Asthma Deadly ... But Treatable

By Christine Gorman

You name it, and Olympic track star Jeanette Bolden, 32, is probably allergic to it. Household dust, cats, seafood. Just the smell of fish cooking on a grill is enough to make her eyes puff up and start to water. But Bolden's allergies are linked to a more serious problem. Like 15 million other Americans, she suffers from asthma, a chronic affliction of the airways in the lungs that can turn the simplest act of breathing into hard labor and leave a person gasping, coughing and wheezing for air. Last fall the gold medalist (100-m relay, 1984) was hospitalized for a severe attack in which her airways closed off altogether. "Imagine slicing an orange and squeezing all the juice out of both halves," Bolden suggests. "That's how my lungs felt -- as if someone or something was squeezing all the air out."

Not long ago, Bolden's asthma might have kept her from competing or even coaching. But asthma specialists have learned so much in the past few years that they now believe they can keep most potentially fatal attacks at bay. They have found that allergies play a dual role in causing asthma to develop in the first place as well as in triggering individual episodes of wheezing. By studying families in which asthma appears to be inherited, scientists hope one day to discover the genes that predispose people to develop it. And by controlling the underlying irritation and inflammation of the lungs, most asthma patients should be able to enjoy a full and active life.

Despite these advances in knowledge, both the incidence and severity of asthma appear to be growing worldwide. Epidemics have been reported in Britain, Australia and New Zealand. In the U.S., the number of asthma cases rose 70% from 1980 to 1989. Even more alarming, the death rate, which had been declining steadily during most of the 1970s, began inexplicably increasing, and is now rising 8% a year. Asthma accounts for $5 billion in medical costs each year in the U.S.

Acute attacks of asthma occur when the bronchial tubes of the lungs become partly blocked. For reasons that are not entirely clear, the lungs are overstimulated by viral infections, allergens or pollutants. The body responds by activating various defense cells from the immune system. Their mobilization causes the airways to swell. At the same time, the muscles surrounding the airways contract, cutting off airflow. When that happens, asthmatics must inhale an adrenaline-like substance to stop the muscle spasm and reopen their airways.

If the attacks recur enough times, however, the lungs do not return to normal. They continue to act as if they are being invaded by parasites. This constant state of inflammatory alert damages the bronchial walls, creating scar tissue. As a result, the airways can no longer clear the mucus that forms deep in the lungs. The ensuing buildup reduces the flow of air and sets the stage for the next attack. "In olden times, which was only about five or 10 years ago, we all concentrated on the bronchospasm and assumed the patients were all right between episodes," says Dr. Peter Konig of the University of Missouri. "Now we see that inflammation is there from the beginning even in mild or asymptomatic cases."

Once asthma begins, it establishes a powerful feedback loop that may not even need an allergen to trigger an attack. General irritants such as cigarette smoke and urban smog can cause the already inflamed airways to constrict. "It is my opinion that parents or caregivers who smoke in the presence of a child are guilty of child abuse," says Dr. Allan Luskin of the Rush Medical Center in Illinois. "Smoke not only increases the risk of a child getting asthma in the first place, it makes asthma worse when it is there."

Scientists have developed a number of plausible explanations for the recent jump in asthma's prevalence and severity. In the process, they have also | generated a fair amount of controversy and no little confusion. Certainly, some of the growth in the caseload results from more accurate diagnosis. But several researchers blame the increasing amounts of time that human populations are spending in tightly sealed, air-conditioned homes and workplaces, and the resulting exposure to concentrated allergens and pollutants.

After studying a group of 67 children with a family history of asthma, Dr. Thomas Platts-Mills, head of the allergy division at the University of Virginia, concluded that exposure to a high concentration of dust mites in infancy was linked to a greater chance of developing asthma. The children became sensitized to the dust, and in many but not all cases their initial allergic reaction led to a chronic inflammation of the airways. "We spend 20 to 22 hours a day indoors," says Platts-Mills. "And newborn babies spend almost all their time inside for the first few months. It seems very likely that indoor allergens are one of the primary causes of asthma."

Other researchers blame the jump in asthma rates on gaps in the availability of health care, particularly in the U.S. In Chicago and New York City, the number of hospitalizations for acute attacks in chil dren under age four has surged. "A black child in the inner city has a 13- to 16-fold better chance of dying from asthma than his white suburban counterpart," says Dr. James Wedner, an allergist at Washington University in St. Louis. Poor or uninsured asthmatics often get medical attention only on a crash basis at the hospital emergency room. They receive no treatment for the underlying condition, so their lungs deteriorate.

Indoor pollution can play a powerful role in urban settings. Many city dwellers live in damp, humid apartments where cockroaches and mold spores as well as dust mites can trigger allergic responses. Even if these people realize that such conditions are conducive to asthma, they may not be able to change their circumstances.

Most controversial of all is the suggestion that physicians themselves have exacerbated the epidemic. Over the years, doctors have come to rely on powerful adrenaline-like substances called beta-agonists to treat asthma. When inhaled, these drugs open airway blockages in the lungs. But in the past 18 months a couple of studies have indicated that beta-agonists may be overprescribed. They are still the drug of choice during an acute attack, but many specialists now contend that if patients need to use beta-agonists four or more times a day, their treatment should be changed because their underlying condition is getting worse.

Part of the reason may be that beta-agonists work too well at providing relief. "If you're allergic to a cat, and a cat walks into the room, you'll cough and wheeze," explains Dr. Clive Page of the University of London. "What your body is saying is 'Leave the room or get rid of the cat.' What you actually do is use your inhaler. You feel wonderful and sit there watching the television with the cat." Meanwhile, the inflammation gets worse because the lungs are still being exposed to allergen. "By dampening down the symptoms, you feel better, but you're deluding yourself into believing that you're O.K."

In addition, the majority of asthma patients are seen by nonspecialists who still treat it as an intermittent problem rather than on a continuous basis. For that reason, the National Institutes of Health last year published a set of guidelines for health-care workers that emphasize closer monitoring of lung function and more comprehensive care for the underlying condition. For any but the mildest cases of asthma, the nih recommends that doctors reorganize their first line of defense to include such anti-inflammatory agents as cromolyn sodium or inhaled steroids. This strategy, the experts believe, should lessen the number and severity of later complications.

Just as important, asthma sufferers should learn all they can about their condition and try to eliminate their exposure to as many allergens as possible. Even if they cannot avoid every single irritant in the indoor or outdoor environment, they can certainly try to allergy-proof the bedroom. And with proper treatment, their symptoms will be kept under control. "People with asthma can live normal lives," Rush Medical's Luskin declares. "They and their families should expect nothing less."

With reporting by Mary Cronin/New York