Is there a link between air polution and asthma?

Is there a link between air pollution and asthma? That is a question I am going to spend the next seven days investigating, and reporting on here at the RT Cave.

What is the answer to that question? I do not know. Many of us may have an opinion in this area, but are we really right?

It is true that there is a certain level of pollution in the air, and some of it is definitely caused by the burning of coal and oil, and some of it caused by natural things like the sun and ozone.

Setting opinion aside, we have some facts documented.

We know that, according to the AAAAI.org that between 1980 and 1994 the prevalence of asthma increased a whopping 75%. There are many theories for this increase, and one of them is air pollution. But there are other theories too

Likewise, according to the authors of a book called Fatal Asthma, the incidence of asthma related deaths has increased from being "negligible" in 1930 according to asthma experts at that time, to 3,000 per year in 1998 and 5,000 per year as of 2006.

Is pollution the cause of this rise in the prevalence of asthma? Is pollution the cause of the increase in asthma related deaths?

My goal in the next week is to clear my head of any bias I have (and I ask you to do the same), and I aim to investigate this matter and come to a logical conclusion based on the facts.

However, before you clear your head of any bias you might have, take the poll at the top of this blog. Go ahead, do it right now! I'll wait here for you.

Good. Sometime in the next week I will participate in the poll too. Throughout the next week (and time permitting because I do have to work 8 of the next 10 days), I will read, study and report to you facts regarding this matter.

Next Wednesday (April 1, 2009) at midnight the poll will close, and I will announce the results next Thursday. Likewise, at that time I will give you the latest information regarding pollution and asthma, and together we'll come up with a conclusion to our question: Is pollution the reason for the increase in the prevalence of asthma?

Once all the facts are on the table we'll retake the poll and see if the results change.

Oh, and one more thing: If any of my readers has any information regarding pollution, or that shows how pollution is or is not linked to asthma, send it my way and I will share it with my readers.

Go vote! Now! And then, with an open mind, stay tuned to the RT Cave for an open minded discussion on this matter. And don't be afraid to admit you are wrong or gloat if you are right.

20 facts about asthma

Here are some interesting facts about asthma:

1. The majority of childhood wheezers do not have asthma. They are called "transient wheezers."
2. 95% of children with persistent asthma still have symptoms into adulthood
3. 60% continued to have persistent asthma characterized by acute episodes and interval symptoms
4. The remaining 40% the asthma seemed to be less troublesome in adult life
5. The average life expectancy of mild episodic asthma should be the same as nonasthmatics. Right now this is 80 years.
6. Only 10% of asthmatics develop severe asthma. That comes to less than 1-2% of the population.
7. A near fatal asthma attack consists of a PaCO2 of >50, need to be ventilated, or arrival at the hospital with altered consciousness or unconscious.
8. Nearly all cases of asthma related deaths come as a result of asphyxia and not a cardiac arrest.
9. In most cases, rapid administration of oxygen will prevent asphyxia (which is a severe lack of oxygen).
10. Most fatal asthma attacks do not occur in the hospital. Most patients who reach the hospital with an intact central nervous system survive.
11. Most fatal asthma attacks occur because the patient delayed going to the hospital. A major problem here is denial.
12. Asthmatics with a near fatal episode have an increased likelihood of having a fatal attack in the future. This is why very close contact with your doctor is essential.
13. Most asthmatics who suffer a near fatal attack are severe asthmatics, mild or severe asthmatics who didn't take their medicines as prescribed, delay in seeking treatment, and those who are taking large amounts of beta agonists regularly.
14. Fatal Asthma does not care how old you are, nor what sex, nor what color or race or creed.
15. Mild asthmatics can die of fatal asthma, but mostly due to improper care or delayed treatment.
16. There is no evidence that Albuterol increases the risk of a fatal asthma attack.
17. Use of Albuterol as the sole treatment may possibly contribute to fatal asthma, but probably due to lack of inhaled corticosteroids to manage chronic inflammation.
18. Boys are twice as likely to develop asthma than females, but the exact reason is unknown. Studies show boys are more likely to have a positive allergy test, to show more bronchial hyperresponsiveness and appear to have different patterns of airway function development.
19. Socioeconomic status and asthma fatality are inversely related. Or, poverty and asthma fatalities are linearly related.
20. African Americans have an increased incidence of asthma than whites. Socioeconomic status may be a factor, but recent studies show higher IgE serum levels and prevalence fo bronchial responsivemenss in blacks as compared with whites.

