Dr EV Rapiti

I7 Cindercllrr CrescentEast RiclgeMitchcll's Plain7764

Curriculum vitaeDr Rapiti studied in India (Bombav) u.'here heobtained a BSc(Hons) in 1972 and a MBBS,Gri'alior in 1977.l{e came to the RSA rvhe rche h;rs obtained the MIGP (1987) and DCH(1990). Afier internship in McCords Hospitaland 3 vears in Livingstone Hospit:rl (PE) hehas bee n ir-r General Practice in Mitchells Pl:rinsince 1983. Dr Rapiti is ex-Chairman ofNAMDA (Western Cape Brar-rch), Chairmirnand fbunding member of the DispensingFamilv Practitioners Association and sen'es onthc c.xecutive board ot NGPG. His inte rcstshave alu'ays bcen in communitl'rvork,stimulated b1'u'orking in rural health careclinics in India. He is interested in expandingthe ro lc of the Gl and has rvr i t ten nranvanic les. mainly championing rhe r ighrs ofdoctors to dispense.

Asthma: More than a Tight ChestDr EV Rapiti

Suw'r.runryThet"e is a challenge to nery GP toa.ctillely d.stect the nca.ny und.erd.ia.gn0sed.and und.il'lraq.ted asthtuatics in ourczuntry, to d.estroy the ruany barrnfwlrnyths which still exist in the cotnwunitya.nd. t0 ,na.ke use 0f the trernend.owsscienffic ad.vancencent in tbewnd.erstand.ing and. ncanag etnen t ofa.sthwta.. This will helo tbei.r nsthru.aticpatients to enjoy e ttfestyle botb nt worknnd. at play, whicb is no d.ffirent froruthe non-asthtnatic.

S Afr Fatn Pract 1990; 11: 505-10

I(EYWORDS:Asthma; DiagnosticD-g Therapy.

errors;

Introduction

The word '4stbwa. from its very earlydcscription ti l l today conjurcs upimases in the minds of thc afflictcdof bcing physically cripplcd. In thcminds of the lav public asthmaticswere and still aribranded as pcoplewith a severe debilitating disease r'vhoat all times need sympathy.

In the minds of niany doctors,asthma means an audible wheezeheard with a stethescope.

In spite of tremendous scientificadvincement in the undcrstandinsand management of asthma, the Jdand outdated concepts still persist. Ifthese old conceDts are not rootedout, asthma *ould continue toremain a grossly under-diagnosedconoltlon.

Other less recognisedsymptoms of asthma

Cough must be one of the most-common presentrng symptom otasthma. Unfortunately the diagnosisof asthma is missed because cough isoften unaccompanied by a wheezc.The cough of asthma usually comeson at night, at dawn, after mildphysical exertion, during a change inseason or weather, after contact withan allergen like dust or after a Viralbronchitis.

\A4reezing is not a commonaccompanying feature because theairways are not narrowed downsufficiently to produce the wheezingsound of asthma.

Mucosal oedema would be the mostplausable explanation for theirritating cough of asthma.

Cowgh should also be regarded as thelungs' cry for air, to treat the coughand not the cause is like switching offthe warning signals instead ofrepairing the fault that triggered offthe warning signal in the first place.

IJnwanted side -effects / moneywasted

Failure to recognise cough as animportant symptom of asthma hasrcsulted in many asthmatics receivingcountless nurnber of antibiotics,sedating antihistamines, coughmixtllres, apart from the numerousfruitless investigations like FBC's,ESRS', Chest X-rays, Sputa Analysis

Floarse Voice

Many patients with undiagnosedasthma awake, particularly on wintermornings, with a hoarse voice which

505 SA Familv Practice Octobcr 1990 SA Huisartspraktyk Oktober 1990

clears as the morning temperaturerlses.

There are two explanations for thishoarse voice. One is the fall in theearly morning peak flow caused bythe cold air, and the other is theswelling of the laryngeal mucosa inresponse to the cold air.

This irnpottant syruptom is oftenmissed by the unsuspecting doctorbecause the patients regard this as

!\rheezing is not a commonaccompanying feature

normal for them and never mention itwhen consulting a doctor. Further, bythe time most patients consult theirdoctors, their voices would havereturned to normal.

In normal consulting hours the firstchange that may be noticed in apatient with a hoarse voice, who isgiven a puff of a bronchodilator,would be an increase in the tonalquality of the patient's voice, that is ifthe patient does not suffer fromlaryngitis or has a laryngeal pol)?.When this is noted, asthma should bestrongly suspected and investigatedtor.

