Asthma
Questions Received:
Responses:
What is the death rate for asthma in adults?
8th March 1999
It is difficult to give a precise answer to this question - there are local and regional differences in the occurrence of asthma deaths and thoroughness of reporting. In a comprehensive review of this problem, Sly and ODonnell (1997) report that the rates of death from asthma in the United States have increased from .8 per 100,000 in 1977 to 2.0 per 100,000 in 1989 and have been 1.9 or 2.0 since then until an increase to 2.1 in 1994. Rates of death have been higher for black people than for whites, and among whites rates have increased more for females than males. The rates of death from asthma have also risen in England and Wales, Australia, Canada, the Netherlands, Sweden, France, West Germany, Israel, and Denmark (Meza and Gershwin, 1997).
Pollution may contribute to this problem. Much of the rise in asthma death rates has occurred in urban areas, where dust mites, cigarette smoke, ozone levels, exhaust fumes, and cockroach droppings are among the many factors that can trigger an attack.
Most deaths follow a period of unstable and deteriorating control of asthma, and post mortem examination of the lungs shows an intense inflammatory response with widespread plugging of the airways by mucus (Barnes, 1994). A small proportion of patients, however, die from asthma attacks that progress from minimal symptoms to respiratory arrest within one to two hours - a condition termed "sudden asphyxic asthma". Examination of the lungs in these cases showed little inflammation and clear airways, and it is assumed that the patients died of extreme physiological narrowing of the airways.
There are several indicators identifying people at risk from death from asthma. These include severe asthma, poor compliance with therapy, denial of the disease, delay in seeking medical attention, and instability of airway function (Barnes, 1994).
References
Barnes, P.J. (1994) Blunted perception and death from asthma. The New England Journal of Medicine, 330(19) Editorial (May 12).
Meza, C., and Gershwin, M.E. (1997) Why is asthma becoming more of a problem? Current Opinions in Pulmonary Medicine, 1, 6-9 (Jan 3).
Sly, R.M., and ODonnell, R. (1997) Stabilization of asthma mortality. Annals of Allergy and Asthma Immunology, 78, 347-354 (Apr).
My child has asthma and in the last week has started to snore very loudly (whilst she is asleep) - is this normal?
20th April 1999
The answer to this question will depend on whether your child breathes regularly while snoring and sleeps undisturbed, or whether the snoring is accompanied by restlessness, irregular patterns of breathing, and perhaps night-time asthma. Regular, continuous snoring that does not disturb the sleeper is usually nothing to worry about, although it is distressing for those who have to listen to it.
Snoring is less common in children than in adults but is by no means rare. For example a study of French children showed that 10% were habitual snorers. In that study, snoring was significantly associated with asthma, adenotonsillectomy or enlarged tonsils, and a personal or family history of allergy (Teculescu et al, 1992).
A problem arises when discontinuous snoring leads to sleep fragmentation and daytime sleepiness (Bloch, 1995). Loud snoring, occasional pauses in the pattern of breathing followed by waking up, and excessive daytime sleepiness are the hallmarks of what is known as the obstructive sleep apnea syndrome. The main risk here is that the level of oxygen in the blood can fall during the periods when there is a pause in breathing - apnea (Partinen, 1995). There is however an effective treatment. Nasal continuous positive airway pressure applied by a nasal mask is both efficient and safe in the treatment of children and adults with sleep apnea (McNamara, Harris, and Sullivan, 1995). Its only limitation is related to variable acceptance by patients (Krieger, 1996). Recurrent upper airway obstruction and snoring may be important triggering mechanisms of nocturnal asthma attacks (Chan, Woolcock, and Sullivan, 1988). In a group of adolescents and adults treated with nasal continuous positive airway pressure during sleep, snoring and airway obstruction were eliminated, together with the nocturnal asthma attacks (Guilleminault et al, 1988).
References
Bloch, K.E. (1995) Sleep apnea syndrome and morbid snoring. [Article in German] Schweiz Rundsch Med Prax, 84(24), 736-7341 (Jun 13).
Chan, C.S., Woolcock, A.J., and Sullivan, C.E. (1988) Nocturnal asthma: role of snoring and obstructive sleep apnea. American Review of Respiratory Disease, 137(6), 1502-1504 (Jun).
Guilleminault, C., Quera-Salva, M.A., Powell, N., Riley, R., Romaker, A., Partinen, M., Baldwin, R., and Nino-Murcia, G. (1988) Nocturnal asthma: snoring, small pharynx and nasal CPAP. European Respiratory Journal, 1(10), 902-907 (Dec).
Krieger, J. (1996) Medical treatment of snoring and obstructive sleep apnea syndrome. [Article in French] Schweiz Rundsch Med Prax, 85(21), 692-695 (May 21).
McNamara, F., Harris, M.A., and Sullivan, C.E. (1995) Effects of nasal continuous positive airway pressure on apnoea index and sleep in infants. Journal of Paediatric and Child Health, 31(2), 88-94 (Apr).
Partinen, M. (1995) Epidemiology of obstructive sleep apnea syndrome. Current Opinions in Pulmonary Medicine, 1(6), 482-487 (Nov).
Teculescu, D.B., Caillier, I., Perrin, P., Rebstock, E., and Rauch, A. (1992) Snoring in French preschool children. Pediatric Pulmonology, 13(4), 239-244 (Aug).
What advice do you offer to persons with respiratory problems with regard to playing a wind instrument? Does playing help or hinder conditions such as asthma and allergies?
11th June 1999
Within reason, there should be nothing to prevent a person with asthma playing a wind instrument, provided that they perceive the exercise as rewarding and not stressful. The respiratory effort required generally has beneficial effects - playing involves conscious control over both inspiration and expiration. Lucia (1994) found that teenaged wind instrumentalists have a significantly better "asthma health" picture than non-playing peers, and they perceive themselves as better able to cope with the disease. The conclusion was that "playing a musical wind instrument has the potential of being a long-term therapeutic agent for asthmatics". With regard to allergies, that would depend on the nature of the allergies. So for example care would have to be taken to avoid contact with allergenic materials that may be associated with the construction or maintenance of the wind instrument, or the potential for contamination of the instrument with micro-organisms that might produce sensitivity in some people. Presumably such sensitisation if it occurs will soon become apparent and it will be relatively straightforward to prevent further difficulties.
Reference
Lucia, R. (1994) Effects of playing a musical wind instrument in asthmatic teenagers. Journal of Asthma, 31(5), 375-385.
Our thanks to Mrs. Annette Garrett, Clinical Nurse Specialist in Respiratory Medicine at the Royal Devon and Exeter Hospital, Wonford, Exeter, Devon, England for help with this response.