For those of us providing pre-travel care, seeing patients with asthma isn’t anything new. Checking to make certain travelers’ influenza and Tdap vaccines are current is especially important since respiratory infections often exacerbate asthma symptoms.
Patients with asthma have an increased risk of invasive pneumococcal disease (IPD), but sadly many have not been vaccinated. While the Advisory Board on Immunization Practices (ACIP) recommended in 2008 that all adults ages 19-64 who smoke or have asthma receive one dose of pneumococcal polysaccharide vaccine (PPSV23) (MMWR, 2010), far too many primary care providers are unaware of this recommendation. In my own practice, the majority of patients with asthma know they should get a flu shot but are quite taken aback when I mention Pneumovax,™ because they’ve never heard of pneumococcal disease or this vaccine.
Another problem is a significant lack of understanding of the illness. Many patients will say “they grew out of their asthma” and don’t have it anymore. Others will deny having asthma simply because they haven’t been diagnosed. If you probe further, however, and ask if they often get wheezing when they get a cold or put themselves through a tough workout, they will say yes. They just assume this is normal. A good predictor is family history – always ask about this since asthma does run in families. Patients sometimes deny asthma but report that a family member has it. Again, upon further questioning they will admit that at times they have wheezing or shortness of breath with certain triggers. Simply asking someone if they have asthma is not enough.
Any patient that has experienced asthma symptoms can still be at risk, especially with travel. They present ill to my office every day. They often develop significant asthma symptoms when they catch one of the viral respiratory infections that frequently circulate, including influenza. They have to take time out of their busy schedules and come to the clinic – typically for several visits. Their illness prevents them from keeping up with work, school, and family obligations; and they experience increased stress. The recovery period can be quite prolonged and they can develop serious complications such as a secondary pneumonia that requires hospitalization. If they are post-travel, they also need an exhaustive work-up to rule out the myriad of other possibilities that may result in similar symptoms.
About 300 million people worldwide have asthma and it affects 10% of the population in North America. It is underdiagnosed and undertreated everywhere. (Braman, 2006). Many patients do not have any idea that asthma is an inflammatory disorder that leads to symptoms such as wheezing, shortness of breathing, coughing and chest tightness. Many stimuli such as allergens, irritants, viruses, cold air, and exercise, produce inflammatory mediators that cause both airway hyperresponsiveness and airway obstruction. The latter occurs via the contraction of airway smooth muscle, swelling, and mucus secretion.
The good news is that you can prevent or at least minimize their symptoms. In addition to providing the above vaccines, do the following:
- Encourage hand washing – before touching the eyes, nose, or mouth. It’s the last part that is critical. Most people understand the need for handwashing; they just don’t connect it to the need not to touch the face, especially after being out in public. It’s elegantly simple and highly effective.
- Advise them to keep their allergies under control – if a patient reports allergy symptoms, have them talk to their clinician about finding an appropriate medication(s). For many people, if you control allergies, you can prevent asthma symptoms – it’s as simple as that. Of course, all travelers should carry an antihistamine in case they develop a reaction abroad.
- Recommend follow-up with their primary care provider – even if they have not had symptoms in years. Travelers with asthma (or a history of asthma symptoms) should follow-up with their providers since they may contract an illness or encounter more pollution, environmental tobacco smoke (ETS), or allergens abroad. Ideally, it is best to integrate this into the pre-travel visit to make sure they have appropriate medications on hand.
- Suggest they make friends with a steroid inhaler – explain that asthma is an inflammatory process, and inhaled steroids are the safest and most effective way of preventing symptoms. One of the smartest things a patient can do is start using a steroid inhaler at the first sign of a cold or before entering a polluted area (e.g. Shanghai, New Delhi, Mexico City, etc.) or an area with significant allergens. Of course, they should also keep a “rescue” inhaler on hand such as albuterol which may be needed to open up the airway when they can’t breathe. Inhaled steroids (e.g. Flovent™) will not provide immediate relief of wheezing or shortness of breath. I suggest you familiarize yourself with this handy Asthma Care Quick Reference . For more detailed information, the latest asthma guidelines from the National Heart, Blood, and Lung Institute are
- Travelers should have a supply of their usual asthma medications, both types of inhalers, and usually some oral prednisone in case of a severe exacerbation – in 2 separate places, one readily accessible and one somewhere else. CDC has multiple resources here including a video on asthma control during travel.
- Emphasize evacuation and get a plan – we do this for all our pre-travel patients but this is especially important for asthma patients who can deteriorate quite unexpectedly. They may want to identify a provider at destination to treat any exacerbations. Travel to remote areas may not be advisable. Travel health insurance is a must.
- Do they have wheezing or shortness of breath frequently? Get them to their provider right away to help get these symptoms under control and prevent the “downward slide” that can occur with travel. They should have a peak flow meter and a step-wise plan for their upcoming trip.
- Severe symptoms? Patients with severe or uncontrolled asthma may not be able to travel but at a minimum should see an asthma specialist. They may need hypoxic challenge testing to assess for inflight oxygen requirements. This should be considered regardless of resting O2 saturation level.
- Do they plan to be at high altitudes or dive? Exercise, allergen exposure, air pollution, and changes in air temperature can all impact asthma at higher altitudes. If a patient’s asthma is controlled and there’s no active exacerbation, travel to moderate altitude (around 6000 m) may be possible. Divers with asthma are at risk for barotrauma and all require thorough evaluation. They should have normal pulmonary function tests and may require exercise testing. Patients that develop symptoms with cold exposure, exercise, or emotion should not dive. Specialty consultation is recommended in both instances. Here is a wonderful review article addressing both of these concerns.
Travel health nurses are in a unique position to enhance the health and well-being of these patients. Wouldn’t it be great to go home at the end of the day and know you did that?
Julie Richards, President