Hardluck Asthma

1940-2012: The dry powdered inhaler (DPI)

2012-01-26T17:04:00.003-05:00

For almost 8,000 years asthmatics inhaled medicine by smoking it. This changed in the 1930s with the invention of the electric nebulizer and again in the 1950s with the invention of the metered dose inhaler (MDI). A third option that has been slowly gaining momentum is the Dry Powder Inhaler.

A DPI allows you to inhale the powdered version of a medicine, which comes in the form of a capsule or blister that is cracked open inside the inhaler. There is no propellant, and instead the medicine is breath actuated. This means the medicine enters your airway as you inhale.

There are advantages to DPIs:

Since they are breath actuated no propellant is needed
Coordination is generally easy
They are easier to use than MDIs
Dose is easily measured

Of course there are also disadvantages:

The patient must be able to generate enough flow
Each company markets its own device, which means there may be many to learn
You will have to place the capsule into the device prior to inhaling the medicine
The devicess tend to be expensive to manufacture and expensive to purchase

To learn about the history of DPIs we actually have to travel back to before the first MDIs hit the market in the 1950s. According to A.R. Clark in his article, "Medical Aerosol Inhalers: Past, Present, and Future, Aerosol Science and Technology , the first DPI was patented in 1939.

Clark explained that it was not used as an asthma inhaler, though, but to inhale "aluminum dust for the chelation of inhaled silica. It was intended for use by miners who suffered from silicosis induced by inhaling dust." Yet the product never gained popularity and was never marketed. (1)

By the 1940s pharmaceutical companies learned that systemic injection of asthma medicines like epinephrine and atropine caused significant side effects. They were in an all out race to develop a device that allowed asthmatics to inhale medicine and, thus, generate an immediate effect with fewer side effects.

In 1949 the Aerohaler was introduced as the first marketable DPI, and also the first rescue inhaler. Yet it never gained popularity and was later overshadowed when the first MDIs hit the market in 1957 in the form of the Medihaler Epi and the Medihaler Iso.

For all practical purposes, it was ultimately realized DPIs don't work well with rescue medicine because when the medicine is needed many asthmatics have trouble generating enough flow to suck up the medicine. While Ventolin is available overseas as a DPI, none are currently approved by the FDA for sale in the U.S.

When the CFC propellant used in MDIs was determined to harm the environment in the 1990s, DPIs were determined to be a solid delivery device for asthma controller medications.

Aerolator with glass vial containing 3 small epi/ penicillin vials

So, without further adieu, here are your DPIs:

1. Aerohaler: Released by Abbot laboratories in 1949 as the first marketed DPI. The medicine was Norisodrine, isoprenaline sulphate. It was the first rescue inhaler. Clark described the Aerohaler this way: "The device consisted of 'sifter' cartridges containing the powdered dose out of the cartridge and a mouthpiece through which the aerosol was inhaled. There was very little control over the delivered dose, other than patient symptoms titration, and there was no dispersion mechanism inside the device to aid aerosol generation." (2) Each glass vile contained three smaller vials (sifter cartridges) that were set on the inhaler device. The patient then inhaled the powder through the nose. The disadvantages of this inhaler were later outshadowed by the release of the MDI in 1957. The Aerohaler was also used in the late 1940s and 50s as a means to deliver penicillin. A modern version of the Aerohaler was remarketed and available in some countires, yet it has little in common with the original.

Intal Spinhaler and Intal Gelcap

2. Spinhaler: Fisons introduced this device in 1972 as the mechanism to deliver disodium cromoglycate (sodium cromolyn or simply cromolyn). The product was marketed as the Intal Spinhaler to be used with the Intal Spincaps, and remedied many of the problems of the Aerohaler. It was the first commercially successful DPI. The caps were made of a hard gelatin and guaranteed the same dose with each inhaletion (a metered dose). They had to be removed from the foil package and placed in the spinhaler by the patient. The patient then cocks the outer shell of the inhaler and needles inside the device pierce the capsule. The patient then places his mouth on the mouthpiece and inhales. The flow generated causes a fan inside the device to rotate, and as this occurs the powder is inhaled. The Intal Spinhaler was very popular as an asthma controller medicine during the 1970s, 80s and 90. It was ultimately phased out because the powder caused some patients to cough and this caused some asthma attacks. It was replaced by the Intal inhaler in the late 1990s. I wrote more about the Spinhaler here.

