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Managing Asthma Beyond Pharmaceuticals


Prescribing information for relevant GSK licensed products can be found at the bottom of this article.


Asthma is inflammatory disease of the lung. Poor asthma control affects quality of life and risks asthma attacks that can be fatal irrespective of asthma severity1. Effective control is achieved through anti-inflammatory medication supplemented when needed by bronchodilators. While pharmaceutical management is an essential and unavoidable part of asthma management, non-pharmacological management can provide a useful contribution.

Advice should be given to patients about non-pharmacological management as part of asthma management because:
Patients often want this kind of information2.  Patients who are activated to help themselves are more likely to search online for health-related information. One study found that 64% of adults seek health information outside the medical encounter3
If health professionals don’t provide it, patients will find information elsewhere. It is important that patients receive correct rather than incorrect information.
Although non-pharmacological interventions are helpful, they do not replace pharmacological interventions, and it is important that patients understand this
The two types of intervention are best understood if both are provided by the same person and form part of the same narrative. The holistic approach to asthma management combines the benefits of pharmacological and non-pharmacological management.

Non-pharmacological interventions fall into two categories:

Avoiding situations and substances that make asthma worse
Doing things that improve health and reduce systemic inflammation
 

Avoiding situations and substances that make asthma worse


It is not always possible to avoid situations that make asthma worse, but knowledge gives patients the tools to help themselves.  

Asthma triggers make asthma worse and fall into three categories:

Air particulates (smoke, fumes, pollution, dust, air fresheners, perfume/after shave)
Air borne allergens (animal dander, pollen, house dust mite, mould)
Other (psychological upset, premenstrual, exercise, some foods, non-steroidal anti-inflammatories)

Avoidance of air particulates is always helpful but not always possible. Some patients find it helpful to use pollution or pollen forecasts to take preparatory action. Several online sites (including Metoffice and Defra) provide daily pollution and pollen count forecasts. Search for ‘pollen forecast’, ‘allergy forecast’ and ‘pollution forecast.’ Allergy apps can also be found online that allow people to enter symptoms along with food, allergens or other environmental factors and the app then looks for statistical associations between possible causes of symptoms and the symptoms themselves.

Opinions differ with regard to allergen avoidance and national and international guidelines are inconsistent. What is the evidence? It is certainly the case that techniques for removing allergens are effective.  For example, vacuum a mattress reduces house dust mite4 in the mattress. However, a review published in 2018 of 59 randomised and 8 non-randomised studies provides only cautious support for the benefit of indoor allergen reduction5. The review covered acaricides (anti-mite), air purification, carpet removal, HEPA vacuum, mattress covers, mould removal, pest control and pet removal


The authors conclude:
“Single interventions were generally not associated with improvement in asthma measures, with most strategies showing inconclusive results or no effect. Multicomponent interventions improved various outcomes, but no combination of specific interventions appears to be more effective. The evidence was often inconclusive because of a lack of studies.”

Given the research data, what advice should be given to patients? Sensitivity to different allergens varies between patients, so if a patient has been diagnosed allergic, it makes sense to avoid that particular allergen6.  

A pragmatic and personalised approach to trigger avoidance is currently recommended, and this makes sense in view of evidence that allergens and respiratory viruses act synergistically in promoting asthma attacks7.  A useful strategy is to discuss with patients what could cause problems so that patients can work out for themselves what their triggers might be and what can be done to help.

Tip: Get to know the patient. Be sensitive to the possibility that the patient's circumstances may make avoidance difficult.

Doing things that make asthma better


Patients can be strongly motivated to do things that make their asthma better – doing things can sometimes be easier than avoiding things. There is a good deal of information available online and advertised as non-pharmaceutical products that purport to help asthma but are at best placebos, this includes homeopathy8 and the current trend for essential oils9. These commercially available products are unregulated in comparison with pharmaceuticals where stringent safety and efficacy testing is required. Some adverse reactions have been reported for these unregulated products10.


Why should non-pharmaceutical interventions reduce inflammation in the lung?

Asthma is a disease of the lung, but it is also a systemic disease involving systemic inflammation that tends to increase inflammation in the lung11.   Systemic inflammation is raised in people who are overweight, lack exercise, experience psychological stress and have a poor diet.  Not surprisingly, these factors are also associated with poor asthma control. There is a simple rule.  Doing things that improve health in general tends to help asthma control. Things patients can do fall into three main categories: exercise, relaxation/stress avoidance and diet/supplements.  Research is mainly observational because double blind placebo controlled studies are often not possible, but pragmatic studies are useful in demonstrating benefit in real world contexts. 


Exercise

Exercise is one of the most important things that a patient can do to improve asthma control and lung function. The benefit of exercise for asthma is confirmed by systematic reviews12, and more recent studies in adults13 and children14.  Exercise also has benefits for mental health and many other health problems. Quite simply, exercise is an excellent form of therapy. The problem is in motivating people and finding the opportunities for safe exercise.  Information is available online.

Tip: Exercise induced asthma is a common reason why patients avoid exercise. Ask if this is a problem. A SABA taken just before exercise helps.

