Asthma
Asthma, one of our most common diseases. Simply described, asthma is reversible obstruction of the airways,
caused by muscle spasm or mucus blocking or both. In chronic
asthma, the airways may become structurally narrowed by scarring.
Prevention of this "remodeling" of the airways
is a major goal of the new approach to asthma treatment.
The most characteristic (but not universal) asthma symptom is
wheezing, which is a musical sound like a faint whistle, produced
usually while one is exhaling. Lack of breath, coughing, bringing
up mucus, and a feeling of tightness in the chest are also common symptoms.
The airways of the lungs are similar to the branches on a
tree - an upside-down tree. Air moves through the main
trunk of the tree (the trachea, or windpipe) into two main branches
(the left and right bronchi) to the lungs. The bronchi, which are
relatively large tubes, subdivide into smaller and smaller branches.
The smallest, the bronchioles, lead into clusters of tiny sacs in
lungs, called alveoli. There are millions of alveoli, and it is here
that air is exchanged with the blood.
Oxygen enters the blood;
carbon dioxide is removed and exhaled.
In a typical asthma reaction, lung muscle tissue surrounding the
small breathing tubes tightens; mucus production in the cells lining
the airways increases; and the bronchial walls swell and become
inflamed. Sometimes the mucus forms small plugs that clog the
airways and take the shape of the air passages. When these mucus
plugs are coughed up, they resemble bits of string or rope, ranging
in size from about the diameter of apiece of spaghetti to the diameter of a pencil.
With all this happening, normal airflow is reduced, and in
particular exhalation is incomplete. This results in a feeling of
dyspnea, or shortness of breath, and sometimes a feeling that one
cannot breathe at all (the term asthma derives from a Greek word
meaning "panting," or "breathlessness"). Asthma can flare up
anytime of the day or night, and many asthmatics wake up in the early
morning hours with difficulty breathing.
The mechanisms and physiology underlying an asthma
reaction are not entirely understood, but studies indicate that in the
person predisposed to asthma the mucous membrane cells lining
the lungs may not be as tightly packed as is normal, allowing
allergens and other molecules to get below the membrane to where the
mast cells are. The mast cells may then release chemical mediators,
causing asthma symptoms.
Also, people with asthma have an inadequate supply of
a chemical called CAMP (cyclic adenosine-3',5'-monophosphate). CAMP,
which is found in the body's cells, works to prevent muscle
constriction in the lungs; it also inhibits the tendency of mast cells to
release histamine and other chemical mediators that produce
inflammatory and allergic reactions, including mucus production.
One theory about the cause of asthma holds that people prone
to this disease are affected by a dysfunction of one part of the
nervous system. In the autonomic nervous system (which governs our
body organs) there are two opposing subsystems: the sympathetic
and the parasympathetic systems. They have opposing actions and
should balance one another. One slows the heart, one quickens it;
one opens airways, one closes them; and so on. In the sympathetic nervous system, there are so-called
beta-adrenergic receptors, which respond to epinephrine
(adrenaline) stimulation by relaxing the airways and by increasing CAMP,
levels in the lungs. It is believed that in an asthmatic these
beta-adrenergic receptors may not function properly, allowing the
contrary reaction of the parasympathetic nervous
system-constriction of the airways-to take place unchecked, unopposed.
Control of the inflammation is essential to controlling the disease.
Inflammation is a normal physical reaction to trauma, a
reaction that usually is curative but sometimes causes severe problems.
Familiar types of inflammation include the swelling, redness, and
pain that follow, say, a knife cut on the hand or overexposure to
the sun. The inflammation can be quite painful for a day or two,
but it is part of the healing process.
When the skin tissue is injured, certain cells release chemicals
that recruit inflammatory cells to rush to the area to begin healing.
This healing involves new tissue growth, often with scarring. Inflammation in the airways, as in asthma, is not a desirable
type of inflammation. The process causes a sloughing-off of the
cells lining the airways. Collagen, a substance produced by the
body for scar formation (among other purposes) is deposited along
the outside of the airways. Edema (swelling) affects the airways and surrounding tissues.
The cells responsible for these reactions include mast cells,
which, as we have said, play a major role in immune-system activity,
and various white blood cells. Among the white blood cells are neutrophils (especially in severe asthma), eosinophils (involved in
allergic and related reactions), and possibly TH2-type lymphocytes.
Asthma is not the only disease related to inflammation.
Rheumatoid arthritis is inflammation of the joints;
hepatitis involves
inflammation of the liver; diabetes may stem from inflammation that
damages the pancreas. Inflammation is also implicated in
heart
attack, and following a stroke, it is the inflammation and swelling
during the first forty-eight hours that are critical to the outcome.
