by Michael B. Schachter M.D., F.A.C.A.M.
Asthma, a condition whose incidence, prevalence and mortality
rate has been increasing during the past several years, is a very serious health
problem for both children and adults. Approximately 12 million adults and
children now have asthma in the United States. Nearly 5,000 of them die of it
every year. According to the Centers for Disease Control and Prevention, the
death rate from asthma increased by 46% from 1970 to 1987 and it is still
growing. Asthma-related health costs were estimated to be $6.2 billion dollars
annually as of 1990.
In this article, I will describe the pathology of asthma and
how it is generally treated by conventional medicine. Then I will discuss the
shortcomings of this conventional approach by outlining how a complementary
physician might approach the asthma patient. In doing so, I will emphasize how
to prevent asthma attacks by working on one's environment, lifestyle and
Asthma is a disease that affects a person's ability to
breathe. It is a chronic lung disease characterized by airway obstruction that
is reversible (but not always completely so), airway inflammation, which results
from edema or swelling in the lining of the bronchial tubes, and increased
airway responsiveness to a variety of stimuli. The symptoms of an asthma attack
include wheezing, shortness of breath and coughing. Breathing out is
particularly difficult during an asthmatic attack and wheezing during expiration
is particularly characteristic. Asthma may be periodic with relatively symptom
free intervals or it may be relatively chronic with mild to moderate symptoms
present most of the time. Either type of patient may have a severe acute
life-threatening attack, which may require potent drugs in a hospital setting.
Asthma attacks may be triggered by a variety of stimuli, the
nature of which varies from individual to individual. Upper respiratory
infections, either viral or bacterial, often trigger an asthmatic attack.
Exposures to tobacco smoke, perfumes, paints or other strong chemical odors are
often culprits. Changes in weather or temperature, exposure to molds, animal
danders, grass or tree pollens are all triggers for some asthmatic patients. For
some patients, exposure to sulfites, used to preserve foods, has resulted in
deaths due to asthma. Certain food colorings, such as the yellow dye tartrazine,
as well as many other food additives may be triggers. Drugs, such as aspirin,
non-steroidal anti-inflammatory drugs-like Advil, beta blockers-like Inderal,
ACE inhibitors and many others can precipitate an asthma attack.
Diagnosis of Asthma
Aside from the clinical observations of shortness of breath, coughing and
wheezing, how can asthma be diagnosed? In addition, to hearing the wheeze with a
stethoscope, one can use two medical instruments to help with the diagnosis and
response to treatment. The first is called a spirometer. Spirometry involves the
patient taking a deep breath and blowing into the tube of the spirometer as hard
and as fast as he can. The patient may also breathe in and out several times
into the tube for additional information. The spirometer measures the amount of
air expired and how much is expired at different phases of the expiration. With
asthma, we'll see a reduced total amount of air expired or forced vital
capacity. We'll also see a reduced volume expired during the first half second
and second or forced expiratory volume 0.5 and 1.0. Finally, we'll observe a
reduced volume during the middle cycle of the expiration. Each one of these
measurements can be improved after the person breathes a bronchodilator drug,
thus showing that these changes are at least partially reversible. This
reversibility leads one to the diagnosis of asthma rather than a more fixed
irreversible lung disease. Another instrument useful in monitoring the severity
and response to treatment in asthma patients is a peak flowmeter. Again, the
person expires a deep breath as quickly and completely as possible and the peak
flow is measured. This instrument is important for monitoring treatment
Mechanisms of an Asthma Attack
Now, lets discuss the mechanisms of an asthmatic attack. What happens to the
lungs during such attack? First, we see bronchial spasm and/or constriction of
the smooth muscles of the bronchi or airway tubes, leading to a narrowing of
these passages. Second, we get inflammation and edema or swelling of the inner
lining of the bronchi, which further narrows the airways. Third, we observe
increased mucus production with the development of mucus plugs that may further
block air from getting to the little air sacs in the lungs, thus preventing
oxygen from getting into the bloodstream and carbon dioxide from leaving the
bloodstream in order to leave the body. And, finally, we frequently see evidence
of allergic phenomena on a cellular level, with allergy cells called eosinophils,
resulting in further inflammation of the airways. This allergic mechanism almost
always involves the substances known as platelet activating factor or PAF and
histamine, to a lesser extent. In addition to causing inflammation, this
allergic reaction also contributes to bronchial hyper responsiveness.
