Overview of medical care

People with severe asthma reported a wide range of experiences regarding medical care provided. For the older people we talked to, changes in knowledge of how to manage asthma and the recent availability of more potent medications were uppermost in their minds. Some people recalled a time when available asthma treatments were restricted to vaporising liquids, steam tents and altering the bed angle for postural drainage.

Denise clearly recalls the smell of a lamp her mother used.

Diana had postural drainage as a child.

Ian can still see himself back in a steam tent in the hospital.

Asthma care has increasingly focused on personalised management for severe asthma. Guidelines for healthcare providers include recommendations for confirming the diagnosis and severity, identifying and treating co-existing illnesses and addressing risk factors such as smoking. The roles of different types of healthcare providers in providing severe asthma care have also been outlined. In Australia most people with severe asthma will be referred by their GP to a general respiratory clinic, however in some locations a specialised severe asthma service involving a range of healthcare providers is available.  [Chung et al 2018].

People we interviewed talked about who provided the medical care for their severe asthma and where care was accessed. The main three providers mentioned were the GP, specialist, and asthma nurse. Commonly, specialists were seen as having the most insight into severe asthma, and the ability to provide longer term solutions.

Hassan hopes his specialist will prescribe a new improved medication for him, but he does also visit his GP.

Lauren sees the GP to get scripts and the specialist for her action plan.

Specialist clinics were seen as the places where blood tests and lung function tests would be performed. Some people with severe asthma mentioned “rapid access” or similar services, which are set up to fast track people with severe asthma. This concept was viewed favourably by people in the study, as there would be healthcare professionals available with specific expertise in severe asthma.

Patsy isn’t exactly sure what the tests are for.

John G feels people with severe asthma must go to a specialist clinic.

Ed is familiar with a specialised service.

From a medical perspective, the goals of treating a person with severe asthma are to lower their symptom burden and the risk of attacks, as well as to reduce the decline in lung function and treatment side-effects. [Reference: Severe Asthma Toolkit] Up to the middle of the twentieth century asthma treatment consisted mostly of medicines that opened up the airways, and other types of medicines to treat symptoms. For some people we interviewed, the treatment was seen as being as bad as the asthma itself.

Marg didn’t enjoy her treatment.

From the late 1950s steroids were used, firstly by mouth and then as inhaled versions. [Ramsahai et al 2018]. Steroids are effective at reducing inflammation, which is known to contribute to asthma, but also have side effects. For many people with asthma, optimal therapy as per Australian guidelines is high dose inhaled steroids and long acting beta2 agonists, together with attention to inhaler technique and adherence. If this is not effective, then oral steroids may be required. See Managing Medications.

Medication has changed Diana’s life.

Marion explains the impact of inhaled steroids on her family’s quality of life:

People with severe asthma often continue to experience poor asthma control and many flare-ups despite the use of oral steroids; they may be resistant to oral steroids. In these patients other medications can be tried such as long acting muscarinic agents, leukotriene blockers, theophylline or macrolide antibiotics. [Upham et al 2018]. Occasionally people we interviewed mentioned trials of such medications.

Michael was given a macrolide antibiotic called azithromycin.

Karen finds theophylline is the only thing that works for her twitchiness.

For some people with severe asthma a group of biological medications called monoclonal antibodies that target molecular pathways contributing to asthma are available. The medication with the longest history of use in Australia is omalizumab (brand name ‘Xolair’). Although Xolair has been life-changing for many people with severe allergic asthma, some people with severe asthma didn’t feel they derived much benefit from it. Some people we interviewed were aware of other new biological medications available in Australia and hoped they might qualify for a trial of them.

Mick’s asthma didn’t improve on Xolair but his sinuses did.

Marea is hoping that new biological medication will decrease her treatment burden:

Regarding treatment options other than medications, some patients with severe asthma may be suitable for a procedure called bronchial thermoplasty, where a tube is placed into a person’s airways, and heat is used to treat the smooth muscle.

Karen was treated with bronchial thermoplasty.

As part of overall severe asthma care, some people we interviewed talked about hydrotherapy, physiotherapy and exercise therapy. Some people with severe asthma found it difficult to do physical therapy consistently. One person we spoke to suggested that physios design separate programs so that the person can do it when at their worst or at their best. Access to physiotherapy in rural areas was a problem for some people in the study.

Karen can do a package of therapies through her health fund.

Marion does exercises at the local hospital.

Wayne could do breathing exercises but not the treadmill.

References:

  1. Chung LP, Johnson P, Summers Q. Models of care for severe asthma: the role of primary care. Medical Journal of Australia 2018; 209 (2 Suppl)
  2. Severe Asthma toolkit. Available at https://toolkit.severeasthma.org.au
  3. Ramsahai JM, Wark PAB. Appropriate use of oral corticosteroids for severe asthma. Medical Journal of Australia 2018; 209 (2 Suppl)
  4. Upham JW, Chung LP. Optimising treatment for severe asthma. Medical Journal of Australia 2018; 209 (2 Suppl)

Links:

More information on assessment of lung function can be found at https://toolkit.severeasthma.org.au/diagnosis-assessment/lung-function-assessments/