World's first trial to show the benefits of identifying and treating undiagnosed asthma and COPD

Finding and treating people with undiagnosed asthma or chronic obstructive pulmonary disease (COPD) improved their health and reduced the number of visits to the doctor for respiratory symptoms in the year after diagnosis, according to a first-ever clinical trial published in the New England Journal of Medicine.

“An estimated 70 per cent of people with asthma or COPD are not diagnosed,” said lead study author Dr. Sean Aaron, a senior scientist and pulmonary specialist at The Ottawa Hospital and a professor at the University of Ottawa. “This is the first study to show that treating these people significantly improves their health and quality of life.”

How did the research team identify undetected cases?

To identify people with undiagnosed asthma and COPD, the team called random numbers at 17 study sites across Canada from 2017 to 2023. The automated call asked if any adults in the home had had unexplained shortness of breath, wheezing, a persistent cough, or coughing up mucus in the past six months.

26,905 people who reported these symptoms completed questionnaires. Those who were at high risk for asthma or COPD underwent spirometric breathing testing, the gold standard for diagnosis.

A total of 595 people were diagnosed with asthma or COPD, and 508 agreed to participate in a randomised controlled trial to compare different types of treatment.

Half of the people in the study were randomly assigned to usual care (treatment provided by their primary care physician or in an urgent care clinic), while the other half were treated by a lung specialist and asthma/COPD educator (a specially trained nurse or respiratory therapist).

People treated by a lung specialist and a teacher were prescribed inhalers for asthma or COPD and taught how to use them. Some were given action plans to help them manage flare-ups. They were also given treatment to stop smoking, advice on exercise and weight, and pneumonia and flu vaccines if needed.

Of patients treated by a lung specialist and teacher, 92% started taking new asthma or COPD medications, compared with 60% of patients receiving usual care.

Treating undiagnosed asthma and COPD reduces healthcare visits

The researchers found that patients seen by a pulmonary specialist and educator had an average of 0.53 visits per year for respiratory symptoms in the year after diagnosis, compared with 1.12 visits in the usual care group.

Additionally, the average St. George's Respiratory Questionnaire score increased by 10.2 points in patients seen by a pulmonary specialist and teacher, compared with 6.8 points in the usual care group. A four-point increase represents an improvement in health and quality of life.

“In the real world, not everyone can see a lung specialist,” explains Dr. Aaron. “The good news is that if a patient gets diagnosed and treated, their symptoms will improve. People in our study who saw their primary care physician and urgent care clinics had good outcomes, and those who saw a specialist and a teacher had excellent outcomes.”

Study participant notes importance of asthma diagnosis

Jazmynn Hine was 24 and had recently given birth to her first child when she got the call to join the study. Carrying laundry up the stairs or talking on the phone for 10 minutes at a time left her breathless. She saw no reason not to take the breath test.

"For years I told doctors I felt like there was an elephant on my chest and I couldn't breathe. They said it was my anxiety, that I was having panic attacks," Jazminn recalls.

But these weren't panic attacks. They were asthma. Asthma, probably since grade school. A daily inhaler changed her symptoms.

“The diagnosis of asthma is a big deal,” she says. “Your muscles need oxygen, and when you can’t breathe properly, it makes you tired and worn out. I’ve noticed an increase in energy. I have two small children now, and I can keep up with them. I sleep better because I used to wake up constantly short of breath.”

Asthma affects 8% of Canadian adults and can develop at any age, while COPD affects 8% of Canadians over 60 years of age.

“If you have symptoms similar to mine, go to your doctor or urgent care clinic and ask for a spirometric test,” Jazminn recommends. “The worst thing that can happen is that you lose time. But if you have a respiratory condition and it’s treated properly, you’ll be able to do things you didn’t even know you missed.”

Dr. Aaron agrees with Jazmyn. He believes the best way to identify more cases of undiagnosed asthma and COPD is for patients to seek diagnosis. His past research has shown that even early stages of these conditions are associated with poorer quality of life, more health care visits, and decreased productivity.

“Many people know to ask for tests for breast and colorectal cancer when they have certain signs. Ideally, they would ask for a spirometric test when they have symptoms of chronic respiratory disease,” says Dr. Aaron. “People should not have to put up with breathing problems when there are effective treatments available.”