Reducing the ‘Twitch’

Orlando remains among nation’s most challenging places to live for asthmatics

ORLANDO – In the Asthma & Allergy Foundation of America’s list of “2014 Asthma Capitals,” Orlando ranked No. 49, having slipped 13 spots from the previous year’s ranking of No. 62, and has consistently bounced around the 100 Most Challenging Places to Live with Asthma since the annual studies began in 2004.

However, the ranking may not be as dismal as it seems. This year, only tenths of a point separated Orlando from nearly a dozen major cities hovering around its total score of 74.08, calculated as a composite of all factors’ relative impact on exposure to asthma triggers, quality of life, costs and access to care. By comparison, Tampa ranks No. 50, with a total score of 73.49.

Worse than average in Orlando: the uninsured rate, and all four medical factors, including ER visits for asthma, use of quick relief meds and control meds, and number of specialists. The metro area ranked average in self-reported asthma prevalence, public smoke-free laws, and poverty rate; and posted better than average results on estimated asthma prevalence, crude death rate, annual pollen score, air quality, and school inhaler access laws.

Medical News spoke with Jason E. Lang, MD, a Harvard fellowship-trained pediatric pulmonologist and biomedical researcher specializing in asthma at Nemours Children’s Health System in Orlando. Diagnosed with asthma as a child yet symptom-free for decades, Lang, 42, also associate professor of pediatrics at the University of Central Florida, discussed local trends, challenges, and promising clinical trials that could improve the quality of life for asthmatics.

Why is the local asthma prevalence rate rising so rapidly?

Asthma is incredibly prevalent wherever you go. Central Florida is one of those places a little higher in prevalence. It’s been slowly creeping up over the last three or four decades and now it’s a common disease. It’s not completely understood what’s causing asthma, though we’re testing a couple of theories, such as the parallel between the rise in obesity and asthma prevalence.

Another theme: We still don’t have effective treatments in many cases. There’s a real need for hospitals and medical centers to research the best treatments and to come up with new treatments that’ll work better.

Why is the rate for emergency room visits for asthma rising dramatically, and what needs to be done to lessen the frequency of those visits?

ER visits for asthma are incredibly common. Asthma is, year-in and year-out, one of the most common reasons for visits to the Emergency Department. That’s a reflection of how prevalent asthma is, and how serious it can get.

One area of improvement needed: Access for families to good quality primary care. We have many cases in the ER that could be prevented or seen by a primary care provider. Nemours is growing a high quality primary care network around Orlando to prevent asthma attacks and to manage them in the outpatient setting to avoid the ER.

Education is another area for improvement. In just five years since it was established, the Florida Asthma Program has done a great job of educating child care providers and school administrators on the disease. But it’s only a start. Understanding asthma can be really confusing to parents, and requires a lot of education. If families don’t have that education, it’s easy to want to resort to the ER, a place where they know they’ll get immediate, great care.

Overall as a health system, we need to provide better education about asthma to everyone in the community so that asthma can be diagnosed and managed by pediatricians and general practitioners. Also of note: It’s my impression that asthmatics whose primary care doctors are in a practice based on the Patient-Centered Medical Home (PCMH) model – a model we’ve adopted at Nemours – are less frequent visitors to the ER.

Even with improved education and improved access to primary care, what challenges persist managing asthma?

For more than 20 years, the National Institutes of Health has had a set of guidelines for diagnosing and managing asthma. Nemours is constantly trying to reinforce those guidelines to local primary care doctors, school nurses, and others in the community who touch people with asthma. I cannot underscore enough the importance of good primary care.

That said, many cases don’t have the best treatments. I just saw a little boy with asthma, and the medication recommended in the national guidelines hasn’t worked very well for him. We need to continue a real push to find better treatments.

With Nemours’ participation in various clinical trials aimed to produce better outcomes, which ones hold the most promise for the discovery of pivotal data?

We have an ongoing clinical trial involving children and young adults that looks at the role of omega-3 fatty acids in the development of asthma. We think it’s a nutritional component in the diet that may be too low, which may lead to severe asthma in children who are overweight or obese. (See sidebar on clinical trials.)

Another interesting study focuses on how exercise impacts asthmatics. My theory is that exercise helps asthma medicines work better and makes airways less twitchy. That’s one of the parts of asthma that patients don’t like: twitchy airways. Especially in children, I think exercise really reduces it.

We’re always looking to offer people in the community an opportunity to participate in these studies. They often help tremendously.

Improving Asthma Outcomes via Clinical Trials

Nemours’ collaboration with hospitals and medical centers nationwide on clinical trials at its Orlando and Jacksonville sites include:

Best African American Response to Asthma Drugs (BARD)

Obesity and Asthma: Genetics and Nutrigenetic Response to Omega-3 Fatty Acids

Step Down Study/Use of Mobile Devices & the Internet to Streamline an Asthma Clinical Trial

Step-Up Yellow Zone Inhaled Corticosteroids to Prevent Exacerbations (STICS)

Steroids in Eosinophil Negative Asthma (SIENA)

Therapy for Asthma in Toddlers and Acetaminophen vs. Ibuprofen in Children With Asthma

Asthma Walk Study: Effect of low-impact walking on bronchial reactivity and steroid sensitivity in sedentary adolescents with inadequately controlled asthma

Vitamin D-related Oral Steroid Responses in Children with Asthma

SOURCE: Nemours Children’s Health System.