Breathe Deep

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For Nirmal Singh, asthma is not something to be suffered in silence. When he wheezes, the person next to me will hear it, the 48-year-old says. It’s that loud.

The Fiji native and co-owner of a Sacramento auto shop is one of an estimated 3.9 million Californians who have asthma, a chronic inflammatory lung disease that impedes breathing. Although potentially deadly, asthma in most cases flares up only occasionally. The goal for asthmatics is control, and under the program he developed with his physician, Singh has achieved some semblance of it. He has not experienced an asthma attack&emdash;characterized by shortness of breath, wheezing, coughing and chest tightness&emdash;in the past year and can work out on a treadmill for up to a half-hour. But before, even the lowest-energy activities were difficult for Singh.

Not so many years ago, strenuous and sometimes even mild exercise were out of the question for asthma sufferers. Children, who are more likely than adults to first exhibit symptoms of the disease, had attacks so severe that they would be hospitalized and placed in oxygen tents. Parents, desperate to relieve the suffering, bravely would uproot their families and find new jobs or even careers in climates deemed better for asthmatics, such as the high, dry Rocky Mountains or the temperate coastal regions of California, Oregon and Washington. Today, such extreme measures are not as common or as necessary.

With very few limitations, almost all asthma patients can now live a normal life, says Robert Watson, M.D., an asthma-care expert who is affiliated with Mercy General Hospital and Catholic Healthcare West. While there is no cure for asthma, most asthma can be controlled by taking a puff of medicine once or twice a day. Patients with intermittent asthma don’t even need treatment every day. There is a suggestion that by treating asthma early, and aggressively, we may be able to prevent it from becoming severe.

Whether mild or severe, intermittent or persistent, in bodies young or old, asthma is a medical condition that has a lot of people’s attention these days. Most of us know people who suffer from asthma, and the disease is being diagnosed more than it was a generation or two ago.

The Breathing Ain’t Easy

Asthma attacks happen when lung capacity diminishes, whether by inflammation of the airways, constriction of the surrounding muscles or a combination of these two things. Consider this analogy: A living room, furnished reasonably and containing another person or two, represents normal lung capacity. You can move around easily (i.e., breathe) in such an environment. If you suddenly introduce many more people to the room (inflammation), you have trouble finding a place to sit. Cram all that furniture and all those people into a smaller room (tightened muscles) and your movement is greatly restricted.

Maria Bustos-Hillaire was 26 years old when she moved to Sacramento in 1992. She put up with some seasonal allergies, but had no asthma symptoms. By 1998, she had transitioned from being an occasional jogger to a marathon runner. As a respiratory therapist, Bustos-Hillaire was familiar with asthma and its manifestations. When she began experiencing shortness of breath in 2001, she says, I was in denial. But my teammates also noticed the audible wheezing, and some of them are asthma sufferers as well. That is when I realized I had asthma, too.

I remember one particular race that used to take place in the summertime on a Friday evening on the river levee, she continues. I had an asthma attack during the race but was able to finish. But catching my breath afterward was a slow and scary process.

In Sacramento County, about 31,000 children and 75,000 adults have asthma, according to the American Lung Association of California. Nationwide, the Centers for Disease Control and Prevention reported in December 2006 that nearly 9 percent of all Americans younger than 18 have the disease. Diagnoses have increased more than 250 percent since 1980.

Both sexes and all ethnicities are susceptible to developing asthma, although the condition is slightly more prevalent in females and African Americans. According to the Asthma and Allergy Foundation of America, although the disease is not contagious, it has a genetic component: If only one parent has asthma, chances are one in three that each child will have asthma. If both parents have asthma, it is much more likely (seven in 10) that their children will have asthma. The AAFA further reports that asthma is the most common chronic condition among children and the third-highest cause for hospitalization among children. Asthma accounts for one-quarter of all emergency-room visits, kills an average of 14 Americans every day and nationwide carries an annual price tag of $18 billion.

There is no cure for asthma and no known way to prevent it. In some cases, it plagues a person consistently for an entire lifetime. In other cases, it rears its wheezy head only briefly, either during childhood or adulthood, and never again materializes. Or, for some people, asthma comes and goes, with flare-ups years apart, for reasons that are apparent (such as environmental changes) or a mystery.

Bradley E. Chipps, M.D., of Capital Allergy & Respiratory Disease Center in Sacramento and affiliated with Sutter Medical Group, has been practicing medicine in Sacramento for 27 years. The pulmonologist and allergist is widely considered to be the region’s expert on asthma. He is a prolific writer about the subject; in the month before being interviewed for this story, Chipps had given speeches in Chicago, Dallas, Las Vegas, San Diego and San Francisco&emdash;he logs about 150,000 miles in the air every year. Among many other informative pamphlets and publications, his office hands out The ABCs of Asthma: An Asthma Alphabet Book for Kids of All Ages. Under the letter T, it describes the so-called triggers of asthma attacks: pollen (from grass, trees or flowers), mold (that grows during damp or rainy weather), certain kinds of foods (milk, wheat or peanuts), animal fur, hair, dander, dust mites, cigarette smoke and infections.

