Severe Asthma Attacks

Causes of a bad asthma attack

Close-up of a woman using inhaler
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Patients are frequently referred to me with severe asthma that is difficult to control despite numerous asthma medications. Asthma medications are so effective nowadays that when patients have uncontrolled asthma even though they are taking multiple asthma controllers, there is reason for concern. The following are the most common reasons that I find why patients have difficult-to-control asthma. Of course, the major concern for difficult-to-control asthma is that a person actually has asthma to begin with.

Common diseases that can lead to symptoms similar to asthma, such as chronic bronchitis, emphysema, bronchiectasis, idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, and congestive heart failure, need to be considered in people with difficult-to-control asthma. Therefore, asthma should be proven with lung testing such as spirometry, especially severe asthma that is not responding to therapy.

Not Using Medications Correctly

This is probably the most common reason why asthma is difficult to control. Asthma controller medications are so effective, that when I see a person’s asthma not controlled despite taking 2 or 3 asthma controllers, I suspect that the patient is not using their medications correctly, or not using them at all. Remember, physicians can only diagnose a medical condition such as asthma, make recommendations for treatment, and discuss the risks and benefits of taking the medications versus not taking the medications.

The decision to actually take the medication is up to the patient.

Make sure that you’re using asthma inhalers correctly.

Uncontrolled Allergies and Chronic Sinusitis

Since inflammation in the upper respiratory tract, such as with allergic rhinitis and chronic sinusitis, affects asthma, it is common for patients with uncontrolled allergies and sinus infections to have uncontrolled asthma.

Many of these patients may not even be aware of allergies or chronic sinus infections, so trials of allergy medications, such as nasal steroid sprays, are a good idea. As part of my evaluation for difficult-to-control asthmatics, I typically check x-rays of the sinuses to rule out a chronic sinus infection.

Gastroesophageal Reflux Disease (GERD)

GERD can be associated with uncontrolled asthma since acid from the stomach can be inhaled into the lungs and lead to increased asthma symptoms. Symptoms of GERD, such as burping, acid taste in the mouth, and a rising sensation in the chest, may not always be present. Therefore, for patients with uncontrolled asthma, a therapy with GERD medications should be considered. Structural abnormalities, such as hiatal hernias and tracheoesophageal fistulas, can essentially lead to GERD refractory to medical therapies.

Vocal Cord Dysfunction

Sometimes, uncontrolled asthma isn’t asthma at all, which is why asthma medications don’t work for some people. Vocal cord dysfunction (VCD) is a medical condition that mimics asthma but is caused by the vocal cords closing over the airway, leading to shortness of breath and wheezing-like sounds. While VCD is not a life-threatening disease, anyone (including physicians who know what’s actually happening) who sees a patient with VCD would think that the person is suffocating.

The consideration for VCD should be made in any patient with uncontrolled asthma. The diagnosis can sometimes be made with spirometry but is best detected with direct visualization of the vocal cords using nasal endoscopy.

Other Diseases

Less common diseases to be considered when a person has uncontrolled asthma include allergic bronchopulmonary aspergillosis, Churg-Strauss syndrome, primary immunodeficiencies, and cystic fibrosis in children.

An allergist can help determine what's making your asthma difficult to control.

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