The Tribune, Chandigarh, India

Inhaler-associated deaths in asthma & the truth
Dr S.K. Jindal

THERE is a general alarm caused by a recent report on asthma deaths which appeared in the prestigious medical journal Thorax and was widely quoted in the lay Press by different news agencies. I have personally received queries from patients and other people from different walks of life on the implications and details of the results of the investigations reported by Stephan Lanes who attributed up to 50-fold increased risk of death associated with an excessive use of inhalers to seek relief from asthma.

There are several finer points and qualifications in the conclusions which tend to escape the attention of general readers thereby leading to erroneous impressions and conclusions. The fact of the matter is that inhalational therapy continues to remain the most effective and the safest form of treatment of asthma and there is no real cause of fear.

The fear of death from an excessive use of inhalers is not new. It was in the 1960s when a temporal relation was discovered in the UK between the increase in asthma deaths and increased over-the-counter sales of isoprenaline a nonspecific beta against inhaler. Based on the circumstantial evidence linking this “epidemic” of asthma deaths with inhalers, the over-the-counter sale of isoprenaline was stopped. The second epidemic was reported from New Zealand in the late 1970s targeting fenoterol — another beta agonist. The causal association could never be proved but the drug did go into disrepute.

What are the inhalers and the drugs used through them? An inhaler, in fact is not a drug as such but only a device used to administer a drug in the respiratory system. Inhalers of several drugs are already available in the market and many more are waiting in the pipeline. Factually, therefore, an inhaler in itself is neither a problem nor a panacea. Inhaler is a system of administration of a drug similar to the example of a syringe to inject a drug. An inhaler is used to either convert a liquid-drug into an aerosol and release the same as a puff (metered dose inhaler) or to supply and deliver the drug in a fine powder form (dry powder inhalers — rotahalers, turbohalers, accuhalers, etc).

There are two main groups of drugs for asthma used with inhalers — relievers and presenters. The “relievers” act immediately and provide relief from acute symptoms of asthma. Bronchodilators, primarily the short and long acting beta-agonist drugs (salbutamol, terbutaline, salmeterol, formoterol and others), are the important ‘relievers”.

The “preventers” are primarily the anti-inflammatory drugs represented by locally acting corticosteroids such as the beclomethasone, budesonide and fluticasone. It is the difference between the relievers and the preventers which makes all the difference in the control of asthma and in causing any side-effects, including deaths from asthma.

It may seem a bit odd but true that the corner-stone of asthma treatment in the use of “preventers” and not the “relievers”. Although there is a rapid relief after a puff or two of a beta agonist inhalation, it does not last long and the problem comes back. One tends to take more inhalations, and more and more.... till exhaustion and frustration take over.

It is the repeated use of bronchodilator inhalations which must be avoided. As per the recent report, patients who had 13 or more relief-inhaler prescriptions in the previous year had a 50 fold risk of asthma deaths. Among 96,000 asthmatics who had their treatment data entered into the General Practice Research database in the UK, there were 43 asthma deaths.

There are multiple explanations for an excessive mortality in this group. The most important reason is the inability to control the underlying inflammation which is inadvertently allowed to continue. There is an apparent failure to recognise the early signs of deterioration because of an over-reliance on “ reliever” drugs providing a deceptive relief from symptoms. It is akin to treatment of an infection with continued use of antipyretic drugs without taking care of the underlying infection. The drug is factually innocent but gets the blame by default.

It is also likely that those patients who excessively use the beta agonists are suffering from a more severe and different-to-control asthma.

This group of patients are known to have a higher mortality. Beta agonists can also produce problems, especially the cardiac arrhythmias and death when the toxic levels are reached. All efforts must, therefore, be directed to avoid the excessive use.

Another issue of concern with metered dose inhalers is related to the use of chlorofluorocarbons used as propellants. The CFCs are released in the environment and have their effect on the ozone layer which protects the earth’s atmosphere from the deleterious effects of the harmful rays of the sun. They may, therefore, also contribute to the global warning even though negligibly compared to the properlants and other deep freezing gases used for many other industrial and scientific purposes.

In newer forms of inhalers, the CFCs are being replaced by more environmental friendly HFAs. Moreover, the dry powder inhalers are not accompanied with any such fear.

It must also be appreciated that inhalational treatment is a novel and one of the most noble forms of therapy. It is somewhat difficult to understand and costlier than the oral tablets of syrups. But steroids — the preventers given orally — are bound to create problems in the long run.

Inhalational steroids have minimum side-effects. As of today, a locally acting steroid administered through inhalational devices remains the treatment of choice. It is quite likely that some other drugs, used even for diseases other than asthma, may also become available as inhalers in the future.

The writer is Professor and Head, Dept of Pulmonary Medicine, PGI, Chandigarh.