Anxieties, or what Chipps’ asthma facts sheet refers to as emotional upset, also can play a role in an attack. This gives rise to the widespread and inaccurate belief that asthma is solely a psychological affliction. There are patients who have respiratory stress that have a significant psychiatric component to their illness, whether they have hyperventilation because they’re hysteric (or) whether they have vocal chord dysfunction, which is a mimicker of asthma, Chipps says in his East Sacramento office.

Not being able to breathe can make you upset, he continues. I have had asthma and that is a disquieting feeling. Stress can precipitate an asthma attack, but stress does not bring on asthma de novo&emdash;that is, cause it to happen, or aggravate it if it’s already there.

Asked what might explain the rise of asthma cases in the past few decades, Chipps says, Nobody knows for sure. Basically, there’s not one factor. It has to do with smoking and environmental tobacco smoke, crowding, being inside more, poor air exchanges in houses, a higher genetic basis for it, air pollution&emdash;there are a whole cadre of things that bring this on.

Gordon Garcia, M.D., a Kaiser Permanente doctor who specializes in asthma care, suggests that one widely believed explanation behind asthma’s rise in recent decades is the ‘hygiene hypothesis’&emdash;the idea that as we’ve gotten more immunizations and gotten ‘cleaner’ . . . the immune system shifts a little bit from fighting infections to reacting in allergic fashion. In other words, asthma may be becoming more frequent because our bodies no longer are as capable as they used to be of fighting off unwelcome invaders.

How Wheezy Is Our Valley?

The American Lung Association recently determined that metropolitan Sacramento has the 10th dirtiest air, in terms of ozone and/or particle pollution, in the country. The valley basically is like a big vacuum cleaner bag, says M. Eric Gershwin, M.D., who runs the division of rheumatology, allergy and clinical immunology at the University of California, Davis Medical Center. We suck in garbage from the north, from the west&emdash;almost everywhere you can think.

We have very high pollen levels in the Sacramento Valley, Chipps says. We have serious air pollution in the summer. The best months [for asthmatics] actually are June and July, before it gets really, really hot. There’s a trend for increased asthma severity in the fall and it relates primarily to recent-onset viral infections.

Watson, the Mercy physician, points out that smoke from grass and forest fires can trigger asthma incidents in the late summer, while temperate, damp winters encourage molds and dust mites.

Garcia, of Kaiser Permanente, says that we have a fairly robust allergy season in the springtime, when people who experience no troubles the rest of the year are confronted with asthma symptoms. All the allergists in the area have extremely busy springs.

Although climate plays a significant role with asthma, indoor conditions also are influential. Carpets that are not frequently steam-cleaned, for example, can bring on attacks, as can pet dander and secondhand smoke. (Chipps points out some 20 percent of asthmatics are smokers.) No matter where you live, some of the most prevalent environmental triggers come from indoor air, says Norman Edelman, M.D., medical adviser to the American Lung Association.

It’s All About Control

For decades, people prone to asthma attacks or flare-ups were completely dependent on their inhalers. These L-shaped devices, whether they were over-the-counter Primatene Mist, prescription-only albuterol or some other spray-delivery system, were figurative if not literal lifesavers in moments of respiratory crisis. The wheezing, huddled sufferer, sucking on her inhaler and holding the puff in her lungs for as long as she could, rather grimly reminiscent of someone trying to get high on a marijuana cigarette, was an all-too-common and uncomfortable sight for many friends and relatives of asthmatics.

Nowadays, such short-term, emergency self-medicating should be the exception rather than the rule, as long as the asthmatic works with her doctor in establishing a long-term plan. Many patients benefit greatly from using an Advair Diskus, a round, purple device that debuted six years ago. It dispenses precisely measured doses of medication once or twice a day. Advair controls asthma with a corticosteroid, which eases inflammation; and a bronchodilator, which prevents airway constriction.

Watson says that Advair’s two-fisted approach to asthma control is accomplished with low, very safe doses. He points out that the drug comes in three strengths of corticosteroid (in this case, fluticasone propionate), with the bronchodilator (salmeterol) being constant. I personally recommend a lower number of puffs of a stronger [corticosteroid level], such as one puff, once a day, Watson says. This makes the treatment very simple and easy to step up treatment if the asthma starts up&emdash;and this is much less expensive.

