When Asthma Attacks

This week’s guest columnist is Dr. Lindsey Guidry, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

I was testing for my karate black belt, trudging through the last stretch of a two-mile run. The morning was cool and crisp, which seemed fine for exercising. Except the dry cold air made my lungs feel raw. Then they began to burn like fire. I crossed the finish line and doubled over, gasping for what seemed an eternity. My mom brought me my inhaler and after a few puffs, the burning eased and my respirations began to slow. A sense of relief washed over me- I could breathe again!

This was an attack of exercise-induced asthma: if I’m ever in a ninja fight, better have my inhaler!  Almost 10% of kids have some form of asthma. Asthma is airway narrowing in the lungs. When airways get smaller, it’s harder to suck air through them.  When the narrowing gets really bad, air begins to whistle through those tight passages, making that wheezing noise characteristic of attacks.

Kids with asthma have lungs that are extra-sensitive to irritants. Many things can irritate the airway lining, like cigarette smoke, cold viruses, pollens and mold spores, and dust.  In my case cold, dry air triggered narrowing. The American Academy of Pediatrics warns that climate change and increasing air pollution contribute to increasing national asthma rates. Severe weather events like forest fires, droughts, heat waves, and hurricanes are becoming more common, and giving lots of kids trouble with their breathing.  Increasing smog, soot, and other particle pollutants from cars and factories aren’t helping.

What does an asthma attack look like?  Mild asthma results in irritating coughing that doesn’t go away in a few days, like a regular cold would.  Moderate attacks cause a feeling of chest tightness and trouble breathing with exertion, like when walking up stairs, playing, or testing for karate.  When kids’ attacks get really bad, they visibly struggle to breathe, panting away with skin puckering between their ribs as they try to tug air in. Older kids may get a little panicky like I did; younger kids will be fussy. Time to get help!

Asthma, and asthma treatments, have been with us for millenia.  The ancient Greek physician Hippocrates (writer of the physician’s Hippocratic Oath) coined the term “aazein,” meaning “to pant.”  The Greeks had some reasonable asthma treatments, like adding ephedra (an epinephrine-like drug) to red wine; or smoking stramonium, an atropine analog. They also had whackier ideas, like adding owl’s blood to the wine too.

Today’s treatment is more science-based.  As we mentioned above, asthma is the lung’s response to irritants like dust, smoke and pollution, cold viruses, and allergens. First, muscles in the airway lining tighten up, constricting air passage to keep out what’s irritating. After continued insult, the airways become inflamed and swollen, further impinging air movement. Finally, the lungs secrete mucus to wash out the irritants. This mucus gets dried out and sticky with heavy breathing, further clogging things up.

The first pillar of asthma care is albuterol, a medication that relaxes the muscles in the airways. Albuterol is breathed in by nebulizer or inhaler. Initial management of an attack is 2 to 6 puffs of the inhaler, with a “spacer” (a wide plastic tube) attached. These puffs can be repeated in 20 minutes if the first round doesn’t ease symptoms. If that doesn’t work, get seen!  While most prescriptions for albuterol inhalers call for 2 puffs, it takes 6 puffs to deliver the amount of medicine in a nebulizer treatment.

The second pillar is steroids. Steroids are anti-inflammatories, to quiet that airway swelling and mucus production. The most common steroid is prednisone, which comes as tablets, or liquids for kids who can’t swallow pills. Prednisone is not an “anabolic steroid.”  Kids don’t grow hair, hulk out, or have “roid rages.” Given in short courses, it’s quite safe. Myth-buster: injected steroids don’t work faster than when they’re swallowed; getting “cortisone shots” is unnecessary (yay kids!).

Have plenty of your child’s medication on hand in the winter when cold air, viruses, and dusty indoor living make it more prevalent. Be aware of outdoor air quality conditions that might trigger asthma, like cane burning, humidity, and high pollen counts. Finally, the American Academy of Pediatrics asks everyone to advocate for pollution and carbon control; to help your child, and the whole world, breathe easier.

Wheezing Through The Ages

Asthma has been with us for millenia.  The ancient Greek physician Hippocrates, inventor of the Hippocratic Oath, first used the term (from the Greek aazein, “to pant”). The Greeks had treatments- adding ephedra (an epinephrine-like drug) to red wine, and smoking stramonium, an atropine analog.  They weren’t entirely on the ball though, thinking that adding owl’s blood to the wine helped too.

Asthma has become more common in children in recent decades.  This is because of changes in kids’ environments, and because of the Hygiene Theory.  Hygiene Theory posits that since children’s lives have become cleaner, more infection-free, their immune systems attack their own tissues, having nothing else to do.  Also, it seems that when kids had intestinal worms from contaminated food, the worms put out substances that kept the immune system quiet.  This protected the worms from immunity, while lessening immune aggravation of the kid’s lung tissue too.  Now, no one’s advocating giving children tapeworms to lessen their asthma.  Yet.

