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Vol. XXV
No. 6
Cover
November/December
2009

In This Issue

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by Dr. Rodger Sayre
- disclaimer -
Confessions of an Asthmatic

I love a good belly laugh! And though I’ve never seen this written up anywhere, I can tell you from personal experience that laughter can trigger an asthma attack. More than once I have gone from a side-splitting guffaw one minute to scrounging for my inhaler the next. So now you know where the expression, “I could have died laughing” comes from! If you or your loved ones struggle with asthma, don’t stop laughing! Some simple things can be done to decrease the frequency and severity of asthmatic symptoms. First though, I’d like to share my personal story.

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SOME SIMPLE
THINGS CAN BE DONE
TO DECREASE THE
FREQUENCY AND
SEVERITY OF ASTHMATIC
SYMPTOMS.
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At the age of 25, while doing a clinical rotation in my senior year of medical school, I was involuntarily enrolled in a study on the causes and treatment of asthma. It’s amazing how vigorously one studies a subject when one’s own life is in jeopardy! Tom, my assigned roommate during this rotation, never cleaned the house, and he had a live-in German shepherd named Beast. My brain liked Beast, but my lungs sure didn’t! I felt like I was trying to breathe through a straw, and each day the straw got smaller in diameter. After a week of progressive deterioration, it was time to move out. My lungs have never been the same… .

These days, even a brief exposure to an enclosed space where there is a significant degree of animal dander causes my lungs to rebel. I was reminded of this not long ago when we took our ailing dog to the veterinarian. As soon as I set foot in old Doc Lapatofsky’s place, I knew I should beat a hasty retreat. Internal bells and whistles were blaring, but I unwittingly ignored them.

“After all,” I rationalized, “I have to help get Rusty on the exam table.” After the exam, I politely said good-bye to the aging doc, doing my best to hide the escalating constriction of my airways. I handed Mary the keys and settled slow-motion into the passenger seat. Mary looked puzzled. “I’m in trouble,” was my breathless answer to her unasked question.

On the way home I was able to maintain just enough air movement to survive. I sat bolt upright, eyes closed, inhaling in short gasps and exhaling through pursed lips to maximize air exchange. Sometimes I hate my cell phone, but this time I think it saved my life. Mary called home and the kids had an albuterol nebulizer treatment all set up for me. No more visits to the veterinarian for this old wheezer!

Diagnosis

Do you think you or your child may have asthma? The diagnosis is not always straightforward. The National Institute of Health defines asthma as a chronic inflammatory disorder of the airways. The inflammation is associated with spasm of the bronchial musculature, which, to a varying degree, creates further obstruction to airflow. While wheezing is often the presenting complaint, a persistent cough and a sensation of being short of breath (even in the absence of wheezing) also can indicate asthma. Pulmonary function tests (PFTs) are an objective way to diagnose asthma. PFTs are useful in circumstances when the diagnosis is in question, or where it may be helpful to monitor level of control. Sometimes, a more practical approach to diagnosis is quite sufficient, however. If I have a strong suspicion that a patient may suffer with asthma based on their history, I will sometimes forego formal PFTs and just prescribe an inhaler. If the symptoms disappear, I can be pretty sure of my diagnosis.

Causes

While it is true that infection, exercise, emotional stress, certain smells, and yes, even laughter, can trigger an asthmatic response, by far the most common cause is airborne allergens. The offending agents primarily fall into four main categories: animal dander, dust mites, mold spores, and pollen. There are some very practical things that can be done to minimize exposure to these agents, thereby lessening their impact on the airways of your asthmatic family members.

>> Animal dander. Eliminating animal dander sometimes necessitates giving the family pet away. Although this suggestion is occasionally met with glee by some members of the family, especially when dealing with cats (Sorry, I couldn’t resist … ), most families opt for less draconian measures. These include keeping the pets outdoors (the route we have chosen), keeping the pets out of the bedroom, and removing rugs and cloth-covered furniture from the house. I know what you are thinking: At last, the excuse I’ve been looking for to get hardwood flooring and new leather furniture! If you have indoor animals, keeping a clean house has to rise to a level of high priority. This is also true when trying to control dust mites. Speaking of which …

>> Dust mites. Dust mites are ubiquitous critters, exceedingly difficult to completely eliminate from living quarters. Their diet of dead skin is distasteful, but it is primarily their excrement that causes the allergic response. (Sorry. I’ll bet you didn't really want to know that!) Since the bedroom is where we spend most of our time in any 24-hour period, that is where we must focus our preventative efforts. The mattress and pillows should be encased in covers made for this purpose. Washing pillows, sheets, and blankets in water that exceeds 130 degrees kills the mites. Again, eliminating rugs and stuffed animals removes some of the dust mite’s favorite hiding places. Lastly, keeping the humidity down in the house helps control not only dust mites but mold growth, as well. Methods of humidity control are dealt with in the next paragraph. And not-so-coincidentally, so is mold!

