who just have periodic symptoms, those people also end up in the hospital and unfortunately some of those people die.

So this is serious and it's important. You mentioned at the beginning, the underdiagnosis, this is a problem, especially in these mild people who don't have symptoms that are often, very important to pick up asthma so they can get the proper treatment.

Host: Yeah, it definitely is. And I want to talk about that the over and underdiagnosis of asthma. As you say, it's a serious matter. And so it's important to be diagnosed and be diagnosed and treated properly in a timely fashion. So let's go through this. Why is asthma typically under or overdiagnosed and what can be the consequences?

Dr. Thurm: Okay. So as far as the under-diagnosis, that means people are walking around with symptoms of shortness of breath or wheeze or cough, and it's not picked up as asthma. Maybe they have a cold and their symptoms linger for a few weeks and they blow it off. Oh, I had a cold, but they're little short of breath, a little wheezy and it's just not picked up and therefore they may not get treated. As far as the other side of the coin, the flip side, is that some people may be overdiagnosed. And what that means is that people are labeled asthma when they don't have asthma. And there was, an important study, a very interesting study that showed that people with a diagnosis, a label of asthma when they were carefully evaluated to see if they truly had asthma, a third of people didn't actually have asthma, but the consequences are people get labeled asthma. Every other care provider puts asthma in the chart. They get medications. When they're more short of breath, they get more asthma treatments and in truth, they don't have asthma. And we commonly see this in our clinic, in the chest clinic, the pulmonary clinic, where patients come in and they're labeled asthma. The first thing I ask is, does this patient really have asthma? And after a careful evaluation again, there's a good number of people that I say to them, listen, you don't have asthma. You don't need to use inhalers and you have something else. And what is that something else? Sometimes it can be something as simple as being overweight or having arthritis of the knees or some musculoskeletal problem that then they walk, they get short of breath.

Sometimes it's another pulmonary process, like a COPD or interstitial lung disease, scarring or inflammation or fibrosis of the lungs or some other process, or it's cardiac disease like heart failure. But it's not always asthma and that's the first thing you have to do. So, to summarize people can be underdiagnosed. They could have some mild symptoms. It's not picked up. They're not getting treatment and that's not good. And then you could have people who are labeled asthma in truth, they don't have asthma, they have something else.

Host: And doctor when you're diagnosing asthma, are there some behavior and lifestyle factors to consider? And are inhaled therapies still the gold standard for the treatment of asthma?

Dr. Thurm: There are things that set off asthma, make asthma worse that people can do something. About just to give you a laundry list, things like smoking, where you're inhaling fumes into your lung in a patient who has inflammation of the airways. And then you're breathing in cigarette smoke or inhaled drugs that can make asthma difficult to control those are clearly bad things. Allergies, people who have cats in the home, are allergic to cats or other allergens, upper airway disease. We talk about like allergic rhinitis or reflux. These things may make asthma worse. Obesity, sleep apnea. These all may tie into asthma control. Some people may actually be on medication that can worsen their asthma.

So if you could figure that out, that could be an easy fix. So we have all these other non-medication things we always have to go through. Sometimes people take aspirin or nonsteroidal drugs that can worsen their asthma or beta blockers in some people can worsen asthma. So again, going through this list of other things that you can do, medications, occupational exposures, people who work in certain industries, that can worsen their asthma.

So you want to go through this checklist first, but after that, the next thing you think about in your head is okay, medication. And as you said, you're a hundred percent right. The most important therapy are inhaled therapies. Getting the medicine directly into the airways, into the lung, as opposed to pills, which circulate through the whole body and may affect other organs like the heart. Instead, we're getting medication right to the airway and the cornerstone of asthma therapy are inhaled steroids, inhaled corticosteroids.

Host: Okay. So let's talk more about inhaled therapies and how they can help patients.

Dr. Thurm: It is very important, remember I said at the beginning, asthma is an inflammatory disease. There's inflammation going on, even in mild asthma inflammation and to control that inflammation, the best medications are inhaled steroids, and there are a variety of them and I'm not going to get into different names of different medications, but there are a variety of them.

And we have them either alone, inhaled steroids alone, or in combination with beta agonists. These are medications that broncodilate, that open up the airways. So we have a lot of these inhaled steroids and it's crucial that people who have real asthma, who have symptoms are using these medications.

And I want to highlight something very important in recent guidelines. It used to be that people were just using albuterol, albuterol, albuterol when they got bad enough, they said, okay, now you can start an inhaled steroid. But now the current thinking is earlier use of these inhaled steroids so they can even be used as needed. This is a shift. This is a change. They can be used as needed. Yes, you need an opener too. So you can combine an inhaled steroid with say albuterol which rapidly opens up your airways, or you can combine the steroid with a long acting broncodilator, and use that as needed. So the shift has been for mild asthma, if you have symptoms, you take out your inhaler and you use it as needed, but it's going to have an inhaled steroid in it, not just albuterol. One of the biggest messages I have for people listening at home is that if you have asthma and you're symptomatic, you're short of breath, you're wheezing, you're coughing and you're sucking on an albuterol over and over again, and you're not on inhaled steroids to decrease the inflammation, that's bad. And that means you're not getting the proper treatment. And you really should go to someone who can advise you and get you started on an inhaled steroid. So inhaled steroids are really cornerstone. They need to be used. They should be used even earlier in patients, than in the past.

Host: Well, it's great to have your expertise today and learn more about this and good to know that through a thorough patient history and exam, and just a conversation with you and other doctors we can figure out, okay, is this something that you could fix easily or do you need inhaled steroids and so on?

And I was doing some reading before we got on the line here to talk about this and reading about biologics, and it sounds kind of interesting, yeah, I want to have you talk about like what's the future of asthma treatment options?

