Repel the asthma attack
Medication can reduce symptoms, while avoiding triggers can head off flare-ups
People who claim San Diego has no seasons probably do not suffer from allergies or asthma, a chronic disease that inflames the lungs’ airways. While the distinctions among the seasons are less defined here than in other parts of the country, locals with allergies and asthma certainly can tell when it’s the season for wheezing and sneezing.
“In other parts of the country, there are large seasonal pollen exposures – grass pollen and mold spores in the summer,” said Dr. John Kelso, allergist at Scripps Health’s Division of Allergy, Asthma and Immunology. “In San Diego, our pollen is spread over year-round. The seasonal differences are less dramatic.
“Nonetheless, there is a noticeable increase in patients complaining of nasal allergy symptoms this time of year likely associated with some increase in tree pollen and grass pollen counts,” Kelso continued. “Since allergy is an important trigger for asthma, this then also leads to some increase in asthma symptoms this time of year as well.”
In addition to dealing with pollen all year round, San Diegans, like all other people with the disease, face many other factors that cause an asthma flare-up or attack. These factors, called triggers, can range from dust mites and pet dander to tobacco smoke.
About 25 million Americans suffer from asthma, many of them children, according to the U.S. Centers for Disease Control. In 2010, the disease sent more than 11,000 people to the emergency departments in San Diego alone, says California Breathing.
Once you get asthma, the likelihood is you’ll have it the rest of your life. However, it’s possible to manage asthma and live a normal life.
“We’ve established the process to identify patients with asthma, outreach to them and do assessments,” said Christine Tedeschi, manager of Sharp Rees-Stealy’s Ambulatory Disease Management Programs, which help people prevent chronic diseases, including asthma, from ruling their lives. “We also look at whether asthma is controlled or not controlled. We help individuals and families manage triggers to have more days without symptoms, fewer days that adults miss work or children miss school.”
Statistics show that one in 12 people in the U.S. now has asthma, up from one out of 14 in 2001, according to the CDC’s report, “Asthma in the U.S.: Growing Every Year.” The cases of asthma seem to be increasing at a lower rate, but the medical profession is concerned with its steady rise, along with the increase in food allergy and allergy-related diseases like hay fever.
“The theory (explaining the increase) that has the most weight is the hygiene hypothesis,” Kelso said. “If you grew up with farm animals, your chance of getting asthma is reduced. Also, having older siblings protects people from allergies and asthma.”
Some medical experts believe that growing up in more hygienic environments doesn’t sufficiently strengthen the immune system, making many of us more susceptible to disease and allergies.
Even so, a big part of getting asthma has to do with genetics. According to Ohio’s Cleveland Clinic, people with a family history of asthma have an increased risk of developing the disease. But it’s more than just a history of asthma.
“An allergy evaluation is important,” Kelso said. “Eczema, food allergy, hay fever and asthma are lumped together because if a patient has one, it’s a threefold chance that they have the other. They are genetically linked and, also, in terms of family history. We see people who have asthma and they say: ‘No one in my family has asthma.’ But if someone in their family had hay fever, that’s linked to asthma.”
While diagnosis can be tricky, spirometry helps doctors determine a patient’s lung function.
“Spirometry is a critically important test,” Kelso said. “It’s quick and easy – patient just breathes into a machine a few times. If it’s abnormal, they wait a few minutes, inhale an asthma medication and use a bronchodilator. If the second test shows improvement, that’s an ironclad diagnosis. But spirometry doesn’t catch people with low symptoms or no symptoms when taking the test.”
Another test is the methacholine challenge, in which the patient inhales the medication methacholine in increasing doses to see if there’s a change in the patient’s pulmonary function. If a diagnosis is still not clear, a physician may prescribe an inhaled corticosteroid. If it helps significantly, the likely diagnosis is asthma.
Once asthma is diagnosed, the next step is knowing what starts an attack. It takes careful monitoring to identify a person’s triggers.