>> Mold. Warm, moist environments are what mold growths like best. That’s why your bathroom is a prime spot to find mold. When our house was built, the plumber vented our bathrooms into our attic. Not a good idea! Now our attic is black with mold in places. So in addition to redirecting the bathroom vents outdoors, I need to spray the affected areas with Clorox bleach. You should do the same wherever you find mold growth. Humidity control is the key to controlling mold. The moisture in your home comes from exhaled air, poorly vented clothes dryers, cooking, and bathing. (A family of 13 does a lot of exhaling. I have asked my kids to exhale less, but this request has been met with universal disobedience.) Humidity can also come from the great outdoors if you live in a humid area of the country. Keeping the windows closed when the relative humidity is high can be a big help. It will also keep pollen out of the house. Did I mention pollen?

>> Pollen. Lastly, pollen is a well-known seasonal cause of allergy and asthmatic response. Staying indoors when pollen counts are high, keeping the windows closed, and relying on the air conditioner during that time of year when pollen is a problem will minimize exposure. For most people who struggle with pollen-triggered asthma, this may only be a couple of weeks out of the year, depending on the type of pollen implicated.

Treatment

The medical therapy for control of asthma has improved greatly in the past few decades. For many years, our main effort in the treatment of asthma was directed toward reducing spasm of the airways. But spasm, we have learned, is a consequence of inflammation. Therefore preventing inflammation treats the problem at its source, often eliminating the need for medications that dilate the airways (bronchodilators) altogether.

We have adopted a stepwise approach to asthma therapy that is based on assigning patients to one of four different categories, according to their symptoms. These categories are intermittent, mild persistent, moderate persistent, and severe persistent.

>> Medications. For those with intermittent asthma, requiring treatment only once or twice a week, the occasional or as-needed use of a simple bronchodilator (e.g., albuterol) is sufficient medical treatment. But for individuals with persistent asthma, requiring treatment more than twice a week, a preventative medication is indicated. Unlike as-needed medication, preventative therapy must be used daily to be effective. Studies show that inhaled corticosteroids (e.g., fluticasone) should be the first approach. The second step includes the use of oral leukotriene antagonists (e.g., Singulair) either in addition to or instead of the steroid inhaler. When breakthrough wheezing occurs despite preventative medications, bronchodilators can be used as needed. This is sometimes dubbed rescue therapy. There are a multitude of other medications available when these simple modalities fail, but a thorough discussion is beyond the scope of this article.

>> Spacers. One last note on inhalers: they work best, especially in small children, when used with an attachment called a spacer. Spacers hold the medication in suspension in a chamber of some sort. This allows for the individual to inhale the contents without having to time the inhalation with the squeezing of the inhaler. More medication ends up in the lungs and less in the back of the throat or on the tongue.

>> Immunotherapy. Lastly, desensitization therapy (or immunotherapy) as prescribed by an allergy specialist is available for those who suffer from asthma due to dust mites, dander, and pollen. Unfortunately, it does not work very well for adults or for those whose primary allergen is mold.

For those of you who have stuck with me to the bitter end of this long article, I offer the following from the Sayre Family Files. Although Mary and I work hard at instructing our children both spiritually and academically, our failures are sometimes painfully evident. In one recent angry interchange between children, one shouted at another, “You are such a jerk! G - E - R - K! Jerk!” That sent me searching for an inhaler… .


About the author

Rodger Sayre, MD, FAAFP, has been an HSLDA board member since 1997. He and his wife, Mary, have graduated 6 of their 11 children and continue to teach the rest at home in Pennsylvania. Dr. Sayre is certified as a Diplomat of the American Board of Family Medicine and is a Geisinger Medical Group associate with a busy practice in Tunkhannock.