If you want to know what an asthma attack feels like, ask someone to sit on your chest and stay there after you've exhaled. After a minute or so, a deep breath will be impossible, so you'll try to move the inert weight by sucking bursts of air into your collapsed bronchial tubes. When that doesn't work-and it won't-your mind will start telling you that you won't be able to breathe again. And that's when you'll start to panic.
"It doesn't necessarily hurt," says Sarasota County Commissioner Shannon Staub, an asthma sufferer. "But it's scary. It's total fear."
Asthma is a chronic inflammation of the airways that causes recurrent episodes of wheezing, breathlessness, chest tightness and cough. The Asthma & Allergy Foundation of America estimates that 14.5 million Americans suffer from the condition, including 4.8 million children. According to the National Center for Health Statistics (NCHS), asthma sends patients to their doctors 14 million times a year and to emergency rooms more than two million times, hospitalizing half a million of them annually. It costs the U.S. more than $8 billion every year in direct health care and nearly $5 billion in lost productivity.
And it's a killer, taking some 6,000 lives every year. The mortality rate for asthma has risen more than 100 percent over the past two decades. Females are twice as likely to die from it as males, and African-Americans die from asthma at nearly double the rate of Caucasians.
Like the common cold, it can't be prevented because no one knows for sure what causes it. The suspects are myriad, from viral and bacterial disease to allergies and chemical irritants. Even the flu can bring on a patient's first attack. And it can disappear-or worsen-as mysteriously as it appears.
"Asthma is just one specific physiological circumstance that can be brought on by different environmental triggers," explains Dr. Richard Krumholz, a board-certified allergist and pulmonologist with Allergy & Asthma Care in Sarasota. "It's really just a descriptive term that refers to the wheezing noise one makes with breathing."
Regardless of figures from the NCHS, Krumholz isn't sure that the "absolute rate" of asthma has increased. He thinks doctors are just doing a better job diagnosing it, and as more people gain access to health care, more cases come to the attention of the medical community. Scientists link environmental factors, such as air pollution, to childhood asthma, since almost 25 percent of American children who develop the condition live in areas where ozone levels are above the national standard. It is now the No. 1 chronic disease of children, affecting one in every 20.
Genetics also play some role. "If a parent has it, it does predispose children," says Krumholz. Plus, he adds, "The allergic disorders that cause the overwhelming majority of childhood asthma are genetically based."
A more sinister cause may be our own immunity, or growing lack of it. An article that appeared in the Atlantic Monthly details the belief by some scientists that Western immunizations, hyper-cleanliness and heavy antibiotic use in young children may be hampering their ability to build immunity to chronic lung disease. "The whole field is circulating through a revolution," says Dr. Fred Bloom, an allergist with Allergy Associates in Sarasota. "Up until two years ago, we were telling parents to keep their children away from small animals." Now, he says, studies are showing that children who grow up with pets experience fewer allergies than those who don't. "And kids born on farms have less problems than those born into spotless high-rise condos."
The good news is that asthma deaths among children are rare. Krumholz says one third of those who develop asthma outgrow it. One third get worse and require more extensive treatment as adults, and one third stay the same throughout their lives.
Adult onset asthma is more complicated. "It's not rare and probably increasing in frequency," says Dr. Bruce Fleegler, a pulmonary and critical care physician at Lung Associates of Sarasota. Often linked to environmental irritants, adult asthma "requires more intense treatment and is more persistent," says Fleegler.
Staub has lived with asthma for nearly 30 years, experiencing it for the first time in Canada, where she lived for several years before moving to Sarasota. Her symptoms were triggered by aromas: heavy musk colognes and chemical odors. The fumes she encountered during a tour through a plastics extrusion plant in Canada sent her to the emergency room.
Adults with asthma experience problems year-round, especially in the winter, when cold air constricts airways even further. They also face problems from occupational asthma, a condition that occurs when the airways overreact to dusts, vapors, gases or fumes that exist in the workplace. The U.S. Department of Labor estimates that 11 million workers face exposure to numerous agents known to cause asthma, including nearly 600,000 workers exposed to grain dust and 1.4 million health care workers exposed to latex products.
Even exercise can be a culprit in children or adults who already have a propensity to be asthmatic, according to Krumholz. Any abrupt increase of air over the bronchial tubes can create problems. "This should not affect their mobility, however," says Krumholz. "If it's being treating properly, physical activity shouldn't bother asthmatics at all. In fact, it's better if they can reap the benefits of exercise and avoid the psychological stigma that some people attach to the condition." While Staub's asthma did initially limit her activities, she was able to resume them after treatment with Krumholz.
But asthma has psychological affects as well. Even though she hasn't had an attack in two years, Staub keeps an inhaler at home and in her pocketbook, just in case. "It never leaves the back of your mind that it could happen," she says. Like the time Staub visited a remote Caribbean island that had no medical facilities. The minute she lit the cottage's gas stove, the fumes threw her into a full-blown attack. "It was the first time I thought I wasn't going to be able to breathe again," she remembers. She was forced to leave the island to seek help.
