BREATHING LESSONS: Learning to live with asthma

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St. sburg Times, published February 11, 2001

BREATHING LESSONS: Learning to live with asthma

The number of people with asthma is jumping exponentially. As researchers

float various theories for the cause, doctors struggle to keep it under

control.

By WES ALLISON

Kenny Slaby coughs. When he runs around outside, when he sleeps at night,

when he eats ice cream, Kenny coughs. It's a thick, rheumy cough that comes

and then goes, several days or a week at a time, for no apparent reason.

Kenny's cough had become background noise at home, his mom says, a glitch in

the 5-year-old's otherwise perfect health that didn't seem to bother him or

his pediatrician.

But then he awoke late one night in December, hacking so hard he couldn't

catch his breath. The spell passed as his terrified parents called the

emergency room, but it earned Kenny a diagnosis that was all but unheard of

when his parents were kids: asthma.

His parents, Anne Barrins and Ken Slaby of St. sburg, were surprised by

the diagnosis and by the detailed plan and medication he will need to

control it. They also were surprised to learn how much company Kenny has.

" When you mention this to somebody, it's like, " So does mine, so does mine,

so does mine, we have an inhaler, too.' It seems like everybody has it, "

Barrins said.

Since 1980, the number of Americans with asthma has jumped by 154 percent to

17.3-million, including 5-million children, the U.S. Centers for Disease

Control and Prevention reports. It's expected to nearly double again in the

next 20 years.

Other developed countries are seeing comparable increases. Doctors and

researchers are at a loss to explain it.

Asthma is now the leading cause of absenteeism in schools, where it has

become so ubiquitous that many Florida schools offer asthma management plans

tailored to each student. Special state legislation allows children to carry

inhalers with them, while other drugs must be locked in the office.

Hillsborough County has one of the state's highest rates -- 7.1 percent of

students have asthma, compared with 2.7 percent four years ago. Pinellas and

Pasco schools each count about 5 percent.

" People are starting to say this really is an epidemic out of control,

what's going on here? " said Dr. Ewig, a pediatric pulmonologist and

asthma specialist at All Children's Hospital in St. sburg who is

treating Kenny. " I just don't think we have all the answers yet. "

To understand asthma, it helps to understand allergies, which affect about

one in four people in the United States and other industrialized countries.

Allergies occur when the body's immune system raises alarms about things

that should be harmless, such as oak pollen, ragweed, dust mites, pet dander

or some foods.

Over time, exposure to allergens can lead to asthma, which is marked by a

chronic swelling of the airways of the lungs. During an attack, the lungs

produce mucus, and the muscles around the airways constrict, often causing

coughing or wheezing.

Having allergies doesn't mean you will develop asthma, but people with nasal

allergies are three to five times more likely to get asthma than others.

Allergic asthma, the most common type, typically occurs during childhood or

young adulthood. Older adults can develop another type, called intrinsic

asthma, that can be prompted by repeated respiratory infections.

Because humans haven't changed genetically in the past two decades, experts

seeking the culprit behind the spike in the asthma rate have fingered our

environment, especially indoor air quality.

We spend about 95 percent of our time in modern, climate-controlled homes

and offices built so tightly that the pollutants we put in -- hair spray,

perfume, cleaners, pet dander and the like -- can't get out.

Sixty-million Americans own pets, more than ever before. Wall-to-wall

carpeting has replaced wooden floors, and dust mites have followed. Two-job

families have less time for dusting and vacuuming and beating the rugs.

Automotive pollution, smoking, inactivity and poor prenatal care that can

lead to underdeveloped lungs also can contribute.

Even though the progression to asthma is usually gradual, the disease can

appear to strike suddenly. It's not uncommon for parents to learn a child

has asthma only when he suddenly is gasping for air.

" The first time that we realized he had asthma we almost lost him, because

he couldn't breathe, " said Howe of St. sburg, who took her son to

the emergency room that day 11 years ago.

Her son, , was 15 at the time, and his asthma grew steadily worse.

More than once, Howe said, she found him collapsed and unable to breathe.

Although was on an array of medications and his doctor seemed

determined to help him manage his disease, he never quite got it under

control, Mrs. Howe said.

