Four years ago, April Dittrich was working at an outdoor flea market on a summer day when things started to get bad. “It was also a high-pollution day, and I was having some difficulty breathing,” she says now. “I was using my inhaler every hour instead of every four to six hours like I’m supposed to.”
Dittrich’s dad, Steven Auerback, remembers what happened next: Dittrich’s asthma got so bad that she had to be taken to the hospital. “She couldn’t take in any wind at all,” he says. “She was in tears and turning blue and I was pretty sure I was going to lose her.”
It wouldn’t have been the first time Auerback, who is 50, lost someone to asthma; about four years before this incident, a friend died of the disease. “She was in her early 30s and had pretty severe asthma,” he says. “But she knew how serious it was and took good care of herself.”
His friend was a nurse, so she knew how to handle her attacks. But when she had one in her sleep, she couldn’t even leave the bed or reach her medication. “Her death left an impression on me,” says Auerback, who is himself asthmatic. “It’s a frightening disease.”
You’d think any disease that afflicts an estimated 17 million Americans would be well understood, especially since, according to the National Institutes of Health, the number of children diagnosed with asthma has increased dramatically since 1980. But that’s not the case with asthma. Public perception tends to belittle the disease as a humorous, benign nuisance. (Who hasn’t seen a “funny” scene involving some kid’s inhaler in a film or television comedy?)
Even worse, asthma’s still something of a medical mystery. Doctors don’t know what causes asthma or why some people get asthma and others don’t—not even in Baltimore, a medical research hub that has some of the highest asthma rates in the U.S.—but heredity and allergies seem to play a significant role.
Here’s what we do know: Asthma is a chronic inflammatory lung condition in which the airways over-react to irritants that in healthy people would not be a problem. With asthma, airways can become blocked or narrowed during attacks. Symptoms of an attack can include a persistent cough, wheezing, whistling in the chest, shortness of breath, and difficulty breathing. About 11 percent of Marylanders suffer from asthma to one degree or another, and 82 of them died of the disease in 2000—nine of them under the age of 24.
Contrary to popular opinion, people don’t “outgrow” asthma. True, about half of all children with asthma stop having symptoms by the time they reach adulthood. But even they have abnormal lung-function tests, and about half of them have at least one relapse in their adult life.
Fortunately, medicine has found several medications to help regulate the disease. Sometimes, regular use of antihistamines or decongestants
can help quell symptoms. A very common treatment is regularly used anti-inflammatories—including corticosteroids—to keep the bronchial tubes from become inflamed and sensitive to irritation. Anti-inflammatories are usually given through an inhaler, though some more severe asthmatics need to take them in pill, liquid, or injection form.
Many asthmatics also carry an inhaler full of a bronchodilator, which can be used as a “rescue medicine” to open up bronchial tubes during an attack.
For years, these have been the best medicines available for asthmatics. But recent research may change that. One addition to the medical arsenal is a group of oral drugs called anti-leukotrienes. Leukotrienes are potent chemicals released by cells known to cause airway inflammation. They incite a veritable riot in the body, making muscles contract and blood vessels leak within the lungs and airway. Further studies are ongoing to gauge just how effective anti-leukotrienes will prove to be, but they’ve already been shown to help regulate chronic asthma.
Meanwhile, other research is looking into asthma’s genetic aspect. One team at the University of California at Berkeley recently identified the section of DNA that regulates three key immune substances involved in asthma. Any application to humans is still years away, but trials to see if genetic therapy is effective on mice have already begun.
Perhaps the most exciting new development, however, is Xolair, the first bioengineered drug for severe asthma. Xolair works by targeting another immune-system molecule called immunoglobulin E (IgE), which normally is one of the body’s defenses against disease but in some asthmatics goes into overdrive in response to allergic triggers.
For severe allergic asthmatics whose symptoms can’t be controlled with existing methods, Xolair may be “the light at the end of the tunnel,” says Jerry Krishnan, M.D., an instructor of medicine at the Johns Hopkins School of Medicine’s Pulmonary and Critical Care Department. But, he cautions, it’s not perfect. For one thing, it has yet to be FDA-approved, though an advisory panel unanimously backed the drug. For another, it will only be available as an injection given once or twice a month.
There’s another drawback: Analysts expect Xolair to cost close to $1,000 a month, and insurance companies may balk at paying for it.
There are other, non-medical
ways to control asthma. As researchers have learned, asthma attacks don’t happen arbitrarily. They are caused by triggers—what kind depends on the individual asthmatic. For some, it could be an external trigger—an allergen, pollution, cold air, exercise, cigarette smoke, or other irritants—while for others, it could be internal, like hormonal changes or an emotional upset.
Even something as simple as the common cold can send an asthmatic to the emergency room, says Laura Pimentel, M.D., chair of the Department of Emergency Medicine at Mercy Medical Center. Pimentel has been working in the ER for 13 years and estimates that about three or four patients with asthma attacks come into Mercy’s ER every day. The typical cold and flu season of winter and spring are her ER’s busiest months for asthma attacks.
