The East Hampton Star: Blow out your candles asthma

(August 13, 2010)

To Your Health
Blow Out Your Candles Asthma
By James N. Dillard, M.D.  

(August 12, 2010)  I was a resident working the night shift at Harlem Hospital. We heard the E.M.S. call over the radio. It was a 6-year-old girl who couldn't breathe coming in. Her parents had tried the inhaler over and over at home, but she had just gotten worse. As the doors to the ambulance bay opened, we could hear the child coughing and gasping for air.

That night was Maria's birthday party. Her dad had just gotten home from work, and he lighted the candles on the cake. But Maria couldn't blow them out. Her mom gave her another couple of puffs on the inhaler and asked her to try again. But she still couldn't do it. Then the coughing started. That's when they called 911.

We rolled her into the back and turned up the oxygen. Our attending physician talked rapidly with Maria's mom and called for intravenous steroids. A pediatrics resident was prepping to put a breathing tube down her throat. Maria gripped the rail of the gurney with wide eyes and wheezed furiously, pale as a ghost. We were all praying that she would make it through the night.

Close to nine million children under the age of 18 have asthma, according to the American Lung Association. It is the most common chronic disease of childhood. More than four million children have at least one asthma attack every year. Hundreds die, even with the best medical care.

In total, 38.4 million Americans have asthma, and 70 percent of asthmatics also have allergies. There is a strong link between these two conditions. Asthma burdens our nation with $15.6 million in direct health care costs and $5.1 million in lost productivity.

What you do at home can make a big difference when it comes to whether your asthma is mild or severe. And how you deal with asthma at home can determine whether you break an asthma attack or head to the hospital to get intravenous steroids and maybe even a tube down your throat.

The 300 million tiny air sacs in our lungs must constantly exchange air  with the outside. In asthma, inflammation in the wall of the small airways causes mucus production and the spasm of smooth muscle cells, constricting the tube and blocking air flow.

   Asthmatics have more trouble blowing air out of the lungs than sucking air in. That's why Maria couldn't blow out her candles. Asthma is a disorder that slows the speed of air leaving the lungs. A quick test for asthma is to get the person to blow out a match at various distances. The real test is pulmonary function testing, or spirometry.

   During the testing, you might be given an inhaled medication called a bronchodilator that relaxes the smooth muscle cells in the walls of the tiny tubes of the lung. If the speed of air getting out of your lungs then improves significantly, you have asthma.

   These inhaled bronchodilators are a mainstay of asthma treatment. But just opening up the airways without addressing the underlying allergic inflammation can be dangerous. In the last 15 years, the emphasis in asthma care has been treatment of inflammation in the lungs with inhaled steroids.

   If you open the airways with lots of inhaled allergy-causing substances (allergens) present, you can make an asthmatic much worse. It will drive more allergens deeper into the lungs. So the underlying inflammation must be suppressed, but even more important, the allergens must be removed. These can include pet dander, dust mites, mold, carpet dust, cockroach dust exposure, secondhand smoke, and sometimes pollen.

   "A good place to start before we begin prescribing medicines is to find what is driving your asthma, why is it so severe," said Dr. Christopher Fanta, an associate professor in pulmonary and critical care medicine at Harvard Medical School. "Is it the moldy basement where you live — and what about that pet cat?"

   Asthmatics should be tested and treated for allergies. But more important, if allergens are removed from the home, asthmatics will get better and health care dollars will be saved, according to a September 2004 article in The New England Journal of Medicine.

   Inhaled bronchodilators like albuterol are often coupled with inhaled cortico­steroids like budesonide and fluticasone because they work well together. Inhaled steroids are not associated with all the adverse side effects of oral steroids. Rarely inhaled steroids can produce easy bruising, adrenal gland suppression, and decreased bone-mineral density with long-term use.

   Another drug class is the leukotriene blockers. Leukotriene is an inflammatory trigger, and blocking it can improve symptoms. These medications decrease coughing, open the airways slightly, and reduce lung tissue inflammation. They are generally well tolerated.

   The new kid on the block is a man-made antibody called omalizumab (Xolair) that cleans reactive allergic antibodies out of the blood. It is quite expensive and has to be injected every two to four weeks. This is space-age stuff.

   Doctors' goals include having asthmatic people use bronchodilator inhalers only twice a week and having them wake up with symptoms only two times a month. The spirometry studies should be within the normal range, or close to normal. With these goals met, many people can almost forget they have asthma.

   I stopped by to see Maria on the pediatrics floor the next evening. She looked tired, but she was going home in the morning. She gave me a little smile when I said, "Hola, nina bonita," and squeezed her hand. She had made it through.

  With careful removal of household allergens and proper use of medications, people with asthma can keep blowing out their candles year after year.