Mistreating asthmatics

Asthma can be a debilitating disease and is not uncommonly fatal, especially when undertreated.

Each day 11 Americans die from asthma. There are more than 4,000 deaths due to asthma each year, many of which are avoidable with proper treatment and care. In addition, asthma is indicated as “contributing factor” for nearly 7,000 other deaths each year.

Much is understood about asthma, but in a simplified version.

Asthma is characterized by inflammation of the air passages resulting in the temporary narrowing of the airways that transport air from the nose and mouth to the lungs. Asthma symptoms can be caused by allergens or irritants that are inhaled into the lungs, resulting in inflamed, clogged and constricted airways. Symptoms include difficulty breathing, wheezing, coughing tightness in the chest. In severe cases, asthma can be deadly.

With proper treatment, asthmatics can function as well as non-asthmatics, at least most of the time. There are numerous professional athletes who suffer from asthma, and in my own family, one of my sons is a severe asthmatic who has cycled across Canada and is an accomplished trumpet player.

The standard treatment for asthma, along with the lifestyle changes that involve avoiding triggers, include pharmaceutical interventions such as corticosteroids, bronchodilators, and leukotriene inhibitors. These are the interventions that allow people to function at or near the level they would without asthma.

Of course, into the fray come the sCAM artists. They claim to treat asthma without these proven remedies. They might use aromatherapy or reiki, homoeopathy or acupuncture, or anything else they can make money on. There are two recent studies on the use of ‘alternative’ medicine looking at asthma. The first by Dr Elizabeth Thompson of Bristol Homeopathic Hospital entitled  The feasibility of a pragmatic randomised controlled trial to compare usual care with usual care plus individualised homeopathy, in children requiring secondary care for asthma published in Homeopathy is deconstructed by David Colquhoun at his blog DC’s Improbable Science. I’m not going to copy his attempts to obtain the results, nor the details of his discussion. To keep it simple, here is his summation of the results of the paper:

The results are completely negative, In fact it shows that the homeopathic treatment didn’t even produce a placebo effect, never mind an effect of its own.

The other is a study headed by Michael E. Wechsler, M.D., published in the New England Journal of Medicine entitled Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma.  The results section states:

Among the 39 patients who completed the study, albuterol resulted in a 20% increase in FEV1, as compared with approximately 7% with each of the other three interventions (P<0.001). However, patients’ reports of improvement after the intervention did not differ significantly for the albuterol inhaler (50% improvement), placebo inhaler (45%), or sham acupuncture (46%), but the subjective improvement with all three of these interventions was significantly greater than that with the no-intervention control (21%) (P<0.001).

In other words, the medication had a measurable increase in lung capacity, but the patients ‘felt’  just as well with regardless of the treatment. Acupuncture, sham acupuncture, and an empty inhaler did not improve lung capacity while the ‘real’ inhaler did. What we can determine from this is that spending time with patients makes them feel better whether they receive actual treatment or not, but it does not actually make a difference. Peter Lipson at Science Based Medicine discusses this paper, and includes a discussion on the ethics of using treatments that are no better than placebo at objective measurements of patient improvements.

…we have a huge literature on quality of life metrics in asthma.  Huge.  And we also know that objective changes in asthma are what save patients’ lives.  Yes, I care how my patient feels, but it is not more “clinically relevant” than how they are actually doing physiologically.  Both are important, but not equal.  And the idea that comparing active treatment to placebo is not ideal is not new to researchers.  It’s simply that following the natural history of the disease as a “control” is not usually appropriate (cf. Tuskegee syphilis experiment).

No good clinician would consider treating an asthmatic with placebo. Improper treatment of asthma leads to debility and death.  This study chose mild asthmatics, but I still feel very uncomfortable with the ethics of the study design.  Rather than using a disease we know how to treat to study placebo, we should be finding ways to get treatment to the millions of people who aren’t getting it.

There is a big business in these ‘alternative’ modalities. Practitioners are everywhere, and many people are buying into their treatments, sometimes at great expense to themselves. There is a push towards including these practices in medical schools in an effort to legitimize them. Any well designed study shows that all of the treatments are no better than placebo. Homoeopathy is advertised as having no side effects—of course not, it is only water. The primary harm is the avoidance of appropriate treatment. Acupuncture on the other hand does have the direct potential for harm. The reuse of improperly sterilized needles can expose patients to blood borne diseases such as Hep C or HIV. In other cases, patients’ chest walls have been punctured resulting in punctured lungs and death.  The risks vs benefits of any treatment must be weighed before it is recommended. In that light, no ethical practitioner  could use or recommend either of these.

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3 Responses to Mistreating asthmatics

  1. Nan says:

    My ‘other half’ has suffered from severe asthma from childhood. In desperation, he has tried numerous alternative methods over the years. None have worked. Fortunately, for the most part, his asthma is now under control using proven medication.

    I lean towards natural methods of healing in some cases, but not all. I think a person needs to use common sense and not be taken in by practitioners who offer dubious, at best, treatments.

  2. The problem is nearly all ‘natural’ healing methods are unproven and many are harmful. Deciding treatments is always a risk/benefit analysis. When a treatment has no proven benefits, even a small possibility of harm is too much.

  3. Richard Friedel says:

    Asthma treatment: Time for a fresh start without pharmaceuticals. The success of inspiratory muscle training gadgets such as Powerbreathe and many other devices from other non-related manufacturers can no longer be ignored. “Weak-chested” has an important literal meaning and is not just a figure of speech.
    The ongoing failure of pharmaceutical treatment with unloading and hence detraining (use it or lose it) of the breathing muscles and the success of of inspiratory muscle training mutually confirm each other. Training the inspiratory breathing muscles to a suction level of say 50 cms water, makes good sense, when it is a question of overcoming cramped bronchial muscles The strictly pharmaceutical treatment around since the middle of the last century has been accompanied by paradoxically increasing asthma rates as nobody can deny. ( Asthma and the Indoor Environment – Current Issues and Potential Strategies, by Dr Gillian Durham Chief Executive Public Health Commission.)

    The advantage of such choke devices over just breathing energetically is that an asthma attack is avoided and that because of their calibration a given suction can be targeted.
    However there is the disadvantage that the suction level cannot be varied during the course of an inhale.
    My experience of asthmatic breathing is that frantic efforts to overcome the shortening of the breath and the lack of oxygen lead to sudden pressure peaks. One approach might therefore to damp respiratory efforts by a choke in view of the success of the inspiratory muscle training gadgets and indeed the placement of a piece of soft but elastic foil between the lips instead of the mouthpiece of a gadget.
    During at the start of each inhale the foil is squeezed progressively somewhat so the inhale is soothed and does not start in a staccato fashion. Then the inhale may be continued in a satisfying relaxed manner. This is an advantage over standard inspiratory muscle training devices, although they do have the advantage of calibration. The foil element may be a piece of PE blister foil flattened out to a convenient degree measuring 6 times 2 cms. I hope to organize supply through pharmacies. Richard Friedel, Starnberg Germany

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