Identifying patients at risk for fatal asthma
- J Mark Madison, MD
J Mark Madison, MD
- Professor of Medicine and Microbiology and Physiological Systems
- University of Massachusetts Medical School
- Richard S Irwin, MD
Richard S Irwin, MD
- Professor of Medicine
- University of Massachusetts Medical School
Assessing patient risk for a future fatal asthma exacerbation is important because many, if not most, asthma-related deaths are preventable if risk factors are recognized and addressed early .
Asthma is a prevalent disease and ranks 35th as a cause of death worldwide . Based on World Health Organization (WHO) data, age standardized death rates per 100,000 range from 33.9 in Zambia, 7.5 in India, 6.2 in Russia, 5 in South Korea, 1.3 in China, 1.1 in the United Kingdom, 1 in Germany, 0.9 in the United States, and 0.8 in France . After reaching a peak in the 1990s, asthma mortality in the United States, and many other countries, declined (figure 1), for reasons that are not clearly established . From 2001 to 2009, United States deaths due to asthma decreased from 15 deaths per million population to 10.5 deaths per million population . Among subjects with asthma, the rate of asthma deaths per 10,000 persons decreased from 2.1 per 10,000 persons in 2001 to 1.4 per 10,000 persons in 2009 . In 2013, there were 3630 deaths due to asthma in the United States for a rate of 1.1 per 100,000 population .
The epidemiology and risk factors for fatal asthma are reviewed here. The evaluation and management of severe asthma are discussed separately. (See "Evaluation of severe asthma in adolescents and adults" and "Treatment of severe asthma in adolescents and adults".)
Patients who have frequent and severe asthma symptoms and evidence of airflow limitation are at greatest risk; however, cluster analysis has identified significant patient heterogeneity . Fatal and near-fatal asthma exacerbations can occur sporadically and inexplicably in a minority of asthmatics whether the baseline level of disease activity is mild, moderate, or severe [7,8]. Therefore, any acute exacerbation of asthma may be a potentially fatal attack. (See "Management of acute exacerbations of asthma in adults".)
Group-based trajectory analysis has suggested three distinct clinical trajectories for patients with severe and/or difficult to control asthma . In this study, 58 percent of patients with asthma had infrequent severe exacerbations during five-year follow-up, 32 percent improved, having fewer exacerbations in subsequent years, and 10 percent had persistently frequent exacerbations. Near-fatal asthma events occurred in all three trajectories but were significantly more frequent for patients in the trajectory with persistently frequent exacerbations.
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