Ventolin Rotahaler and Rotacaps

3. Rotahaler: In the early 1960s Allen and hanbury introduced the Ventolin Rotacap to go along with the Ventolin Rotahaler. The product was marketed throughout the 1980s and 1990s but was ultimately discontinued because some asthmatics who needed the rescue medicine had trouble generating enough flow to suck in the medicine. Another problem was that each individual unit dose Rotacap had to be handled by the patient and carefully inserted into the device. The Ventolin Rotahaler was a failed experiment, and since it was discontinued only asthma controller medicines have been available as DPIs. The Rotahaler was later refined so it contained a month supply of capsules and re-marketed as the Becotide Rotohaler and the Spiriva Handihaler in 2009.

4. Turbuhaler: Astra Zeneca introduced this product as one of the first multi dose DPIs in the early 1990s. The Pulmicort Turbuhaler was approved by the FDA in 1997, and the Symbicort Turbohaler in 2000, according to FDA.gov. Various other products have been marketed in other countries such as the Bricanyl Turbuhaler (terbutaline) and Formoterol Oxis Turbuhaler. The Pulmicort DPI has since been discontinued.

Diskhaler

5. Diskhaler: GlaxoSmithKline intruduced the disk in the early 1990s and asked for FDA approval in 1992. The original discus contained 4-8 blisters per cartridge, which made it so the patient didn't have to worry about handling each dose. The device has since been refined so each discus contains 60 capsules, or two capsules for each day, or one month supply. The recommended dose is one puff twice daily. Each disc is equivalent to two puffs of the MDI version of the medicine. A blister of capsules are stored in a roll, or disc inside the device. All the patient has to do to prepare a dose is to open the device and pull down a lever. This moves a new capsule into the delivery chamber and decreases the counter by one so the patient knows how many doses are left. The Serevent Discus was FDA approved in 1997 and the Advair Discus in 2000 according to fda.gov. The Flovent Discus was approved in 2000 but was never marketed. The Serevent Discus may also be referred to as Seritide, Viani, ForAir, and Foxair in some countries. Advair is a combination of Serevent and Flovent. The Advair Discus is currently the most popular asthma controller medicine on the market. The discus is referred to as the autohaler or diskus in some countries. Other products available but not approved by the FDA are the Becodisk which contains beclomethasone, and the Ventolin Autohaler

6. Inhalator: The device is marketed by Novaris. I've found various articles that mention studies comparing salmeterol (Serevent) inhaler with the formoterol inhalator (Barotec) from as far back as 1985, although I'm not certain it was actually approved for use in any country at this time. The inhaler was improved upon by 2001 and renamed the Centihaler. It was this product that was finally approved by the FDA in 2001 as the Foradil Centihaler. In 2006 the FDA approved the Foradil Aerolizer which will be under patent until 2019. (3) The recommended dose is two puffs of the inhaler twice daily or one puff on the DPI. As a note here, the FDA seems to have the strictest policy for drug approval. As a rule of thumb, if the FDA approves a medicine chances are it's been run through the gambit and is proven relatively safe, or at least the benefits far outweigh the disadvantages. I believe this product was slow to be approved by the FDA due to it being linked to asthma related deaths. However, many believe it wasn't the medicine so much as poor education that resulted in the deaths, yet it was never proven either way. A similar problem plagues salmeterol. The problems was addressed in 2003 with a black box warning on the packaging.

