Asthma

by Michael B. Schachter M.D., F.A.C.A.M. 

Asthma, a condition whose incidence, prevalence and mortality rate has been increasing during the past several years, is a very serious health problem for both children and adults. Approximately 12 million adults and children now have asthma in the United States. Nearly 5,000 of them die of it every year. According to the Centers for Disease Control and Prevention, the death rate from asthma increased by 46% from 1970 to 1987 and it is still growing. Asthma-related health costs were estimated to be $6.2 billion dollars annually as of 1990.

In this article, I will describe the pathology of asthma and how it is generally treated by conventional medicine. Then I will discuss the shortcomings of this conventional approach by outlining how a complementary physician might approach the asthma patient. In doing so, I will emphasize how to prevent asthma attacks by working on one's environment, lifestyle and nutritional supplements.

Asthma is a disease that affects a person's ability to breathe. It is a chronic lung disease characterized by airway obstruction that is reversible (but not always completely so), airway inflammation, which results from edema or swelling in the lining of the bronchial tubes, and increased airway responsiveness to a variety of stimuli. The symptoms of an asthma attack include wheezing, shortness of breath and coughing. Breathing out is particularly difficult during an asthmatic attack and wheezing during expiration is particularly characteristic. Asthma may be periodic with relatively symptom free intervals or it may be relatively chronic with mild to moderate symptoms present most of the time. Either type of patient may have a severe acute life-threatening attack, which may require potent drugs in a hospital setting.

Asthma attacks may be triggered by a variety of stimuli, the nature of which varies from individual to individual. Upper respiratory infections, either viral or bacterial, often trigger an asthmatic attack. Exposures to tobacco smoke, perfumes, paints or other strong chemical odors are often culprits. Changes in weather or temperature, exposure to molds, animal danders, grass or tree pollens are all triggers for some asthmatic patients. For some patients, exposure to sulfites, used to preserve foods, has resulted in deaths due to asthma. Certain food colorings, such as the yellow dye tartrazine, as well as many other food additives may be triggers. Drugs, such as aspirin, non-steroidal anti-inflammatory drugs-like Advil, beta blockers-like Inderal, ACE inhibitors and many others can precipitate an asthma attack.

Diagnosis of Asthma
Aside from the clinical observations of shortness of breath, coughing and wheezing, how can asthma be diagnosed? In addition, to hearing the wheeze with a stethoscope, one can use two medical instruments to help with the diagnosis and response to treatment. The first is called a spirometer. Spirometry involves the patient taking a deep breath and blowing into the tube of the spirometer as hard and as fast as he can. The patient may also breathe in and out several times into the tube for additional information. The spirometer measures the amount of air expired and how much is expired at different phases of the expiration. With asthma, we'll see a reduced total amount of air expired or forced vital capacity. We'll also see a reduced volume expired during the first half second and second or forced expiratory volume 0.5 and 1.0. Finally, we'll observe a reduced volume during the middle cycle of the expiration. Each one of these measurements can be improved after the person breathes a bronchodilator drug, thus showing that these changes are at least partially reversible. This reversibility leads one to the diagnosis of asthma rather than a more fixed irreversible lung disease. Another instrument useful in monitoring the severity and response to treatment in asthma patients is a peak flowmeter. Again, the person expires a deep breath as quickly and completely as possible and the peak flow is measured. This instrument is important for monitoring treatment response.

Mechanisms of an Asthma Attack
Now, lets discuss the mechanisms of an asthmatic attack. What happens to the lungs during such attack? First, we see bronchial spasm and/or constriction of the smooth muscles of the bronchi or airway tubes, leading to a narrowing of these passages. Second, we get inflammation and edema or swelling of the inner lining of the bronchi, which further narrows the airways. Third, we observe increased mucus production with the development of mucus plugs that may further block air from getting to the little air sacs in the lungs, thus preventing oxygen from getting into the bloodstream and carbon dioxide from leaving the bloodstream in order to leave the body. And, finally, we frequently see evidence of allergic phenomena on a cellular level, with allergy cells called eosinophils, resulting in further inflammation of the airways. This allergic mechanism almost always involves the substances known as platelet activating factor or PAF and histamine, to a lesser extent. In addition to causing inflammation, this allergic reaction also contributes to bronchial hyper responsiveness.

