Thursday, June 08, 2000

Asthma's spread stumps experts

Doctors can diagnose it and treat it, but they can't explain why more adults have it

By Peggy O'Farrell
The Cincinnati Enquirer

Donald C. Vogel
(Craig Ruttle photo)
| ZOOM |
        For years, Donald C. Vogel had a chronic cough. When he exercised, he was short of breath. A few months ago, Mr. Vogel, 59 and the vice president of financial management for the American Lung Association of Ohio, learned he had asthma after his doctor ordered a pulmonary function test during his routine physical.

        Mr. Vogel, who lives in Anderson Township, has joined the ranks of thousands of American adults who are finding out that, somewhere along the line, they have developed asthma.

        Doctors know how to diagnose asthma. They know how to treat it and how to teach patients to manage the chronic lung disease. They're still trying to find out why more and more adults are developing it.

        Pediatric asthma is well-documented, said Dr. David Bernstein, an allergy and immunology specialist with the Bernstein Allergy Group and Research Center. But researchers are just beginning to focus their microscopes on adult-onset asthma, he said.

        “There's really very little known about the natural history of asthma in adults,” Dr. Bernstein said.

        “We know some get better. Some get worse. And that's about all we know,” he said.

        Experts call asthma an epidemic among Americans of all ages, and the epidemic is growing. Approximately 17 million Americans now have the disease. By 2020, that figure could rise to 29 million, according to a recent study by the Pew Environmental Health Commission at the Johns Hopkins School of Public Health in Baltimore.

        The projected increase in asthma cases mirrors the growth tracked over the last several years. Data from the U.S. Centers for Disease Control and Prevention indicate 6.7 million total cases reported in 1980. By 1994, that number had more than doubled to 13.6 million.

        “The truth is, we really don't know why we're seeing more,” said Dr. Ira Finegold, chief of allergies at St. Luke's-Roosevelt Hospital in New York City. “But we are seeing more.”

  • In 1980, an estimated 6.7 million Americans had asthma.
  • In 2000, an estimated 17 million Americans have asthma
  By 2020, asthma cases could rise to 29 million, or 1 in 14 Americans.
  • Asthma deaths increased from 2,598 in 1979 to 5,667 in 1996.
  In 1996, 474,100 Americans were hospitalized for asthma.
        • Estimates of asthma's direct costs, including hospital care, physicians' services and medications, range from $3.6 billion to $5.1 billion annually.
  • Indirect asthma costs, including lost work days and lost earnings, are estimated at $2.5 billion.
  Sources: American Lung Association, Centers for Disease Control and Prevention, National Center for Health Statistics, American College of Allergy, Asthma and Immunology.
        Mr. Vogel, who was worked with the American Lung Association for 37 years reads all the educational materials the association mails and goes to educational seminars and talks to doctors about asthma incidence and occurrence all the time.

        It never occurred to him that he might have asthma. He doesn't wheeze. He doesn't have allergies. But his cough and shortness of breath are the classic symptoms of adult-onset asthma.

        “I just thought that it was normal for me to cough,” he said.

        But, he said, it does illustrate the point that everyone needs to be aware of the risks, and the prevalence of asthma and other chronic lung diseases.

        Asthma is generally associated with children, and primary care physicians may not think to look for adult-onset asthma or recognize its symptoms: shortness of breath, and a nagging cough, just like Mr. Vogel's symptoms.

        “They don't necessarily have to wheeze,” said Dr. Michael Kreindler, an allergy specialist in North College Hill.

        “There's times I'll see patients who come in with a chronic cough they've had for a year or more and they go to other doctors who do chest X-rays and don't find anything.”

        Summer is the mean season for people with asthma and other chronic lung diseases. An abundance of smog, pollen and mold combined with high humidity make breathing a chore for sufferers.

        Summer in Cincinnati, like in many river cities, is especially ugly when bad air quality meets a high allergen count, said Dr. Kreindler.

        “We sit in a bowl, and there's static air masses, so the stuff just sits there,” said Dr. Kreindler. “We sit in an inversion layer and all this stuff never moves.”

        Mr. Vogel said his symptoms don't get any worse during hot weather. But during smog alerts, he tries to stay indoors.

        He says stress and exercise seem to trigger his symptoms.

        Allergies, diagnosed or otherwise, probably play a big role in adult-onset asthma, experts say. Stress and exercise also trigger asthma attacks in adults.

        In younger adults, commonplace allergies, such as pollens, grasses and molds, seem to be the culprit when asthma makes a sudden appearance, said Dr. Bernstein. For others, triggers they're exposed to in the workplace can be to blame.

        “There are over 300 substances that are known to induce occupation-induced asthma,” Dr. Bernstein said. In the electronics industry, the chemicals used in soldering compounds can trigger asthma. Bakers may become allergic to the wheat and rye compounds they use to make flour. People who work in health-care settings or in laboratories where latex gloves are used can be prone to asthma, he said.

        For some adults, asthma may develop after a viral infection, he said. Researchers are trying to find out just how that might happen.

        And there's some evidence that older men who were allergic to cats during their childhood may develop asthma well into adulthood.

        Sometimes it's hard to pinpoint a single trigger, Dr. Bernstein said.

        “In adulthood, there are a lot of people who develop asthma for which no cause can be identified,” he said.

        There are several theories to explain the overall increase in asthma, Dr. Finegold said.

        “It seems to be occurring where Westernization of civilization is occurring,” he said. More pavement, more industry, more traffic all seem to be factors.

        Some experts say construction of new, air-tight and energy-efficient buildings could be to blame, because allergens can't move in and out with the air currents in tightly built construction.

        Dr. Finegold also cited a recent study in the Lancet that suggests we aren't exposed to enough germs. The article suggests that improved sanitation and hygiene and mass immunizations may have triggered human immune systems to respond more strenuously to allergens, since pathogens aren't the threat they used to be, he said. “The problem with that is, if we have more infections, we die younger,” he said.

        Other theories:

        • Diesel fuel fumes in inner-city areas are creating more air pollution.

        • Latex rubber, a known asthma trigger, is more prevalent in the environment “because of all those tires hitting the pavement,” Dr. Finegold said.

        • Children getting viral infections early in life that might trigger asthma later.

        “It seems to be a byproduct of civilization, that the more civilized we become, the more asthma we get,” he said.

        But there is good news amid all the questions, Dr. Finegold and Mr. Vogel point out. Although asthma is increasing at an alarming rate, effective remedies are available to treat the disease. Mr. Vogel takes Proventil, which helps expand air passages in the lungs, and Aerobid, a respiratory corticosteroid inhaler that reduces inflammation in the linings of the airways.

        Two or three weeks after he began taking the prescriptions, Mr. Vogel said, his symptoms were almost gone.

        Identifying and avoiding allergens and a variety of other prescriptions are also available, Dr. Finegold said.


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