7. Cyclohaler: This is another DPI introduced to the market in the early 1990s. The medicine is stored in hard gelcaps that are inserted into the cyclohaler with each use. The mouthpiece is long to optimize drug distribution even if the patient isn't able to generate enough flow. Several puffs were often necessary to get an optimal dose. The initial product was marketed as the Aerolizer Cyclohaler, and the products available were albuterol and ipatropium bromide. Since the product wasn't marketed in the U.S. the medicine was referred by it's non-U.S. name, such as the Salbutamol Cyclohaler and Salbutamol Cyclocaps. The product has since been refined and marketed with other medicines such as salbutamol (Sultanol), beclomethasone (Becotide), Formoterol (Foradil) and budesonide (Miflonide). The latest version is marketed as the cyclohaler 400.

8. Other: By 2008 there would be over 20 different DPIs on the market (3), and by 2012 that number would rise to 35. While many are available for use in Europe, only a select few have been approved by the FDA. DPIs currently on the market (as of 2012) are (you can view pictures of the various devices here):

Acu-Breathe (Respirics)
Aerolizer Novartis)
AIR (Civitas/Alkermes)
Airmax (Teva)
Aspirair (Vectura)
Axahaler (S.M.B.)
Breezhaler (Novartis)
Clickhaler (Vectura)
Conix Dry (3M)
Cricket (Mannkind)
Cyclohaler (Teva)
Diskhaler (GlaxoSmithKline)
Diskus (GlaxoSmithKline)
Dreamboat (Mannkind)
Easyhaler (Orion)
EZ Aer (Aerovance)
Flexhaler (AstraZeneca)
Genuair (Almirall)
Gemini (GSK)
Handihaler (Boehringer Ingelheim)
MicroDose (MicroDose Therapeutx)
Next DPI (Chiesi)
Novolizer (Meda)
Oximax (Mantecorp)
Podhaler (Novartis)
Pulmojet (sanofi-aventis)
Pulvinal (Chiesi)
Skyehaler (SKyepharma)
Solis (Sandoz/Novartis)
Taifun (Akela)
Taper Dry (3M)
Trivair (Trimel Bipharma)
Twincaps/Flowcaps (Hovione)
Twisthaler (Schering /Merck)
Turbuhaler (AstraZeneca) (4)
Dura Spiros (3M) -- battery powered (introduced in 1990s)

spiros dry powder inhaler

Foradil

Asmanex

Pulmicort flexhaler

Advair

Symbicort

Spiriva the new inhaler device

One such inventor attempted to create a dry powdered inhaler for the medicine Ioprenaline sulphate in 1949, yet the inhaler never caught on due to the complexity of the device. This was unfortunate for the DPI market, because in 1957 the first metered dose inhalers were introduced to the market and became a major

With the introduction of the Spinhaler DPIs started their comeback. The Advair Discus has since become the #1 b;a b;a b;a

Just to quelch a fallacy here, MDIs, DPIs and nebulizers all provide relatively equal distribution into the lungs, and most studies on the subject show they all work equally as well as the other.

Note: I have found it exceptionally challenging to find exact dates when the above products were tested, introduced and approved by various countries. For this reason the above dates are estimates unless a specific date (such as 1949) is written. If you have access to more detailed information, or if you have pictures to share, please let me know.

article

References:

Clark, A.R., "Medical Aerosol Inhalers: Past, Present, and Future, Aerosol Science and Technology, 1995, 22:4, 374-91
Foradil Aerolizer Briefing Document, Available to the public without redaction, pulmonary drug advisory committee on the safety of long acting beta agonist bronchodilators, fda.gov, http://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4148B1_02_01-Novartis-Foradil.pdf, page 9
Patterson, Roy, "Patterson's Allergic Diseases," 7th ed., page 610
"Dry Powder Inhalation: Technology, Devices, Markets and Opportunities," prnewswire.com, Jan. 19, 2012, New York, http://www.prnewswire.com/news-releases/dry-powder-inhalation-technology-devices-markets-and-opportunities-137656553.html

1968-2010: Mast Cell Stabilizers for asthma

2012-01-26T03:07:00.000-05:00

Intal Spinhaler used by asthmatics in the 1970s, 80s and 90s

In the early 1980s my doctor introduced me to the Intal Spinhaler that crushed a capsule with a medicine called disodium cromoglycate or chromolyn. It was a white powder that was proven to improve lung function by decreasing inflammation.