Shortness of breath

This alarmingly common symptom ofasthma is often ascribed to causes likeold age, overwork, work stress,depression, lack ofexercise, lack ofvitamins or iron. While many of theseconditions can explain a patient's easyfatigability, it is imperative that theattending doctor includes asthma inthe differential diagnosi s.

.. Asthma

Exercised induced asthmatics must bethe single large pool of asthmaticsthat are missed by primary carephysicians because they rarely presentto the doctor with the now outdated"classical" symptoms like audiblewheeze, bronchospasms andintercostal recession.

Inadvertently many of these patientsare given tonics and appetitestimulants when many of themshould really be on a diet.

Student grades drop inWinter,/Spring

When asked about it, many parentswould give a history that their child'sgrades fell considerably during thewinter term and that the teachercomplained that the child lacked inconcentration or had become veryfidgety. The child on the other handmight state he,/she felt very sleepy inclass in spite of having gone to bedquite early at night.

An unsuspecting doctor might labelthe child as having a psychologicalproblem and refer the child to apsychologist for an opinion.

Failure to recognise cough asan lmportant symptom otasthma, has resulted innumerous fruitlessinvestigations and antibiotics

The problem could easily beexplained on the basis of nocturnalasthma. At night the peak flow woulddip to quite low levels, unbeknown tothe child who is asleeo at the time.Other members of thi family might

506 SA Familv Practice October 1990 SA Huisansprakwk Oktober 1990

mention hearing the child cough atrugnt.

These two factors (low night peakflow and cough) are responsible for ahighly disturbed sleep pattern. Anactive search for asthma and its

A hoarse voice, especially in themorning, should beinvestigated for asthma

appropriate treafinent would be amost rewarding exercise to bothdoctor and his patient.

IJnderuse of the peak flowmeter

In terms of screening the peak flowmeter must be one of the simplesttests available to yield such usefulresults, yet sadly, is seldom used bythe primary care-physician whenexaminations of the chest are carriedout. The moderate and mildasthmatics would almost never bediagnosed using a stethescopebecause, as was mentioned earlier, theairwavs in these Datients are notnarrowed down iufficiently toproduce a wheezy sound.

A peak flow meter wouldimmedrately pick up these categoriesof asthmatics. It would often befound that many of these patientswith a clear chest would blow 2570 to50%o less than the expected for theirheights.

One or two puffs of a bronchodilatorwould conclude the diagnosis ofasthma if the deficit in oeak flow iscorrected.

I must hasten to add thar notinfrequently clinical improvementdoes not correlate well with the peakflows. The lnessa,ge tberefore is not toneat peah Jhws bwt to treat tbe paticnt.The peak flow should merely be usedas a guroe.

Medical Students,/Peak FlowMeters

The only way to increase the pickuprate of asthma would be to eive asmuch importance to the peik flowmeter as is given to the stethescope

The peak flow meter totallyundemsed by GPs

where examination of the chest isconcerned. No examination of thechest should be considered completewithout a peak flow reading.

Myths that need to bedestroyedl. Astbruatics are sich people who can d.ie

a,t a,ny tifiLe

This is absolutely untm.e. Asthmaticsare merely people with a breathingproblem that can easily be controlledwith medications. It is only a verysmall minority that need intensivetherapy. The majority requireintermittent spasmodic treatment.

Most importantly, virnrally allasthmatics can enjoy the same activelifestyle as non-asthmatics providedthat their asthma is properlycontrolled.

2. The purnp is d.angerows

The moment patients are told that

. . . Asthma

they have asthma and that they needto go on a pump, the news is receivedwith utter shock. They would do theirutmost to refuse the pump because ofan unfounded side-effect namelv-"weakens the heartt'.

This m1"th about the pump stillpersists in the minds of patients inspite of the well-known fact that noside-effects have been reported fromthe use of bronchodilators in theirproper dosage.

Patients would request tablets andsuffer their side effects rather thanuse the relatively harmless pumpbecause of the unfounded stismaattached to it.

The pump is the quickest, cheapestand safest bronchodilator that noasthmatic should be without.

This message has to be firmly driveninto the minds of patients, the laypublic and the primary care physician.

