The GP's role in reducing falls
I know how frightening asthma can be
Dr Vincent McGovern's vivid memories of poorly controlled asthma have convinced him that GPs and patients need to raise their expectations of treatment
poorly controlled asthma have convinced
him that GPs and patients need to raise
their expectations of treatment
I developed asthma around the age of two. It wasn't a difficult diagnosis: recurrent cough and wheeze in a child covered in atopic eczema with a family history of asthma. In any case I never grew out of it, so it couldn't have been wheezy bronchitis!
That was the early 1960s. Treatment options were very limited and I was prescribed Tedral syrup. Now we know that such theophylline preparations can cause nausea – I suffered nausea and retching just trying to swallow the syrup. Still that's all there was in those days and drastic times called for drastic measures.
I experienced intermittent, but significant, flare-ups of asthma throughout my childhood, and these had a significant impact on my life.
As a boy I was out on the street playing football from the minute I arrived home from school. There were no computer games in those days and we played on until way after dark. I usually started playing with no symptoms, but always ended up wheezing in goal. There is a myth about asthmatics wanting to be goalkeepers – we usually start playing outfield and only end up in goal when we can't breathe.
In those days my asthma attacks were very frequent. I can remember them happening late at night, visits from the GP by the light of the bedside table, and injections into my arm which could only have been aminophylline. I remember when the GP was called out after dark – there was always a new bar of soap and clean towel left out for him. There seemed to be more fuss being made about the doctor having to come out than there was about my asthma attack. How times have changed!
Convinced I was dying
As a child asthma attacks were very emotional for me. I can remember one particularly bad attack that left me sitting hunched forward in the middle of the living room with my distressed family surrounding me. I was sobbing uncontrollably and bidding my parents farewell, thanking them for everything they had done for me and convinced that my next breath was going to be my last. At the age of 11 my GP prescribed an Intal Spinhaler, an early dry powder device. Looking back now I realise how clued in my GP was – such treatment was a real innovation back then. Intal Spincaps were supposed to be a preventive, but I soon worked out that the isoprenaline of the Intal Compound Spincaps provided great relief!
My teens were punctuated by repeated flare-ups, with resulting rounded shoulders. Image is everything as a teenager but the figure-of-eight support I bought from a Sunday newspaper to improve my posture stood no chance against my poorly controlled asthma.
During my A-levels nocturnal waking became a regular occurrence. My doctor told me it was a stress-related exacerbation and prescribed diazepam, which stopped the wakenings – at least I think it did but maybe I just slept through them.
As a newly-qualified doctor in my 20s, I became the 'Ventolin inhaler in every pocket, coat and orifice' kind of asthmatic. I checked my peakflows diligently; they were 400L/min, dipping most nights to 250L/min with Ventolin needed from the bedside table. If ever I discovered I had left home without my inhaler I would always have to go back for it, no matter how far I had travelled.
It wasn't until 1989 that a pharmaceutical company rep persuaded me that inhaled steroids would make a difference. Within weeks the night-time wakings had gone and my need for Ventolin was dramatically reduced. My peakflow stabilised between 400-440 L/min – still not great but I was very grateful for the dramatic improvement in my quality of life.
A few years later I added in a long-acting bronchodilator and my peak flows rose to 520. My need for Ventolin disappeared almost overnight and my asthma was no longer exacerbated by exercise.
We now know that low-dose inhaled steroids and long-acting bronchodilators work very well together. I have been on a combination inhaler for a while now. I rarely get symptoms, do not have exercise intolerance and hardly ever need my blue inhaler. My compliance is good; I take my inhaler every morning without fail and I have learnt over the years that it keeps me well.
But, it's clear to me that 30 years of unopposed asthma inflammation have taken their toll on my lungs. Re-modelling does occur and I think I now have some degree of chronic irreversible airflow obstruction. I just hope the ongoing treatment will prevent the damage from worsening now my symptoms are well controlled.
Low expectations must be tackled
So do asthmatic doctors or doctors with asthmatic children tend to treat the condition more sympathetically? You bet they do! Only someone who suffers from asthma can understand the impact the symptoms have on daily life – and what the fear of having an asthma attack really feels like.
The majority of asthmatics have mild to moderate disease, which can be controlled by appropriate, enthusiastic, individually tailored treatment. Low-dose inhaled steroids taken on a regular basis remain the cornerstone of management and where residual symptoms persist, additional therapy such as long-acting ß2-agonists can be added in to provide better control. Compliance with regular treatment remains a problem; patients have to be educated and persuaded to take regular treatment. The aims and benefits of doing so must be carefully explained.
I always ask patients the same series of questions to assess their disease control (see left).
Too many patients and health care professionals have low expectations of what can realistically be achieved for the majority and treatment standards often fall far below what should be expected.
What my asthma has taught me
••Poor asthma control is a vivid memory for me but still a painful reality for many others
•Asking the right questions is crucial to identifying poor control
•Good control is achievable for the majority but takes time and effort from doctor and patient alike
Questions I ask to assess asthma control
•How often do you have asthma symptoms?
•How often do you need your blue reliever?
•Do you ever wake at night as a result of your asthma?
•Do you have asthma attacks that cause you to need emergency treatment or take time off work or school?
•lDo you ever avoid doing things because of your asthma?
•What do you hate most about having asthma?
Vincent McGovern is a GP in Belfast and a clinical assistant in adult chest medicine at Belfast City Hospital and in paediatric asthma at the Royal Belfast Hospital for Sick Children – he was a member of the panel that updated the BTS/SIGN national asthma guidelines