To review, the important mechanisms of asthma are: 1) an increased responsiveness of the airways to a variety of stimuli; 2) a narrowing of those airways due to a contraction of the smooth muscles of the bronchi; 3) a further narrowing due to inflammatory changes in the walls of the bronchi; and 4) an increased production of mucous and fluids in the airways causing further narrowing and even blockage.

These mechanisms are important to keep in mind as we discuss both conventional and complementary treatments.

Conventional Treatment Approaches to Asthma
A good conventional approach to asthma will look at the environmental stimuli that set off a response from the super sensitive airways. Here, a careful medical and ecologic history is most important to establish which stimuli are most important for this particular patient. Do asthma attacks occur mostly indoors or outdoors? If indoors, are they worse at home or at work? Are they worse during a particular season? Tree pollens, for example, are very high in early spring, grass pollens peak in the late spring and the classic ragweed season begins in late summer and ends with freezing weather. Sometimes asthma attacks are precipitated by exercise.

Patients will be warned about the adverse effects of active or passive tobacco smoke. They may also be advised to avoid dust or fumes of chemicals, exposures to people who have upper respiratory infections, cold air, known inhalant allergens such as cats or dogs, grasses or pollens and various drugs such as the beta blockers, ace inhibitors, aspirin and certain non-steroidal anti-inflammatory drugs. Once allergens have been identified, measures recommended to minimize exposure to them might include avoiding outdoor activities in early morning when allergen levels are highest, keeping windows closed as much as possible during the peaks of allergy seasons and keeping indoor humidity levels between 40 and 50 percent to reduce pollen and mold exposure. Eliminating carpeting and upholstery when possible and using plastic pillow and mattress casings will help to keep dust exposure to a minimum. Laundering bedclothes weekly in hot water is also recommended. High efficiency particulate air, abbreviated HEPA filtering devices, effectively reduce airborne allergens and other inhaled irritants.

Occupational exposure must be explored as more than 200 different occupational asthma triggers have been reported in the medical literature. The concept of total body burden of toxic and allergy factors is very important here. To prevent and treat asthma attacks, the goal is to reduce exposure to toxic and allergenic substances as much as possible to lower the total body burden.

Use of Bronchodilator Drugs by Conventional Physicians to Manage Asthma
Frequently, an asthma attack may be precipitated by a bacterial infection. In such a case, an antibiotic medication is helpful in clearing up the infection. During severe attacks, respiration may be limited so much that the oxygen concentration in the bloodstream may be dangerously low. Breathing in oxygen will help to correct this situation. Aside from oxygen and antibiotics, the medications to treat both acute and chronic asthma are classified into two categories, bronchodilators and anti-inflammatory agents. Together, these medications are used to reverse or prevent air flow obstruction. The smooth muscles of the airways contain receptors that are known as beta 2-adrenergic receptors. Upon stimulation, these receptors cause a relaxation of the smooth muscles of the bronchi.

A hormone in our body that stimulates this type of receptor is adrenaline or epinephrine, which is the fight or flight hormone secreted by the adrenal medulla. The drugs used to stimulate these receptors are called beta 2- adrenergic agonists. One of the most used of these drugs is albuterol whose brand names are Proventil or Ventolin. They are administered mostly by metered dose inhalers (abbreviated MDI). For severe attacks, albuterol may be administered in the hospital by nebulizer every one or two hours. However, the frequency is reduced as soon as possible, and the patient is switched to the metered dose inhaler. Outside of the hospital the medication is used as necessary, preferably only one or two puffs daily. It may be used prior to exercise to prevent an exercise induced asthmatic attack.

Although the product literature states that up to 12 puffs a day may be used, patients with mild asthma should need these drugs only 3 or 4 time a week. A pattern of regular or increasing use approaching 8 to 12 puffs a day reflects poor asthma control and warrants immediate re-evaluation. Although these beta 2-adrenergic agonists are reported to be reasonably safe, they do stimulate the autonomic nervous system and may produce rapid or irregular heartbeat, insomnia, shakiness and nervousness.