Dr. Thurm: For severe patients, we have new therapies and you mentioned biologics, but before I get there, I got to say that one of my major pet peeves, and again, one of the main messages I want to get out there to the audience is that people do not use their inhalers properly, which leads to them not getting the medication, whether it's inhaled steroids or other inhaled medicine into the lungs. And I have to tell you that in my practice, when I see patients in the clinic, in the office, and I see them. I ask them right away. Show me how you use your inhaler. I have to tell you over 50%, I would say over 70% thinking about it, do not use their inhaler properly.

And this is such a big issue. People need to be taught how to use their inhaler properly. It should be assessed and reassessed. And we have all these great devices now. It's not just the metered dose inhaler that has been around for a very long time. We have all different kinds of inhalers. Some you don't have to coordinate, some you just open it up and take a breath and get it in and just hold it.

There are so many devices that we have now that can help people overcome this problem. But I have to tell you if people aren't getting the medicine into their lungs, they're not going to do well. Right. And one of the first things is, show me how you use your inhaler. And they may often show me that they can't. And when we fix that, suddenly their asthma is better. So before we talk about these newer treatments for more severe patients, you have to make sure you cover the bases and the bases are covering those things that we talked about that maybe worsening their asthma, like cigarette smoking, et cetera. Then that you're on the right medicines, the inhaled steroids, the long acting beta agonists.

You're taking them properly. You're taking them at all. You're adherent to therapy. And then when we have patients who meet all of these things, we've done everything. We've tried to fix everything. They're using the medications properly. They're using the right medications properly and we're stuck and they're still not doing well, then we have newer therapies that have been game changers for these really severe patients. And they're the biologics. And biologics refer to injectable. Most of them are given subcutaneously. They can be given at home most of them, or in the office and there are people who just don't like to stick themselves and will come into the office for their injections.

And there are other people who learn how to do it and are happy to do it at home. And you may not see them for months at a time because they're doing great. Now, there are different biologics and they have different mechanisms and they work on the inflammation, but there are different types of inflammation and certain patients would qualify for biologic A based on their blood work based on the type of inflammation they have.

And other people might qualify for biologic B or biologic C. So, if you go to a physician and you have severe asthma, now severe asthma is only about five to 10% of all asthma. That's what we're talking about here. And again, you've checked all the boxes that they're on the right medicine. They know how to use their medicine and they're still in trouble and they're not doing well. They're ending up in the emergency room. They're taking prednisone. They can't breathe. They're having symptoms all the time. You want to help these people. And now we have these new treatments, these biologics, and not every patient is going to do great, but I have to say that my experience with these drugs has been very positive and I have a number of people that I've taken, who have severe asthma, who were taking prednisone all the time, ending up in the emergency room all the time. Symptomatic, waking up several times a week at night, who after starting, a couple of weeks after starting biologics have had major turnarounds. And, they come to me saying, I don't want to take any asthma medicine, cause I don't have any more symptoms. Now, not everyone has that kind of result.

And I have patients who improve their symptoms, but they're not perfect. And then there are some people who don't respond to the biologic given, but we have a lot of options now. So if the patient doesn't respond to one, say six months later, we say, okay, maybe let's try something else. But again, you have to pick the right biologic for the right patient, for the right type of inflammation. And I really have found them to be extremely helpful for the severe patient. But again, that's a minority of overall asthma population.

Host: Yeah, as you said, it's only five to 10%, but for that five to 10% good to know that there are options, as you say, choices, options, love to hear all of that. This has been so educational today, doctor and is before we even got rolling where it's saying we could probably talk for hours. I know you definitely could. And there's so much to talk about, but for today's purposes, as we wrap up here, tell us about bronchial thermoplasty.

Dr. Thurm: Okay. Bronchial thermoplasty is a technique that's used for patients with more severe asthma. It's done through a bronchoscope, which is a flexible fiber optic scope that we pass into the airways. And we put a catheter into the airways and apply local heat energy to the muscle in the airways. And it's usually done in the operating room. The patient is under anesthesia and is out, it's usually done in three sessions. Each session takes about 45 minutes to an hour or so.

And I think has become less popular because of the development of the biologics. So, it's a procedure that you have to come to the hospital, you have to get multiple procedures. You have to have anesthesia. There is a risk of worsening the bronchospasm, after the procedure, think about it. You have someone with inflammatory airway disease that gets wheezy, and then you take a scope and you put a catheter in and you inflame the airways. So they often get wheezing after the procedure, but, most of the time I've had good success with safety, meaning I haven't had people get into trouble. I haven't had patients, you know, have major complications. I've seen some benefit, but then I've seen other patients who have no benefit.

So it's something that's out there that is being used less and less, I think because of the availability of new medications to control asthma. This procedure, I do do it at Jamaica Hospital. But again, it's done more and more infrequently because of these other treatments. But it is something I keep in my back pocket and for a patient who isn't responding to biologic, or can't get a biologic who has significant disease and is willing to try the procedure it is something we still offer.

Host: So, yeah, just another one of the many tools in your toolbox, right? The bronchial thermoplasty, biologics, inhaled steroids, and so on. It's been so educational today. Doctor, thanks so much and you stay well.

Dr. Thurm: Oh, thank you so much.

Host: To schedule an appointment with a pulmonologist at Jamacia Hospital, please call 718-206-7126.

And if you found this podcast helpful, please be sure to share on social media and check out the rest of our library at Jamaicahospital.org/podcasts. Thanks for listening to Jamaica Hospital Med Talk, the podcast from Jamaica Hospital Medical Center. I'm Scott Webb, stay well.

All the content of this podcast is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions discussed on this podcast.