With asthma, inflammation of the airways makes them
hypersensitive to any irritation and liable to constrict and pinch off the
flow of air. Swelling and mucus production also reduce air flow.
Perhaps most important, scarring can actually remodel the
structure of the airways for the worse.
One of the most important areas of current asthma research is
the question of whether treatment with anti-inflammatory
medications can prevent the undesirable scarring and remodeling of the
airways. Parallels with the treatment of other inflammatory
diseases, such as rheumatoid arthritis, suggest that the answer is yes.
Control of inflammation should prevent airway remodeling.
Asthma attacks can be brought on by
exercise, cold air, aspirin or other nonsteroidal anti-inflammatory
medications, environmental pollutants, odors or irritants, smoking or
exposure to cigarette smoke, infection, and laughing. It can also be
related to gastro esophageal reflux, a fairly common problem,
especially among older people. Acidic fluid from the stomach moves
upward into the esophagus, which in some instances causes asthma to worsen.
One clue to diagnosing the kind of asthma resulting from
gastro esophageal reflux is that the attacks come mostly at night
and usually affect older people. When one is lying down, the stomach
contents can more easily flow into the esophagus-gravity isn't
helping to keep the fluid in the stomach. But another, even more
common cause of nocturnal asthma is a natural reduction in pulmonary function. This occurs in all people at night and in the early
morning but is exaggerated in asthmatics.
The symptoms of asthma may be confused with ordinary bronchitis
or a cold or hay fever. In the case of asthma that is caused by
exercise, you may think that you are extremely out of shape.
Unfortunately, the experience of an asthma attack during or following
physical activity is likely to discourage further efforts toward physical conditioning.
Any of the following symptoms should prompt you to call a doctor:
- shortness of breath, whether following exercise, in the
morning, in the middle of the night, or indeed at any time
- wheezing
- coughing up phlegm, especially if it is discolored or bloody
- persistent cough
- chest tightness or pain
In taking a medical history, the doctor should ask you about
similar respiratory episodes in the past. Often patients report a
history of frequent "bronchitis" when growing up.
Through a physical exam, chest X ray or CT scan, and tests, the
doctor will focus on determining whether the breathing difficulties
are the result of asthma, heart disease, emphysema,
lung tumor,
cystic fibrosis (in young children), hypersensitivity pneumonitis (a
dangerous, progressive condition affecting the lungs in some cases
of untreated allergy), infection, or some other cause.
A disease sometimes associated with asthma is allergic
bronchopulmonary aspergillosis, which can sometimes be detected by chest
X ray or blood tests and often shows a fever accompanying the
asthma attacks. This disease, caused by a
fungus, requires a
somewhat different approach to treatment.
In the physical examination, especially with children, one sees
at times a distension of the chest resulting from asthma. The
distension is caused by the asthmatic's reduced ability to exhale air
from the lungs. The physician may also hear wheezing when
listening to the chest. Examination of the nose may reveal nasal
polyps or evidence of allergic rhinitis.
The pulmonary function test is often the key to
making the diagnosis. The test will usually detect difficulty in
exhaling air from the lungs. The diagnosis of asthma will become
almost certain if the difficulty in exhaling is diminished after
treatment with a bronchodilator (patients with emphysema are not
helped much by a bronchodilator).
If the diagnosis is still unclear, a mecholyl challenge test may be
recommended. This test involves inhaling increasing
concentrations of methacholine while changes in pulmonary function are
monitored. Below a certain concentration, the nonasthmatic will
not show any reaction, but a person with asthma and certain other
conditions, such as hay fever, will begin to wheeze and show a
decrease in pulmonary function.
- Allergens
- If asthma is diagnosed, the next step is to determine what triggers
the attacks. If the asthma is related to an allergy, this is often
apparent in the patient's history and can be confirmed by skin tests
or RAST, a blood test.
In children under age three, as compared with older children and adults, pollen
allergy is less commonly the cause of asthma.
Allergies triggered by non-seasonal factors, such as dust or mold
in the home, can become a problem and lead to asthma at an early
age, even among toddlers.
In patients aged five to fifty, allergy of some sort often plays a
significant role in causing their asthma. After age fifty, allergy is
less likely to be involved. But this is not a hard and fast rule. There
are people who develop allergic asthma in their seventies, and
there are young children whose asthma is not allergic.
The patient's history often reveals what is causing the asthma. Your doctor will
ask if allergies run in your family. Are your asthma attacks more likely to
occur in some places than others? At the office? And so on.
