Thunderstorm asthma: What can GPs do to help patients?

Neelima Choahan

26/06/2018 4:37:46 PM

Ten people died in the epidemic thunderstorm asthma event in Melbourne in 2016. What can GPs do to help their patients if such an event occurs again?

Ten people died in the epidemic thunderstorm asthma event in Melbourne in 2016.
Ten people died in the epidemic thunderstorm asthma event in Melbourne in 2016.

Most, if not all, of the people who died in the 2016 Melbourne thunderstorm asthma event could have survived if they had received timely treatment, a researcher says.
According to the Victorian Government, Melbourne experienced the world’s largest epidemic thunderstorm asthma event on 21 November 2016, with thousands of people developing breathing difficulties in a very short period of time and 10 people dying.
Research published in The Lancet Planetary Health shows more than 70% of the patients in the Melbourne epidemic had untreated airway hyper-responsiveness: previous asthma with no symptoms in the past year; asthma-like symptoms not diagnosed; or seasonal allergic rhinitis with no asthma symptoms.
Many of the individuals with current asthma seemed to have been undertreated.
Epidemic thunderstorm asthma is thought to be triggered by a unique combination of high pollen levels and a certain type of thunderstorm, causing a large number of people to develop asthma symptoms over a short period of time.
Grass pollen grains get swept up in the wind and carried for long distances; some can burst open and release tiny particles that are concentrated in the wind gusts that come just before a thunderstorm. These particles are small enough to be breathed deep into the lungs and can trigger asthma symptoms, making it difficult to breathe.
This can become very severe, very quickly and many people may require medical help at the same time.
According to the Victorian Government, the peak demand for ambulances occurred during the 15 minutes from 7.00 –7.15 pm, during which the state’s emergency call answering service, ESTA, answered 201 emergency calls.
Ambulance Victoria had 2036 cases on the day of the event, with 1268 of these those being the highest priority. On 21 and 22 November 2016, 9909 people presented at public hospital emergency departments in metropolitan Melbourne and Geelong. Of these, 3270 were additional presentations compared to the previous week.
There were also 231 additional presentations at private hospitals.
The research in The Lancet Planetary Health shows the affected were not the very young or old, but those aged 20–59. The reason for this could include the fact that individuals of this age might be more likely to be outdoors, and potentially more active. Both of these factors would increase allergen load.
There was also a high prevalence of Asian or Indian ethnicity among the patients, including six of the ten deaths.
The research also points to issues around treatment and adherence.
‘Although most patients did not have doctor-diagnosed asthma, 100% of the 35 critically ill patients admitted to an ICU had a previous diagnosis of asthma, 66% of whom were not using inhaled corticosteroids,’ the research stated.
The study noted that based on history, thunderstorm asthma is likely to recur particularly in Melbourne, but communication and education of patients, physicians, and emergency healthcare services can help mitigate the severity. 
‘Early warning based on environmental factors – mainly pollen levels and meteorology, can alert emergency health services as well as direct at-risk individuals to remain indoors with windows shut, a practice which seems to reduce exposure,’ the research stated.
‘The major emphasis, however, should be directed to medical management of individuals at-risk. Since all fatal and life-threatening asthma occurred in individuals who currently had asthma, most of whom were not using inhaled corticosteroids, the need for enhanced treatment and treatment adherence in this group must be emphasised.
‘Identification and treatment of any asthma in patients with allergic rhinitis patients who have respiratory symptoms should prove beneficial.’
National Asthma Council Australia Chairman Dr Jonathan Burdon said GPs should ensure patients with asthma are reviewed at least annually.
‘They should have a written action plan so if your asthma is getting worse it is already written down what you do,’ Dr Burdon told newsGP.
‘Those patients who are prescribed preventive medication, that is medication they should take every day whether they feel they have got asthma or not, should be encouraged to take it every day.’
Dr Burdon said there was an over representation of people who weren’t taking their medication regularly among the people who presented and were admitted to hospital during the thunderstorm asthma event.
‘When the asthma is getting worse they should consult their action plan, and if the action plan is not working they should seek medical consultation promptly,’ Dr Burdon said.
‘That means, call an ambulance, go see a doctor, go to an emergency department.
‘And the reminder that 455 people died from asthma in 2016 in Australia. We know from studies in the past that most deaths and most admissions to hospitals are preventable.’
A coronial investigation into the thunderstorm asthma event is currently underway. It will focus on identifying systemic issues, if there are any, and will seek to identify avenues through which similar deaths may be prevented in the future.

allergens corticosteroids emergency health services The Lancet thunderstorm asthma

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