From last week’s post about inhaled steroids:
I’ve read some info on airway remodeling… the concept being that untreated asthma makes permanent changes to the airway that makes treatment later on more difficult. I don’t know how valid it is… but I would probably tend to come down on the side of inhaled steroids rather than risk such a thing. And I’d really rather come down on the side of inhaled steroids as opposed to oral.Do you have any scoop on schools of though behind airway remodeling? –Asthmagirl (the blogger, not my kid)
New asthma research from Australia actually has some relation to subject of airway remodeling, but bear with me because it will take a moment or two to get there.
First, what’s airway remodeling?
My simplified explanation: chronic inflammation like in severe and/or under-treated asthma patients forces the airways to keep trying to fix themselves over and over again in response. Researchers think this process may actually change the structure of the airway, and that’s airway remodeling. In the worst-case scenario, these structural changes may cause irreversible airway obstruction later in life, which means air never moves through the airways to and from the lungs as well as it needs to, and typical asthma medications won’t help.
If you think I’m hedging on my explanation, you’re right, and that’s because researchers aren’t sure of the process themselves. According to the best explanation of the issue I’ve found,
In asthmatic patients, the epithelial layer, the lining of the airway, has undergone structural and functional changes, which may contribute to airway remodeling.
In other words, all asthma patients have airways different from us non-asthma folks, and it’s unclear exactly why some patients have more significant structural changes and therefore more obstruction than others. Yes, under-treating all but the mildest asthma is probably a factor, but some people experience steroid-resistant asthma for no known reason.
The research does show the longer you have asthma symptoms, the more likely your asthma will get worse. And since inhaled corticosteroids decrease inflammation, and chronic inflammation may cause major airway remodeling, the thinking is that prevention doesn’t just increase your quality of life now. It may also decrease your chance for complications like severe, steroid-resistant asthma in the future.
Does this line of reasoning remind you of *IF. . . THEN* conditional statements from math class?
Me too.
This new Australian research, though, shows some mild asthmatics may want to think about inhaled corticosteroid maintenance, too. The usual guideline for inhaled steroids–you should consider them if you consistently need your albtuerol inhaler more than twice a week–excludes many patients with mild asthma. Some people, for example, only flare during strenuous exercise and never have problems with allergens, airborne irritants, or illness. They can maintain good health simply by carrying a quick-relief inhaler to the 5K or the soccer game.
But the mild asthmatics in this study showed a noticeable increase in lung function and a decrease in airway twitchiness after using maintenance steroids.
This finding is kind of a big deal, what with current treatment guidelines not really advocating maintenance meds for patients with mild asthma. The research lead, Associate Professor Helen Reddel, explains the results don’t necessarily point to sticking all mild asthmatics on inhaled corticosteroids. They do, however, mean maintenance steroids for people with mild asthma may decrease the chance of worse asthma later, and she compares this possibility to high blood pressure patients taking medications now to try to avoid strokes as they age.
Basically, inhaled steroids in these people might work as long-term preventatives rather than provide the daily prevention that moderate persistents like my daughter need.
This study makes perfect sense to me. I know as a parent of a late diagnosed asthmatic (age 10), I origianlly didnt like the idea of inhaled steroids at all. Unfortunately, at the time the Dr. just handed them to us and said have dd take this 2 puffs/2x per day. Really if he had taken the time to explaing the long term benefits, I would have been more compliant b/c I would have understood the necessity. As it was I was in denial……I just thought she had a bad cough from a virus. Fast fwd. 18 months………she was fine for a yr. and 1/2, so I didnt even think about the inhaler. HOWEVER, she then got a dandy virus that left her coughing for 3 weeks (much longer actually)…..which is when I finally took the time to REALLY get educated on my own. I found Amy’s blog and realized a lot more about inhaled steroid use. Prolonged inflammation anywhere in the body causes problems long term………so I am now so thankful for the PREVENTATIVE action of these inhaled steroids. I do believe if over time there is ongoing inflammation…..permanent changes do occur (my mother in law recently died from Pulmonary Fibrosis, from Chronic smoking…….that inflammation definitely caused permanent damage….) All this to say, now that I am educated, I realize the bennefit and am thankful the inhaled steroids seems to be working as a preventative to asthma inflammation in our dd. Thanks Amy for your informative Blog!!! I know I may still be frustrated if I hadnt found an easy way to understand this Asthma stuff
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Well, you’re welcome.
I think there just has to be a better way to explain maintenance steroids to parents. For a long time, I felt like very foolish and guilty for not using inhaled CS with AG since she ended up having so many problems, and then I realized how many other parents went through just the same thing.
As far as this study goes, I’ll be interested to see if it (or any further research) will eventually cause new guidelines for mild asthmatics.
Good explanation… I’ve heard that not every pulmo buys into the remodeling theory however everyone seems on board with inhaled steroids reduce inflammation. Apparently there’s still a little discussion about what the long term effects of the inflammation might be.
I personally get nervous when I think of asthmatics that are mild not using even low dose inhaled steroids. It seems as though sometimes when I hear those stories it’s followed with “and a year later, my asthma got worse and now I have to use inhalers… how do I get back to where I was.”
My original thought at 44 was to use as little as possible. Now I subscribe to the theory of “whatever it takes”.