Sometimes the probable cause is fairly obvious. The patient
reports spending a weekend at a house with a cat and getting an
attack of asthma. Or the patient's asthma flares up after eating
Chinese food, suggesting sensitivity to monosodium glutamate or sulfites.
In children under age three, food allergies tend to be as
important as allergies to inhalants, such as dust-mite allergen, cat dander,
mold spores, and pollen. From age three until adulthood, inhalants
are much more likely culprits.
- Food allergies
- When foods are associated with childhood asthma, the foods most
often at fault are milk, wheat, corn, and eggs.
Among adults, foods are even less often the cause of asthma,
but the possibility cannot be ignored. Sometimes the relationship between asthma
and food allergy is difficult to pinpoint.
A sensitivity to aspirin and other anti-inflammatories often
causes problems for asthmatics. Another occasional cause of
asthma attacks among adults is a sensitivity to food additives,
including FD&C Yellow #5 (tartrazine) and sulfites, used as
coloring and preservatives in a wide range of foods, such as salad
dressing, beer, cider, potato chips, and so on.
- Other allergens
- You should be aware that your asthma may be caused by some
substance that you use in your work or hobby. There is a phenomenon
called baker's asthma, caused by a sensitivity to flour. And one
patient suffered weekly attacks of asthma, which she and her
doctor finally realized always occurred a few hours after she had
dried the family laundry. She was extremely sensitive to the fabric
softener. The family settled for less-soft laundry, and the patient
had no more attacks.
Some medications may make asthma worse, so your doctor should
be aware, as always, of any medicine that you take at all frequently.
- Aspergillus
- Asthma can be seriously complicated by infection with the Aspergillus
fungus. This common fungus is sometimes involved in baker's
asthma, for example. It proliferates in unclean humidifying systems.
Aspergillus infections usually affect only patients already
weakened, for example, those with abnormal immune systems or
cancer. These
infections are treated with fungicidal medications. Allergic bronchopulmonary aspergillosis (ABPA) can turn moderate asthma into a fatal
illness even in the absence of other serious problems.
Essentially, ABPA is an allergic reaction to Aspergillus
fungi
growing in the bronchial tubes. When this happens, the asthma
patient suddenly begins to require more frequent doses of steroids
to prevent breathing distress and begins to suffer from fever and at
times coughs up brown plugs of mucus. A chest X ray is likely to
show signs of pneumonia.
If a timely diagnosis is not made, the disease may progress to the
point that the lungs become fibrotic (scarred). Steroids no longer relieve the
asthmatic symptoms. The patient suffers chronic breathing problems similar to emphysema, and may eventually succumb to
the disease.
Diagnosis is made on the basis of the clinical history of the
disease; a positive result in skin testing for sensitivity to Aspergillus
fumigatus; a high level of the allergy antibody, IgE, in the blood, as
well as an elevated eosinophil count and the presence of antibodies
to Aspergillus. Finally, a bronchogram or CAT scan may reveal a
widening of portions of the air passages.
Aspergillus is
most often found in crawl spaces and basements, especially those
with dirt floors (it thrives in soil). Special attention must be given
to humidifying and air-conditioning systems. An asthmatic who is
being exposed to Aspergillus associated with flour or grain at work may have to
change jobs.
With asthma, it can sometimes be very difficult to figure out
whether symptoms you are feeling are serious or not. Feelings of
anxiety, rapid heartbeat, breathlessness, or nervousness can be due
to lack of oxygen because of the asthma, or to the effects of certain
medications, or to anxiety or to all three causes.
- Acute attacks
- Asthma attacks vary from person to person and time to time. An
acute attack can begin suddenly, peaking in minutes, or develop
more gradually over hours or days. Death sometimes occurs
because a patient does riot realize how stressful prolonged
respiratory difficulty can be for the functioning of the entire body.
The earlier you are aware that you may be in trouble, the better
you will be able to manage the attack. You should also have a plan
worked out with your physician on how to handle emergencies and
who will cover if the physician is not available. Your doctor may
advise you to keep a peak-flow meter at home to test respiratory
function yourself. A drop in peak flow may be a warning that an
attack is approaching and that an adjustment in medication is needed.
You should know what medicines to take or increase in bad
times, and should always be able to reach your doctor to discuss
changes in medication and if a trip to an emergency room may be in order.
You should discuss with your physician what signs to look for that may indicate
that your asthma is getting worse. The following general rules were formulated
in 1997 by the National Institutes of Health in "Guidelines for the Diagnosis
and Management of Asthma."
- You begin to use your short-acting beta 2 agonist inhaler
after not having needed it for a while or you start to use it more
frequently than is typical for you.
- You finish a canister of a short-acting beta 2 agonist inhaler
in a month.