It was also proven to improve exercise related asthma.
Each month you'll pick up a small white and yellow box from your pharmacist that contained a bunch of small capsules called Spincaps wrapped in tinfoil. You unwrapped one and set it aside.

Now you grab the inhaler and hold it so the mouthpiece is facing down. You unscrew the cap and place it onto a cup on the propeller, screw the body back on the mouthpiece, and slide the outer sleeve (the blue part in the picture) down as far as it will go and then back up again. This pierces the capsule and makes the spinhaler ready for use. (1)

You exhale as much air as you can, place your mouth over the mouthpiece, and inhale. As you inhale the powder will enter your airway, with a good portion going to your air passages. You can feel the powder as it enters, and taste it. This is how you know you did it right.

This was the first dry powder inhaler that hit the market. It was a great medicine, and when used with an inhaled corticosteroid it worked great to prevent asthma.

When I was a kid I had what my doctors referred to as high risk asthma. I was allergic to pretty much everything outdoors, and had exercise induced asthma (EIA). Unless I was in an allergy proof bubble my asthma was usually acting up. By the time I entered the 9th grade in September of 1984 I pretty much stopped going to gym class per my doctor's instructions.

By January of 1985 I had made so many trips to the ER I was admitted to NJH/NAC in Denver. Once they managed to get my asthma under control they did some pulmonary function testing (PFT) on me to see what medicine might help me with my EIA.

In one test I took no medicine and ran on the treadmill. My lung function dropped significantly. A week later I did another PFT, this time taking two puffs of Alupent before I ran on the treadmill. My lung function once again dropped significantly, indicating Alupent had no effect.

A week later I used my Intal Spinhaler before exercise, and while my lung function declined it wasn't as steep of a decline, indicating that disodium cromoglycate prevented EIA. (You can see my PFT tests here).

Intal Inhaler

I was using this inhaler four times a day (which was a pain in the butt anyway), so there was no need for me to use it prior to every time I exercised. Yet the medicine was proven to reduce inflammation in your air passages so your asthma triggers don't irritate you as much, and don't constrict your air passages as much.

In a way, it worked the same way inhaled steroids worked, yet apparently not as well. Prior to being at NJH/NAC my doctors had me using my Intal every day all the time, and only using my inhaled steroids as needed. Yet by the time I left NJH/NAC in July of 1985 I was using both medicines four times every day, along with a ton of other medicines as you can see here. Yes, this was a lot of medicine.

Yet the Intal Spinhaler was a good medicine for asthmatics since it was introduced to the market in 1968. The medicine disodium cromoglycate was isolated by Roger Altounyan who had bad asthma himself and decided to test a variety of substances that were already proven to benefit asthma. He was working at Bengers Research Laboratories. (2)

Cromolyn Nebulizer Solution

Khella was used by local natives living in Eastern Mediterranean countries for quite a few years to treat asthma with some success. They made various "concoctions" from the seeds of the plant Amni Vasnaga, from which the substance Khellin was extracted in 1879. (3)

Various studies in the 1940s and 50s showed the medicine relaxed smooth muscles throughout the body, including the muscles surrounding air passages in the lungs. Yet the bronchodilating effect was less than epinephrine. The various studies showed the medicine accumulated in your system if used regularly, and was proven effective for both asthma and other lung diseases. (4)

In 1953 The American Journal of Physical Medicine published the results of a study that showed inhaling aerosols of 7mg of Khellin improved lung function. Perhaps it was studies like this that inspired Altounyan to study this extract. (5)

Amps of Cromolyn solution

By experiments in the lab Altounyan produced a safer version of khellin called disodium chromoglycate. While his goal was to improve his own asthma, what he ended up with was a new product. It was marketed by Fisons and sold as the Intal Spincaps and Intal Spinhaler. It became yet another option for many asthmatics worldwide suffering from asthma and allergies.