To review, the important mechanisms of asthma are: 1) an
increased responsiveness of the airways to a variety of stimuli; 2) a narrowing
of those airways due to a contraction of the smooth muscles of the bronchi; 3) a
further narrowing due to inflammatory changes in the walls of the bronchi; and
4) an increased production of mucous and fluids in the airways causing further
narrowing and even blockage.
These mechanisms are important to keep in mind as we discuss
both conventional and complementary treatments.
Conventional Treatment Approaches to Asthma
A good conventional approach to asthma will look at the environmental stimuli
that set off a response from the super sensitive airways. Here, a careful
medical and ecologic history is most important to establish which stimuli are
most important for this particular patient. Do asthma attacks occur mostly
indoors or outdoors? If indoors, are they worse at home or at work? Are they
worse during a particular season? Tree pollens, for example, are very high in
early spring, grass pollens peak in the late spring and the classic ragweed
season begins in late summer and ends with freezing weather. Sometimes asthma
attacks are precipitated by exercise.
Patients will be warned about the adverse effects of active or
passive tobacco smoke. They may also be advised to avoid dust or fumes of
chemicals, exposures to people who have upper respiratory infections, cold air,
known inhalant allergens such as cats or dogs, grasses or pollens and various
drugs such as the beta blockers, ace inhibitors, aspirin and certain
non-steroidal anti-inflammatory drugs. Once allergens have been identified,
measures recommended to minimize exposure to them might include avoiding outdoor
activities in early morning when allergen levels are highest, keeping windows
closed as much as possible during the peaks of allergy seasons and keeping
indoor humidity levels between 40 and 50 percent to reduce pollen and mold
exposure. Eliminating carpeting and upholstery when possible and using plastic
pillow and mattress casings will help to keep dust exposure to a minimum.
Laundering bedclothes weekly in hot water is also recommended. High efficiency
particulate air, abbreviated HEPA filtering devices, effectively reduce airborne
allergens and other inhaled irritants.
Occupational exposure must be explored as more than 200
different occupational asthma triggers have been reported in the medical
literature. The concept of total body burden of toxic and allergy factors is
very important here. To prevent and treat asthma attacks, the goal is to reduce
exposure to toxic and allergenic substances as much as possible to lower the
total body burden.
Use of Bronchodilator Drugs by Conventional Physicians to
Frequently, an asthma attack may be precipitated by a bacterial infection. In
such a case, an antibiotic medication is helpful in clearing up the infection.
During severe attacks, respiration may be limited so much that the oxygen
concentration in the bloodstream may be dangerously low. Breathing in oxygen
will help to correct this situation. Aside from oxygen and antibiotics, the
medications to treat both acute and chronic asthma are classified into two
categories, bronchodilators and anti-inflammatory agents. Together, these
medications are used to reverse or prevent air flow obstruction. The smooth
muscles of the airways contain receptors that are known as beta 2-adrenergic
receptors. Upon stimulation, these receptors cause a relaxation of the smooth
muscles of the bronchi.
A hormone in our body that stimulates this type of receptor is
adrenaline or epinephrine, which is the fight or flight hormone secreted by the
adrenal medulla. The drugs used to stimulate these receptors are called beta 2-
adrenergic agonists. One of the most used of these drugs is albuterol whose
brand names are Proventil or Ventolin. They are administered mostly by metered
dose inhalers (abbreviated MDI). For severe attacks, albuterol may be
administered in the hospital by nebulizer every one or two hours. However, the
frequency is reduced as soon as possible, and the patient is switched to the
metered dose inhaler. Outside of the hospital the medication is used as
necessary, preferably only one or two puffs daily. It may be used prior to
exercise to prevent an exercise induced asthmatic attack.
Although the product literature states that up to 12 puffs a
day may be used, patients with mild asthma should need these drugs only 3 or 4
time a week. A pattern of regular or increasing use approaching 8 to 12 puffs a
day reflects poor asthma control and warrants immediate re-evaluation. Although
these beta 2-adrenergic agonists are reported to be reasonably safe, they do
stimulate the autonomic nervous system and may produce rapid or irregular
heartbeat, insomnia, shakiness and nervousness.
Anti-cholinergic agents constitute the second class of
bronchodilators. Whereas the beta 2-adrenergic agonists mimic the sympathetic
nervous system, the anti-cholinergic agents work by inhibiting the
parasympathetic nervous system as the latter tends to constrict the bronchi. So
by inhibiting the action of the parasympathetic nervous system with anti-cholinergic
drugs like ipratropium bromide or Atrovent, bronchodilation is promoted.
