In my research of the history of asthma I have come across a very interesting phenomenon, or a conundrum perhaps. It is that asthma was never considered a fatal disease before the 1900s. Why is that?
The authors of "Fatal Asthma" ask it this way: "If the under treatment of asthma is invoked as an important cause of fatal asthma, then we must explain why people are dying from asthma now, when deaths from the ailment were negligible in the past."
You'd think with all the modern asthma wisdom and all the new medicines on the market today that there would be fewer asthma related deaths and not more.
Some have proposed that pollution may be the cause, but many scientists rule this out because prior to the 1900s air was polluted by coal and wood burning stoves, horses roamed the streets leaving their droppings, streets were of sand that caused dust, people did not shower daily and were often breeding grounds for diseases that triggered asthma. Plus people smoked frequently in public buildings and homes.
All of those obstacles to clean air have been removed. Yet, "Still there is genuine concern about newer sources of pollution, because the asthma rates have been rising in some American cities during the same period as pollution legislation has led to cleaner air. And this remains a possibility.
Another possibility, or theory, is that asthma did not become a fatal disease until 1903 when epinephrine (adrenaline) was first used in hospitals to treat asthma. One doctor observed that it's "possible that mortality from asthma first appeared when adrenaline became available... The pattern of events of no adrenaline, no deaths; some adrenaline, some deaths..."
The conundrum of doing such research, however, is that there is no research of untreated asthma. For the most part, if a doctor has a patient who is suffering with asthma the patient is going to be treated.
However, it wasn't until after "isoprenaline was introduced in a nebulizer formulation during the 1940s when mortality began to increase..."
In the 1960s "asthma mortality increased dramatically." Scientists evaluating the data determined the cause was "due to new methods of treatment. Interest focused initially on the possible role of pressurized metered-dosed-beta-agonsit aerosols, which had been introduced in the early 1960s."
In the 1970s there was a significant jump in New Zealand, and this was associated with a long acting beta agonist fenoterol that patients were allowed to use at home. When some patients were having trouble breathing, they'd often use it more than prescribed. This medicine, like epinepherine and isoprenaline, can have fatal cardiac effects if used in too high of doses.
The debate of whether asthma related deaths were caused by the routine use of these early beta agonists, or if it was that these meds were abused by asthmatics during periods of life threatening asthma "in which the cardiac side effects are likely to be particularly harmful in the presence of severe hypoxia."
However, unlike Albuterol, both of these classic asthma rescue medicines were not selective to the lungs only. They had an equal effect on the heart. When warnings were given out of the adverse side effects of overusing these medicines, the death rate dropped.
Another theory of why there are more fatal asthma episodes now is that asthma was under diagnosed, which may also be the reasoning for the trend the number of asthma cases nearly doubling between 1985 and 2009.
However many scientists have ruled this out. Still it's a theory worth considering.
I would guess the increased incidence of fatal asthma would be due to a combination of all three theories mentioned above, but I would lean toward the theory of modern medicine overuse as the one that makes the most sense to me.
I haven't seen trends after 1998, but I do know that many recent fatal asthma episodes have been linked to Symbicort and Advair, or the long acting bronchodilator within these meds. As was the case with fenoterol in New Zealand in the 1970s, scientists aren't sure if it is the drug itself that is causing fatal asthma, or that the drug is being used as a rescue inhaler for life threatening asthma.
The FDA has recently advised doctors that modern long acting bronchodilators such as those included in Symbicort and Advair (Serevent and Formoterol) are safe and that the benefits far outweigh the risks in managing asthma. Which makes one think the FDA believes abuse of these medicines is the reason for the recent spike in Fatal Asthma.
And, like in the 1970s, I believe, as the word gets out that Symbicort and Advair can have fatal consequences if not used exactly as prescribed, the asthma death rate will again go down once again.
No one knows for certain why episodes of fatal asthma have increased since 1900, and particularly since 1940, but most of the trends point toward the same meds doctors prescribe to treat acute and chronic asthma.