Anti-cholinergic agents constitute the second class of bronchodilators. Whereas the beta 2-adrenergic agonists mimic the sympathetic nervous system, the anti-cholinergic agents work by inhibiting the parasympathetic nervous system as the latter tends to constrict the bronchi. So by inhibiting the action of the parasympathetic nervous system with anti-cholinergic drugs like ipratropium bromide or Atrovent, bronchodilation is promoted. Atrovent is also given by inhaler. Potential adverse effects include dry mouth, cough, headaches, a worsening of glaucoma and urinary retention.

A third class of bronchodilators are the methylxanthines, such as aminophylline and theophylline. Caffeine is another example of a methyl xanthine, although it is not used in asthma. The exact mechanisms of action of the methylxanthines in causing bronchodilation is unclear. Previously, these drugs had been considered the first line of therapy for asthma, but because of their serious side effects, they are somewhat less important at the present time. However, aminophylline or theophylline may be used intravenously if other treatments have not gotten an attack under control.

For chronic asthma, theophylline, whose brand names include Theo-Dur, Uniphyl, Slo-bid and others, is now considered a third-line choice, but may be of benefit in nighttime asthma, due to its long duration of action. Adverse effects of theophylline involve many organ systems. They may be mild or severe and life threatening. Gastrointestinal symptoms include heartburn, nausea and vomiting. Central nervous system negative side effects include headaches, insomnia, tremor and seizures. And finally abnormal heart rhythms and deaths have been reported.

Some studies have shown that frequent over use of the bronchodilators may result in an overall worsening of the asthma condition. This effect and the adverse effects on the cardiovascular system may explain in part the increasing death rate from asthma during the past several years. In other words, increasing mortality from asthma may be partially iatrogenic, or in other words, doctor caused.

Anti-inflammatory Drugs
Control of inflammation is currently the primary focus in managing asthma. The most effective agents for this purpose are the corticosteroids. These medications interfere with the synthesis of inflammatory mediators and prevent migration and activation of inflammatory cells. Also, they improve responsiveness of airway beta receptors, which promotes relaxation of bronchial smooth muscle. Corticosteroids, produced naturally by the adrenal cortex, include hydrocortisone or cortisol, which can be prescribed by physicians.

However, conventional physicians usually prefer to use one of the synthetic corticosteroids. During an acute severe asthmatic attack requiring hospitalization, the patient is usually given methylprednisolone (brand name Solu-Medrol) as a 60 to 80 mg intravenous push every six to eight hours for the first 36 to 48 hours of hospitalization. The patient is then switched to high doses of oral prednisone or methyl prednisolone, which is rapidly tapered over the next 10 days to two weeks. Short-term adverse effects from oral or intravenous steroids include increased appetite, weight gain, elevated blood sugar, fluid retention, mood changes, and gastrointestinal upset. Most patients can avoid long-term (months or years) use of corticosteroids, which have additional adverse effects and risks. These include a suppressed immune system, adrenal suppression, osteoporosis, muscle weakness, cataracts, skin changes, and peptic ulcers.

I have just discussed the use of intravenous and oral corticosteroids in treating acute asthmatic attacks. However, the administration of corticosteroids by inhalation is being acclaimed by many clinicians as the greatest advance in asthma management in the last 20 years. Inhalation corticosteroids are being recommended by many physicians as the first-line maintenance therapy for the adult with daily or frequent asthma symptoms. However, inhaled steroids appear to be underutilized, as they constituted less than 15% of all asthma prescriptions in 1993, according to a pharmaceutical industry survey. Their dosage varies from 1 to 5 puffs, two to four times a day, depending on the preparation. Local adverse effects include hoarseness, cough, and oral candidiasis or thrush. Generally, chronic adverse side effects of steroids given orally are not seen to any extent with the inhaled form of steroids. The inhaled steroids should be given at the lowest possible dose, capable of controlling the asthma. Examples of inhaled steroid products are: Beclovent, Vanceril, Azmacort, and Aerobid.

A non-steroidal anti-inflammatory inhaler that can be used for asthma is cromolyn sodium or Intal. It prevents mediator release from airway mast cells and inhibits both early- and late-phase immune response in asthma, but it is not as effective as the corticosteroids. The most common side effect is coughing.

Complementary Approach to Treating and Managing Asthma.
In addition to all of the triggers considered by conventional medicine such as stopping exposure to cigarette smoke, reducing exposure to known indoor allergens, and reducing exposure to outdoor allergens, the complementary physician will evaluate areas that are usually not considered by the conventional physician.