The above facts come from a book called fatal Asthma.

8 factors may increase risk of fatal asthma

I've been reading this great book called Fatal Asthma lately, in which the authors have pinpointed some factors that might contribute to increasing your chance of having a fatal asthma attack.

Factors that increase your risk of a fatal attack are:

1. Low socioeconomic status: It causes barriers to good care including lack of health insurance and financial ability to pay for meds needed to manage asthma. Plus, poor economic status makes it difficult to get away from poor quality housing such as those infested with common allergens like dust mites, cockroaches and even rodents. Another barrier to good health created here is lack of funds to afford regular doctor visits and the medications required to prevent and treat asthma.
2. Poor social support: It's important to have people around you who understand asthma and can encourage you to take care of yourself, and help you spot early warning signs. If you are a severe asthmatic, it's good to have someone encouraging you to eat right, exercises and take your meds. The same can be true of kids. Also, failure of parents to remove a child from harmful environments (such as second hand smoke, allergens, , dust mites, etc) may be a problem that contributes to uncontrolled and chronic asthma.
3. Smoking: This increases airflow obstruction and usually results in severe asthma.
4. Cardiac disease: Drugs used to treat arrhythmia's may worsen asthma.
5. Substance abuse: This can delay treatment for asthma and require its own separate treatment.
6. Previous near fatal attack: Bronchial sensitivities may persist as steroids and other meds are being weaned, predisposing the asthmatic to an even more severe episode. Plus the fact that one was just released from the hospital may lead one to not wanting to go back, thus delaying treatment upon return of symptoms. Denial that symptoms have returned can also lead to further asthma complications which increase the risk of fatal asthma.
7. Denial: If you don't admit you have a problem you will not get the care you need to manage your disease.
8. Poor perception: Some people may overlook early warnings signs and under treat, and this may result in the asthmatic waiting too long to get the care he or she needs.
9. Location: All of the following may lead to an inability to get proper and quick care: Lack of easy access to medical help, or if the closest hospital is far from where the asthmatic is, or if the asthmatic is alone
10. Allergies: 60-80% of asthmatic children have at least one allergy.

Modern meds may be cause of fatal asthma

In my research of the history of asthma I have come across a very interesting phenomenon, or a conundrum perhaps. It is that asthma was never considered a fatal disease before the 1900s. Why is that?

The authors of "Fatal Asthma" ask it this way: "If the under treatment of asthma is invoked as an important cause of fatal asthma, then we must explain why people are dying from asthma now, when deaths from the ailment were negligible in the past."

You'd think with all the modern asthma wisdom and all the new medicines on the market today that there would be fewer asthma related deaths and not more.

Some have proposed that pollution may be the cause, but many scientists rule this out because prior to the 1900s air was polluted by coal and wood burning stoves, horses roamed the streets leaving their droppings, streets were of sand that caused dust, people did not shower daily and were often breeding grounds for diseases that triggered asthma. Plus people smoked frequently in public buildings and homes.

All of those obstacles to clean air have been removed. Yet, "Still there is genuine concern about newer sources of pollution, because the asthma rates have been rising in some American cities during the same period as pollution legislation has led to cleaner air. And this remains a possibility.

