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Thunderstorm asthma -

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Norman Swan: Hello and welcome to this week's Health Report with me, Norman Swan.

Today, a warning about a potentially dangerous drug interaction that some people with what's called atrial fibrillation might have.

Success in Western Australia reducing the rate of preterm births, but it's hard work.

A calculator for success with IVF.

And the media who have been full of the thunderstorm asthma event in Melbourne two weeks ago, thousands of people turning up in emergency departments, intensive care admissions and several deaths. One reason for the impact is thought to be that too many people with asthma don't recognise that their condition is worse than it is and are on the wrong treatment. Basically throughout Australia there is a cohort of people who live with unacceptable asthma symptoms. Someone who studied this is Matthew Peters who is professor of respiratory medicine at Macquarie University in Sydney. Welcome to the Health Report.

Matthew Peters: Good evening Norman.

Norman Swan: I should just say that Matthew is speaking to us via Skype from Vienna where he is at a conference. Just before we get to this unacceptable level of symptoms in the community, what do we know about the causes of this huge event? Is it simply pollen?

Matthew Peters: It's a combination of circumstances, including pollen. You need a build-up of pollen, so typically in Australia it's grass pollen because that is carried on breezes. So a number of days of pollen build-up, and then preceding the thunderstorm typically there are winds and downdraughts. They take the pollen up into the cloud base, simply because there's distilled water, the larger pollen particles are broken up into much smaller pollen particles, and the smaller ones are then dispersed in the storm, and these smaller ones are of a sufficiently small calibre to penetrate deep into the airways and establish an asthma reaction.

Norman Swan: And it's a true asthma reaction?

Matthew Peters: No question, and probably electrical forces contribute as well, it's a very complex milieu.

Norman Swan: So tell us about this group of people with unacceptable asthma symptoms, and what asthma symptoms are we talking about here?

Matthew Peters: We are talking about wheeze, breathlessness, chest tightness, general incapacity to consistently go around your tasks of daily life without breathlessness. The ones we worry most about are those which are disturbing during the small hours of the morning or on waking because they are good markers of poor asthma control. Of course frequent use of Ventolin or a blue puffer is a marker again of poor asthma control that can generally be much improved with good care.

Norman Swan: So when you talk about Ventolin or salbutamol, you're talking about what's called a reliever, it doesn't treat the asthma, it just opens up the airways?

Matthew Peters: That's it, yes. It's a temporary stopgap solution but unfortunately relied on by too many people in our community as the core treatment for their asthma.

Norman Swan: Indeed this week, in fact this morning new statistics have come out to show that there were 3 million prescriptions for Ventolin in the last 12 months. So that's a lot of people sucking on Ventolin.

Matthew Peters: Despite all our efforts, it's still very heavily used and we just have had for decades better ways to manage asthma, we haven't been able to effectively and consistently roll out.

Norman Swan: Although asthma deaths have gone down in Australia.

Matthew Peters: And that's one of the really fascinating things. So we've dramatically reduced asthma deaths in our community, but we haven't got good current symptom control improved to the same degree, and it's one of the conundrums. There clearly are people in the community at risk of dying from asthma. One presumes they are taking enough of their core asthma treatment to avert very severe asthma and deaths in the majority of cases, but are still tolerating a level of asthma symptom control that we think they don't need to tolerate and does still put them at risk of some significant asthma crises.

Norman Swan: So what other numbers? What proportion?

Matthew Peters: The core number that we worry about is people who by standard criteria have poorly controlled asthma, so we know around 25% of all people in Australia with asthma, surveyed well, have uncontrolled asthma symptoms and are not taking a regular asthma preventer, or if you like a solution puffer for their asthma. So that's one group of 25%. Separately there is 20% who report that they are using their core asthma treatment or preventer, but they still have poorly controlled asthma.

Norman Swan: As typified by the sort of symptoms that you were talking about a moment ago.

Matthew Peters: Correct.

Norman Swan: And we've also had on the Health Report, but some time ago, the research which suggests that when people…first of all people think they grow out of asthma when they are adults, which in fact is not true, some grow out of it as children, but you don't grow out of it when you're an adult.

Matthew Peters: If you have established asthma in adult life, spontaneous resolution is extraordinarily rare.

Norman Swan: But there is research to suggest that when you are not feeling too bad about your asthma, you think you haven't got it anymore, it's only when you have an asthma attack you think you've got asthma.

Matthew Peters: Yes, and this is the problem of terminology, a nut we haven't quite cracked, that some people would describe or some people living with asthma would describe an asthma attack as when their Ventolin doesn't work or relieve their symptoms as quickly as they would expect it to. Whereas we think the very need for Ventolin is a marker of poor asthma control and is in itself an asthma attack and something that we should worry about. So getting a common language, common terminology, a common way of approaching the goals of asthma care is something we are still striving to achieve.

Norman Swan: So in other words up to 40% or 50% of people with asthma are on a bit of a knife edge and therefore when something like this thunderstorm asthma event comes along, they are hit particularly hard.

Matthew Peters: Correct, and some of the 20% who have uncontrolled symptoms despite using their regular puffer appropriately may have symptoms for other reasons. They may report breathlessness because they are not as fit as they'd like to be, but within that group there will be people with asthma who are genuinely at risk because they might be using their inhaler but very badly. And that in itself is a signal to some of the things that we can do, just simple attention to detail in taking treatment regularly, in taking their inhalers with the correct techniques so delivery is good and the effect is maximised.

Norman Swan: So just take us through the solutions here. So we've got all these complicated terminologies like relievers, preventers and so on, what is the evidence-based treatment for asthma that…you're using your blue puffer too often, you've got these symptoms, what is the evidence-based treatment?

Matthew Peters: Well, at the very least, patients…I shouldn't call them patients, that's not dogma…people living with asthma who have regular symptoms and are on no regular preventer treatment or core asthma treatment should be taking one that includes an inhaled steroid component. And just the administration of a relatively tiny dose of inhaled steroid regularly virtually eliminates the risk of asthma deaths and asthma crises, trips to hospital. So that's the core. That should be taken in an inhalant the patient is familiar with, and they have good technique, and one would expect that their symptoms—breathlessness, cough, wheeze, chest tightness—will improve well. Where they don't improve well then sometimes a long-acting form of Ventolin or similar needs to be added.

Norman Swan: Matthew, thank you very much indeed.

Matthew Peters: It's a great pleasure.

Norman Swan: Matthew Peters is professor of respiratory medicine at Macquarie University in Sydney.

And you're listening to the Health Report here on RN, ABC news radio and CBC radio across Canada.

Professor Matthew PetersProfessor of Respiratory Medicine, Macquarie University.

Further Information
Asthma control in Australia: a cross-sectional web-based survey in a nationally representative population - Medical Journal of Australia

PresenterDr Norman Swan ProducerCathy Johnson