Along with being the first dry powder inhaler, it was also the first mast cell stabilizer. It prevented inflammation by preventing mast cells from releasing the mediators of inflammation (like histamine) which ultimately cause the inflammatory response.

A problem with the spinhaler was that it couldn't be used during an asthma attack, and the dry powder entered your airway at such a force it was known to cause a fit of coughing and, thus, cause some asthma attacks. I never experienced this problem however. It was a nice option for me until modern inhaled steroids made it unnecessary.

Tilade inhaler

Nedicromil Sodium was approved by the FDA in 1992 as an alternative to Intal, and was marketed as the Tilate inhaler. (6) It was equally effective in treating inflammation and reducing allergy and asthma symptoms. I never used Tilade, and I have little clinical experience educating it to patients either.

By 1995 Chromolyn was available as a solution to be nebulized, and this was ultimately a good option for pediatricians to prescribe for kids with asthma. I have no recollection of ever giving this via aerosol to an adult, and rarely gave it to kids either for that matter. I believe we no longer carry it in our stock.

The Intal Spinhaler was ultimately phased out in the U.S. and Europe in favor of an inhaler, and the inhaler was ultimately phased out on December 31, 2010. I imagine by information I've read on the Internet it's still a viable and cheap option for some asthmatics in 3rd world nations. Yet here in the U.S. it's an antique.

Tilate was phased out on June 14, 2010. Altounyan's product was a great option for many asthmatics for many years, and for that we owe him thanks. Perhaps some form of this product will make a comeback someday and replace the need for inhaled corticosteroids.

References:

"Intal Spincaps Powder for Inhalation, Sodium cromoglycate, Consumer Medicine Information, " package insert for the Intal Spinhaler and Intal Spincaps, 2005
Jackson, Mark, "Asthma: A biography," 2009, New York, page 187
Kennedy, M.C.S, J.P.P. Stock, "The Bronchodilator Action of Khellin," Thorax, 1952, 7, 43, pages 43-65
Kennedy, ibid, page 43
Braun, K, E. Eilender, "Khellin Aerosol in Bronchial Asthma," American Journal of Physical Medicine, Dec., 1953, Vol. 32, Issue 6,
"Tilade approved by FDA; Fisons Announces Co-Promotion Agreement with Rhone-Poulenc Rorer," Press Release, TheFreeLibrary.com, http://www.thefreelibrary.com/TILADE+APPROVED+BY+FDA%3B+FISONS+ANNOUNCES+CO-PROMOTION+AGREEMENT+WITH...-a013101159

1781-1826: Laennec: The inventor of the stethoscope

2012-01-23T01:05:00.000-05:00

Rene Laennec (1781-1826)

Before the 19th century the only way for a physician to hear heart and lung sounds was to place his ear upon his patent's chest. This was a method first described by Hippocrates, although it wasn't standard practice. Of course some patent's were gross and filthy in those days, considering the shower was not common place nor easy for some people.

Likewise, for a gentleman doing this to a lady the experience might be a bit uncomfortable for both the patient and the doctor. Obesity also posed a problem because fat tissue muffles sound. When he was 38-years-old on a hot and humid day in 1816 Laenec was posed with all of these problems.

According to Kendall F. Haven in his book "One hundred greatest inventions of all time," Laennec was a "well established doctor and diagnostician of chest and abdominal disorders when he was asked by a fellow physician to assess an obese young woman with breathing difficulties." (1)

Not that it matters, but for the record the patient's name was Marie-Melanie Basset, and she was only 40.

Laennec listens to man with tuberculosis*

Laenec's normal technique was to have the woman partially disrobe so he could place his ear against a hanker chief over her chest. He'd listen to lung sounds over five spots: the underside of each arm, each side of upper back, and upper breast bone. Yet he heard nothing, so he tried percussion.

Percussion is another handy technique to help a doctor diagnose lung disorders. This was a tecnhique not common worldwide, although in Paris it was. In fact, percussion was a technique made famous by Laennec's teacher, Jean Nicolas Corvisant. The doctor would tap on the chest and the sound created would be indicative of different conditions. Doctors still use the technique to this day.

