Difficult-to-treat and severe asthma

Asthma affects people in different ways. There may be a number of reasons for this, including a person’s genetic make-up, whether they have any other conditions, such as allergies, that could also affect their asthma, and lifestyle factors, such as stress levels and physical activity. Treatment must therefore be tailored to each individual. Healthcare professionals follow a series of treatment steps for controlling asthma: if the first step is not helping to control your symptoms, they will try to find out why the medication is not working. They may also try a different medication or an increased dosage of medication until your asthma is controlled. Despite trying alternative treatment options, sometimes asthma can remain difficult to treat.

There are a number of factors that can affect asthma and these should be taken into account if you are experiencing symptoms that are hard to control.

Smoking

If you smoke, you are almost three-times more likely to have to visit hospital for an emergency due to your asthma than someone who doesn’t smoke. You are also less likely to respond well to medicines than someone who doesn’t smoke. If you quit smoking you will increase your chances of gaining control over your asthma symptoms.

Allergies

If you suffer from allergies, you may find it harder to control your asthma. It is important to try to understand what you are allergic to and what you need to avoid. You may also be able to get treatment for your allergies, which will also help you to control your asthma.

Other lifestyle factors

Other factors can also affect your asthma, including:

• Psychological conditions, such as anxiety, stress or depression
• Environmental factors, such as living in an area with high levels of air pollution, living in a building with dampness or mould or being exposed to second-hand smoke
• Occupational factors, such as working with dust, baker’s flour, chemicals or other triggers of asthma in the workplace
• Inactivity; evidence has shown that regular physical activity or exercise at a level you are comfortable with can help improve asthma symptoms

Following your treatment regime

There are two types of asthma medication:

• Preventer medication, which should be used every day to treat the inflammation in your lungs, which will reduce symptoms, and lower the risk of an attack
• Reliever medication, which can provide quick but short-term relief for symptoms of wheeze or breathlessness

Once you and your doctor or nurse have found a treatment regime that works for you, you should continue following this to maintain good control of your symptoms. It can be tempting to stop preventer medication once symptoms have settled, but if you do this, symptoms are likely to get worse again.

Inhaler technique

It is really important that you learn the correct way of using your inhaler. This can be difficult initially and you may need to spend some time with your healthcare professional learning the right way to use your inhaler. If you aren’t using your inhaler properly, you may not be getting the correct dose of your medication. This is a very common reason for people’s asthma not being under control.

Other health conditions

You may have another condition that you need to manage alongside your asthma, which your healthcare professional may refer to this as a co-existing condition or a co-morbidity. Some co-morbidities can affect asthma control, and include:

• Acid reflux
• Nasal polyps
• Intolerance to aspirin (approximately 5% of people with asthma have an adverse reaction to aspirin )
• Obesity
• Chronic cough
• Obstructive sleep apnoea
• Hay fever or rhinitis (often described as a persistent head cold with a runny or blocked nose, itching in the nose and/or sneezing)

“My asthma was uncontrolled for over a year and a half. During this time, I focused on monitoring the factors that could affect my control: being around people who were smoking, exposure to smoke from wood fires and how much I exercised. One factor I found that helped to improve my asthma was regularly swimming. It was important for me to find my own limit; everyone will be able to achieve a different level. However doing some exercise can be a big benefit in helping to control your symptoms.”

Betty Frankemölle, the Netherlands, who has severe asthma.

Knowledge and understanding

After you initially receive a diagnosis of asthma, it can be difficult to understand what triggers a worsening of your symptoms and what factors could be preventing you from gaining control. One way to understand this, is to take some time to monitor your lifestyle; this could be through keeping a diary of your peak flow scores, making a mental note about when and where you are when your symptoms are worse; and working with your healthcare professional to find a lifestyle and a treatment regime that works for you.

Support

If your asthma remains uncontrolled, regular meetings with your healthcare professional can help you find ways to improve your symptoms; this could be through an alteration to your treatment regime or through making some changes in your lifestyle. You should continue to see your healthcare professional at regular intervals until you are confident that your symptoms are under control and you are happy with your treatment regime. If you and your regular healthcare professional cannot reach this goal, you may be referred to a specialist clinic which can provide a more in-depth analysis of your symptoms and contributing factors. Receiving a self-management plan from your doctor is another good form of support. This should detail how you might recognise when your asthma is going out of control and what steps you should then take.

“It is sometimes easy to identify the factors that affect control of your asthma symptoms. Documenting complaints in a diary in order to see a pattern can help to identify these factors. In my case, I noticed a big difference when I move to a better climate, for example from the city to the country, where the air is cleaner. I also saw a big improvement in my asthma symptoms when I changed my job and began working in an indoor environment with cleaner air. Other times, it is not so straightforward. Regular meetings with my healthcare professional are very important to me at times when I do not have control of my asthma. They offer me the psychological support that is often required and they may look at a factor I had not considered and help me adjust my lifestyle to regain control.”

Juliëtte Kamphuis, the Netherlands, who has had difficult-to-treat asthma since 2006 and has gained control over her asthma for over a year now.

When all the above factors have been addressed, the majority of people gain control of their asthma. However, in a small number of people (less than 10% of all people with asthma), asthma symptoms remain uncontrolled. If this is your experience, you may have a condition described as ‘severe asthma’. The European Respiratory Society (ERS) defines this as asthma that requires a high level of treatment with two types of preventer medication to prevent it from becoming uncontrolled, or asthma that remains uncontrolled despite this high level of medication. Healthcare professionals are still in the process of trying to understand why some people experience this severity of asthma and to find out the best methods to treat them. Experts think that asthma is not just one condition as each individual is affected differently. Current research efforts are looking at the different genetic patterns seen in people with severe asthma to try and understand how people respond to different treatments to identify patterns in the disease. One example of this research is the EU-funded U-BIOPRED project.

If your healthcare professional confirms that you have severe asthma, then there are a number of treatment options that can be considered. The ERS has published guidelines on severe asthma, giving recommendations to healthcare professionals on how to treat the condition. You can read the patient version of these guidelines to find out more about the treatment steps involved under the ‘asthma’ heading.

This material was compiled with the help of Dr Dermot Ryan, Betty Frankemölle and Juliëtte Kamphuis.