Asthma

Asthma

Breathing Easy Again

Many of us can remember the girl in grade school who had asthma. We can still hear her, wheezing along beside us in gym class or panting for breath after a quick run to the bus stop. And we can still see her standing there, the last one to be picked for a game of soccer, softball or capture the flag.

Then there were the days she couldn't come to school at all because her asthma was so bad. And the times she had to use her inhaler, the one she always had to carry with her in a coat pocket or her book bag. Whenever she had an attack, she'd grab it, clutch it tightly and hold it to her mouth to suck in deep, quick breaths. From the look on her face we could tell that whatever asthma felt like, it was scary, and we were glad it wasn't happening to us.

Even if you never had asthma as a child, it's possible to develop it when you're older. "Of the general asthma population, 30 to 40 percent will get it as adults," says Sally E. Wenzel, M.D., assistant professor of medicine at the National Jewish Center for Immunology and Respiratory Medicine in Denver. And while little boys tend to get asthma more often than young girls, after puberty that trend reverses. After age 20, women are more likely than men to have asthma for the first time.

The disease can also be more difficult for women. Between the ages of 20 and 50, women are nearly three times more likely than men to be hospitalized for asthma. Asthma can also make pregnancy more complicated, and pregnancy sometimes makes asthma symptoms worse. Finally, evidence suggests that hormonal changes may cause asthma to flare right around the time a woman starts her period.

The Asthma/Allergy Link

An estimated 10 to 12 million people in the United States have asthma, and the majority of those--about 7 million--are adults. The number of women with asthma is estimated to be just over 3.5 million.

Doctors don't know the exact cause of asthma. They used to think the disease involved a spasm of the airway due to some defect in the nerves and muscles there. But over the past several years, many allergists and immunologists have come to believe that the breathing difficulty is the result of airway inflammation and constriction that's somehow related to allergy. Through some mechanism that experts don't fully understand, substances like dust, mold, pollen and smoke trigger cell inflammation and mucus production. Both reactions cause the airway to narrow, and the symptoms of allergy--coughing, wheezing and chest tightness--result. A higher percentage of allergic people have asthma than nonallergic folks, says Michael Schatz, M.D., clinical professor of medicine at the University of California, San Diego, School of Medicine and a staff allergist at Kaiser Permanente Medical Center in San Diego.

But not all asthma is triggered by allergies. Women can also have asthma attacks after taking aspirin, while working in certain occupations and even while exercising.

In the case of aspirin-sensitive asthma, researchers suspect that aspirin interferes with a special chemical pathway in the body. When the pathway is blocked, chemicals are released that trigger asthma. Individuals can become asthmatic in response to pure aspirin as well as to some over-the-counter nonsteroidal anti-inflammatory products that contain aspirin (such as Excedrin).

With occupational asthma, people have trouble breathing only when they're exposed to certain chemicals and substances at work. In some cases it's because they're allergic, but in other cases the agents may cause cellular damage that triggers asthma. Occupational asthma can occur in many lines of work, including the pharmaceutical, automobile, textile, hair-care, farming and printing industries.

Exercise-induced asthma is another type of nonallergic asthma. Cold or dry air coming into the lungs or a change in the fluid balance of cells stimulates the airway in such a way that the smooth muscles surrounding the airway constrict. Within about five to ten minutes after beginning exercise, individuals experience asthmatic symptoms such as chest tightness, coughing or wheezing.

Getting It as an Adult

Why asthma develops in adulthood is a mystery, says Dr. Schatz. Yet several things tend to trigger its development then. The first is cigarette smoking--if a person smokes or used to smoke, that may predispose them to asthma, he says. The second is a respiratory infection. Often adults will develop asthma soon after they've had one. Finally, in women with allergies, moving to a new location--with its different dust or air quality--or getting a new pet can sometimes trigger asthma.

Asthma can be just as frightening for adult women as it is for young girls. During a mild attack, a woman may feel as if someone is hugging her just a little too tightly. But in a more severe attack, the airway tightens to the point that airflow is restricted and the woman feels like she's suffocating. "Being unable to breathe or feeling like you can't breathe is one of the single most scary things you can go through," says Dr. Wenzel.

