Brain damage or death from asthma? Possible, doctors warn

SINGAPORE – Mr Tan Teck Juan’s first acute asthma attack in his late 20s left him in a coma and hooked up to a life support machine for nine days.

Up until then, he had been unaware he had asthma. But after narrowly escaping death and his discharge from hospital, the 44-year-old social worker at The Hiding Place, a drug addiction treatment centre, did not show up for any of his follow-up treatments and continued smoking heavily.

“I thought I was fine because I didn’t have any more symptoms,” he said.

What ensued was a decade of acute asthma attacks and frequent trips to the emergency department. The chronic inflammatory condition of the airways also made everyday tasks a challenge – Mr Tan got tired easily, could not sleep well and felt like he never had enough “qi” (breath).

“Several times after using the nebuliser at the emergency department, I would feel better and then ‘discharge’ myself even though the doctors said I had to be admitted. I thought (the asthma symptoms) were due to my lifestyle, maybe because I was drinking or smoking too much at the time. I didn’t think that asthma was a sickness,” said Mr Tan. A nebuliser is a device that allows one to breathe in medication through a mask or mouthpiece.

Such high-risk, foolhardy behaviour is not unheard of among asthmatics in Singapore, who put themselves at risk of death or permanent brain damage should a severe asthma attack occur.

The condition affects about one in 20 people in the adult population here.

Despite easy access to treatment in Singapore, asthma-related admissions to the intensive care unit (ICU) and deaths continue to occur. Many of these cases are preventable, experts told TODAY.

“Often, these patients did not seek medical help when they had symptoms of asthma, did not get properly diagnosed or did not take their inhaler medications every day even though they were diagnosed with asthma,” said Associate Professor Mariko Koh, senior consultant at Singapore General Hospital’s (SGH) department of respiratory and critical care medicine.

HIGH-RISK BEHAVIOUR, POOR CONTROL OF DISEASE

Citing a local survey involving 400 asthmatics, which found that only 14 per cent of patients had well-controlled asthma, Assoc Prof Koh said control of asthma among local patients is “generally poor”.

More than two-thirds (67 per cent) of asthma patients admitted into ICU with fatal or near-fatal disease had “untreated asthma”, according to a local study on fatal asthma published in the journal Annals by the Academy of Medicine, Singapore in 2012.

Most were young asthmatics who only sought treatment for acute attacks and were not receiving regular reviews; none was on appropriate control medication.

The SGH, where Mr Tan is currently being treated for asthma, sees around 1,200 to 1,500 emergency department attendances and approximately 550 to 650 admissions for asthma every year. Most of the patients admitted for asthma were difficult-to-treat or severe asthma cases, who were already on high doses of medications, said Assoc Prof Koh.

Changi General Hospital’s (CGH) emergency department saw 2,481 asthma cases in 2015, of which a quarter required hospital admission. Nine cases required ICU admission that year, said Dr Tay Tunn Ren, consultant of respiratory and critical care medicine at CGH.

Studies also show that asthma-related deaths in Singapore are about two to three times higher compared to countries like the United States and New Zealand, said Assoc Prof Koh.

Patients with poor asthma control are at risk of experiencing daily persistent symptoms that can affect activities such as work and school, impair lung function or cause an asthma attack, said Assoc Prof Koh. A severe attack can lead to death.

“In some cases, the patients do not die but suffer from permanent brain injury due to lack of oxygen supply to the brain and remain in a vegetative state forever,” she said.

Approximately 10 to 15 asthma patients are admitted to the ICU at SGH every year, and about one in 10 patients die as a result of a severe asthma attack, she said.

From 2010 to 2015, eight out of 82 patients admitted to CGH’s ICU for an asthma attack died as a result of asthma, said Dr Tay.

NOT CURABLE, BUT GOOD CONTROL POSSIBLE

To prevent serious asthma-related complications and deaths, experts said attitudes of patients and misconceptions of the disease must change.

Assoc Prof Koh said many patients tend to view asthma as an acute episodic illness rather than a chronic medical condition that requires long-term treatment and management.

“Patients tend to over-estimate their asthma control, leading them to be complacent with their asthma-controller use and doctor visits. Many patients stop using their asthma controllers when they feel well but asthma attacks can occur even if an individual has minimal daily symptoms,” said Dr Tay.

Patients may also be over-reliant on their relievers, said Dr Tay. While relievers (fast-acting medication) provide quick symptomatic relief, they do not improve long-term asthma control, she said.

While asthma is currently incurable, the majority of patients can achieve good control of the disease.

A patient is considered to have well-controlled asthma if he or she has not had any asthma attacks in the past year, has daytime symptoms fewer than twice a week, uses relievers fewer than twice a week, does not wake up at night due to asthma symptoms and does not have limitations of daily activities due to asthma, said Dr Tay.

Presently, the mainstay of asthma treatment is use of steroid inhalers, which are safe and effective, and help reduce inflammation in the lungs and reactivity in the airways, said Assoc Prof Koh. For more severe asthmatics, additional medications may be required.

There are also newer treatments including bronchial thermoplasty and medications called biologics for severe asthma, said Assoc Prof Koh.

Bronchial thermoplasty involves using thermal energy to heat up the smooth muscles in the airways through a probe. Carried out over three sessions, the treatment reduces reactivity of the smooth muscles, frequency of attacks and improves control of asthma in up to 80 per cent of patients who receive the treatment, said Assoc Prof Koh.

As long as patients take their prescribed asthma controllers daily using the right technique, avoid asthma triggers and stop smoking, it is definitely possible for patients to have zero asthma attacks and lead a normal life,” said Dr Tay.

Mr Tan changed his attitude towards asthma treatment after he survived a machinery-related accident in 2010 which left him with burn injuries, broken ribs and a punctured lung.

In 2015, he underwent bronchial thermoplasty, which helped reduce the frequency of his asthma attacks.

Currently on follow-up with Assoc Prof Koh, Mr Tan said he is lucky to be alive today. He no longer skips his medications and has learnt how to avoid his asthma triggers such as cold, sour and spicy food.

“I’ve heard of people who die from asthma. Don’t try your luck with asthma. Not everyone is as lucky as I am to be able to tell my story,” he said.

ASTHMA FIRST AID

Asthma patients require emergency care if they experience difficulty breathing, talking or walking despite using their relievers, said Dr Tay Tunn Ren of Changi General Hospital.

When suffering an asthma attack without a rescue inhaler on hand, here’s what to do, according to Associate Professor Mariko Koh from Singapore General Hospital:

1. Sit upright

2. Take long, deep breaths

3. Stay calm

4. Get away from the trigger

5. Take a hot caffeinated beverage

6. Seek emergency medical help