Another possibility, or theory, is that asthma did not become a fatal disease until 1903 when epinephrine (adrenaline) was first used in hospitals to treat asthma. One doctor observed that it's "possible that mortality from asthma first appeared when adrenaline became available... The pattern of events of no adrenaline, no deaths; some adrenaline, some deaths..."

The conundrum of doing such research, however, is that there is no research of untreated asthma. For the most part, if a doctor has a patient who is suffering with asthma the patient is going to be treated.

However, it wasn't until after "isoprenaline was introduced in a nebulizer formulation during the 1940s when mortality began to increase..."

In the 1960s "asthma mortality increased dramatically." Scientists evaluating the data determined the cause was "due to new methods of treatment. Interest focused initially on the possible role of pressurized metered-dosed-beta-agonsit aerosols, which had been introduced in the early 1960s."

In the 1970s there was a significant jump in New Zealand, and this was associated with a long acting beta agonist fenoterol that patients were allowed to use at home. When some patients were having trouble breathing, they'd often use it more than prescribed. This medicine, like epinepherine and isoprenaline, can have fatal cardiac effects if used in too high of doses.

The debate of whether asthma related deaths were caused by the routine use of these early beta agonists, or if it was that these meds were abused by asthmatics during periods of life threatening asthma "in which the cardiac side effects are likely to be particularly harmful in the presence of severe hypoxia."

However, unlike Albuterol, both of these classic asthma rescue medicines were not selective to the lungs only. They had an equal effect on the heart. When warnings were given out of the adverse side effects of overusing these medicines, the death rate dropped.

Another theory of why there are more fatal asthma episodes now is that asthma was under diagnosed, which may also be the reasoning for the trend the number of asthma cases nearly doubling between 1985 and 2009.

However many scientists have ruled this out. Still it's a theory worth considering.

I would guess the increased incidence of fatal asthma would be due to a combination of all three theories mentioned above, but I would lean toward the theory of modern medicine overuse as the one that makes the most sense to me.

I haven't seen trends after 1998, but I do know that many recent fatal asthma episodes have been linked to Symbicort and Advair, or the long acting bronchodilator within these meds. As was the case with fenoterol in New Zealand in the 1970s, scientists aren't sure if it is the drug itself that is causing fatal asthma, or that the drug is being used as a rescue inhaler for life threatening asthma.

The FDA has recently advised doctors that modern long acting bronchodilators such as those included in Symbicort and Advair (Serevent and Formoterol) are safe and that the benefits far outweigh the risks in managing asthma. Which makes one think the FDA believes abuse of these medicines is the reason for the recent spike in Fatal Asthma.

And, like in the 1970s, I believe, as the word gets out that Symbicort and Advair can have fatal consequences if not used exactly as prescribed, the asthma death rate will again go down once again.

No one knows for certain why episodes of fatal asthma have increased since 1900, and particularly since 1940, but most of the trends point toward the same meds doctors prescribe to treat acute and chronic asthma.

Lack of interest in asthma means less funding

Asthma is one of the oldest ailments known to man. It was documented as far back as ancient Sumeria 5,000 years ago. And yet we still know so little about this disease, however our wisdom has grown.

The truth is that asthma has been growing at such fast rates in recent years that there are few people who don't know anyone who has it. It is a disease as prevalent as coronary artery disease and cancer, and yet funding received for asthma research is far below those diseases.

Why is this? The reason, perhaps, is that less than 3% of the America's population have asthma. And the only other people who care about the disease are those immediate family members who see the asthmatic suffer.

So, you have almost 95% of the population who have no interest in asthma. And it is exactly that 95% of the nation of whom we need to get interested in asthma, because it is that 95% who pay the taxes that will go on to fund future asthma research.

One of the reasons, according to the authors of Fatal Asthma, that so little tax money is available for asthma research is because so few people die of asthma. Yet between 1985 and 1998 asthma deaths doubled to 5,000 per year, but that death toll pales in comparison to other diseases.

