Asthma Management and Emergency Room Utilization

Introduction to Asthma: Mechanisms and Triggers

Asthma is a particularly debilitating condition characterized by tightening in the chest, difficulty breathing, and wheezing. This difficulty in breathing can result, at best, in a decrease in quality of life and an inability to carry out normal functions. At worst, the symptoms of asthma can lead to death. Incidences of asthma have increased significantly in the last twenty years, perhaps due to increases in urbanization, industrialization, and the accompanying pollution — including dust and exhaust from automobiles. While the effects and symptoms of asthma are well known and widely studied, the underlying causes are not fully understood, because indicators vary considerably from person to person.

It is important to understand the basic mechanism of an asthma attack. During normal breathing, air enters through the nose, is filtered by nasal hairs, and is conducted through the trachea into its branches, the bronchi. The bronchi, as they enter the lungs, further subdivide into bronchioles. When an asthma-triggering event occurs, the tissues inside the bronchioles become inflamed. At the same time, the muscles on the outside of these tubules contract. These two actions cause the air pathways to constrict severely, greatly reducing airflow into the lungs. The body's defense mechanism responds by producing thick mucus in the airways, which further restricts airflow. If breathing is restricted for a sufficient length of time, the oxygen supply to the blood is diminished, which can lead to heart failure and death (Drugdigest.org, 2003).

Asthma is difficult to manage because triggers differ from person to person. In some cases, hereditary factors play an important role. No single gene has been identified as responsible for all cases of asthma; however, certain genes are associated with the transmission of susceptibility to allergens. The susceptibility to allergens is called atopy. Atopic patients are said to produce certain immunoglobulin E (IgE) antibodies — proteins generated by the immune system in response to perceived pathogens. There is a possible relationship between an inherited variant in the IL (interleukin) 4 promoter gene and hypersensitivity to allergens that are harmless to non-atopic individuals (Burchard et al., 1999).

Tobacco smoke is a major risk factor for asthma in children, particularly secondary (secondhand) smoke, and is also a critical trigger for adults. For many sufferers, exercise-induced asthma is a major concern; just a few minutes of sustained exertion can bring on an attack. Emotional factors also play an important role: crying, laughing, and hyperventilating can precipitate an episode. Cold air, wind, rain, changes in weather, and irritants such as sprays, certain spices and food preservatives, fumes, and smog also increase the likelihood of an attack. Some medications — including aspirin and beta blockers — can also trigger asthmatic episodes. Hospital and emergency room statistics indicate that seasonal and climatic variations, especially cold temperatures and low humidity, are primary contributors. Bacterial and viral infections — including rhinovirus, coronavirus, influenza, parainfluenza, respiratory syncytial virus, mycoplasma, and Chlamydia infections — are also known precipitants (Johnston et al., 1995). Additional allergens include pet hair and dander and insect droppings.

Those most susceptible to asthmatic attacks are typically atopic individuals, those sensitive to known triggers, or those with weaker lungs and a predisposition to respiratory diseases. Asthmatic mothers who do not have their condition well controlled may experience stillbirth or fetal complications, since restricted oxygen supply to the fetus is a recognized risk.

Effects and Impacts of Asthma

Children are particularly affected by asthma. The numbers have increased over the last two decades and in some instances have more than doubled. According to the American Lung Association, chronic asthma is the primary chronic illness in children. The ALA estimates that 6.3 million children under the age of eighteen have asthma. While symptoms are mild to moderate for most, there are enough instances of serious illness that asthma is the third largest cause of hospitalization in children, with close to three-quarters of a million emergency room visits per year. The ALA also reports that the costs of treating asthma run into the billions of dollars, with additional costs from several million cumulative school days lost each year.

More than eighty percent of children with asthma develop symptoms in the first five years of life. Three types of very young asthmatic children have been identified. The first type suffers from transient wheezing — asthma-like problems resulting from viral infections at a very young age that eventually resolve as children grow older. The second type is less fortunate; the ill effects of early infections do not resolve and persist for many years. The third type is atopic and tends to develop symptoms after the second and third years of life — atopy that can continue into adulthood (Martinez & Helms, 1998).

Asthma as a condition can have a retarding influence on a child's development. Intellectual and emotional development may be affected because days lost to illness often hinder extracurricular and social activities. Fortunately, current treatment regimens, when properly prescribed and followed, can allow a child to carry on normal day-to-day activities.

Adult asthma is also an important concern. Most adults with asthma experienced symptoms in some form during childhood, but there are several reasons why adult-onset asthma deserves attention as well. Taking up smoking without recognizing it as a trigger can bring previously hidden symptoms to the surface. Occupational asthma is another cause of adult-onset disease. Workers in unfamiliar environments may develop asthma from exposure to chemicals, materials, and dust levels to which they are unaccustomed. Occupational asthma may take several years to develop. Triggering materials range from plastics and polymers, aerosolized chemicals, and metal dust to organic dusts such as flour, grain, coffee, cotton, flax, and hemp. In addition to other symptoms, adult asthma may be characterized by intolerance to chemical smells and chronic nighttime coughing (Marabini, Siracusa, Stopponi, Tacconi, & Abbritti, 2003).

Older people also develop asthma with age. Chronic exposure to a triggering agent over a long period can eventually result in asthma, particularly when the body's defenses are weakened. It is important to recognize that asthma can affect a person for the first time at any age. With older patients, it is important to distinguish dyspnea from fatigue and to differentiate bronchitis and emphysema from an actual asthmatic attack. Of the more than twenty million people diagnosed with asthma in America, ten percent are over sixty-five years of age. Elderly individuals are also more likely to be taking medications for other conditions, some of which may be previously unrecognized asthma triggers (Lungusa.org, 2003).