The environmental issues are more clear.  Modern housing emphasizes energy saving with better sealed doors and windows.  This means less fresh air circulates into the house through those leaky portals.  Thus kids breathe more house dust, which irritates lungs.  People also open their windows less and make air conditioners and heating systems, which accumulate and circulate dust and other irritants, do more work.  Kids also spend more time indoors than out with TVs, computers, games, and phones; thus breathing that dusty indoor air more.  Less exercise clearly worsens asthma- kids need exercise to prevent it.  This may seem counter-intuitive, since exercise can sometimes trigger or worsen individual asthma attacks.  However, in the long run, more active children have fewer attacks.

These are clues to prevent asthma in children, and prevention is the mainstay of treatment.  Once kids start having asthma it’s a lot of trouble- they visit Emergency Departments for attacks, and sometimes get hospitalized.  They miss school, and parents miss work.  Occasionally kids end up on life support in the Pediatric Intensive Care Unit, or die.  Makes tapeworms sound better and better.

Continuing our asthma history lesson from above, asthma theory took a weird turn in the early 20th century, with Sigmund Freud’s theories of the subconscious mind.  Since anxiety attacks were known to trigger asthma, some over-enthusiastic Freudians believed that all asthma was psychological; even when patients had audible wheezing, that high-pitched whistle from deep down the throat. They thought that whistling was generated subconsciously as a tiny scream for help from the patient’s buried anxiety. 

Fortunately, in the 1940s and ’50s, physiologic understanding of asthma prevailed.  That understanding holds today, that asthma comes from two glitches in the airway.  First, the muscles that control airway diameter overreact to noxious stimuli like dust, allergens, and viruses.  When those muscles contract, they narrow airways to keep out the irritants. But doing that keeps out the air too.  Second, after too much stimulation, the airways become inflamed, causing swelling into the passage, and excess mucus production.  With airways narrowed by muscle contraction and swelling, and clogged with mucus, no wonder it’s hard to breathe.

Asthma treatment is two-pronged.  First, we use medicines inhaled as a mist, like albuterol.  Albuterol breathed into the airways relaxes the muscles lining them, opening the passages up.  Second, we use steroids, which decrease inflammation and mucus production.  Steroids have minimal side effects.  Sometimes when people hear steroids they think “anabolic steroids,” the kind that some athletes take to build muscle mass.  These aren’t the kind we use for asthma- kids aren’t going to bulk up, grow beards, and have rage attacks.

The most important treatment for asthma is prevention.  Like we mentioned above, regular exercise prevents asthma.  As kids exercise less these days, asthma has become more common.  Since individual asthma attacks can be worsened by exercise, some parents restrict their asthmatic kids’ activity.  However, over the course of childhood, regular exercise actually lessens asthma.  Also, like we said above, kids should get outdoors more to breathe fresh air, instead of dust-laden indoor air. 

Children can take medicines to prevent asthma attacks as well, particularly for air-borne allergen sensitivities, like to molds and pollens. Those kids can play outdoors too.  Talk to your doctor about treatment plans, prevention medication, and exercise plans for your child.  Asthma’s another good excuse to get your kids away from their screens and into the real world.     

Asthma: How Can We Breathe Easy?

When I was in college, I volunteered at a homeless shelter.  Back then people were allowed to smoke indoors, and after a night shift I would leave with my hair stiff with cigarette smoke.  Then I caught a cold, and a cough that did not go away.  I hacked all day and woke up through the night coughing.  After a month of misery, I went to the infirmary.  The Physician Assistant there said I had a cold and gave me some cough drops. 

Weeks later, still hacking, I went back.  The PA did the same things, to no effect.  Weeks after that I went back yet again, insisting on seeing the doctor.  The doctor listened carefully to my story, said I had mild asthma from the combination of the cold and the cigarette smoke, and gave me an inhaler.  Within days my cough was gone.

Many people find asthma confusing and complex.  It is sometimes hard to diagnose, like my episode above.  It can be triggered by many things and the medicines can be confusing- what do I give my kids when they are sick?  How do we use an inhaler?  What medicines should they take when they are well?  How do I avoid asthma attacks?

Asthma, simply put, is wheezing that can be reversed by medicines.  In asthma, the airways in your lungs are extra sensitive to irritants.  The airways close up to keep out those irritants: cold viruses, pollen, cigarette smoke, extra cold air.  When the airways narrow and close, the wheezing you hear and feel is your breath whistling through those skinnier passages. 