So whatever research is going to be done to find a cure, a way to prevent, or to make the lives of those who suffer with it better, is going to have to come from private funding from people like you and me.

Or, to achieve more tax funding, better asthma education among the greater population is a must.

A case study: Does intervention worsen asthma?

I would like to discuss further today the topic of "Fatal Asthma" and the somewhat controversial theory -- although I don't think it is and aim to find proof -- that PURE asthma does not kill. (Actually, books have been published on this topic as you can see by the link above.)

When I first started out as the lone night shift RT a bad asthmatic walked through the doors of the ER. For the purpose of this post I'll refer to her as Cindy.

She walked into the ER one night in SEVERE respiratory distress. However she was awake, alert and orientated and perfectly able to GRASP at the table, hold her shoulders intentionally high, and suck a little bit of air in.

Fortunately for her, her Internist happened to be in the ER along with the ER Dr. While the ER physician proposed lying her flat and intubating her due to progressively worsening blood gas values (the CO2 was creeping up), the Internist decided to give this asthmatic more time.

"This is a risky move," he said to me, "but I'm sending her up to the CCU. If she is not better within a half hour we will have no choice but to Intubate our good friend here."

We were all worried for our asthmatic friend as she gasped and gagged and sucked wind or whatever you want to call it. However, being the consummate professional, THE DOCTOR DID NOT PANIC AND THUS OVER TREAT THE PATIENT. I think this is critical when it comes to treating asthma -- not over reacting and over treating.

I think the Internist gave her only one Epinephrine shot. Now, she did get a continuous breathing treatment with Ventolin, but this treatment has been since proven to be safe and effective. (The Epi, however, is not safe, and I will discuss that tomorrow.)

Yes, that's right, we need to be patient (no pun intended). So, with my ventilator all set up outside Cindy's room, and the Internist standing with me alongside her bed, she all of a sudden looked at me and said, "I think I'm better now."

She was better. I redrew the ABGs a half hour later and they were markedly improved. Thus, the Internist saved the asthmatics life. He did this by staying calm, cool, collective and not panicking.

Now, two weeks later Cindy returned to the ER in the same condition as she was the previous visit. She truly looked the picture of someone who should be intubated. This time the Internist was not in the room, and the ER Dr. decided to intubate.

I wanted SOOOO bad to say to the Dr., "She came in two weeks ago equally bad, and we waited, and she got better." Plus, being a fellow asthmatic, I knew that if I came in like this I certainly wouldn't want the ER Dr. to start thinking Intubation, especially considering I have turned my asthma around on a whim many times before (and of course sometimes with the help of ER docs).

That aside, I did not want to see this patient intubated out of panic. But the ER Dr. decided he wanted the head of the bed down so he could stick a breathing tube in the patients airway. I wanted so bad to say we should wait like the Internist waited, but since I was a new RT I didn't think I was in a spot to say anything (however I definitely should have spoken up).

As soon as the patient was lying flat her panic grew. She was given Succicholine to paralyze her, and she vomited under the mask that was on her face. It was the most disgusting thing. So now, on top of her asthma, she had developed aspiration pneumonia.

She was on the ventilator for over a month. The Internist I referred to earlier met me in CCU with the patient and he ordered a tidal volume of 700. Back then high tidal volumes were in. I swear that as soon as I hooked the vent up to the pt and set in this volume, the alarm went into a hissy fit. The high pressure alarm went off every split second. I had never seen anything like it.
I had no clue what to do, so I lowered the tidal volume WAY down, like say to 100. And, lo and behold, the alarm stopped. I also informed the Internist that he should paralyze this patient because otherwise ventilating her will be next to impossible. So he did. Granted I was a new RT here, so I was grasping at straws -- or, better yet, at the fresh RT wisdom stuck in the niches of my brain.

