Asthma is a chronic inflammatory disease of the airways that causes coughing, wheezing, chest tightness, and shortness of breath. For many people, asthma symptoms can be controlled with proper treatment and management. However, some people find that their asthma symptoms do not improve as expected, even with treatment. There are several potential reasons why asthma may not get better.
Inadequate treatment
One of the most common reasons that asthma does not improve is that it is not being treated properly or aggressively enough. Asthma treatment is centered around two main types of medications:
- Controllers: These are daily, long-term control medications taken to reduce airway inflammation and prevent asthma symptoms. They include inhaled corticosteroids, long-acting beta agonists (LABAs), leukotriene modifiers, and biologics.
- Relievers: These quick-relief bronchodilator medications are taken as needed to rapidly open the airways and relieve acute asthma symptoms. This includes short-acting beta agonists (SABAs) like albuterol.
Guidelines recommend that all people with persistent asthma should be on a daily controller medication, usually an inhaled corticosteroid. However, studies show that up to 70% of people with asthma do not take their controller medications regularly as prescribed. This leads to poorly controlled asthma. Even when controllers are taken regularly, the dose may be too low to properly manage the underlying inflammation. People may rely too heavily on their quick-relief inhalers, which only temporarily relieve symptoms without treating the root cause.
The best way to determine if your asthma treatment regimen needs adjustment is through your doctor, who can assess your level of control and adjust medications as needed. Getting lung function tested with spirometry is also important, as this can identify if airflow limitation is responding to treatment.
Unidentified or untreated comorbidities
Comorbidities refer to other medical conditions that coexist alongside asthma. Some common comorbidities that can negatively impact asthma control include:
- Allergic rhinitis (hay fever)
- Chronic sinusitis
- Gastroesophageal reflux disease (GERD)
- Obesity
- Obstructive sleep apnea
- Chronic stress/anxiety
The mechanisms by which these conditions affect asthma are not fully understood. However, research shows clear links between them. Treating comorbid conditions often improves asthma control. If comorbidities are left undiagnosed or untreated, asthma is unlikely to get better.
Environmental triggers
Ongoing exposure to asthma triggers in your environment can maintain chronic airway inflammation and prevent proper control. Common asthma triggers include:
- Allergens – pet dander, pollen, mold, dust mites
- Irritants – cigarette smoke, air pollution, chemicals/cleaning products
- Respiratory infections – colds, flu, sinus infections
- Cold air
- Exercise
- Stress/emotions
Identifying and limiting exposure to your personal asthma triggers can significantly improve control. This may include allergy testing, keeping pets out of the bedroom, using air filters and ventilating while cleaning/cooking, managing infections promptly, and using a scarf over the mouth in cold weather.
Incorrect inhaler technique
Using inhalers properly is critical for getting the full effects of asthma medications. Common mistakes that reduce medication delivery include:
- Not exhaling fully before inhaling the medication
- Inhaling too quickly or slowly
- Not holding breath long enough after inhaling
- Improper spacing between puffs
- Incorrect mouth positioning or angle
Ask your doctor to review your inhaler technique at least annually and demonstrate proper use. Use spacer devices when possible. Check the expiration dates on inhalers and properly clean devices. With the right technique, up to 4 times more medication can reach the lungs.
Medication side effects
Asthma medications, like any drug, have potential side effects. Some people may experience side effects like:
- Oral thrush from inhaled steroids
- Hoarse voice from inhaled steroids
- Tremors, heart racing from beta-agonists
- Paradoxical bronchospasm from beta-agonists
Side effects can lead to poor medication compliance. If you experience any worrisome side effects, talk to your doctor about adjusting treatment. Do not stop taking medications on your own.
Problematic inhaler devices
Using an inhaler device that is unsuitable for you can hinder asthma control. Considerations include:
- Cost: The expensive cost of inhalers leads many patients to underuse them.
- Availability: Insurance restrictions sometimes limit access to preferred inhalers.
- Dexterity: Devices like MDIs require good hand-breath coordination.
- Age: Young children may struggle with proper MDI technique.
Discuss affordable options with your doctor. Nebulizers or valved holding chambers may help overcome some limitations of standard inhalers.
Poor adherence
Taking controller medications daily and avoiding triggers requires dedication. Poor adherence is common and undermines asthma control. Barriers like cost, side effects, coming complexity, and forgetfulness all contribute. Open communication with your doctor is key. Consider tools like phone alerts or calendars to help remember medications and appointments. Ongoing education and support also improves adherence.
Severe or difficult-to-treat asthma
A small proportion of patients have severe asthma that remains uncontrolled despite optimal treatment. Reasons may include:
- Having asthma that is intrinsically less responsive to treatment due to different underlying biological mechanisms
- Airway remodeling changes like increased smooth muscle mass and mucus secretion
- Genetic differences affecting drug metabolism
See an asthma specialist (pulmonologist) if your symptoms remain uncontrolled despite adherence to maximal therapy. Emerging biologic drugs that target specific immune pathways may provide hope for some with severe asthma.
Masking of symptoms
Relying on quick-relief bronchodilators like albuterol to rapidly relieve symptoms as they arise can temporarily mask ongoing worsening of asthma control. People may feel fine in-between uses, leading them to underestimate their impairment. But frequent quick-relief medication use signals poorly controlled disease. Preventative anti-inflammatory therapy is needed to treat the underlying problem.
Misdiagnosis
Sometimes asthma-like symptoms are actually caused by another condition entirely. Vocal cord dysfunction, congestive heart failure, chronic obstructive pulmonary disease (COPD), and lung infections can all mimic asthma. Reevaluation of the diagnosis is warranted if treatment does not provide the expected benefits. This may require additional lung function tests and imaging.
Smoking
Smoking and secondhand smoke exposure can cause permanent lung damage that worsens breathing problems. Quitting smoking is a critical step for asthma control. The irritants in smoke heighten airway reactivity and reduce the effectiveness of corticosteroid medications.
Pregnancy
Hormonal changes during pregnancy can affect asthma in various ways. About one-third of pregnant women with asthma find their symptoms worsen. Exacerbations are also more common in the 6 months after delivery. Closely monitoring symptoms and adjusting medications under medical guidance is important during this time.
Stress and emotions
Asthma is closely tied to emotions and stress. Strong emotions like laughter, stress, grief, anxiety, and anger can trigger airway narrowing. Learning stress management techniques may help. Emotion-focused therapy and relaxation techniques like yoga and meditation have been shown to improve asthma control.
Hormonal changes
Shifts in hormones at different stages of life like puberty, menstruation, and menopause can affect asthma susceptibility and control in some people. This is likely related to the effect of hormones like estrogen on immune pathways involved in asthma.
Weight changes
Both obesity and being underweight are linked to poorer asthma control. Excess weight contributes to shortness of breath, airway inflammation, and insulin resistance. Losing weight through diet and exercise may improve asthma symptoms if you are obese.
Conclusion
Asthma is a variable condition, and periodic worsening of symptoms does not necessarily mean treatment is not working. However, if your asthma has persistently not improved for several months despite medication and avoiding triggers, it is important to work with your doctor to reassess your situation. There are often further steps that can be taken to achieve better control.
With a multifaceted approach that addresses all the potential factors involved – including proper medications, management of comorbidities, control of the environment, optimizing inhaler technique, improving adherence, and adjusting the treatment plan as needed – most people with asthma can achieve good symptom control and marked improvements in their quality of life.