Being close to treatment is one thing. Determining you have asthma is another. Like Staub, who attributed her problems to bronchitis, many people suffer for years with what they believe is common illness. A Canadian physician finally diagnosed Staub's asthma, but only after Krumholz prescribed allergy shots did her symptoms abate for good.
Bloom says the difference between the common cold or flu and asthma is recurrence. "If it keeps coming back and isn't associated with fever, it may be asthma," he says. General practitioners can diagnose and treat many cases by analyzing a patient's history and then performing a physical exam and simple pulmonary function testing. But if initial treatments don't work, follow up with a pulmonologist or an allergist.
It's also vital to determine what triggers will set off an attack, be it a chemical irritant, physical exertion, or even the air outside your house.
A trigger specific to our region is red tide, a naturally occurring algae bloom that contains toxins fatal to fish and harmful to humans with chronic lung conditions. Many locals suffer no more than itchy eyes and a dry, hacking cough. For those with asthma, the effects can be much worse.
In conjunction with the National Institute for Environmental Health Sciences (a division of the National Institutes of Health), Sarasota's own Mote Marine Laboratory has been conducting research on the possible link between asthma outbreaks and red tide. They hope their three-year study will help develop a test that can identify red tide toxin in the bloodstream, much the same way a common swab test can detect strep bacteria in a doctor's office.
This would be especially useful for tourists, says Dr. Barbara Kirkpatrick, a staff scientist at Mote. "If a visiting patient comes into a doctor's office or the emergency room with symptoms of asthma, it would be great to have a test that immediately clarifies the trigger as red tide."
Such a test would be another victory in a decade-long reversal of the way doctors treat asthma. "Originally, we thought asthma was an intermittent disease," says Krumholz. "We now know that it is actually a chronic inflammatory bronchial disease." Krumholz says new medicines target the inflammation instead of just halting an attack.
Over the past decade, researchers have learned that fluctuations in human eosinophil cells can predict an attack weeks in advance, and such attacks can often be prevented with proper treatment.
"Ten years ago I would have had four or five patients in the hospital with asthma," says Krumholz. "Today I have none." But he stressed that people with severe asthma should be on daily medication.
Many asthma cases are reversible if diagnosed and treated, but the damage the disease causes to lungs can become permanent if untreated. "If you need more than an inhaler twice a week," says Fleegler, "you need to be on daily medication." (At one time, Staub was using an inhaler twice a day and taking oral medications.)
Bloom says today's inhaled steroids have none of the undesirable side effects of traditional oral steroids. New, non-steroidal drugs, like R411 from Roche, target the inflammatory process underlying asthma and have proven effective in animals; in pre-clinical studies, R411 appeared much more effective than either Flovent or Singular. Other drugs that require only a monthly injection are also in development.
"Properly treated," says Krumholz, "asthma can be essentially cured. It can certainly be brought under almost complete control." Knowing that can help a lot of people breathe easier.
ASTHMA IN SARASOTA
Poor air quality and lots of allergens make our city asthma-prone.
In Sarasota, asthma affects nearly 3,000 children and more than 14,000 adults-and surprisingly, part of the problem is the air we breathe.
The American Lung Association's "State of the Air 2002" gives Sarasota an "F" grade for unhealthy air for the period of 1998-2000. Kim Titus, regional manager for the local chapter, says the poor grade can be partially attributed to smoke from wildfires that plagued the region during our recent drought. But she adds, "We also have 'blow-in' pollution from large power plants nearby and exhaust from our own local traffic."
No Florida counties got a grade of "A." The only ones scoring a "B" were Baker, Leon and Saint Lucie. And even with an "F," says Titus, Sarasota is not among the state's 25 worst cities. Actually, with only 5.7 percent of its residents (some 740,000) reporting asthma, Florida has one of the lowest populations of asthma sufferers in the country.
But this figure is misleading. "There are lots of variables," says Titus. "Portions of the population go undiagnosed, and especially in a transient state such as Florida, seasonal residents may be receiving their health care in Northern states."
That may explain low numbers in a state where environmental allergens far outlast those in other parts of the country. "Instead of a two- to three-week tree pollinating season, we have a three- to four-month season," says allergist Dr. Richard Krumholz. "We also have a six-month grass pollinating season."
Medical professionals agree that pollution aggravates asthma symptoms, so stay alert to weather conditions that can exacerbate pollution in your area. Check local television weather reports before venturing outside, and heed this list of tips from the American Lung Association on high pollution days.
Avoid exercise and strenuous outdoor activity during midday or afternoon, when ozone levels are highest.
Avoid congested streets and rush-hour traffic that can emit high levels of fuel exhaust.
If your child has asthma, alert teachers and coaches that they should offer alternative indoor activities for them on high pollution days.
Watch the calendar. Ozone tends to be worst during the May-to-October "smog season."
If you think you may be sensitive to red tide, check the Florida Marine Web site at www.floridamarine.org to monitor red tide outbreaks before you visit the beach.