Atrovent is also given by inhaler. Potential adverse effects include dry mouth,
cough, headaches, a worsening of glaucoma and urinary retention.
A third class of bronchodilators are the methylxanthines, such
as aminophylline and theophylline. Caffeine is another example of a methyl
xanthine, although it is not used in asthma. The exact mechanisms of action of
the methylxanthines in causing bronchodilation is unclear. Previously, these
drugs had been considered the first line of therapy for asthma, but because of
their serious side effects, they are somewhat less important at the present
time. However, aminophylline or theophylline may be used intravenously if other
treatments have not gotten an attack under control.
For chronic asthma, theophylline, whose brand names include
Theo-Dur, Uniphyl, Slo-bid and others, is now considered a third-line choice,
but may be of benefit in nighttime asthma, due to its long duration of action.
Adverse effects of theophylline involve many organ systems. They may be mild or
severe and life threatening. Gastrointestinal symptoms include heartburn, nausea
and vomiting. Central nervous system negative side effects include headaches,
insomnia, tremor and seizures. And finally abnormal heart rhythms and deaths
have been reported.
Some studies have shown that frequent over use of the
bronchodilators may result in an overall worsening of the asthma condition. This
effect and the adverse effects on the cardiovascular system may explain in part
the increasing death rate from asthma during the past several years. In other
words, increasing mortality from asthma may be partially iatrogenic, or in other
words, doctor caused.
Control of inflammation is currently the primary focus in managing asthma. The
most effective agents for this purpose are the corticosteroids. These
medications interfere with the synthesis of inflammatory mediators and prevent
migration and activation of inflammatory cells. Also, they improve
responsiveness of airway beta receptors, which promotes relaxation of bronchial
smooth muscle. Corticosteroids, produced naturally by the adrenal cortex,
include hydrocortisone or cortisol, which can be prescribed by physicians.
However, conventional physicians usually prefer to use one of
the synthetic corticosteroids. During an acute severe asthmatic attack requiring
hospitalization, the patient is usually given methylprednisolone (brand name
Solu-Medrol) as a 60 to 80 mg intravenous push every six to eight hours for the
first 36 to 48 hours of hospitalization. The patient is then switched to high
doses of oral prednisone or methyl prednisolone, which is rapidly tapered over
the next 10 days to two weeks. Short-term adverse effects from oral or
intravenous steroids include increased appetite, weight gain, elevated blood
sugar, fluid retention, mood changes, and gastrointestinal upset. Most patients
can avoid long-term (months or years) use of corticosteroids, which have
additional adverse effects and risks. These include a suppressed immune system,
adrenal suppression, osteoporosis, muscle weakness, cataracts, skin changes, and
I have just discussed the use of intravenous and oral
corticosteroids in treating acute asthmatic attacks. However, the administration
of corticosteroids by inhalation is being acclaimed by many clinicians as the
greatest advance in asthma management in the last 20 years. Inhalation
corticosteroids are being recommended by many physicians as the first-line
maintenance therapy for the adult with daily or frequent asthma symptoms.
However, inhaled steroids appear to be underutilized, as they constituted less
than 15% of all asthma prescriptions in 1993, according to a pharmaceutical
industry survey. Their dosage varies from 1 to 5 puffs, two to four times a day,
depending on the preparation. Local adverse effects include hoarseness, cough,
and oral candidiasis or thrush. Generally, chronic adverse side effects of
steroids given orally are not seen to any extent with the inhaled form of
steroids. The inhaled steroids should be given at the lowest possible dose,
capable of controlling the asthma. Examples of inhaled steroid products are:
Beclovent, Vanceril, Azmacort, and Aerobid.
A non-steroidal anti-inflammatory inhaler that can be used for
asthma is cromolyn sodium or Intal. It prevents mediator release from airway
mast cells and inhibits both early- and late-phase immune response in asthma,
but it is not as effective as the corticosteroids. The most common side effect
Complementary Approach to Treating and Managing Asthma.