“We help patients figure out how they can eliminate that trigger,” Tedeschi said. “A common example is the dust-mite trigger. Covering bedding and bed pillows and washing bed linens in hot water can help avoid that trigger. There’s a whole cascade of triggers both in the home and outside.”
Exercise both acts as a trigger and a deterrent of asthma, because it maintains good health and helps avoid obesity.
“Some patients may have bronchospasms induced by exercise,” Tedeschi said. “Some people can pre-medicate, for instance, to help them exercise without a flare. We encourage them to work with their physician.”
In recent years, more and more experts have linked asthma and obesity. In fact, Kelso thinks the increase of asthma could be partly due to the obesity epidemic.
“It’s a chicken and egg thing with asthma,” Kelso said. “A patient may say ‘every time I run I start wheezing, so I won’t run.’ That may help cause obesity. But it’s not the entire explanation.”
It’s been suggested that obesity is also an inflammatory disease. Gastroesophageal reflux disease (GERD) and sleep apnea, both obesity-related, can exacerbate asthma. They all play into each other, Kelso said.
Identifying and determining triggers is as important as asthma medications. Sharp Rees-Stealy has started a pilot program for an app with a GPS function to help track flare-ups and their triggers. But until it’s widely available, people with asthma have to use the trial-and-error method. Both triggers and the severity of the disease can fluctuate.
“You may or may not see asthma changing over a lifetime,” Tedeschi said. “Children, for example, have allergies that are triggers and they can change over the years. Once asthma’s well controlled for a period of time, you and your physician can see if it would be appropriate to ratchet down your medications to very little or maybe no meds.”
Long-term control medications are key to reducing the inflammation in the lung’s airways. Among the most common are inhaled corticosteroids, which cause few side effects because they aren’t ingested. During a flare-up, quick-relief inhalers and bronchodilators can open swollen airways.
“The biggest reason people end up in emergency rooms is that they weren’t using their inhalers,” said Kathy Knippel, case manager for the asthma and COPD program at Sharp Rees-Stealy. “They have the medication, understand it and feel good. But with time, it’s easy to forget or think they no longer need it.”
For very serious asthma cases, some doctors are trying a procedure called thermoplasty.
“In a thermoplasty, the patient is sedated, a tube is inserted, heat is applied to their airways,” Kelso said. “It is a very, very new technique. It’s FDA-approved and a handful of studies say it’s successful.”
Do you have asthma?
According to Dr. John Kelso of Scripps Health’s Allergy Asthma and Immunology, medical detective work is required in determining a diagnosis of asthma. The symptoms are:
• Coughing and/or wheezing
• And/or chest tightness
• And/or shortness of breath.
The “and/or” is key. A person with asthma doesn’t necessarily have all these symptoms.
Triggers are factors that make asthma flare up or worsen. They include:
•Season and climate changes
•Smoke from burning wood or grass
•Strong scents, like perfumes
•Viral respiratory infections
•Exercise (without pre-medicating or proper warm-up)
•Strong emotional reactions such as crying or laughing hard
Asthma in San Diego
• 12.3 percent of San Diego County’s population has asthma.
• 17.2 percent of San Diego adults with asthma missed work due to asthma in 2005.
• 24.9 percent of San Diego children with asthma missed school because of asthma in 2005.
Asthma in the U.S.
• About 25 million Americans suffer from asthma.
• About nine people die from asthma each day.
• Asthma is responsible for 2 million emergency department visits each year in the United States.
• More than 10.5 million school days are missed each year in the U.S. because of asthma.
• Black Americans are two to three times more likely to die from asthma than any other racial or ethnic group.
For more information
• American Lung Association
• American Academy of Allergy, Asthma & Immunology
• Allergy & Asthma Network Mothers of Asthmatics (AANMA)
• California Air Resources Board, Asthma and Air Pollution
• Cleveland Clinic
• Mayo Clinic
• San Diego Regional Asthma Coalition
• Scripps Health
• U.S. Environmental Protection Agency
• U.S. Centers for Disease Control
Beth Wood is a San Diego-based writer.