Garcia says that Advair is a popular medication and it’s quite effective. It would be a rare instance when someone with asthma doesn’t get better with Advair, which he also praises as being easy to use. However, just as taking daily vitamins and doing back exercises prove most effective when done daily, Advair (or its generic equivalent) needs to be inhaled once or twice every day for it to prevent asthma attacks or flare-ups. The situation is that a lot of people who have asthma don’t take the asthma medicine that’s been prescribed, Garcia says.

A patient’s not following orders is one of four reasons Chipps gives in explaining why 20 to 30 percent of asthmatics do not respond well to treatment. The other reasons are a genetic predisposition for a lack of response, poor technique in self-administering the medication or, as mentioned before, the patient is a smoker.

Singh, who co-owns S&N Auto Electric in Sacramento, has gained control of his asthma. Under the care of Garcia, he takes twice-daily doses of Advair and supplements that with prednisone and albuterol. He figures his lung capacity is up to 70 percent, a vast improvement over what until a year ago had become a crippling affliction. I was in bad shape, he says. It was hard for me. I couldn’t do everyday work. I was out of breath. I was gasping for air.

Bustos-Hillaire, the respiratory therapist and marathoner, says she keeps her asthma under control with twice-daily doses of Advair. She also uses Singulair, Nasonex nasal spray and the occasional short-term bronchodilator (Xopenex) a half-hour before a race or an intense workout. Also, my home is kept as clean as possible. We have two cats and one dog in our family, but vacuum often.

Asthma is a potentially serious health condition and certainly should be monitored by a physician, Watson advises.

What’s Next?

Among the asthma experts interviewed for this story, Chipps expressed the most optimistic prediction about the future of asthma care. It’s wonderful. Very, very promising, he says. We’ve got a lot of new drugs coming. We’re not quite there (meaning: total control of the disease) yet, but we’re going to get there.

Gershwin of UC Davis anticipates some fine-tuning in the short term. I don’t see anything new in the next two or three years, he says. I can see a better understanding of selecting drugs in the future.

Safer and much simpler allergy shots will play a key role in the future treatment of asthma, Watson believes. He also hopes that doctors and their patients can do a better job of preventing colds and influenza, and that steroid phobia will no longer hinder some asthmatics from taking daily inhalants such as Advair. Genetic testing will someday tell us who is at greatest risk of severe asthma and who may respond, or not, to different treatments, he adds.

Bustos-Hillaire encourages people who suffer from asthma not to let the disease drag them down or interfere with the pursuit of life’s dreams.

I have met a lot of outdoor athletes who have developed asthma symptoms well into their adulthood, some more severe than others, and the common thread is that we don’t abandon our sport but take the medications that have come such a long way to help control the asthma symptoms, she says. Like a coach used to put it, it is like we are running at altitude, but the majority of the time the breathing is good and life is wonderful!          

Asthma in Brief

What It Is&emdash;A chronic disease of the lungs characterized by inflammation of and mucous buildup in the airways, and tightening of the muscles around the airways.

What Triggers It&emdash;Allergens; cigarette smoke and air pollution; dust and chemical odors; viral infections; changes in temperature, humidity or barometric pressure; and exercise.

How To Control It&emdash;Reduce exposure to triggers; monitor the frequency and severity of asthma attacks and incidents; work with a doctor to develop a long-range plan.

Sources: Capital Allergy & Respiratory Disease Center and GlaxoSmithKline    

A Complementary Approach&emdash;

Western medicine is not the only tool for asthmatics in search of control. Acupuncture, an ancient practice that hails from the Far East, also has proven to be effective.

The needles are placed according to the diagnosis, not the symptom, says Roxanne Feher of East West Acupuncture in Roseville. Some of the acupuncture points are classically known to open up the lungs and relieve wheezing. There is one in the chest on the sternum that is commonly used.

Feher spent 12 years as a registered nurse before she trained in Traditional Chinese Medicine and founded East West Acupuncture, which treats about 30 asthmatics a year. It would be a lot more if the public were aware that acupuncture helps asthma, she says. Sometimes, [patients] are able to stop their medications.

But the longer and more severe their asthma has been, the harder that will be to do. She adds that herbs, especially Chinese herbs, can be very beneficial for asthma patients.

To learn more about Feher and her practice, visit eastwestacupuncturecenter.com.

Asthma Resources 

Allergy & Asthma Network Mothers of Asthmatics
aanma.org

American Academy of Allergy, Asthma & Immunology
aaaai.org

American Lung Association
lungusa.org

Asthma and Allergy Foundation of America
aafa.org

Centers for Disease Control and Prevention
cdc.gov

Global Initiative for Asthma
ginasthma.com

National Heart, Lung and Blood Institute

nhlbi.nih.gov/about/naep