	Home management of acute respiratory infections Dr Shakuntala Lavasa ACUTE respiratory infections (ARI) are the common cause for morbidity and mortality. ARIs are also the easily identifiable source of most antibiotic use and abuse. In most communities all over the world, on an average three-seven days are spent at home before any medical consultation is sought for an ARI. The typical home treatment consists of a regime of various teas and chest rubs. Teas are usually made from common herbs but sometimes dangerous substances are added. Rubbing the chest with a salve, ointment and oil is very common. Although most of these are safe and soothing, but in some families dangerous substances like kerosene and mustard oil are used. Another dangerous practice is the oral use of menthol balm diluted in water or tea, tight wrapping or swaddling of the chest and burning and lacerating it. Commercial cough syrups, over-the-counter prescription drugs, decongestants antibiotics, salbutamol and even steroids are found in home remedies. Antibiotics left out from a previous illness or purchased without prescription are given commonly before proper medical care is sought. Although families should be supported and encouraged to maintain good practices, including giving additional fluids, safe and soothing remedies under hygienic conditions, it is important to discourage harmful practices like self-medication, inappropriate antibiotics, over-the-counter medicines, extra-clothings in spite of fever, depriving a patient of nutrition due to the so-called cough-producing food items like milk, and banana. Throughout the world families have rich culturally based economic means for dealing with the challenges of illnesses. Many of these actions are appropriate and positive. However, for potentially life-threatening ARIs modern medical care is a must. Families must recognise the two most visible danger signs: (1) rapid breathing and (2) chest drawing. The management of a child hood illness requires a partnership between families and health care providers. The first task is to recognise the indicators of potential seriousness, but equally important is to follow the advise. It is seen that when a doctor recommends hospitalisation there are a number of reasons which lead to a delay in doing so. It is also very common not to give the full dosage and course of antibiotics, not to take the child for a review if he is better. When a child is better, a change of action is called for just as it is when his/her condition is worse. These problems and issues present difficult challenges for a busy practitioner with poor health care resources and educational agencies. Unless these problems are addressed, there may not be any major improvement in the management of ARIs. Better home management is the key factor in reducing the chances of morbidity and mortality due to ARIs. This can be achieved only through close partnership between the affected families and doctors. The writer is a senior consultant paediatrician and allergy specialist based at Chandigarh. Ph. 0172-562239, 892226
	HOMOEOPATHY & YOU Treating sinusitis Vikas Sharma THAT a cold is just a simple disease and would pass away without causing any harm is a misconception. Many a times this simple cold gets converted into a chronic disorder. Sinusitis is an acute or chronic inflammation of the nasal sinuses-hollow cavities within the cheekbones found around the eyes and behind the nose. The primary functions of these sinuses are to warm, moisten and filter the air in the nasal cavity. They also play a role in our ability to vocalise certain sounds. Sinusitis, which is common in winter, may last for months or years if inadequately treated. It can affect the nose, eyes or middle ear, and may be indicated by profuse, thick, coloured nasal drainage, bad-tasting post-nasal drip, cough, head congestion and an accompanying headache. Symptoms may also include a plugged-up nose, a feeling of facial swelling, toothache, constant tiredness, and occasionally fever. There are two types of sinusitis. Acute sinusitis, is often caused by a bacterial infection and usually develops as a complication five to 10 days after the first symptoms of a respiratory infection such as the common cold. Then there is chronic sinusitis, which may also be caused by bacterial infection. Although colds are the most common cause for acute sinusitis, those with allergies may also be predisposed to develop this problem. As always, an ounce of prevention is worth a pound of cure. To avoid developing sinusitis during a cold or allergy attack, keep your sinuses clear by: · Using homoeopathic medicines to treat common colds · Gently blowing your nose, blocking one nostril while blowing through the other · Drinking plenty of fluids to keep nasal discharge thin · Avoiding air travel. To prevent the blockage of the sinuses allowing mucus to drain · If you have allergies, try to avoid contact with things that trigger attacks. · Vitamin C is helpful as it is involved in the repair and maintenance of the respiratory tract Homoeopathic medicines useful in treating sinusitis: Silicea — It is useful when sinusitis is chronic and frontal sinuses are more involved. The patient is very sensitive to cold weather and the discharge is thick yellow and lumpy, and the right sinuses are more affected. Hydrastis — when chronic sinusitis is associated with post-nasal drip and thick, yellowish, ropy secretions. Kali bichrome — when there is chronic inflammation of frontal sinus with stepped-up sensation. There is pain at the root of the nose and the discharge is thick, ropy, greenish-yellow. If relief is not forthcoming as expected, one should consult an experienced homoeopath. The writer is a Chandigarh-based homoeopath and can be contacted at telephone numbers 0172-721501/ 870739 (mobile).
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