3. Towch of astbrna

Here, responsibility for thisillconceived concept lies squarely onthe shoulders ofthe patient's generalpractitioner. Doctors seem to believe

No examination of the chesrshould be considered completewithout a peak flow reading

that they are reassuring their patientswhen they use the phrase "touch ofasthma." All this merely does is toprevent patients accepting the factthat they have asthma. Patients feelmuch happier to be told that theyhave bronchitis and consume bottles

507 SA Family Practice October 1990

of "red medicine" (Theophylline) andall the alcohol that goes with it.

Patients should be told the rvDe ofasthma they have. Any one ofthefollowing types ( i ntermittent,nocturnal, seasonal, exertional,perennial) should cover the widespectmm of asthmatics.

4. Owtgrow a,stbnta. in later life

Doctors tend to please parents bymaking such a statement. The dangerof such a statement is only realised

GPs should tell their patientswhich type of asthma they haveand help them to accept thetact

when a patient in his twenties is toldthat he has mild or moderate asthma.The patient would refuse to acceprthat he has asthma because he wastold that he would outsrow hisasthma.

5. Pati.ents ase the purnp only whennecessotry

This is dangerous advice becausepatients would only use the pumpwhen their wheeze is audible. By thetime the wheezing is heard, thebronchospasm is quite far advancedrequiring more than just a puff.Sometimes it could meanhospitalisation.

Patients should be taught torecognise early warning symptomslike shortness of breath after mildphysical exertion and use their pumpsimmediately.

SA Huisansprakwk Oktober 1990

Treating more than a tightche st

The common error made bv mostfamily doctors is to end trcitmentwhen the bronchospasm is relieved.The other aspects like the patient'scualiw of life and that of theasthmatics family for some strangereason are seldom addressed by theattending physician.

Quality of life will depend on the ageof the asthmatic.

.. Asthma

In a child it could mean reducedphysical activity or missing out onexcrtlng sportlng actlvrtles

The pump is the quickest andsafest bronchodilator: noasthmatic should be without it !

like athletics, condemning the childto the inactive role ofthe sDectator orbystander. Manv of thes. .hildr.n

tend to become hear,y eaters out ofshecr boredom, which in turnentrenches them to the unenviablegroup of social misfits. They grow upwith the line "I was never a ereat onefor sports."

On an academic level the lack ofproper sleep especially in winter dueto undiagnosed nocturnal asthma,leads to a drop in academicachievement. This rn'ould mean agreat dcal to any student intcnt ongood grades.

r , ' , ' , t .i;..:..'i:l: -::::: '"

' , - ' PUT ASTHMATO

action on bronchial smooth

VENTEZEhFLIGHT... UNLEASH

LETS YOURASTHMATIC PATIENT

BREATHE EASIER.The inhaler offers quick action lor rapidrelief of bronchospasm.Microgram dosage of inhaler allows fordirect action on bronchial smoothmuscle reducing the risk of skeletalmusde tremor.

b'receptors redwes the risk ofrscular stirrrula$on at

Proper control of such a child'sasthma would make a tremendousdifference to the child's sporting andacademic achievements and thatchild's future prospects in life.

Adults in the prime of their workinglife need to be frt and energetic toperform well in their workingenvironment. People involved inhear.y physical work who suffer fromundiagnosed exertional asthma wouldnot be able to oerform as well as theirfellow workers. There Datients areoften criticised as being lazy and of

. . . Asthma

shirking, consequently affecting theirwork references for future iobs.

"A touch of Asthma" is thewrong message

For the mentally strained executive oroffice worker, having undiagnosedexertional asthma means missine outon the much nceded social conrictswith colleagues who play the regulargame of squash or tennis.

Sex life in many of these patients isalmost non-existent. The usual excuseis "I am too tired". The damage thiscan do to many couple's married lifeis well known to all familypractitioners.

Conclusion

Thc challenge to every primary carephysician for the nineties should beto actively detect the "under-diagnosed and undertreatedasthmatic" and to instirure

.. Asthma

appropriate treatment that would notonly alleviate the wheeze but enablethese patients to enjoy a lifestyle both

Cough is the lungs' cry for air- to stop it does not reallytouch the basic problem

at work and at plav that is nodifferent from ihe' non-asthmatics.

With the current advances in the

management of asthma, I stronglybelieve that most asthmatics could beeasily managed by the primary-carephysician. Too much time and moneyis wasted by these patients attendingtertiary referral centres.

The challenge is there. It's up to us totake it.

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HikerLabopitorles Atrica (Pty) Lrd.Reg. No. 52tO1640 07, . " v 1 ' " .

t: l i l l ini:, ., ' r Barbaia Road, Elandsfontein, Transvaal.

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