For example, asthma causes air to be trapped in the lungs and causes a hollow sound. Sound travels better through fluid -- like pneumonia -- and amplifies sound. Once again, however, fat tissue drowns out sound. While Leannec suspected the lady had heart failure, he was unable to diagnose her by heart and lung sounds.

Thinking off the cuff, however, he "grabbed 24 sheets of paper, rolled them tightly into a bundle, and secured them in shape with paste glue," wrote Haven. "He applied one end of this paste roll against the young woman's chest, and the other to his ear."

Leanecc was "delighted" to learn he could hear the woman's heart and lung sounds better this way than with the unaided ear against her chest. He was so excited at how simple a device could make this job so much easier that he set out to do a series of experiments to find metals and tubes that would aid his ear in hearing heart and lung sounds.

After some tinkering he came up with the perfect device, and you can read more about it and check out some pictures by clicking here at www.hhmi.org. His device was 12 inches long and about 1.5 cm in diameter with a 3/8 inch bore hold throughout its length, according Antiquemed.com. (2)

He actually wanted to name the device le cylindre claiming it was frivolous to name such a device. Since he didn't like names given to his device by his colleagues, he later called it a stethoscope. Dictionary.com defines stethe as Greek for chest and scope is Latin for aim.

Laennec's Stethoscope (1820)**

His model was pretty much a wooden tube that you put in one ear. In the ensuing years the model was adjusted by others, and eventually a stethoscope with two ear pieces (binaural) was invented. In 1850 George Camman fine tuned the stethoscope so it was similar to the models we use today.

Later Laennec recollected how a little kid's game where little kids would listen to sounds through long, hollow sticks. While one end of the stick was held up to the ear, the other was scratched with a pin. The sound would be amplified. He wrote:

"The other method just mentioned [direct auscultation] being rendered inadmissible by the age and sex of the patient, I happened to recollect a simple and well-known fact in acoustics, . . . the great distinctness with which we hear the scratch of a pin at one end of a piece of wood on applying our ear to the other. Immediately, on this suggestion, I rolled a quire of paper into a kind of cylinder and applied one end of it to the region of the heart and the other to my ear, and was not a little surprised and pleased to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of my ear.

He was also skilled with the flute, and this may have helped him come up with his idea as well. By taking a hollowed out tube he was able to create his first sthethescope.

He discovered that his invention was better for hearing sounds inside the human body than the ear alone. He found it very useful, and would incorporate his new tool as a means of assessing all of his patients. He likewise used it in his efforts to study many diseases, such as tuberculosis.

Painting of Laennec using his stethoscope***

Yet when he told his peers of his new invention he was ridiculed, wrote Suzanne Barchers, in her book "I've Discovered Sound," (Brainworks, 2009). "What a ridiculous idea," his colleagues would say. "We doctors are called upon for our brilliant medical minds. To say we should carry some frivolous tool around with us is absolutely ridiculous and below us." (3)

One doctor wrote, ""He that hath ears to hear, let him use his ears and not a stethoscope."

Once again the paradigm slows down progress. So many times during the annals of time people reject change, and this resistance to change was never more paramount than in the medical profession. For thousands of years physicians rejected any scientific idea that opposed Galen's superstitions, and now they reject a tool that would allow them to do their jobs better.

In fact, Laennec was ridiculed so much that he would end up retiring early and moved to the country side. Yet Laennec would end up with the last laugh, as by the time he passed away in August of 1836 the stethescope became a standard tool to assess and diagnose.

Brainworks explains that Leanec's invention was used to help diagnose many patients with tuberculosis. And when he was 46 "he got very sick. His own invention confirmed that he had tuberculosis."

To view more pictures of the Laennec stethescope click here.