In addition to all of the triggers considered by conventional medicine such as
stopping exposure to cigarette smoke, reducing exposure to known indoor
allergens, and reducing exposure to outdoor allergens, the complementary
physician will evaluate areas that are usually not considered by the
In his approach to any health problem, the complementary
physician will recommend cleaning up the diet by eliminating or reducing refined
carbohydrates (such as sugar and white flour), hydrogenated fats (which mess up
fatty acid metabolism), and synthetic food additives, (such as preservatives and
artificial sweeteners). The diet should emphasize whole organic foods, as much
as possible. Water should be free of both fluoride and chlorine. In addition,
tests may be run to pick up subtle food allergies to some of the good foods.
An appropriate exercise program, which includes aerobic
exercise, stretching and strengthening will be recommended as tolerated. Stress
management techniques will be utilized in patients for whom anxiety seems to be
an important trigger.
Rather than emphasizing the bronchodilator and
anti-inflammatory drugs that conventional physicians use routinely, the
complementary physician will keep them on the back burner, and use them only if
the disease cannot be controlled by natural means. These natural means will
include dealing with detoxification, supplying natural substances like vitamins,
minerals, enzymes, and herbs either orally or by injection, dealing with less
accepted infections, such as Candida Albicans overgrowth in the gut, balancing
the hormonal system, using homeopathic medications and/or using energy balancing
techniques such as acupuncture.
If the patient has had exposure to a lot of antibiotics and
steroids, as many asthma patients have, Candida overgrowth is likely and is
probably contributing to the difficulty in controlling the asthma. In such
cases, a sugar free, yeast free diet should be recommended. A number of natural
supplements are helpful in controlling the Candida, including caprylic acid,
garlic, pau dí arco herbs, and dioxychlor. Friendly bacteria, such as
lactobacillus acidophilus and bifidus, should be supplemented. Of course,
exposure to antibiotics and corticosteroids should be reduced and eliminated, as
soon as the patient can tolerate this. If necessary, anti-Candida medications,
such as nystatin, Diflucan or Nizoral may be recommended for a limited time.
Other unfriendly organisms in the gut, such as certain bacteria or parasites may
also be eliminated by appropriate herbs or medications.
Detoxification procedures are designed to reduce exposure to toxic substances
and to help the body improve its ability to rid itself of toxic substances. To
do this, it is necessary to carry out earlier suggestions by both conventional
and complementary physicians on reducing toxic exposure. Additionally, the
organs of the body that deal with detoxification need to be addressed. These
organs include the gastrointestinal system including the liver, the kidneys, the
lungs and the skin.
The function of the gastrointestinal system or gut is to allow
necessary nutrients into the body while preventing toxic substances from
entering the bloodstream through the gut. Malabsorption problems relate to a
reduced ability to get nutrients into the body. Leaky gut problems relate to the
intestines allowing toxic substances, such as large molecules into the
bloodstream. The latter may encourage allergic inflammatory responses, which can
aggravate asthma. The leaky gut may be caused by Candida, parasites or other
organisms. Other causes of the leaky gut are damage from toxic substances, such
as non-steroidal anti-inflammatory drugs like ibuprofen, and nutritional
deficiencies. Repair can be carried out by eliminating the toxic offenders and
supplying the repair nutrients. Among the most important nutrients for repair
are L-glutamine, zinc, vitamin A, vitamin C, vitamin E, GLA and gamma oryzanol.
These may be given as capsules or as part of a specially designed therapeutic
food powder, like Ultra Clear Sustain. By repairing the leaky gut, allergic
responses will be reduced and asthma should be improved.
The liver is the major organ of the body to carry out
detoxification of toxic substances that are already in the body. These toxic
substances may be from external sources or as a result of normal or abnormal
metabolism within the body. The details of this process will be the subject of
another Medical Update. Suffice to say at this point, that bolstering the liverís
abilitly to detoxify by supplying the necessary nutrients may result in
significant improvement of asthmatic conditions. The types and amounts of
nutrients to be supplied in an individual case will depend on the individual and
can be determined by specialized testing.
The role of the kidneys in detoxification involves the
elimination of water-soluble toxins from the body. Drinking sufficient amounts
of pure water will be helpful. The skin eliminates toxins through sweat and
other secretions. Applying a dry brush massage to the skin helps to stimulate
circulation and improve this function. The elimination of toxins through the
skin by sweating can be accomplished with aerobic exercise and saunas. To
eliminate heavy metal toxicity from lead, aluminum, cadmium or mercury,
chelating agents may be used. The removal of mercury amalgam dental fillings may
be recommended to eliminate a source of mercury contamination.
