Podcast: An Einstein Perspective on Asthma
Asthma is a serious chronic disease, according to the American College of Allergy, Asthma, and Immunology. Asthma episodes account for 2 million visits to the emergency room, and 439,000 hospitalizations every year.
What is asthma? How is it diagnosed? And how is it treated?
For answers to these questions and more, we turn to Einstein Healthcare Network Allergy Specialist, Gary Huang, MD, PhD, with a Master’s in Immunology. He is medical director of Allergy, Asthma and Immunology at Einstein Medical Center Philadelphia. Dr. Huang, let’s start with a definition.
Dr. Huang: Asthma is a syndrome. It’s very well known. Everyone will use the word asthma when they come to a doctor, but very often it carries very different meanings when they come telling us they have asthma. Sometimes they are told by their doctor. Other times they are told by their parents. And other times they grew up thinking they have asthma.
The bottom line of the defining feature of asthma is threefold. It’s a very variable airway disease, characterized by obstruction, lots of secretions, and excessive inflammation of the airway. That seems to be the common bottom line.
When it comes to the patient, of course, that’s not what they will be telling the doctor, and their common complaint will be, “doctor, I struggle with breathing. I feel my chest is congested. I feel wheezy. Or I hear myself wheezing. I have cough. I have problem breathing that wakes me up at night or during exercise. I get out of breath when I exercise.” Those are the common complaints patients will be telling us that would make a physician concerned for asthma.
It is worth noting that very often, other medical conditions can be mimicking the asthma symptoms. For example, other lung problems, heart problems, and sometimes problems outside the heart and lungs, such as anemia, can give people a lot of shortness of breath problems. We have to keep our thoughts broad, but once we confirm it is asthma, there are very specific treatments approaches we can do to make them feel better.
Bill Fantini: What are the causes?
Dr. Huang: What are the causes? Well, the most common concern people have when they think they have asthma or when they are told they have asthma, is to find out what is causing the inflammation of that airway, and naturally one of the very common things people like to think is because I have shortness of breath, it must be something in the air that is irritating me, so allergy or allergens in the airway is one common concern, and it is certainly at epidemiology level a huge problem causing allergic airway disease.
However, it is also worth noting that a lot of added pollutants and irritants in the air can cause similar irritable airway excitement, so some of the examples are pollutants. So people in the city, by default, have a lung that is aging at a faster pace and irritated at a faster pace than people in the rural side, and then you will also have people who smoke. That certainly put a higher concentration of nicotine and combustible materials that basically inflame the airway, and makes the airway kind of irritated at a faster pace.
Other people who tell you when I smell certain perfume, bleaches, or cleaning material, I will cough nonstop. And that is almost like an irritant-type of effect, similar to if I put some chili on people’s tongue or the skin, they will feel very spicy or irritated so there is the irritant pollutant in addition to the allergen from my perspective as an allergist.
The key distinction is allergen. There is measurable response in the body to these triggers where irritant and pollutant, they cause tissue damage and irritation through a different mechanism, and it’s not testable or necessary to be tested, but needs to be identified through a careful history taking, or other breathing studies we can do in the lab.
Bill Fantini: Is there a common profile on the people who get asthma?
Dr. Huang: Yes. There are people who have a higher risk of asthma, and the most common well described predictive model is actually describing the children, the pediatric population. It is worth noting before I explain further, that asthma is a very common condition in America, and worldwide.
On average, about one in 10 Americans, and nine in 100 children, have asthma. Very, very common, and the prevalence is still rising over the years. It can affect both adults and children. When the parents come to me and say, “My kids have wheezing. Does he or she have asthma?” we will do a predictive model, and here are some of the common questions we ask. First of all, do they have eczema? Do they have a family history of asthma? And do they have evidence of allergy to certain allergens?
Positive for any of these markers are predictors of the asthma onset later in their lives, especially when they have airway complaint of cough, wheezing, shortness of breath—and we are certainly most concerned about nighttime symptoms, even though daytime and exercise-time symptoms are also very important. There is risk we consider. That usually runs in the family in the allergy profile.
Bill Fantini: When you say family history, it can be hereditary, then?