Eleven days ago, he suffered an asthma attack in his car in the parking lot

of the Eckerd at 5400 Fourth St. N, where a refill prescription of

Combivent, a powerful fast-acting inhaler, was waiting for him at the

pharmacy. A passer-by dialed 911 but paramedics could not revive him.

They found two empty inhalers in his jacket pocket.

Apparently, Howe, 26, left early from his job as manager of a nearby

Chick-Fil-A to pick up the medication, his mom said through tears after his

funeral last week. He had been fighting a cold, which tends to exacerbate

asthma.

" I kept telling him to go to the doctor. He said, " I'll be all right, Ma,

don't worry about me.' "

Although allergens get much of the blame for prompting asthma, a growing

number of researchers, including Dr. F. Lockey, director of the

division of allergy and immunology at the University of South Florida in

Tampa, have come to believe some children also might be coaxed into asthma

by a common respiratory infections, including respiratory syncytial virus,

or RSV.

RSV hits virtually all children by age 2, and usually causes a cold or bad

cough and goes away. In children genetically predisposed to allergy and

asthma, however, the virus causes an asthma-like inflammation of the lungs,

then " sets up some sort of cascade of events in the lungs that causes it to

self-perpetuate, " Lockey said.

Last year, Lockey and other USF researchers published a study in the Journal

of Immunology showing that repeated RSV infections in mice led to

" persistent airway inflammation and hyperresponsiveness " -- the hallmarks of

asthma.

To further test this theory, the National Institutes of Health is backing

researchers at the University of Wisconsin who are following 200 children

from birth and testing them for RSV each time they get a cough or cold. They

will then watch to see which children develop asthma.

Granted, RSV and other respiratory illnesses have been around forever, while

the asthma epidemic is new. But changes in our environment, diet and immune

systems might be giving infections the leeway to set up the right conditions

for asthma, Lockey said.

" All of these factor into it. Which ones and how much, I don't know, " he

said. " There's a whole host of things that are at play here. "

The most provocative theory behind the asthma rise is known as the hygiene

hypothesis, and it has become quite trendy. It holds, simply, that we've

become too clean, that the ultra-sterile environment in which we spend our

first few weeks and our obsession with anti-bacterial soaps prevent babies

from developing balanced immune systems.

When that child is exposed later to allergens, the immune system is unable

to cope properly. It overreacts and causes allergic reactions that can lead

to asthma.

The theory was introduced in Britain in 1989 and gained momentum after the

Berlin Wall's collapse. Epidemiologists measuring the alarming rate of

asthma in West Germany and other Western nations were certain the prevalence

would be even greater in communist East Germany, where health care lagged

and people lived in dirtier, more crowded conditions.

Instead, they found asthma was far less prevalent.

This fall, a study in the New England Journal of Medicine showed that

children who entered day care earlier and had more siblings were 40 percent

less likely to develop asthma. The study, by researchers at the University

of Arizona who had followed 700 children since the early 1980s, reasoned

that those exposed to a variety of germs and bacteria shortly after birth

had heartier immune systems that protected them against allergies.

Our immune systems have two parts: one we're born with, called Th1, that

uses large cells to surround and kill invading organisms. The other, called

Th2, we develop shortly after birth, and it dispatches antibodies to

selectively kill other germs.

Dr. Anne L. , an airways researcher at Arizona's School of Medicine,

argues that an overly clean environment prevents the Th2 system from

properly developing. If that happens, the Th1 system might step in. But Th1

isn't particularly adept at handling minor irritants; it's like using a

hammer to crush a fly, when a quick flip of the swatter would do.

This overreaction can produce familiar allergic symptoms -- runny nose,

inflamed airways, excess mucus.

Other studies have found that children who live on farms have less asthma

than city kids and that the asthma epidemic hasn't been mirrored in less

developed countries. The asthma rate in East Germany also has risen since

reunification, said , the lead investigator of the Journal study.

So does that mean new parents should suppress their urge to wipe every last

germ from their baby's new world? " I would say that, yes, " she said.

" Our immune systems . . . evolved in a very dirty world. And that's what

they're designed to do, to protect us in a very dirty world, " added.

" When we really clean everything up, we have to look at what the effect is.

Exposure to bacteria may be critical. "

Still, other researchers warn against simplistic conclusions about a very

complicated immune response.

Lockey, who has seen trendy theories come and go, is among the skeptics.