Of course now I'm sweaty and nervous myself thinking this Dr. thinks I'm an idiot. I'm pretty confident he thought how unlucky he was to have to work with such a fool of a green RT. So, I snuck away from the vent a moment, and nervously called a co-worker of mine to verify what I had done. She said, the way I explained it to her, that I had done all the right things. She said she would have done the same thing.

I said, "Well, the Internist is mad at me. He said he wants his 700 tidal volume, and he thinks the vent is not working."

So my co-worker friend came in to help. You'll never know how relieved I was that she came in. And she basically took over this patient for the rest of the night. This patient was now so sick, and so difficult to ventilate, that she was a one on one all the rest of that night.

At the end of the shift I discussed this case with my co-worker RT. I told her I felt stupid that I called her. She said, "Rick, the fact that you had the common sense to admit you didn't know everything and call me impressed me and the doctor immensely."

"Hugh!"

"Well," she said, "What you did for this patient is exactly what I would have done. Ventilating asthma patients can be very difficult. And that you sacrificed your pride and called me for my advice is proof that you are not over confident."

Well, I certainly wasn't over confident. I was still upset that this patient was intubated in the first place. I fear that we nearly killed her. Now, this case still bugs me to this very day. And this question still races around in my head for an answer: "If we had not intubated this patient, would she have turned around in the next half an hour or so?"

I will never know. We may never know. And this is why treating severe exacerbation's of asthma -- status asthmaticus -- is such a hard thing to do. Sometimes we think we are doing the right thing by helping them, and many times we do -- but sometimes we cause more harm.

Now I must add that all the Dr.s I mentioned in this post are among the greatest in the profession. I am not questioning their skill. What I am questioning is this: in the future, how should cases of status asthmaticus be treated in the ER? At what point do we take the invasive step and intubate?

Truly this patient had all the right indicators for intubation. She fit well inside all the guidelines. And, if nothing else, this case is a perfect example that perhaps sometimes -- as the Internist did the first time the patient was admitted -- it's important to resort to common sense over the guidelines of an era.

I will discuss this patient further and Fatal asthma further in the days to come.

Is it possible pure asthma is NOT a fatal disease?

When I was a child asthmatic rarely did I think of the disease as something that could kill me. Yes it can be a very stressful and hard to deal with at times, but even during the worse asthma attacks I never thought I would die.

My doctors, and my parents, on the other hand thought otherwise. They feared for my life so much that, on January 9, 1985, they had me admitted to an asthma hospital in Denver Colorado. While there I was faced with the notion that, if I don't take better care of myself, and if my doctors don't get my asthma under better control, I might of an asthma attack.

I even had a friend while there who was discharged to home and later died. I also met another boy while there who had a brother die of asthma just months before I met him. Since then, however, I have never heard of any asthmatic die from his disease. I work as an RT, and I have never had an asthmatic die while in my care nor in the care of my hospital.

I'm not saying that asthma doesn't present some serious complications, but I do wish to propose a theory by this post which may not be common but has been brought up by prominent physicians of the past: that pure asthma in itself is not a deadly disease.  Even prominent physicians such as Henry Hyde Salter and William Henry Osler made such an observation.

How shocking does that sound? Think of it this way. As postulated by Albert Sheffler in his book "Fatal Asthma," which was published around 1995, who explained that famous asthma physicians and authors starting throughout the 19th century wrote that pure asthma does not kill.  It may be extremely uncomfortable, but it doesn't (or rarely does) kill.  Various other authors have noted the same.

Sheffler explains in his book that Henry Hyde Salter, in his book, "On Asthma"that was first published in 1860, wrote, "Asthma never kills; at least I have never seen a case in which the paroxysm proved fatal." You have to note here that Salter was the prominent figure on asthma in the 19th century.

Yes it is true that the number of asthma related deaths had doubled since 1985 (to about 5,000 per year), however, upon further analysis, is it possible that those deaths were not caused by asthma per se, but the person taking care of the asthmatic or other ailments coupled with asthma, such as pneumonia or -- as might be caused by the unsteady and untrained eye -- a collapsed lung from artificial respiration.  Or perhaps the asthma was coupled with emphysema, bronchitis or heart failure, and it was this that caused the death and not asthma.

