In honor of Asthma Awareness Month, Pulmonology Advisor spoke with David A. Hill, MD, chair of the Northeast Regional Board of the American Lung Association (ALA), and assistant clinical professor of medicine at the Yale University School of Medicine, to discuss diagnosis and treatment advances, the role of climate change in disease, and potential changes in clinical practice.
Editor’s Note: This interview has been edited for length and clarity.
Pulmonology Advisor: Where do we stand on asthma diagnosis and treatment? Where do we need to be?
Dr Hill: I think overall clinicians do a good job diagnosing asthma when they are suspicious of it, but it is still underdiagnosed. We have good current treatments for asthma, but it is not always being properly evaluated and diagnosed with spirometry. Patients often are treated for recurrent “bronchitis” several times before an asthma diagnosis is considered. We have come a long way, but asthma is a diagnosis that is still missed.
There are also issues with access to care; for example, patients may know they have the disease but cannot get care (no insurance, etc). In addition, even patients with good insurance may have high deductibles. There are also socioeconomic and ethnic disparities as well: African Americans often have worse asthma, as do Hispanics. Sometimes that is because of where they live (eg, pollution) or the lack of care. Another area we tend to overlook is occupational-related asthma. Workplace exposures can exacerbate the existing disease.
However, we are getting more aggressive about treating early. The latest GINA (Global Initiative for Asthma) guidelines recommend using inhaled corticosteroids in pretty much everyone with asthma, regardless of severity. We have not been able to see whether treating asthma more aggressively is preventing more severe disease.
Pulmonology Advisor: What are your thoughts on the new biologics?
Dr Hill: I have been in practice for about 25 years and we have made tremendous strides in terms of therapies. We are fortunate to have good medications to control the disease, especially in patients who can afford their care and are adherent. Steroids, inhaled corticosteroids, all of those drugs, the day-to-day therapy, have made this a disease we can have good control over. However, the other side of this is it still carries a huge burden for patients whose asthma is not well controlled. There is a lot of money spent in health care, and we are still not doing as good a job as we could. The biggest challenge in our healthcare system is that we have a lot of good medications for diseases, but we do not distribute the resources. It is one of the biggest contributing factors to physician burnout. We know how to treat our patients but we cannot get the care to them.
There have been breakthrough drugs for more severe asthma, which are very effective in patients who fit the right profile. We can now target to eosinophilic asthma. All of these medications are effective and over time, will most likely be cost-effective as well. Physicians do need to use clinical judgment when considering which medications to prescribe (eg, is it going to be worth it using those dollars, will there be copay issues?). But we have seen patients where these medications are life changing. They are no longer going to the emergency department, etc. We still see a lot of asthma cases in the hospital, but not nearly as much as we used to see. Now, if a patient with asthma ends up in the hospital, it is most likely because they were not taking medications or they are still smoking.
Regarding smoking cessation, yes, it has to be part of the conversation in any lung disease. In my own practice, I make it a priority to talk to them about it. The ALA has a lot of resources and training available. Providers have to take the time to set up patients to succeed. I will bring a patient back just to talk to them about smoking cessation.
Pulmonology Advisor: How can we address the effect of climate change on asthma? As the ALA just recently reported, “More than 2.5 million children and more than 9.7 million adults with asthma live in counties of the United States that received an F for at least one pollutant. More than 306,000 children and more than 1.2 million adults with asthma live in counties failing all 3 tests.”
Dr Hill: We have the perfect storm of power plants and high traffic corridor in the northeast United States, and climate change is the perfect storm of all this. This is the 20th year of the ALA report. The Clean Air Act was really helpful in reducing power plant waste, etc, but it did not help with certain other types of pollution (eg, particle pollution, which includes pollen, dust, and fires).
The hotter it is, the more ozone or smog there is. The days in the summer when they tell you to stay inside refer to this type of pollution. That is an example of a short-term danger. Longer-term exposure leads to worse disease.
Last year’s California wildfires were not even included in this report. The smoke was all over the West Coast and really all over the country. We will be talking about these fires in pulmonary medicine for decades. This year in North Carolina they were talking about “pollmageddon” — literally yellow smog. Plants are producing more pollen because of the growth patterns.
To me, climate change is a public health issue. That is how we have to look at it. Lung disease is really going to be affected. There are more days reported when it is dangerous to be outside even as a healthy person (ie, no lung disease). There are good air quality monitoring systems in parts of the country but not everywhere. People just need to be aware.
Based on epidemiologic studies, there will be an increase in asthma and allergies in healthy people. And based on what we are experiencing in the United States right now, we are taking scientists out of the equation, so therefore, we are going to increase those negative effects.
Pulmonology Advisor: How do you think this will change clinical practice?
Dr Hill: I think what we see now, in our electronic health records, one of the things we have built into the system is how heat and humidity affect your disease (mainly asthma and COPD). Patients recognize that they are being triggered. Patients with more severe disease will generally stay inside if they can, but they go stir crazy. The knowledge of the general public is increasing and as is that of clinicians. I think the diagnosis may not change but the prevalence may. Clinicians are starting to talk about traffic density, being more aware of where our patients live. There is always local variation, being aware of an individual patient’s situation.
Pulmonology Advisor: How are screening practices currently different between clinicians who treat in more urban/more densely populated areas vs nonpolluted areas?
Dr Hill: I think populations may be somewhat different in terms of what they are exposed to and we should recognize what triggers our patients (eg, cockroach vs farm exposures or hay), but mold and other pollutants are everywhere. And even some of our rural populations have high levels of air pollution. The air quality in ranching communities where prescribed burns have taken place, for example, has changed, and downwind of that, rural communities are feeling that. Anchorage, Alaska, for example, did not do well in the ALA report.
Pulmonology Advisor: Are doctors being adequately trained to care for patients in those areas with high pollution and/or exposure to certain allergens?
Dr Hill: There is definitely a growing awareness of air pollution and climate change and lung disease links. There are more review articles and position papers by prominent organizations (CHEST, ATS, etc) being published. It is an emerging area that people are becoming aware of. The connection is not being made as clearly as it could be, and making that connection is very important.
I honestly think if we are going to address this as a society, healthcare providers are going to be major players in making the public and the legislature aware of the cost of all of this. We need to help guide our patients, help guide society as to what we can do. The more we can do that, the better off we will be in the future. There are currently no guidelines tailored to clinical care with pollution exposure, but there may be down the road.