Dr. Huang: It certainly can be hereditary. Direct family members, siblings, and parents or children with a history of asthma is very much predictive of the likelihood of the patient or the subject themselves having asthma. The odds increase by as high as 50 percent, depending on the study you cite.
Bill Fantini: What happens during an asthma attack?
Dr. Huang: During the asthma attack, one can imagine the airway as a little tree, with branches of little pipes that get finer and finer into the air bubbles that exchange oxygen in the air into the blood, and takes the carbon dioxide out of the blood into the air when we breathe out. In the case of asthma, this kind of branch-like pipeline of the airway becomes very, very excited, and when it’s excited it does a few things. The smooth muscles contract and go into a spasm. This spasm triggers symptoms such as cough and turbulence in the air that produce wheezing sounds. So that’s the one complaint.
Another is when the airway becomes very excited, they make a lot of mucus. And that mucus will translate into more phlegm and difficult expectorant of their phlegm. So they feel almost that their chest is always congested, and they bring up increased number of phlegm.
And lastly with the airway inflammation, their airway is almost more painted with inflammatory cells, make it less linear for the oxygen to have an effective exchange. They either complain of resting shortness of breath, or increasing exercise intolerance. Minor activity either makes the airway irritability even worse, or during the exercise, they can’t keep up with their oxygen demands, and as a result, they complain of shortness of breath. This is common to adults and children.
Bill Fantini: You mentioned triggers earlier. Are there any particular triggers or factors that exacerbate or set off asthma attacks?
Dr. Huang: Absolutely. The most common trigger for the asthma is actually cold, and coming down with a viral cold. Very often we may not even find out what is the culprit of the cold virus. Most people will have a runny nose for a few days, feeling tired, a bit of muscle ache. In the case of asthma people, that airway inflammation and secretion can very well tip their internal balance into a lot more excitement in their airway, resulting in muscle constriction with more cough and wheezing with more secretions going into more phlegm, and of course, more shortness of breath. Their symptoms are more exaggerated and they cope much less well with a simple cold.
Now if they do come down with a virus with notorious names such as influenza, that is a terrible news. There are also suggestions such as virus, such as rhinovirus and respiratory syncytial virus, or RSV, in children, can both give children a lot of wheezing during the active infection, confusing people with residual asthma after they recover from the virus. But these viruses sometimes can increase the risk and change the immune system for a good period of time, and make these patients more likely to develop asthma later in their life.
Another two important things about virus and infection with the asthma trigger, is that we definitely encourage people to receive vaccines to prevent their asthma so they can have a head start advantage to deal with airway infections. So, pneumonia vaccine, as well as influenza vaccine are very much encouraged. And one of the treatments for asthma is the inhaler mechanism. Some of the inhalers contain a little bit of steroid that is necessary to control the inflammation of the airway. We never enjoy putting patient on steroids if we don’t have to, and we’re trying to find a fine balance of controlling their inflammation, but steroids can increase the slight chance of having airway infection down the road, and therefore we always want to make sure these patients are well vaccinated against both pneumonia, as well as the influenza virus.
Other triggers of asthma can very well be a physical trigger such as exercise, because exercise change the body’s physiology. It brings more circulation. It requires the airway to work harder. It can increase excitability unintentionally for certain asthma populations. Not everyone will have exercise-induced asthma exacerbations, but a certain fraction of people, especially younger folks, can complain of exercise-induced asthma symptoms.
Other triggers of asthma can include other factors, such as increased allergens. Some people living in an environment either with mouse infestation, or who have pets with them but are allergic to their pets, can certainly have a harder to control asthma situation. Allergen is definitely a relevant factor. And dust is another one in addition to animals.
Bill Fantini: Have there been any changes to those triggers? Or even new ones that have developed over recent time?
Dr. Huang: I think many of them we came to know better and better. One should look at exacerbation and day-to-day symptoms. For example, people who live with dust or animals that triggers their asthma symptoms are more likely to have day-to-day symptoms, and they more easily go into an exacerbation. Whereas on the other hand, the virus probably does not dictate your day-to-day function, but when you are exposed and come down with a cold virus or, God forbid, an influenza or pneumonia, you will go into a horrible exacerbation. So it doesn’t contribute as much to a day-to-day symptom, but it makes the exacerbation so much more likely.