References:

Haven, Kendall F, "One hundred greatest inventions of all time," 2006, page 96-98
"Now I hear: The history of the stethoscope," http://antiquemed.com/, 1998-2011
Barchers,Suzanne, "I've Discovered Sound," Brainworks, 2009, page 9

Pictures:

* Picture from http://www.hhmi.org/biointeractive/museum/exhibit98/content/b6_17info.html
**Copy write Science Museum/ Science and Society Picture Library
***The picture was taken from a painting by Robert A. Thom, copyrighhted in 1960

1800-2012: Evolution of back-door bronchodilator

2012-01-21T10:31:00.000-05:00

Our quest to learn the history of back door bronchodilators took us all the way back to 4000 B.C. when recipes for remedies for asthma-like symptoms were recorded. In this post I'd like to list some of the back door bronchodilators used over the years.

As a quick refresher, back-door bronchodilators are scientifically referred to as anticholinergic medicine. These are medicines that, once inhaled, sit on the receptor sits of the neurotransmitter acetylcsteine to prevent it from causing bronchospasm.

In this way, anticholinergics cause bronchodilation by preventing bronchoconstriction. This is where the term back door bronchodilator comes from. When inhaled they cause mild breathing relief, and in this way can help an asthmatic breathe better. They aren't nearly as effective as rescue medicine, yet prior 1900 were among the few effective options for asthmatics.

Studies ultimately proved back door bronchodilators dried up secretions to reduce sputum production and improved lung funtion. Surely the medicine comes with side effects, and this was the main reason pharmaceuticals ultimately tinkered with the herbs and evolved this line of medicine available to asthmatics.

Back-door bronchodilators originally came from the nightshade family of plants called solanaceae, and were included in many ancient recipes for asthma remedies. Some members of this family include:

Datura strammonium
Atropa belladonna
Hyoscyamus niger (henbane)
Lobelia inflata.

That in mind, the following are the back door bronchodilators:

1. Belladonna: It was dried and crushed by ancient Egyptians, placed on rocks heated on coals, and the asthmatic would roll up stalks of a reed, place one end up to the crushed herbs and inhale the smoke. Surely this sometimes made asthma worse, yet more often than not the herb provided breathing relief. This method was first recorded in 4000 BC, yet it was probably done long before this.

2. Stramonium: This herb was likewise ground up by ancient civilizations like Egypt, dried under the hot sun and inhaled in a similar fashion as noted above. In India the process of inhaling these herbs evolved to stuffing the powder into pipes or wrapping them in paper and smoking them that way. This technique was discovered in 1803 for Europe and the U.S. and the asthma cigarette craze began.

3. Asthma cigarettes: They were used during most of the 19th ccentury, and became a craze among asthmatics in America and Europe around 1879. Surely there were some risks, but they made breathing easier and had hallucinogenic effects to help ease the feeling of air hunger. The cigarettes contained belladonna, stramonium, lobelia, henbane and atrovent (see below). The craze lasted until the 1950s when the inhaler was invented, and asthma cigarettes were taken off the shelves in the early 1980s due to concerns kids were abusing them. I wrote about these in more detail here.

4. Asthma pills: Belladona, stramonium, and other back-door bronchodilators were available in pill form. A popular brand was Potter's Asthma Pills. These were common from around 1880 to 1950s.

Ad for Ozone Paper (1891)*

5. Nitre paper: This is something I have trouble picturing, yet drugs.com describes it as "paper impregnated with potassium nitrate that is ignited to produce fumes inhaled as treatment for asthma. (1)
Strammonium and belladonna were available as nitre paper by the 1850s and in 1873 was recommended for the treatment of asthma by Dr. John Thorowgood in the British Medical Journal. It was burned to relieve spasmotic asthma, and was proven by studies to cause bronchodilation.(2) It may also be referred to as ozone paper. One advertisement for the product even mentions Dr. Thorowgood's endorsement (see picture to right.

6. Various nebulizers and inhalers: I'm referring to antique versions here, and non electric. Potter's sold a funnel that acted as an inhaler to inhale strammonium or belladonna. You can see a variety of these old inhalers by clicking over to the inhalatorium here. While not all these devices may have been used to inhale back-door bronchodilators, it's still neat to check out these old advertisements.