In his approach to any health problem, the complementary physician will recommend cleaning up the diet by eliminating or reducing refined carbohydrates (such as sugar and white flour), hydrogenated fats (which mess up fatty acid metabolism), and synthetic food additives, (such as preservatives and artificial sweeteners). The diet should emphasize whole organic foods, as much as possible. Water should be free of both fluoride and chlorine. In addition, tests may be run to pick up subtle food allergies to some of the good foods.

An appropriate exercise program, which includes aerobic exercise, stretching and strengthening will be recommended as tolerated. Stress management techniques will be utilized in patients for whom anxiety seems to be an important trigger.

Rather than emphasizing the bronchodilator and anti-inflammatory drugs that conventional physicians use routinely, the complementary physician will keep them on the back burner, and use them only if the disease cannot be controlled by natural means. These natural means will include dealing with detoxification, supplying natural substances like vitamins, minerals, enzymes, and herbs either orally or by injection, dealing with less accepted infections, such as Candida Albicans overgrowth in the gut, balancing the hormonal system, using homeopathic medications and/or using energy balancing techniques such as acupuncture.

If the patient has had exposure to a lot of antibiotics and steroids, as many asthma patients have, Candida overgrowth is likely and is probably contributing to the difficulty in controlling the asthma. In such cases, a sugar free, yeast free diet should be recommended. A number of natural supplements are helpful in controlling the Candida, including caprylic acid, garlic, pau d’ arco herbs, and dioxychlor. Friendly bacteria, such as lactobacillus acidophilus and bifidus, should be supplemented. Of course, exposure to antibiotics and corticosteroids should be reduced and eliminated, as soon as the patient can tolerate this. If necessary, anti-Candida medications, such as nystatin, Diflucan or Nizoral may be recommended for a limited time. Other unfriendly organisms in the gut, such as certain bacteria or parasites may also be eliminated by appropriate herbs or medications.

Detoxification
Detoxification procedures are designed to reduce exposure to toxic substances and to help the body improve its ability to rid itself of toxic substances. To do this, it is necessary to carry out earlier suggestions by both conventional and complementary physicians on reducing toxic exposure. Additionally, the organs of the body that deal with detoxification need to be addressed. These organs include the gastrointestinal system including the liver, the kidneys, the lungs and the skin.

The function of the gastrointestinal system or gut is to allow necessary nutrients into the body while preventing toxic substances from entering the bloodstream through the gut. Malabsorption problems relate to a reduced ability to get nutrients into the body. Leaky gut problems relate to the intestines allowing toxic substances, such as large molecules into the bloodstream. The latter may encourage allergic inflammatory responses, which can aggravate asthma. The leaky gut may be caused by Candida, parasites or other organisms. Other causes of the leaky gut are damage from toxic substances, such as non-steroidal anti-inflammatory drugs like ibuprofen, and nutritional deficiencies. Repair can be carried out by eliminating the toxic offenders and supplying the repair nutrients. Among the most important nutrients for repair are L-glutamine, zinc, vitamin A, vitamin C, vitamin E, GLA and gamma oryzanol. These may be given as capsules or as part of a specially designed therapeutic food powder, like Ultra Clear Sustain. By repairing the leaky gut, allergic responses will be reduced and asthma should be improved.

The liver is the major organ of the body to carry out detoxification of toxic substances that are already in the body. These toxic substances may be from external sources or as a result of normal or abnormal metabolism within the body. The details of this process will be the subject of another Medical Update. Suffice to say at this point, that bolstering the liver’s abilitly to detoxify by supplying the necessary nutrients may result in significant improvement of asthmatic conditions. The types and amounts of nutrients to be supplied in an individual case will depend on the individual and can be determined by specialized testing.

The role of the kidneys in detoxification involves the elimination of water-soluble toxins from the body. Drinking sufficient amounts of pure water will be helpful. The skin eliminates toxins through sweat and other secretions. Applying a dry brush massage to the skin helps to stimulate circulation and improve this function. The elimination of toxins through the skin by sweating can be accomplished with aerobic exercise and saunas. To eliminate heavy metal toxicity from lead, aluminum, cadmium or mercury, chelating agents may be used. The removal of mercury amalgam dental fillings may be recommended to eliminate a source of mercury contamination.