- The short-acting beta 2 agonist inhaler does not provide you
with the relief it used to.
- You awaken in the morning needing to use your short-acting
beta 2 agonist inhaler because of chest tightness or you begin to
awaken at night to use it.
- Everyday activities leave you winded or breathless.
- You start coughing, wheezing, or having shortness of breath
or begin producing sputum.
- Your peak-flow number goes down.
If you experience any of these changes, do not wait until there
is a crisis-call your doctor.
Your doctor should help you to learn how to manage your
asthma, avoid allergens and irritants, and deal with any
unexpectedly severe asthma attack.
- Mild intermittent asthma
- You have mild intermittent asthma if you experience symptoms no more than
twice per week, with normal breathing otherwise. The flare-ups of symptoms are
brief (hours to a few days) with varying intensity. Nocturnal symptoms occur no
more than twice a month.
For this level of asthma, no long-term medications are needed;
in other words, no inhaled corticosteroids, mast-cell stabilizers, or
long-acting bronchodilators. Quick-relief measures are
appropriate, that is, inhaled beta 2 agonists used no more than twice a week.
- Mild persistent asthma
- You have mild persistent asthma if your symptoms occur more
than twice a week but not every day. Flare-ups may interfere with
your normal activities. Nocturnal symptoms appear more than
twice a month but not more than once a week.
For this level of asthma, you should be taking one long-term
control medication that is used daily. This could be a low-dose
inhaled corticosteroid or cromolyn (Intal) or nedocromil (Tilade).
Children usually begin with a trial of Intal or Tilade. Leukotriene
modifiers may be recommended for patients age twelve or older or
six or older for Singulair. Theophylline is an alternative, but it is
much less preferred these days.
You should have a quick-relief medication, that is, a short-acting
beta 2 agonist, which you can use as needed. If
you are turning more and frequently to the quick relief, you may
need instead an additional long-term medication.
You should learn how to use a peak-flow meter as part of your
general management plan for the asthma.
- Moderate persistent asthma
- You have moderate persistent asthma if the disease limits your
physical activity and asthma attacks, or exacerbations, are frequent
(two or more times per week), bothering you at night as well as
during the day.
Long-term control should be provided by either medium-dose
inhaled corticosteroids or a somewhat lower dose combined with a
long-acting bronchodilator (Serevent, Proventil Repetabs, Volmax,
or sustained-release theophylline), especially for relief of nocturnal
symptoms; at this time Serevent is the medication of choice, far superior to
the oral preparations. Quick relief can be provided by inhaled beta
2 agonists, but if they are used on a daily basis or with increasing
frequency, more long-term control is indicated. Leukotriene modifiers
may also be recommended.
- Severe persistent asthma
- You have severe persistent asthma if you have continual symptoms
that limit physical activity, and flare-ups, or exacerbations, occur
frequently. Nocturnal symptoms are also frequent. Tests of
pulmonary function indicate that the disease is severe.
For long-term control, you may be prescribed a high dose of
inhaled corticosteroids and a long-acting bronchodilator and oral
corticosteroids. Your doctor should encourage a controlled
reduction in the use of oral corticosteroids whenever possible. This
weaning process can be abandoned when necessary, and then
started over. You can use the beta 2 agonists for quick relief, keeping
in mind that increased use indicates that a change is needed in
long-term control. Your doctor may also recommend leukotriene
modifiers.
You should use a peak-flow meter to monitor pulmonary function.
Supplements and herbs
The supplements are meant to
complement conventional asthma therapy.
Never stop taking medication prescribed for
asthma without consulting your doctor. People
with asthma are often deficient in key
nutrients, especially vitamin C,
magnesium, and
vitamin B6. Vitamin C, the major antioxidant present in the lining of the
respiratory tract, appears to act immediately to combat inhaled oxidants.
In addition, it may halt an allergic reaction by preventing the cells from
releasing histamine. Furthermore, vitamin C is very effective for exercise
induced asthma; according to various studies, taking 2,000 mg before
a workout may even thwart an asthma attack. As for the mineral
magnesium, it can prevent attacks by inhibiting the contraction of the bronchial
muscles. Other studies have shown that vitamin B6 supplements reduce
wheezing and other asthma symptoms.
The flavonoid
quercetin has two main effects: If inhibits the release
of histamine, and as an antioxidant, it neutralizes unstable oxygen
molecules, which can cause bronchial inflammation. The herb
ephedra (also
called Ma huang) can widen respiratory passages. It appears to work best
when used with herbal products that bring up phlegm, such as
licorice
or horehound. (Don't use licorice for longer than a month.) But ephedra
has many side effects; for asthma, it is best taken under a doctor's care.