Recall that the major medications that are used to treat
asthma are bronchodilators to dilate the constricted bronchi, anti-inflammatory
agents to reduce inflammation, and antibiotics when infection is playing a role.
Building Immunity to Reduce Need for Antibiotics
To reduce the need for antibiotics to treat infections, a complementary
physician will use nutrients to bolster the personís own immune system. These
may include liberal use of vitamin C, vitamin A, zinc, copper, thymus extracts
and herbs like Lomatium and Echinacea. These may be given orally. In addition, a
course of intravenous infusions of vitamin C and other nutrients, or low dose
hydrogen peroxide will generally bolster the immune system and help the patient
to feel better.
The mineral magnesium, which has been covered in a previous
medical update, is possibly the single most important nutrient for managing
asthma because of its multiple effects on the asthmatic condition. It is
extremely effective in the relaxation of bronchial smooth muscle tissue,
resulting in a reduction of bronchospasm and increased airways diameter. It may
do this in part by stimulating production of cyclic AMP and ATP, two important
mediators that bring about relaxation of bronchospasm.
Magnesium also reduces the histamine response, which mediates
allergic inflammation. Patients suffering from asthma often have exaggerated
histamine release from certain white blood cells, which leads to inflammation
and bronchoconstriction. Magnesium helps to dull this response.
Various lifestyle practices contribute to magnesium
deficiency, including chronic caffeine and alcohol consumption, dieting and
excessive exercise without sufficient magnesium replacement. Use of diuretics or
water pills contribute to magnesium depletion. Ironically, studies have shown
that asthma bronchodilator medications, such as theophylline and albuterol can
cause magnesium wasting, thereby contributing to the worsening asthmatic
condition. Magnesium may be given orally or by injection. Some patients because
of gut problems develop diarrhea when magnesium is given orally and those
patients may need to be given magnesium by injection, until the gut problem is
The counterpart of the mineral magnesium is the vitamin
pyridoxine or vitamin B6. Like magnesium, vitamin B6 is important in stimulating
the production of ATP and cyclic AMP, which promote relaxation of bronchial
smooth muscle, resulting in an increased bronchial diameter. As with magnesium,
the bronchodilator medications deplete vitamin B6. So, vitamin B6 should be
given along with magnesium, both orally and by injection.
For some asthma patients, sulfites are a major trigger. These
patients may be suffering from a relative enzyme deficiency, which results in
difficulty oxidizing sulfites to sulfates. Two co-factors that are involved with
this oxidation are vitamin B12 and the mineral molybdenum. Sulfite sensitive
patients may greatly benefit from oral and injectable supplementation with B12
Anti-inflammatory Herbs and Nutrients
Some herbs that are being used by complementary physicians for treating asthma
for their anti-inflammatory and/or bronchodilating effects are Gingko Biloba,
Coleus Forskholii, MaHuang, Lobelia and Glycyrriza glabra. These herbs are
complicated substances containing many compounds. They have multiple effects,
which may include anti-inflammatory actions, bronchodilator effects and
Precursors of the anti-inflammatory prostaglandins are often
helpful. These include sources of omega-3 fatty acids, like flaxseed oil and
fish oils, and sources of gamma linolenic acid or GLA, like evening primrose oil
or borage oil.
Since much of the inflammation is mediated by free radicals,
anti-oxidant enzymes vitamins and minerals are useful. These would include
vitamins A, C and E, the carotenoids, many bioflavonoids like quercetin,
superoxide dismutase, glutathione, and N-acetyl cysteine. Again these nutrients
may be given orally or by injection. Digestive enzymes may be used as natural,
non-toxic anti-inflammatory supplements. Examples are pancreatic enzymes,
bromelain, papain and others.
Homeopathic medications which must be prescribed on a highly
individualized basis, depending upon the patientís symptoms and
characteristics can be quite effective in the hands of a well trained,
experienced homeopath. Some of the most used homeopathic remedies for asthma are
arsenicum album, kali carbonica, calcarea carbonica, pulsatilla and sulphur.
Other alternative therapies that may be useful in individual
cases of asthma are acupuncture, chiropractic or osteopathic manipulation,
massage and Rolfing.
In summary, asthma is one condition which responds well to a
wide variety of alternative and complementary medicine practices. Using these
methods more widely should result in an improvement of treatment results and a
reduction of mortality and morbidity associated with the use of conventional
© 2000 Michael B. Schachter M.D.