Having said that, if you have a poor day-to-day symptom control, you are definitely more likely to be handicapped at handling an exacerbation. Day-to-day control is vital to prevent a bad exacerbation. Both controls are very important, and that’s why we have what we call an asthma action plan that is try to cope with an unexpected exacerbation. In each doctor’s visit when we decide what is your day-to-day medication, that is to help you with day-to-day symptom control. And I think both are important to maintain a healthy outcome and quality of living.
Bill Fantini: How serious is asthma? Can it be life-threatening?
Dr. Huang: Absolutely. And when we take a history, we ask some features of what we call dangerous asthma, and the people with dangerous asthma, one of the features is, “Has your shortness of breath ever been so bad that you require multiple emergency room visit every year?” And another question we ask is, “Have you had life-threatening asthma in the past?” And that is really defined by the need to visit intensive care units, that need to be put on some form of breathing machine, ranging from a mask, called noninvasive ventilation support, to BIPAP mask, or God forbid, people needed to be intubated. And as you can imagine, asthma is an insult to the airway, and when you are short of air, you go into almost like an asphyxiation and low oxygen type of circumstance. And without oxygen, you have five minutes before your brain suffers irreversible injury.
When a patient comes to me and says, “Doctor, I’m very short of breath.” I examine them, and we look for the work of breathing. When people become very hard at their work of breathing, they are at real risk of exhausting themselves, especially younger children, older adults, but even young folks or pregnant women, the people with different physiological needs can really compromise and surprise you. You often have very little time to undo that horrible inflammation of their airway and support their breathing. And if need be, we have to put them on airway support through anesthesiology and airway interventions to keep that airway open and the body oxygenated. It absolutely can be deadly.
Bill Fantini: Are children especially vulnerable? And if so, why?
Dr. Huang: Yes. When it comes to diagnosing children with asthma, one should bear in mind a few factors. First thing is, obviously children have a difficulty at explaining and specifying their complaints, especially before age of 5 or 6. Also, certain asthma studies, such as lung function study, what we call the PFT, pulmonary function test, cannot be reliably done in children less than, usually, age of 6, but sometimes we can accomplish it—you know, children from 4 years and above. It really requires a lot of cooperation in their breathing effort to measure if there is airway obstruction.
So, for younger children, it’s very hard to accomplish, and they definitely have communication difficulties to make their complaints well known and well-characterized. It’s very hard to label a child an asthmatic before the age of 6, and therefore, anyone before the age of 6, and whose parents get told by their doctor that their child has asthma, should really take it with a grain of salt, and come back to review that diagnosis later when the child is older, because before 6, we really try to call this a wheezing of childhood, and there’s a chance they will outgrow it because the airway can get bigger, and the allergy profile of the body is still evolving until age 6.
After age 6, we can do more tests, and the allergy profile becomes better and better defined. As to your question, are children more vulnerable to developing asthma, the answer is yes, and that is definitely the population of increasing allergy prevalence, and we think it is in part due to the whole hygiene hypothesis—and this is also in part supported by the increasing of the food allergy and eczema, especially in the child population, and it is again probably to do with the modern hygiene culture and the upbringing environment.
Most of the children are growing up in the city, compared to the countryside, and definitely the children in the city have more asthma complaints and food allergy and eczema than the children in the countryside.
Also, the cities are more polluted nowadays, and there’s a very, very famous study just in the last two years in New England Journal of Medicine that basically studied the children who are suffering from pollution that kind of put them on a little handicapped position compared to other children growing up in a cleaner air situation. Their lung is relatively tainted compared to people who grow up breathing cleaner air.
Bill Fantini: You mentioned medications earlier. How is asthma treated, generally?
Dr. Huang: Considering asthma’s physiology is that of a variable airway obstruction and a lot of airway inflammation and some increased secretions, it is no surprise that asthma is handled by targeting the underlying physiology. Importantly, we should also consider what the patient tells us, because a patient is more likely to take a medicine that relieves their symptoms, whereas when you try to control their inflammation, if it doesn’t give them direct symptoms, it may have variable implications on their compliance.