Homeopathy
Depending on the intensity of symptoms, remedies can be taken every
half hour initially, cutting back to hourly, then every two hours or less. If
the remedy is correct, results should be seen within 30 minutes. For
longer term management, remedies may be used one to three times daily.
- Arsenicum album
Asthma after colds, bronchitis or
allergy to dust, smoke, animals, etc.
Wheezing, tightness of chest. Short of breath, with sweating. Very chilly.
Thirst for small sips. Burning in chest. Anxious, restless, fear of death.
Worse: after midnight or 1-2 a.m., lying, cold, motion, every 2 weeks.
Better: sitting upright or bent forward, heat, warm drinks, hot compress.
- Ipecac
Rattling cough, hard to hawk up mucus. Retching or
vomiting. Bronchitis.
Wheezing, heavy and constricted chest. Short of breath, suffocation.
Anxious, pale; cold and clammy. No thirst. Nausea-but clean tongue.
Worse: heat, damp, humidity, motion or exertion, night, overeating,
lying, rich food. Better: open air, rest, sitting up, standing, expectoration.
- Kall carb
Difficult, wheezing breathing. Stitching pains in chest, through to back.
Asthma with nausea or headache. Sweaty, weak. Children or elderly.
Asthma alternates with diarrhea or vertigo. Aversion to solitude.
Worse: 2-4 a.m., cold air, drafts, least motion, walking, at menses, lying,
open air, touch Better: sitting up or bending forward, rocking, warmth.
- Lobelia
Constricted chest, short of breath. Hyperventilation. Much rattling
mucus.
Attacks with faint feeling in pit of stomach, prickling allover. Yawning.
Nausea, constant salivation, faintness, cold sweats. Extremely fearful.
Worse: exertion, after sleep, tobacco, touch, cold bathing,
alcohol, tea.
Better: warmth, towards evening, eating a little, rapid walking, beer.
- Nat sulph
Wheezing, shortness of breath, heavy pressure in chest. Sore, raw chest.
Cough with thick yellow-green mucus, rattling in chest. Empty feeling.
Stitching chest pains. Diarrhea with asthma. Depressed, suicidal moods.
Worse: damp in all forms (weather, houses, locations), slight exertion
4-5 a.m., pressure. Better: dry, open air, sitting up, holding chest, rest.
What else you can do
- Keep your home clear of dust and pollen. Avoid cigarette smoke.
- Stay away from cats; their dander is highly allergenic.
- Remain calm. Managing stress helps fight asthma.
- Treat colds and the flu promptly to reduce the chances of an attack.
- Wear a scarf over your mouth and nose to warm the cold winter air.
- Keep an asthma diary to help you determine your asthma triggers.
- Drink at least eight glasses of water a day to keep mucus loose.
Usual dosage
-
- Vitamin C
- 1,000 mg 3 times a day.
Reduce dose if diarrhea develops.
- Magnesium
- 400 mg twice a day.
Take for 6 weeks to achieve adequate levels.
- Vitamin B6
- 50 mg twice a day.
Especially important if you take the prescription asthma medication theophylline.
- Quercetin
- 500 mg 3 times a day.
Use 20 minutes before meals; often sold with vitamin C.
- Ephedra
- 130 mg standardized extract 3 times a day.
May cause
insomnia. Don't use if
you have high blood
pressure, heart disease, or anxiety or take an MAO inhibitor.
- Licorice
- 200 mg standardized extract 3 times a day.
Can raise blood pressure; see your doctor before taking.
For kids
Herbal treatments for asthma are directed at preventing or supporting recovery
from an asthma attack, rather than treating an acute episode. In the event of an
acute asthma attack, seek immediate medical care for your child.
See age-appropriate dosages of herbal remedies
- Astragalus (Astragalus membranaceous) is a Chinese herb that helps to increase
what the Chinese call wei chi, or a person's own protective energy. It also helps
strengthen the lungs. Give your child one dose, twice a day, for two weeks out of
every month, for six months following an asthma attack.
Note: This herb should not be given if a fever or any other signs of infection are
present.
- Licorice root soothes the lungs and helps to strengthen adrenal function. Give
your child one dose, once a day, every other month, for six months after an asthma attack.
Note: This herb should not be given to a child with high blood pressure.
- Minor bupleurum formula is a Chinese herbal combination that is helpful in
restoring and building the immune system. Give your child one dose daily for
three months following an asthma attack. Stop for three months, then repeat.
Note: Minor bupleurum should not be given to a child with a fever or any other
sign of an acute infection.
More useful herbs
|