Exercise acts as a stressor in the short term but, if taken regularly, exercise protects against stress.  Everyone has a therapeutic window for exercise tolerance – too little and too much is bad.  For people who are unfit and overweight it is important to start gradually and then build up exercise tolerance.  The therapeutic window is low in people who are unwell due to fatigue and pain conditions such a fibromyalgia. Gentle exercises such as tai chi can be a useful starting point for these patients. Recommendations to go to a gym may be unhelpful for people who feel embarrassed to exercise with people who are often found in gyms, so it is often a matter of finding what kind of exercise people enjoy rather than making any particular recommendation.  Walking is an excellent form of exercise.

Tip: people are more likely to exercise if they enjoy the exercise. So the important question is not what exercise is best but what form of exercised is enjoyed by that particular patient.

Stress reduction

People often underestimate the effect of psychological stress and relaxation on asthma.  There is weak evidence that psychological stress is a causal factor and strong evidence that a combination of psychological stress and dirty air is a causal factor in developing asthma15.  Exacerbations are triggered by stress in people where psychological stress is a trigger – for example, asthma attacks occurring after family rows or for children or students just prior to an exam16.  

There is weak evidence that any of the many different relaxation techniques that are available has limited benefit in asthma, including mindfulness17,18, tai chi19, yoga20,21, and massage therapy in children22,23.  It is possible that benefit is due to placebo effects or reporting bias and there is no evidence that one relaxation technique is better than any other.  Interest in these techniques is associated with beliefs and social background24.

In addition to relaxation techniques, there are also small adjustments that a person can make to lifestyle to avoid stress in everyday life, such as leaving early to avoid rushing to catch a train.  Understanding how and what causes stress and how to avoid it is sensible, not only for asthma but also for health in general. Awareness of the problem is probably the most important contribution a HCP can provide for the patient. 

Tip: get to know the patient. Stress avoidance/life management may be more helpful than relaxation techniques.

Foods and food supplements

One of the most popular strategies people have for improving their health is through food or dietary supplements.  What is the evidence in asthma?

Food

Vegetables: Vegetable intake is associated with reduced asthma symptoms in some studies25 but not all26. However, the most recent conclusion from a review is that fruit and vegetables may be helpful in improving asthma control27, as does a healthy diet28,29 and Mediterranean diet30.  

Meat and fish: There is evidence that fast foods31 and cured meats32 are associated with increased asthma symptoms but otherwise meat does not carry a risk33. Oily fish is recommended and may be more effective than supplements29.

The dietary advice to give to patients is very similar to the dietary advice that could be recommended for anyone.  Eat plenty of vegetables and keep consumption of cured meats low. Have a varied diet, and if you find that a particular type of food makes asthma worse, then avoid it.  Only avoid things that you notice makes asthma worse because unnecessarily restricted diets don’t help – variety of food is recommended.  Things to watch out for include food additives (including sulphites used to preserve dried fruit) which can act as a trigger for some people.

Supplements: 

Vitamins and other food supplements can be advertised as helpful in asthma, but the evidence is weak.  Although studies are inconsistent, reviews find in favour of Vitamin D34,35, though this vitamin is often recommended for the general population in the winter when light levels are low. At first there was some evidence that Omega-3 was helpful in asthma, but further studies failed to confirm these earlier findings leading to reviews now suggesting that omega-3 has little benefit36,37, a conclusion confirmed in a recent study38.  Note: oily fish is recommended29. The evidence for probiotics is inconclusive39,40 but there is some support for prebiotics41.

The advice with regard to supplements is no different from the advice given to the general population.  There may be benefit if people are low in particular vitamin or mineral but overall it is far better to have a healthy diet than to use supplements.

Tip: healthy eating should be recommended for all patients, not only those with asthma.

Conclusions


Patients want non-pharmaceutical advice and providing that advice as part of overall management plan will be an effective way of communicating with patients.  

My experience is that it best not to tell patients what to do as they often don’t follow advice.  Patients judge what is best for them based on their narrative of illness. Instead of instructing, provide patients with a narrative.  

The narrative goes like this:
1. “You have a disease which produces inflammation in the lung, and that inflammation needs to be controlled by asthma medicine.”
2. “The inflammation in the lung is increased by 
a. Things that irritate the lung (triggers)
b. Systemic or general inflammation that affects the whole body and tends to increase the information in the lung.”
3. “These are the things you can do to stop lung irritation”
4. “These are the things you can do to stop the general inflammation. These are exactly the same things that improves health in general, because general inflammation is caused by poor health.”
5.  “However, if you have asthma, there will be inflammation in the lung even when you control for systemic inflammation, so although lifestyle changes can help, they don’t remove the need for asthma medication.”

By providing this type of narrative, pharmaceutical and non-pharmaceutical interventions are part of the same story.  One affects the lung directly, the other indirectly. One is needed, the other helps. The narrative of ‘one is needed, the other helps’ is probably the most important message to get across.



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Prescribing Information


1. Ventolin (salbutamol) Prescribing Information

Professor Michael Hyland has received an honorarium from GSK for developing this article/content.

PM-GB-ASU-WCNT-200009 August 2020

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