I think if you talk just mechanistically, the drug works on the following mechanism. There’s what we call the symptom relief, and that is usually through dilating their airway. You give them a rescue inhalator—the most well-known drug is Albuterol—that can be delivered either through a pump, a rescue inhalator, or a nebulizer. These are all the same medicines delivered through different delivery mechanisms through the airway, and keep their airway muscles more relaxed and therefore the air can move smoothly. And that is regarded as a rescue. That medicine is very popular with asthma patients. Everyone carries it in their pocket almost always. It’s designed to alleviate shortness of breath, and give them about six to eight hours of peace of mind.
The shortcoming of becoming too dependent on these medicines is they are so used to relief from the medicine, a lot of patients think that is the only medicine they’ll ever need—not to know it does nothing or very little about the underlying inflammation, and it’s short-lived. And if you use it every single day, it starts to lose its magic after a while, so I always, always tell my patients that rescue is good and nice and necessary, but depending on a rescue everyday does mean that you’re walking on thin ice. What if this rescue doesn’t work? Then you’re always living an inch away from 911, and that is not safe.
What is important is to mechanistically go after the underlying allergy and inflammation. This is where a lot of other inhalers that we tell the patient to use on a day-to-day basis come in, and sometimes there’s these pills, such as Montelukast, that we tell patients to take on a day-to-day basis that is important to modify their underlying inflammation and allergy.
A lot of inhalers that are designed to control asthma contain inhaled steroids because steroid is a good medicine to bring down inflammation, but not so desirable if you take it by pill, because then it can go to many organ systems. Steroids can deliver very powerful anti-inflammatory effects on their airway, and when used correctly at the right dose can be very safe for the body while controlling breathing trouble, and prevent the needs to use Ventolin or albuterol altogether, so it’s very, very rewarding for us to tell the patient how potentially it can make them feel.
I do want to caution the patient and prescriber, the pleasant feeling of breathing without effort can sometimes be very thankless, and we don’t realize how, even when I’m talking to you now, how I’m having peace of mind able to just breathe without struggle, and once you accomplish that, it’s easy to forget to take your day-to-day medicine, or forget to take your vaccine against influenza or pneumonia, and I want to just urge patients and prescribers never to forget and take it for granted able to breathe nicely without the need of these albuterol and rescue inhalers, and not to become very dependent on your albuterol to rescue you, because that means you’re always living in trouble.
Bill Fantini: How hard is it overall to control asthma? Are people with asthma generally getting state-of-the-art treatment?
Dr. Huang: Yes. There are new medicines in asthma in the last 10-20 years, and it is really, really a very, very exciting time for asthma, because 30-40 years ago, people with asthma complaints would just be given an EpiPen in the emergency room, and as much as that can sound impossible nowadays, there was the real struggle of how bad asthmatics were handled in the old days.
Nowadays we have different relief or rescue, and we have different controllers on a day-to-day. And for the people who can’t be controlled by inhaled steroid, there is actually now a very good medicine that targets the underlying allergy and inflammatory pathway, such as allergy cell of eosinophils, and allergy antibodies of IGEs. There is now very new fancy, what we call, biologic medicines that are available to go after those and deliver very smart bombs in blocking the asthma pathways.
I think nowadays we have forever more armamentarium against the underlying inflammation pathway, and it’s a really, really exciting time for asthma patients who previously were not getting the benefit of their treatments, and I encourage everyone to talk to their allergy and asthma and lung doctors about these new therapy options.
Different allergic conditions will make the control of asthma so much harder. For example, if you have a very bad seasonal and sinus or nasal allergy or eye allergies, essentially they are all connected to the airway. The tear ducts from lacrimal glands, the nose, the sinus, they’re all eventually connected to the upper airway leading to the lower airway. Very, very angry year-round or seasonal nose allergy can very much make asthma harder to control, and certainly the post-nasal drip can make the cough so much harder to control if the patient unfortunately has additional asthma beyond their nose trouble. Optimizing of their nose allergy is very important in the control of asthma, and studies have shown that symptoms are so much better in asthma if the upper airway is also taken care of. We can help you with that with an allergy test and our ENT doctors can also help you.