Part of what's so frightening is that asthma attacks are so unpredictable. Those who have asthma don't know when one is going to strike. They worry about having an attack when they're alone, without their medication or far from a hospital. But the scariest thing is that asthma can kill. When an attack is severe and not treated sufficiently or in time, oxygen can be cut off from the brain. Although it's rare, asthma can be fatal.

On a daily basis, asthma can leave women feeling exhausted as well as limited in what they can do. Asthma often wakes women during the night, adding to the fatigue they already feel from raising a family, pursuing a career, or both, says Dr. Wenzel. The disease can also limit the amount of physical activity women can do, she says. "One of the biggest complaints is 'Gee, I used to be able to exercise and do everything I wanted to do and I can't any more.' "

Asthma and the Menstrual Cycle

Although they don't know exactly how, researchers suspect that reproductive hormones may play a key role in the experience women have with asthma.

A study conducted at the Medical College of Pennsylvania in Philadelphia of 203 women who came to the emergency room with a severe asthma attack found that more women had the attack around the beginning of their period than at other times in the menstrual cycle.

Emil Skobeloff, M.D., clinical assistant professor of emergency medicine at the William H. Spivey Research Lab at the Medical College of Pennsylvania, who was the lead researcher on the study, suspects that the occurrence of these severe attacks is somehow related to the declining levels of estrogen at that time in a woman's cycle. This would mean that the days surrounding the start of a woman's period--when estrogen levels are dropping--may be the time when women are most susceptible to severe asthma attacks, he says.

Dr. Skobeloff first suspected that reproductive hormones might play a key role when he noticed that women are admitted to hospitals more often than men for serious flare-ups of asthma and, after puberty begins, new cases of asthma are more likely in females than in males the same age. In one study, 75 percent of the hospital admissions for asthma were women and 25 percent were men. This is in stark contrast to hospital admission rates for children with asthma. In the childhood years, 65 percent of admissions are boys and 35 percent are girls.

Pregnancy and Asthma

A particular concern for women is how pregnancy will affect their asthma. Some women find their symptoms get worse, while others find their symptoms stay the same or get better. Doctors can't predict how a woman's asthma will react, but they do know that women with more severe asthma are more likely to have their asthma worsen during pregnancy than women with milder forms. And the way a woman's asthma responds during her first pregnancy is often the way it will react in later pregnancies.

Studies show that women with asthma tend to have an increase in pregnancy complications compared with women without the disease, says Dr. Schatz. Women, particularly those with severe asthma, have been found to give birth to lower-birthweight babies, deliver their babies prematurely and in some cases, lose their babies through stillbirth.

Women may be wary about taking their asthma medication during pregnancy for fear that it may harm the baby in some way. While some drugs can pose potential harm, there are asthma drugs available that appear to be safe to take during pregnancy. Not taking asthma medication can be more dangerous than taking it, experts say. If a woman doesn't take her medication, she's taking the risk of having an asthma attack. If she has one, the baby is endangered, because when the mother can't breathe properly, oxygen is denied to the baby. Uncontrolled asthma over a period of time can limit the amount of oxygen the baby gets, which can limit the baby's growth and result in low birthweight. And if an attack is severe, the baby can be stillborn; in very severe cases, both the mother and baby can die.

Taking Care of Yourself

Adult asthma can range from unpleasant and bothersome to life-threatening. But there are some things you can do to make living with asthma easier. Here are some suggestions.

Avoid your triggers. If you have allergies, avoiding the triggers that set them off may help reduce your asthma symptoms, says Dr. Schatz. To fend off dust, cover your mattresses and pillows with vinyl cases, keep wall-to-wall carpeting to a minimum and cut down on piles of clutter. For pollen allergies, keep outdoor activities to a minimum when pollen counts are high and use air conditioning both at home and in the car. (For more details on how to control your allergies, see page 14.)

Know your body. As much as you can, learn to understand the signals your body sends during an asthma attack, says Dr. Schatz. This will help you make the best decisions about when to increase your medication, call the doctor or go to the hospital, he says. Some women find it helps to keep a journal of their symptoms, says Dr. Skobeloff.