Recall that the major medications that are used to treat asthma are bronchodilators to dilate the constricted bronchi, anti-inflammatory agents to reduce inflammation, and antibiotics when infection is playing a role.

Building Immunity to Reduce Need for Antibiotics
To reduce the need for antibiotics to treat infections, a complementary physician will use nutrients to bolster the person’s own immune system. These may include liberal use of vitamin C, vitamin A, zinc, copper, thymus extracts and herbs like Lomatium and Echinacea. These may be given orally. In addition, a course of intravenous infusions of vitamin C and other nutrients, or low dose hydrogen peroxide will generally bolster the immune system and help the patient to feel better.

The mineral magnesium, which has been covered in a previous medical update, is possibly the single most important nutrient for managing asthma because of its multiple effects on the asthmatic condition. It is extremely effective in the relaxation of bronchial smooth muscle tissue, resulting in a reduction of bronchospasm and increased airways diameter. It may do this in part by stimulating production of cyclic AMP and ATP, two important mediators that bring about relaxation of bronchospasm.

Magnesium also reduces the histamine response, which mediates allergic inflammation. Patients suffering from asthma often have exaggerated histamine release from certain white blood cells, which leads to inflammation and bronchoconstriction. Magnesium helps to dull this response.

Various lifestyle practices contribute to magnesium deficiency, including chronic caffeine and alcohol consumption, dieting and excessive exercise without sufficient magnesium replacement. Use of diuretics or water pills contribute to magnesium depletion. Ironically, studies have shown that asthma bronchodilator medications, such as theophylline and albuterol can cause magnesium wasting, thereby contributing to the worsening asthmatic condition. Magnesium may be given orally or by injection. Some patients because of gut problems develop diarrhea when magnesium is given orally and those patients may need to be given magnesium by injection, until the gut problem is cleared.

The counterpart of the mineral magnesium is the vitamin pyridoxine or vitamin B6. Like magnesium, vitamin B6 is important in stimulating the production of ATP and cyclic AMP, which promote relaxation of bronchial smooth muscle, resulting in an increased bronchial diameter. As with magnesium, the bronchodilator medications deplete vitamin B6. So, vitamin B6 should be given along with magnesium, both orally and by injection.

For some asthma patients, sulfites are a major trigger. These patients may be suffering from a relative enzyme deficiency, which results in difficulty oxidizing sulfites to sulfates. Two co-factors that are involved with this oxidation are vitamin B12 and the mineral molybdenum. Sulfite sensitive patients may greatly benefit from oral and injectable supplementation with B12 and molybdenum.

Anti-inflammatory Herbs and Nutrients
Some herbs that are being used by complementary physicians for treating asthma for their anti-inflammatory and/or bronchodilating effects are Gingko Biloba, Coleus Forskholii, MaHuang, Lobelia and Glycyrriza glabra. These herbs are complicated substances containing many compounds. They have multiple effects, which may include anti-inflammatory actions, bronchodilator effects and expectorant properties.

Precursors of the anti-inflammatory prostaglandins are often helpful. These include sources of omega-3 fatty acids, like flaxseed oil and fish oils, and sources of gamma linolenic acid or GLA, like evening primrose oil or borage oil.

Since much of the inflammation is mediated by free radicals, anti-oxidant enzymes vitamins and minerals are useful. These would include vitamins A, C and E, the carotenoids, many bioflavonoids like quercetin, superoxide dismutase, glutathione, and N-acetyl cysteine. Again these nutrients may be given orally or by injection. Digestive enzymes may be used as natural, non-toxic anti-inflammatory supplements. Examples are pancreatic enzymes, bromelain, papain and others.

Homeopathic medications which must be prescribed on a highly individualized basis, depending upon the patient’s symptoms and characteristics can be quite effective in the hands of a well trained, experienced homeopath. Some of the most used homeopathic remedies for asthma are arsenicum album, kali carbonica, calcarea carbonica, pulsatilla and sulphur.

Other alternative therapies that may be useful in individual cases of asthma are acupuncture, chiropractic or osteopathic manipulation, massage and Rolfing.

In summary, asthma is one condition which responds well to a wide variety of alternative and complementary medicine practices. Using these methods more widely should result in an improvement of treatment results and a reduction of mortality and morbidity associated with the use of conventional medicine alone.