Another circumstance when asthma can become harder to control is patients with ongoing eczema in their skin. Again, this is another body surface that is crying for help, together with the body surface inside the airway. Basically the inflammatory marker in one organ can trigger the inflammatory marker in the other, and it is important to look after both. Again, if we can detect an allergen trigger, we can absolutely help you, and again there is also the new allergy targeted medication, such as anti-IGE, anti-eosinophil medication we now have at our hands beyond the use of pure steroid only that we can help these people with allergic problems that worsen their asthma.
I’d like to say, the majority of the patients become much better controlled with the advent of asthma medicine, and the side effects that used to come from high dose steroids and other complications are much, much better, and the asthma mortality is definitely on the improving side, but the battle is not over. That’s because we do know, like I said earlier, one in 10 Americans have asthma, and the incidence is still rising, and about one in 10 of these asthmatics—in other words, one in 100 of Americans—are still struggling with what we call severe asthma, and those people definitely needs to come back to their doctor and revisit the new asthma medicine that is now available, and see if it can help them even further, or those people who think they’re on too much medicine want to revise it and see if they can come down to the new regimen, definitely should have that periodic review and come back and hear about the new therapy we have nowadays.
Bill Fantini: What kind of help for people with asthma is available at Einstein? Are there advances or treatments at Einsteins that makes Einstein special or different?
Dr. Huang: Yes. At Einstein, we have a very dedicated asthma and asthma/COPD program. For me, as an allergy, asthma, and immunology specialist, I work under the pulmonary division, and I work very closely with pulmonologists, as well as pediatricians and primary care doctors and ENT doctors and the emergency room. Together what we are trying to offer is to identify people who have poorly controlled asthma who need frequent visits to the emergency room. We try to have a very healthy referral system in detecting that early, and preventing tragic consequences from frequent emergency room visits and neglect.
We have a very active program to make sure people with bad seasonal allergies, as well as lung allergies, from the ENT and pulmonary program, eventually get evaluated for the allergy through my help, and together with the lung doctor, we try to help people with or without smoking with asthma, and other types of lung injuries. We will consult each other if things don’t seem like a plain fit. We will try to make sure that they are well taken care of.
Another thing I did not mention earlier, is asthma is in this very exciting age of what we call phenotyping. As asthma is a syndrome, you want to find out what is the underlying inflammatory mechanism, and target it accordingly. And that is the latest way we try to handle it.
For example, people with more allergies cells, such as eosinophils, there is one way we handle it, and against other people with more COPD or smoking impacted lung disease, we try to take care of it another way, and people with obesity or sleep apnea causing wheezing, we have a very different program that we can help them with our sleep doctors. And sometimes maybe it’s not asthma, but they come to me, and during the evaluation I notice a problem with the heart or other problems. We will refer them to the appropriate doctors, and we try to be very collegial, and patients who struggle with breathing will not be compromised in any way if they come to our lung or the allergy specialty clinic for evaluation for their breathing complaints.
If it is asthma, we will pin it down. If it is not asthma, we will send you to the right specialist to take care of you.
Bill Fantini: How can people who need help with asthma contact you?
Dr. Huang: We have an active asthma clinic at several Einstein locations. Our main location is in the Klein Building at the main campus of Einstein Medical Center Philadelphia. We also have an active asthma clinic at home Holmesburg in Center One. Both the asthma doctor and the pulmonary doctor go there on a regular basis to offer consultation and advice.
Bill Fantini: I want to thank you so much for your generosity with your time and your expertise. It’s been wonderful speaking with you. Thank you very much.
That’s Gary Huang, MD, PhD, and with a Master’s in immunology. He is Medical Director of Allergy, Asthma, and Immunology at Einstein Medical Center, Philadelphia. You can reach the asthma clinic at the main Einstein campus at 215-456-5960. I’m Bill Fantini with Einstein Perspectives. Thanks for listening.