Be aware of your cycle. Women may be at more risk for an asthma attack in the days surrounding the start of their period, says Dr. Skobeloff. So they need to keep a close eye on their symptoms around that time and be extra vigilant about responding to them promptly. Women also need to educate their doctors about the possible link between menstruation and asthma attacks, he says.

"Many women for decades have been telling doctors they get flare-ups around their periods. And some doctors have been saying, 'Oh, that's all in your mind' or 'That's PMS.' And it's not true," he says. "They need to educate their doctors to the fact that this is real. And their doctors need to be more aggressive in their therapy of these women," around the start of their periods.

Prepare for pregnancy. Ideally, a woman of childbearing age with allergies or asthma should discuss her condition and her medication with her doctor before she gets pregnant, says Dr. Schatz. That way she can get herself on the medications that are best suited to pregnancy and attempt to get in better physical shape before she gets pregnant, he says.

Monitor yourself. If you've got asthma, try a peak flow monitor, which measures the amount of oxygen getting to your lungs. The device basically enables you to monitor your asthma and detect whether you are getting into a real danger zone. Peak flow monitors are now made so you can have one at home. Some are even small enough to fit in a purse, says Dr. Wenzel. One particular monitor, called Personal Best, is about the size of a tampon holder, she says. Look for them at a surgical supply store.

Don't skip your medication. Take your medications, especially inhaled anti-inflammatory medications like beclomethasone dipropionate (Vanceril), on a regular basis, says Dr. Wenzel. "That's been shown to be most effective," she says. Sometimes women get into a cycle where their asthma isn't as bad and they skip medications, she adds. "Continue taking them even when you are feeling good."

Take it when pregnant, too. Pregnant women also need to continue their asthma medications. "It's extremely important that asthma be controlled in pregnancy," says Daryl Altman, M.D., an allergist and immunologist and director of Allergy Information Services, an allergy consulting service in Lynbrook, New York. "Uncontrolled asthma is much more hazardous to the mother and fetus than the medications used to control it," she says. "A lot of people say, 'I'm afraid to take my asthma medication because I'm pregnant or I'm contemplating pregnancy.' Wrong. Take the asthma medication." Do check with your doctor that the medication you're on is okay during pregnancy.

Go smoke-free. Smoking appears to increase your chances of developing asthma. It can also exacerbate your symptoms, and it may increase the risk that your children will become asthmatic. So do your best to quit smoking if you haven't already. If you don't smoke, try to stick to smoke-free environments as much as possible. If you are pregnant, be extra vigilant about avoiding passive tobacco smoke. "The content of poisons from cigarette smoke can easily be found in the hair of newborn babies. So insist on a smoke-free environment," says Ellen Garibaldi, M.D., assistant professor of internal medicine in the allergy and immunology division at St. Louis University Health Sciences Center.

Exercise right. If you've got exercise-induced asthma, there are steps you can take to decrease your symptoms, says Stuart Stoloff, M.D., clinical associate professor of family and community medicine at the University of Nevada School of Medicine in Reno. Five to ten minutes before you exercise, try taking a prescription inhaled bronchodilator drug, known as a beta-agonist, like albuterol (Proventil), he says. If this doesn't help, he suggests adding a nedocromil sodium inhaler (Tilade). Also, warm up slowly. This helps change the temperature of the air coming into your lungs and helps decrease bronchospasm, he says. If it's really cold outside, consider exercising indoors. Or wear a mask over your mouth to help humidify the air coming into your lungs.

Call on a friend. If you live alone or have to spend periods of time without a loved one around, enlist the help of a friend. Tell your friend about your asthma and ask if you can call when you're having trouble or if she'll keep in touch with you. That way you can have some peace of mind that someone will check on you and that you don't have to suffer through attacks completely alone.

Call 911. If your symptoms get worse, use a beta-agonist inhaler like albuterol for up to two puffs every 15 minutes for up to four treatments over an hour, says Dr. Skobeloff. If your symptoms worsen between treatments or if they don't get any better after an hour, go right to the emergency room. "Don't drive. Call 911," he says. Many of the people who are dead on arrival at the emergency room, or near death, are people who had someone drive them to the hospital or who waited too long to call for help, he says. When you call 911, the paramedics have equipment and medication to begin helping you right away.