Allercy and Asthma Health
The Official Publication of AAN - MA

Is My Asthma "Severe" or Just Difficult to Control?


By Marilyn Walton, MHHS, RRT, AE-C, RPSGT

People with asthma usually experience typical symptoms such as coughing, wheezing, shortness of breath, and chest tightness. These symptoms are caused by bronchial muscle spasm and airway inflammation and are treated with commonly prescribed medications. An inhaled short-acting bronchodilator (albuterol) relaxes the bronchial muscle spasms, while inhaled steroids relax airway inflammation.
Some people, however, struggle with symptoms that are unresponsive to the usual therapy. This can have a major impact on their lives, from missing work or school to the inability to participate in everyday activities. These chronic symptoms can sometimes be managed by additional medications. Yet despite more aggressive treatment, there is still a small percentage of people who continue to experience severe symptoms that are difficult to control.

So what is the difference between severe asthma and difficult-to-control asthma? Though seemingly similar, as both do not fully respond to standard medication therapy, there is a distinct difference between the two. Both can be difficult to manage, but for different reasons.

According to national asthma management guidelines, asthma severity is determined by the amount of medication needed to control symptoms. In addition to the usual short-acting bronchodilator to treat acute bronchial muscle spasm, medication plans for severe asthma may include higher dose inhaled steroids for chronic airway inflammation, oral steroids during symptom flare-ups, and add-on medications such as a long-acting bronchodilator.

Researchers have gone further to explain that people suffering with severe asthma, even when consistently following the direction of their health care providers, and despite more aggressive treatment, do not fully respond. They encounter more emergency visits and hospital admissions than most, never actually achieving good asthma control. Extreme hypersensitive airways can cause more frequent and more severe episodes. Repeated insults to the airways can lead to chronic inflammation, thickening and scarring of the walls lining the airways, with eventual irreversible airway remodeling.

Difficult-to-control asthma, on the other hand, refers to asthma that is difficult to manage due to any number of reasons, some which are preventable. Common factors that negatively impact asthma may include:

  • Frequent exposure to triggers
  • Poor patient compliance
  • Misunderstanding of medications
  • Ineffective medication delivery technique
  • Inability to recognize symptoms.

Inadequate treatment of coexisting conditions such as rhinitis, allergies (including molds, pollens, pet dander, dust mites), or GERD (gastroesophageal reflux) may also aggravate asthma. Trigger exposure may be controllable (e.g. secondhand smoke, use of scented products) or less controllable (pollens, molds, weather).

Psychosocial issues, stress, and worries can also affect asthma, but are sometimes overlooked as clinicians concentrate on the clinical aspect of asthma management. Along with their physicians, Certified Asthma Educators can help patients assess ways to gain better control of asthma. Developing good self-management skills begins by increasing awareness and knowledge of:

  • Symptom awareness, worsening, and when to call the doctor
  • Understanding proper use of medications
  • Trigger control

Anyone dealing with asthma should work closely with their physician/health care provider and become an active partner in their own care.

Marilyn Walton is a member of the American Association for Respiratory Care from Ohio who currently serves as program education coordinator, asthma, at the Community Outreach, Education and Support Center at Akron Children’s Hospital Mahoning Valley. She is a Certified Asthma Educator.
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