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Glenn D. Braunstein, M.D.

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The Asthma Epidemic

Posted: 03/26/2012 3:38 pm

For most of us, a cough is nothing more than the usual seasonal bout with a cold. But for 25 million Americans, including 7 million children, with asthma, that cough alerts the asthma sufferer or parent to pull out an inhaler to avert potential tragedy. An asthma attack sends muscles surrounding airways into spasm, squeezing them from the outside. To make matters immeasurably worse, the body mounts a second front of attack from inside the airways through an inflammatory response, plugging them with mucous. Such episodes are nothing short of a battle for breath.

Quick preventive medical action can get breathing back under control, but without the proper medical care, the consequences of a serious asthma attack can be dire. Anthony Shadid, a New York Times reporter on assignment in Syria, suffered a fatal asthma attack early this year, possibly triggered by a severe allergy to the horses that guides were riding as they smuggled the reporter and a photographer into and out of the country.

Deaths from asthma -- about 3,500 a year, according to the Centers for Disease Control and Prevention -- are rare. But asthma is a serious disease with the potential to be dangerous or deadly even in its mildest forms. It causes wheezing, breathlessness, chest tightness and coughing.

Wheezing -- a distinctive whistling sound when breathing -- is the telltale symptom of asthma, as is coughing that often is worse at night or early morning. But sufferers will assure us that it's no common cough they experience. The tightening of airways can feel like someone is sitting on their chests. Then when airways constrict and fill with mucus, it can feel like they can't get enough air either into or out of the lungs.

This affliction also takes a high economic toll, with an estimate that its annual costs run to $18 billion, including almost $10 billion for hospitalization and medical care and another $8 billion in lost earnings and deaths. It's said to be the number four cause for adult absenteeism from work and in school-aged children it's the number one cause among chronic illnesses for youngsters' absences from class.

The number of asthma patients rose rapidly between 1980 and 1996, and currently continues to rise at a slower rate. The number of cases rose by 4.3 million from 2001 to 2009, according to the Centers for Disease Control and Prevention. Los Angeles County has a higher percentage of the population suffering from asthma than the national rate -- 12.5% versus 8.2%.

The movement of what was once a relatively inconspicuous disease to an epidemic of significant public health concern remains both worrisome and mysterious. After all, air quality in the U.S. generally has improved and two common triggers for asthma attacks -- secondhand smoke and smoking in general -- have been reduced dramatically, even as the epidemic has continued its rise. Epidemiological associations between asthma and urban violence along with traffic-related air pollution; Vitamin D deficiency; urban poverty; airborne pollen levels; a mother's diet during pregnancy; and to the post-Labor Day return to school have been described. The latter association most likely is due to rhinovirus infections that occur in the fall and are transmitted from school child to school child. Thus, it has genetic, environmental, biological and social components.

Nature vs. Nurture

With such a broad range of possible associations with the disease, it has been impossible to pinpoint any one specific cause for the epidemic. But a few things are known. People with asthma may have inherited a tendency to develop allergies and asthma from their parents. If one parent has asthma, the child has a 1 in 3 chance of becoming asthmatic. If both parents have asthma, the risk rises to 7 in 10. While having allergies is a risk factor for asthma, genetic factors no doubt interact with environmental factors. Some people with asthma may have experienced viral infections in infancy or early childhood when the immune system is developing. Then there is the "hygiene hypothesis", which posits that a Western lifestyle with its emphasis on sanitation causes a decline in early childhood infections, which in the past toughened up the immune system. It is proposed that this lack of repeated stimulation essentially leaves the young immune system ill prepared to fight off allergies and asthma.

In the United States, for a variety of reasons including income and neighborhood conditions (higher proximity to pollution sources such as freeways, manufacturing plants and poverty-related irritants such as vermin), African Americans and Latinos bear a disproportionate share of the woes with asthma.

Triggers

As researchers continue to try to understand the underlying causes of asthma, science has come a long way in understanding the triggers that can cause asthma symptoms to appear or worsen. While the disease is complicated because those triggers are wide-ranging and diverse, educating patients to recognize and control them is crucial to preventing attacks. They can include allergens, like dust mites, animal fur, cockroach droppings, mold and pollen. The can also include irritants like cigarette smoke, air pollution, chemicals or hair spray. Some medicines can trigger an attack, as can sulfites in foods. A common cold can lead to an asthma flare-up, as can stress, excitement and even physical exercise.

Treatment

Medical treatment is generally two-pronged. Anti-inflammatory agents can have a preventive effect by slowing or interrupting inflammation in the airways. While those medicines can reduce the number of asthma attacks, they don't provide immediate relief when an episode hits. At the start of an asthma attack, what the patient needs is a bronchodilator, or inhaler, to get medicine directly to the lungs and quickly allow the airways room to breathe.

People with asthma need to recognize and control their unique triggers. For example, someone whose wheezing starts on particularly polluted days needs to pay close attention to air quality forecasts, and attempt to remain indoors on especially bad days. If a furry pet sets off an attack and the family can't bear to find it a new home, it might help to bathe the animal weekly, keep animals out of the bedroom, and vacuum often.

Exercise can be a trigger, and the old medical thinking had asthma sufferers sitting on the sidelines. But exercise has tremendous value to overall health, and even if an asthma sufferer has exercise-induced attacks, a physician can help with an exercise plan. For example, using a bronchodilator before exercise can help prevent a wheezing episode during exercise. Certainly, keeping the "rescue" inhaler nearby during exercise is a must. And working with your doctor might help you choose short burst of energy sports, like baseball or volleyball, rather than long-haul sports like marathon running.

The millions of people with asthma can, and do, live long and active lives. While the disease can't be cured, it can be controlled. Always, whether symptoms seem to be an occasional minor annoyance or a major interference with daily activities, it's a condition that demands to be taken seriously.