Another common trigger is also the hardest to avoid and impossible to control: ozone. Ozone is formed when nitrogen oxides (from fuel burning sources, such as automobiles) and volatile organic compounds (from sources like gasoline and solvents) react in the presence of sunlight. Ozone is a chief component of smog and part of what is responsible for the filmy haze that hangs over the region in the summer. In fact, Baltimore earned the unfortunate distinction of being named part of the 11th most ozone-polluted area in America for 2002 by the American Lung Association. What’s worse is that ranking is actually an improvement—we ranked 7th in 2000 and 2001.
Ozone may have contributed to Dittrich’s attack four years ago, but another common trigger probably had a great deal to do with its severity: allergies. The flea market was outdoors and next to a field full of grass and flowers. Dittrich has had asthma since she was 5 years old, but she learned about her allergies’ role in the disease after her first severe attack in fifth grade.
“I was in a new classroom at school, when suddenly I just couldn’t breathe,” says the 25-year-old, who lives in Carroll County. “I went to the school nurse, who gave me my inhaler, and I felt better for a while, but whatever asthma medicine I had wasn’t enough. So I’d have to go back to the nurse again. I remember being in the school nurse’s office with an asthma attack a few times a day, every day, for a week, and nobody could figure out why. Then, one day, I had to be rushed to the hospital.”
It was at the hospital that the truth came to light after a simple question: Where was April’s classroom? It was at the basement level, damp and prone to mold, giving Dittrich attacks that were so severe she ultimately changed schools.
Peyton Eggleston, MD, a Hopkins professor of pediatrics who also directs the Center for Childhood Asthma in the Urban Environment in the Johns Hopkins Bloomberg School of Public Health, is studying other asthma triggers, particularly cockroaches. He believes one reason for the high incidence of asthma in Baltimore and cities like it could be a reaction to cockroach allergen, which is commonly found in many inner-city and older homes, particularly in lower-income areas. “In the middle of an older city like Baltimore, 80 percent of homes could have it,” says the pediatrician and allergist.
Eggleston is currently conducting research to see whether removal of this allergen (through a special pest-removal and cleaning regimen) could lessen the number and severity of asthma attacks children experience. If the technique is effective, it could be a safe and relatively affordable way to curb pediatric asthma in the Baltimore. And the city needs all the help it can get: Its pediatric hospitalization rate for asthma is more than two and a half times the rate of the state as a whole.
Pamela Lein, PhD, is also at the School of Public Health, where she and her colleagues working on the Pesticide Asthma Project are studying another potential asthma trigger that is found in homes of every income bracket: pesticide residue.
The group is looking at the effect of several widely used pesticides on breathing. Their preliminary data—and Lein emphasizes the “preliminary”—shows that organophosphate pesticides (widely used in agriculture, gardens, homes, and commercial buildings) can cause airway hyper-reactivity in animal models at levels below what the EPA considers safe for humans. What this means is that pesticide residue in the air and on fruits and vegetables—residue that we’re exposed to every day—could trigger or exacerbate asthma attacks in some individuals.
Recent research has discovered another potential asthma trigger. A new study from the Catholic University of Louvain in Brussels, Belgium linked higher rates of certain markers for asthma to regular use of chlorinated indoor swimming pools. Some American scientists have questioned the study’s conclusions, but one fact highlighted in the study is undebatably true: When chlorine reacts with organic matter, such as sweat or urine, it forms a gaseous mix of chemicals that includes trichloramine, also known as nitrogen trichloromide—the same noxious, lung-irritating chemical that is produced when you mix household bleach and ammonia.
There was another problem that may have contributed to Dittrich’s attack four years ago, the one that made her father fear for her life: She wasn’t taking her preventive medicines. She’s not alone; many asthmatics occasionally stop taking their medication, either out of forgetfulness or out of resentment against the constant need for inhalers. For Dittrich, it was the latter.
“I’m a hardhead sometimes,” she admits. “I hate having to be dependent on medication. I keep thinking to myself, ‘One day I’m going to outgrow asthma and I won’t need this stuff.’ But deep down, I know that’s not true. I’ll be living with asthma for the rest of my life.”
She does what she can to minimize her risk. Like most asthmatics, Dittrich tries to limit exposure to her triggers. And over the years, her asthma has gotten better, comparatively speaking—her attacks are pretty infrequent these days. She treats her disease with medication she inhales twice a day and uses an inhaler as needed. But Dittrich still has allergies. (She had a terrible reaction to blow-in foam insulation earlier this year. It made her eyes swell shut.) And she still has asthma attacks. And her father will still worry, because as an asthmatic himself he knows how easy it is to start thinking that your
little breathing problem isn’t all that serious as long as you keep taking
“But it is serious,” he warns, “and sometimes, even when you take your medication, you’re not fine.”