To reverse airway narrowing, we use two classes of medicines.  The first are called bronchodilators, that open up (“dilate”) your airways (“bronchioles”).  These medicines are breathed in through inhalers and nebulizers.  the second medicines are steroids, like prednisone, which take away the swelling in inflamed airways.  Prednisone is a different steroid from the steroids athletes abuse.  For the four-to-seven day courses we use for asthma, prednisone does not cause weight gain, hair growth, or rage attacks.  For people with really bad asthma, there are medicines to take daily to make the airways less sensitive and help prevent attacks.  These are called “controller” medicines.

More important than treating asthma is avoiding asthma and its attacks.  Asthma is increasing in the population in the past 25 years, and many of the things that cause asthma are all around us.  Pollutants like smoke, soot, and diesel exhaust eat at our lung tissue as we breathe.  We live more and more indoors these days, and therefore have more exposure to indoor lung irritants like dust and mold.  The more time we spend indoors too, the more time we are exposed to our fellow humans and the cough and congestion viruses they give us. 

All those irritants assaulting the lining of our air passages add up.  Some people have lungs that can take the abuse.  Those with more sensitive lungs, like kids, get asthma.  As we talked about above, when the air passages have had enough, they close up to keep out the bad stuff.  Unfortunately, when they close up, they also keep out the air we need to live.  What little air we can move in and out whistles through those narrowed air passages and we wheeze, and we have to pull and tug to get the air in and out.

So how do we and our kids avoid all those irritants?  First, let’s not be so hard on the Environmental Protection Agency (the EPA).  The EPA is not there to shut down factories, it is there to help those factories do less damage to our lungs from air pollution.  Second, we need to avoid cigarette smoke.  Smokers should never smoke indoors, at home with children, or at work or at bars with adults.  Heck, smokers should see a doctor for help to quit!  Finally, we and our kids need to spend more time outdoors, away from indoor dust and mold and sick people.  Exercise is good for the lungs (and the rest of the body too) so outdoor activities are a double win.

So if you or your kids have a cough that won’t go away, or wheeze, see your doctor.  You should talk about how to avoid asthma irritants, medicines to take for attacks, and if need be, medicines to prevent attacks.  You and your kids should be allowed to breathe easy.     


Asthma- smoke, allergens, inhalers, steroids- help!

When I was in college, I volunteered at the local homeless shelter.  Back then you were allowed to smoke indoors, and the morning after a night shift I would leave with my hair stiff with the smell of cigarettes (I had a lot more hair back then).  The next time I caught a cold, I was left with a cough that did not go away.  I hacked all day and woke up through the night coughing.  After a month of misery, I went to the college infirmary.  The PA there said I had a cold, and sent me on my way with a paper packet of cheap and gritty cough drops. 

Weeks later, still hacking,  I went back.  The PA said and did the same things, again to no effect.  Weeks after that I went back yet again, this time insisting on seeing the doctor.  The doctor listened carefully to my story, said I had mild asthma from the combination of the cold and the cigarette smoke, and gave me an inhaler.  Within days, my cough was gone.

Many people find asthma confusing and complex.  It is sometimes hard to diagnose, like my episode above.  It can be triggered by so many things and all the medicines can be confusing- what do I take when I am sick, and what medicines do I take when I am well?  Hopefully the next few paragraphs will give you a better understanding.

Asthma, simply put, is wheezing that can be reversed by medicines.  In asthma, airways in your lungs are extra-sensitive to irritants, and close up to keep out those irritants- cold viruses,  pollen and other allergens, and cigarette smoke.  When the airways narrow and close, the wheezing you hear and feel is your breath whistling through those skinnier passages. 

To reverse that airway narrowing, we use two classes of medicines.  The first are called bronchodilators, that open up (“dilate”) your airways (“bronchioles”).  These medicines are breathed in through inhalers and nebulizers.  The second medicines are steroids, which take away the swelling in inflamed airways.  Prednisone, taken as pills or syrup, is the most commonly used steroid.  Prednisone is very different from the steroid athletes abuse.  For the short five-to-seven day courses we use for asthma, it does not cause weight gain, hair growth, or rage attacks. 

The most important treatment for asthma is to avoid the things that irritate.  If dogs make your kid wheeze, don’t get a dog!  Teach your asthmatic kids good hand-washing so they don’t get so many cold viruses at school.  If you smoke and your kid has asthma, quit!  At the very least, smoke outside the house and car where your kids breath.  

Finally, for bad cases of asthma, there are medicines to take when you are well, all the time.  There are pills and inhaled steroids (again, perfectly safe)  that keep your airways from being so sensitive.  If exercise makes your kid wheeze, there are inhalers to take before exercise to help that.  All asthmatic kids should get a flu shot in the fall, since the influenza virus is particularly hard on airways.

If all this is still confusing, ask your doctor for a written asthma plan to help you keep it straight.  Your child with asthma should be able to go to school, to run and play, without having asthma attacks.  If he can’t, see your doctor to improve the asthma plan.  And for heaven’s sake, if you smoke, see your doctor about ways to quit!