I have had many bad attacks. Fortunately I have never needed artificial respiration. However, I have taken care of a few asthmatics who required intubation and artificial respiration on a ventilator.  Yet all of those cases were complicated by a smoking history, obesity, pneumonia, or other such ailment.

And, as my colleague Jane Sage brought to my attention, an asthmatic kid she took care of before I became an RT died of asthma.  However, Jane told me, post mortem x-ay showed a massive pneumothorax (collapsed lung).  Jane believed that this asthmatic did not die of asthma more so than because the doctor tried to pump too much air into the patient's lungs. She said this may not have been so much panic, but a bad medical practice at that time.  If not for modern medical intervention, this asthmatic, Sage postulated, would have survived.

Modern intervention, panic, the feeling you have to do something right now may be the cause of many cases of asthma related death.   My theory is that a well trained and educated hand may save the asthmatic from dying an untimely death. In fact, I'm almost sure of this.  Plus patience is required.

Consider in the 1800s and all the way up to the 1960s books have been published where the authors, prominent physicians, wrote that asthma does not kill, as did Salter. Leffler writes that a textbook in 1935 wrote that "life of an asthmatic is not endangered."

Thus, wrote Lefler, , "In 1935 Dr. H. L. Alexander of St. Louis concluded that, prior to 1930, 'death during an asthma attack was almost unknown."

However, this wasn't always the case?  Epinephrine was discovered in 1900 and first used on an asthmatic in 1903.  After this time it became a readily available option to immediately end a fit of asthma.  Yet statistics show that asthma related deaths spiked at this time.

Another spike in asthma related deaths occured after the 1957 invention of the rescue inhaler.  This spike was determined to be caused by lack of education regarding the medicine, not so much that asthma got worse at this time.  This started a debate that continues to this day:

1. Are asthma related deaths caused by asthma rescue medicine?  
2. Are asthma related deaths caused due to poor education about asthma rescue medicines?

One the inhalers were made to not be so readily available to asthmatics, and once a warning label was placed on the boxes, asthma related deaths associated with the inhalers declined. This, in my opinion, shows the spike in asthma deaths following the introduction of epi and the epi inhalers was due to poor education.

It is my opinion that asthmatics are so happy to have the rescue medicine when they are having a fit of asthma, that they overuse it.  So, instead of seeking help, they stay home until it is too late.  Hence, they are found with the inhaler clutched in their grasp, and the blame for the death goes to the inhaler rather than the lack of patient education.

A similar event happened in 1976 when the long acting beta adrenergic Fenoterol was introduced to the market in New Zealand.  Deaths from asthma spiked, and this resulted in a panic that had experts wondering if the medicine was the cause.  Ultimately a warning was included with the product on how to properly use the mediicne, and the death rate declined.

A longer acting beta adrenergic called Salmeterol was introduced to the market in 1994, and has since been combined with the medicine fluticasone in Advair.  Yet Salmeterol was blamed for many asthma related deaths.  Once again the reason was credited to the inhaler and many experts tried to have the medicine removed from the shelves.

Yet, once again, asthmatics wanted the medicine to continue to be available because, like rescue inhalers, salmeterol helped many asthmatics control their asthma.

To encourage proper use of the medicine, the FDA now recommends serevent never be used by itself for asthmatics, and instead be given in combination with an inhaled corticosteroid to control the underlying inflammation of the air passages.  Advair has since become the most popular asthma controller medicine.  Advair also comes with a black box warning so patients know of the dangers of abusing this medicine.  I wrote about this in more detail here.

So while rescue medicine and LABAs can work to make life better for asthmatics, abuse of these medicine, which usually results from lack of education, can kill.  So this is just another long history of examples of why it's important for asthmatics to stay educated.