Did you know there are two types of asthma?

The following was originally published on healthcentral.com/asthma on 9/11/13

Two types of asthma:  Hobby and Hardnosed

Most people don't realize this, but there are two kinds of asthma. I have known this for years, but the medical community is just now coming to this realization, thanks to programs such as the Severe Asthma Research Program (SARP).  

The two types of asthma are as follows: 

• Normal or Typical asthma, or what I will refer to as Hobby Asthma. This type of asthma is easy to recognize and diagnose, and consists of about 90-95 percent of all asthmatics. Their asthma is easy to control with conventional asthma medicaitons. 
• Severe or Atypical asthma, or what I will refer to as Hardnosed asthma.  This type of asthma is difficult to recognize and diagnose, and consists of only 5-10 percent of asthmatics.  Their asthma is less responsive to conventional asthma medicaitons.  They are at increased risk of severe asthma attacks, and have a greater risk of dying from asthma.  

Now for a brief discussion of the two types of asthmatics:

Hobby Asthmatic 

This is your typical asthmatic.  They have a mild or moderate degree of chronic inflammation in their air passages, thus making their air passages hyperactive when exposed to their asthma triggers.  When this occurs, their air passages become increasingly narrow, and they get short of breath (what is called an acute asthma attack).  They may develop air flow limitation (prolonged expiration) during an attack, but generally have little air trapping, according to SARP. The airflow limitation that occurs generaly takes place in the larger air passages.  A gallant hobby asthmatic should be able to live a normal life. To them, asthma is just a hobby.  They generally only think about it when it's acting up, which should be rarely.

What is the treatment?  

Since the airflow limitation that takes place is generally in the larger air passages, it is easily reversed with conventional rescue medicine (like Albuterol) and preventative medicine (like Advair and Symbicort).  These medicines, when inhaled, easily reach the large air passages, and easily treat and prevent any inflammation and narrowing in that area of the lungs.

When using their medicine compliantly, they see a complete reversal of asthma symptoms.  When taking their asthma preventative medicines as prescribed, they should never (or rarely) require the use of their rescue medicine.  Or, as worded by many asthma guidelines, they should not require the use of asthma rescue medicine more frequently than 2-3 times in a two-week period. As Hobby Asthmatics become Gallant Asthmatics, they can gain complete, or almost complete, control of their asthma.  There still remains a lot to learn about Hobby Asthma, although physicians have had a lot of success controlling and preventing it with so-called conventional asthma medicines.  

When to seek help?

They should seek help when peak flow numbers start to decline, or when they notice that they are using their rescue medicine more than 2-3 times in a two week period.  Usually a quick trip to the doctor, followed by a short regime of systemic steroids, and their asthma quickly gets back on track. 

Hardnosed Asthmatic 

They have the same chronic inflammation as with typical asthma, although they may also have a certain degree of lung scarring in the deepest air passages, perhaps due to years of uncontrolled asthma.  This scarring (also referred to as airway remodeling) makes the tissue lining the air passages thicker, and the air passages chronically narrower.  

The result of this scarring that air gets past the scarring and cannot get back out, and this is called air trapping.  You can tell you have this when you feel as though you can never finish exhaling all the air out of your lungs even on a good asthma day. Generally, they typically have some air flow limitation (in the larger air passages) during an asthma exacerbation, and continue to have some air trapping (in the deeper air passages) even on a good day.  As a result of this air trapping, the use of conventional asthma medicine may not always result in complete reversal of asthma symptoms.

 

Even as Gallant Asthmatics, or even when their asthma is controlled, they may present with mild or moderate (sometimes severe) shortness of breath. So even when controlled, they may be seen using their rescue medicine several times during the course of the day.  Their asthma is generally persistent, intractable, and hardnosed. Unlike the Hobby Asthmatic, they have to think of their asthma every day.  

What is the treatment? 

As with Hobby Asthmatics, the general inflammatory component and airway narrowing of the large air passages caused by acute flare-ups can be controlled.  Overall, they generally use the same medicines as for typical asthma, such as asthma rescue inhalers (albuterol, levalbuterol) for acute asthma symptoms, and preventative medicine such as Advair and Symbicort to gain control (to prevent) this aspect of their asthma.

The SARP study showed that even after maximal treatment, these patients may continue to have some airway obstruction.  In other words, even after using their rescue medicine, they may still continue to be mildly or moderately short of breath. For this reason, they may require rescue medicine more than what would be considered normal for a Hobby Asthmatic.

For airway obstruction nonresponsive to typical asthma medicine, some patients may require more aggressive treatment using typical asthma treatment.  For example, higher doses of Advair (The 500/50 dose as compared with the 250/50 dose), or a trial of Qvar, which some studies show gets deeper into the lungs than other inhaled corticosteroids. Other medicines to trial may be Theophylline, Atrovent, Spiriva, Brovana, Combivent, Pulmicort, etc.  

The air trapping component (which generally occurs in the smaller air passages that are deeper along the bronchial tree) is more difficult to control, and may even be uncontrollable with the current medicines available.  I have heard that Spiriva might help with this, although studies are inconclusive.  If this condition results in moderate to severe shortness of breath, anti-anxiety medicines and maybe even opiates, like Morphine, may be required to take the edge off.  

So unlike treatment of Hobby Asthma, treatment for Hardnosed Asthma may tend to be more experimental at least at this time. One of the main reasons for this is because it has only recently been recognized.  And, because new evidence suggests severe asthma may be different than Hobby Asthma, some think it (severe asthma) should be a disease entity of its own.  If this is the case, a completely different asthma treatment plan may be necessary.

Hopefully, further studies will result in a better understanding of this type of asthma, whiich would result in better diagnosis and better treatment. 

When to seek help? 

They should seek help when peak flow numbers start to decline, or when they notice that they are using their rescue medicine more often than they usually do.  Generally speaking, these asthmatics should seek medical attention when they are no longer able to perform daily activities they are normally able to do, such as going for a walk, functioning at work, or playing catch with a child.  

Closing comments:  As I noted above, I knew there were two types of asthma my entire life. I just wasn't able to put my finger on the why my asthma was different. Now, thankfully, we have studies such as the one provided by SARP to prove it.  Also, I think that my good friend Stephen Gaudet explains it best what I want to say next: 

"I often find it frustrating that here I am, a life-long asthmatic, a Respiratory Therapist and an asthma educator, yet still unable, in normal conversation, to describe what makes my type of asthma so different from others."

Stephen refers to Hardnosed Asthma as Double Whammy Asthma, meaning that these asthmatics are hit with both the inflammatory component that may result in acute asthma symptoms and can be controlled, and the lung scarring component that leads to air trapping that cannot be controlled (other than trialing unconventional medicines as noted above). 

For many years I have had to explain to each new doctor: "My asthma isn't like other people's asthma."  If you ever have to say something like that, perhaps you have Hardnosed Asthma, as opposed to Hobby Asthma. The best way to learn more is to read the articles I used as references, and to talk to your doctor. 

Note:  For further explanation of the terms mentioned above, refer to the following articles for further reading: 

• What is good asthma control?
• Asthma severity versus control: what you need to know
• Journey down the respiratory tract
• Bronchoterms you should know

References:  

1. "Severe Asthma May Be a Different Form of Disease," Science News, Science Daily, http://www.sciencedaily.com/releases/2008/01/080129080656.htm, accessed 9/11/2013
2. Gaudet, Stephen, "Double Whammy Asthma," July 15, 2010, Breathinstephen.com, http://breathinstephen.com/double-whammy-asthma/, accessed 9/11/2013

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