Even if the hygiene hypothesis is true, he contends, so what? Innovations in

hygiene have made for healthier babies, children and adults. There should be

better ways to combat or reverse the rise of asthma than getting dirty.

" We want to be very careful, " Lockey said recently in his cluttered office

at the A. Haley VA Hospital in Tampa. " I always tell people that we're

living longer, running faster, jumping higher than at any time in the

history of the world. "

* * *

The good news is asthma is among the most manageable of chronic diseases,

and with proper care asthmatics should be able to do whatever they want. The

bad news, advocates say, is that public health agencies and many family

physicians haven't learned to deal with it properly.

Because it's not a reportable disease, numbers of asthma cases by town,

county or state generally are not available. Florida schools keep count, but

the numbers include only the those children whose parents report the disease

to the school or who have an asthma attack while at school. That leaves out

many high school students.

Pediatricians and family physicians also are not always equipped to diagnose

asthma or manage it properly, specialists say. In Kenny Slaby's case, the

pediatrician who diagnosed his asthma in December prescribed a fast-acting

inhaler to use when he has trouble breathing, but she prescribed nothing to

ease the chronic, underlying inflammation and offered no treatment plan, his

mom said.

Dr. Ewig, a youthful, bearded man who warms his hands before touching the

tiny chests of his patients, treats 40 to 50 asthmatic children every week.

As he quizzed Kenny's mom during their first visit last month, he found the

boy had the hallmarks of the so-called " Allergic March " that makes his a

classic case: an otherwise healthy child who first suffers bouts of severe

dry skin, called eczema, followed by a cough or runny nose that steadily

worsens.

Typically, more things will become irritants -- Kenny, for instance, had no

problem with ice cream when he was younger, but now it's guaranteed to

trigger a coughing fit -- as the body appears to learn to overreact to

organisms that should be harmless. Asthma can follow.

" I had gotten accustomed to it -- Kenny coughs, " Barrins said last month,

during Kenny's first appointment with Ewig. " It never occurred to me that it

was something that needed to be treated on a regular basis. "

The American Thoracic Society, the physician's branch of the American Lung

Association, has launched an asthma awareness campaign for doctors, and the

National Institutes of Health has published guidelines for treatment, but

many family physicians don't follow them, said L. , program

coordinator for the American Lung Association of Gulfcoast Florida, which

covers 15 counties.

Too often, physicians prescribe a fast-acting inhaler but don't treat the

chronic inflammation, she said.

" Children should not be taking rescue-type drugs four times a day to control

their asthma, " said. " There's other things that should be done. "

Ewig agrees. " People need to understand the goals, and I think physicians

have problems with this, too, " he said. " They don't always take it as

seriously as we'd like if it's not right there, the wheezing, during that

visit. "

Barrins made the appointment with Ewig at the urging of a friend who also is

a physician, and it has made a huge difference, she said. Ewig prescribed

Flovent, one of several inhaled steroids that reduces the underlying

inflammation of the lungs, that Kenny uses before school and before bed

every day.

That has helped reduce his use of the fast-acting inhaler to ease coughing

fits, Barrins said. And tearing about the house or yard, once guaranteed to

cause him to cough, seldom causes problems.

" He is much improved, even more dramatically that I had expected. Now he can

go all day almost without coughing, " Barrins said.

Vicki Modica of Largo did not go that route, and every day she wishes she

did.

Although her 8-year-old son, Mikey, needed a variety of medication to

control his severe asthma, which had landed him in the hospital on more than

one occasion, she never took the step of determining exactly what Mikey or

his brother, , were allergic to, and their pediatrician never suggested

it.

They used to pass an allergist's office on the way to her boys' dentist, and

sometimes she would wonder. " But I was also thinking, I'm a single mom, they

hate needles, if the doctor's not saying they should go, why should I put

them through that? " Modica said.

Mikey died June 23, 1997, after a massive asthma attack. He was visiting

relatives in Pennsylvania when a combination of familiar and unfamiliar

allergens apparently set it off, and his throat became so swollen that

paramedics could not get a breathing tube to his lungs. He died on the way

to a hospital.

" The doctors did not explain to me the seriousness of it, " said Modica, who

volunteers for Mothers of Asthmatics and the American Lung Association in

their push for asthma education for the public and for doctors. " Also, as a

parent, I should have been more proactive. Definitely, parents have got to

be their kid's advocate. "