No particular race, sex, or age demographic is spared from asthma. Impact is shaped by several factors: socioeconomic status, geographical location, and productivity. Nearly five thousand people die every year from asthma, and more than fourteen billion dollars are spent annually in medical and indirect expenses. A significant percentage of the millions diagnosed with asthma each year experiences at least one attack annually (ALA, 2002).

Asthma in children increased more than seventy-four percent between 1980 and 1996. Childhood asthma persists beyond childhood in eighty-five percent of women and seventy-two percent of men. Women are more susceptible than men by approximately thirty percent. Urban pollution combined with cramped housing conditions means that poorer urban residents — a category that includes a large percentage of minorities — are more negatively impacted. Asthma is more prevalent among African Americans, with incidences almost twenty-two percent higher than among Caucasians. On average across every state, Black Americans suffered asthmatic attacks almost eight percent more frequently than white Americans. The Hispanic population also experienced a greater number of attacks (CDC, 2001).

Geographic disparities play an important role. In poorer states where residents have difficulty accessing health care, incidences of asthma are higher. States with greater industrial pollution also pose elevated risk. The states of Arizona, the District of Columbia, Illinois, Indiana, Maine, Massachusetts, Montana, Nevada, New Hampshire, Ohio, Oregon, Rhode Island, Washington, West Virginia, and Wyoming have higher percentages of asthma complainants than other states (CDC, 2002a).

Deaths from asthma disproportionately affect African Americans — in some cases, at nearly three times the rate of other groups. Emergency room visits number in the millions annually; African Americans visit ERs almost four times as often as whites. Children visit ERs about twice as often as adults, and women are affected more than men.

Absenteeism from work causes drops in productivity with long-term economic consequences easily running into the billions of dollars. Beyond lost productivity, there is also a loss of income and earnings — also in the billions — attributable to illness and death. Direct medical costs strain emergency rooms, where free treatment is mandated, further burdening an already-stressed health care system.

Research through clinical trials has shown that most of these negative impacts can be substantially reduced through education combined with the establishment of asthma-specific clinics. Such programs can benefit patients while positively affecting the economics of both the pharmaceutical and health care sectors (CDC, 2002b). In terms of morbidity and mortality, it is imperative that greater efforts be directed toward inner cities, where lack of education and inadequate preventive maintenance cause most of the problems that could otherwise be easily managed.

Socioeconomic Factors in Asthma

The negative impacts described above, along with the range of identified asthma triggers, demonstrate that socially and economically disadvantaged patients are more susceptible to asthma and its complications than the general population. Poverty results in inaccessibility to effective medication that has been proven efficacious. The lack of education and awareness among low-income populations is one reason why they cannot access available health facilities. Race is not, per se, a determining factor in asthma incidence — all races are equally susceptible. However, because African Americans and Hispanic Americans are disproportionately represented among the poor in this country, they are more likely to present at emergency rooms or clinics with asthma.

There is significant variability in asthma presentation, and the specific reasons are not fully known. It is possible that multiple factors are responsible. For instance, children in Papua New Guinea have no asthma, while the neighboring Caroline Islands have a 50% incidence among children. As noted, asthma has risen by sixty percent among children in the United States, and has doubled in children in Western Europe during the same period.

A study of asthma hospitalizations from specific inner-city zip codes in New York showed that low family income, minority status, and children under eighteen were overwhelmingly represented (Suarez-Varela, Gonzalez, & Martinez Selva, 1999). A 1999 Chicago study found that nearly a third of inner-city kindergarten children had symptoms of asthma, yet only ten percent had been diagnosed — and only because their condition was particularly severe.

A cross-sectional demographic study based on asthma mortality records showed that Black Americans were five times as likely to die from asthma complications. The study also found that less-educated individuals had mortality levels nearly two-and-a-half times those of more educated individuals, and that low-income patients were twice as likely to die as those with higher incomes. Even when education and income were controlled for, African Americans showed a higher genetic proclivity to suffer from — and die from — asthma than Caucasians (Haan, Kaplan, & Camacho, 1987).

Inner-city living conditions and hygiene have been identified as critical factors in asthma incidence. Cockroach and dust mite allergens are present in overwhelmingly large quantities in inner-city homes. An Atlanta study showed that cockroach allergens were present in the dust of most urban homes but were absent from twenty-six surveyed suburban homes (Ernst, Demissie, Joseph, Locher, & Becklake, 2004).

Conclusion: The Case for Asthma Management Programs

The literature surveyed in this paper makes a very strong case for the establishment of comprehensive asthma management programs. Education is an important criterion: except under the most egregious circumstances, mortality and long-term hospitalization can be prevented through common-sense preventive approaches. Emergency room utilization was significantly reduced in studies where management programs were backed by dedicated asthma clinics, reducing the burden on the health care system and allowing better care for those who truly need it.

Socioeconomic factors play an important role in determining how best to treat asthmatics. African American and Hispanic communities are more likely to suffer from asthma due to a combination of genetic predisposition, poverty, limited education and awareness, and poor access to health care. Education programs must be specifically targeted to these higher-risk groups.

Medications for both quick relief and long-term treatment are available and effective. When taken correctly, the positive effects far outweigh the side effects. Clinical trials provide ample evidence of the efficacy of these medications, and particularly of the advantages of combination therapies. The combination of appropriate medication and effective preventive measures offers the clearest path toward reducing the global burden of asthma and decreasing dependence on emergency room care.