7. Atropine: It was derived from the belladonna plant in 1833, and by 1867 it was isolated and determined to be a component alkaloid of the various nightshade plants found in India, Egypt, South America and other rocky, warm climates. It was first available for asthma cigarettes, but around the turn of the 20th century was available as a solution to be nebulized. It ultimately became a top line treatment for asthma. Ipatropium was introduced by the late 1970s and atropine was ultimately phased out mainly because ipatropium bromide has fewer side effects. I was prescribed Atrovent nebulizers back in 1985 and this was prepared in a large, dark brown bottle by the pharmacy and 0.5cc was drawn up with a syringe and mixed with 0.3cc normal saline (water) in the nebulizer cut. The medicine was usually mixed with Alupent.

Atrovent Inhaler

8. Ipatropium Bromide: It was among the first synthetic anticholinergic to hit the market (that means it could be made in the lab). It was introduced to the German market in 1975 and the rest of Europe and America by the late 1970s. (3) It was available as a solution to be nebulized and as an inhaler and the recommended frequency was four times daily. (4) An atrovent HFA inhaler was approved by the FDA in 2004. (5) This medicine works equally as well as atropine with fewer side effects. Because it's available in generic forms it continues to be the cheapest back-door bronchodilator on the market. I was introduced to this inhaler in the late 1980s and phased off it during the 1990s when back-door bronchodilators were no longer considered top line asthma remedies.

9. Oxitropium Bromide: It was released along with ipatropium bromide as one of the first synthetic anticholinergics, and was marketed as Oxivent and Tersigan. It's an inhaler and solution similar to ipatropium bromide but is available in higher doses, and therefore the frequency was only three times daily. (6) This medicine has never been approved by the FDA for use in the U.S.

Combivent Inhaler

10. Combivent: This is a combination of Albuterol and Ipatropium bromide in an inhaler form. It became available in the late 1990s for the convenience of COPD patients and some asthmatics who don't respond to other top line asthma medications. The medicine was set to be phased out by December 31, 2013, but due to a public outcry a new version of the medicine will be available soon.

11. Duoneb: This is a combination of Albuterol and Ipatropium bromide premixed in plastic amps with 0.3cc of normal saline. It was introduced to the market in the early 1990s for a quicker treatment. It's mostly used in hospitals and by COPD patients, although some studies in the mid 2000s did show that using it in the emergency room can help pull an asthmatic from a severe attack. Other than that, it is not a top line asthma medicine, just another option.

Spiriva HandiHaler

12. Tiatropium Bromide: It was introduced to the market as the Spiriva HandiHaler in Europe in 2002 and the U.S. in 2003. (7) It's the first long-acting back-door bronchodilator that only needs to be taken twice a day. It was proven to improve lung function and has fewer side effects than ipatropium bromide, which in itself is a relatively safe medicine. The product isn't recommended as a top-line asthma medicine, but is an option for asthma unresponsive to other top-line medicines. The medicine is recommended for some cases of asthma, but mainly for COPD. As the medicine has caught on fewer patients have been prescribed ipatropium bromide.

Combivent Respimat

13. Combivent Respimat: This is the new version of combivent approved by the FDA in 2012. (8) The device has no propellant, is breath actuated, and delivers a dose that is supposed to provide greater lung distribution of the medicine than a metered dose inhaler.

References:

"Nitre paper," Drugs.com, http://www.drugs.com/dict/niter-paper.html
Thorowgood, John, "On Bronchial Asthma," British Medical Journal, 1873, Nov. 22, page 600
Sittig, Marshal, "Pharmaceutical Manufacturing Encyclopedia," 1988, vol. 1, New Jersey, page 837
Barnes, Peter J., Jeffrey M. Drazen, Stephen I. Rennard, "Asthma and COPD: Basic Mechanisms and Clinical Management," 2008, page 616-17
Ipatropium Bromide, package insert, http://bidocs.boehringer-ingelheim.com/BIWebAccess/ViewServlet.serdocBase=renetnt&folderPath=/Prescribing+Information/PIs/Atrovent+HFA/10003001_US_1.pdf ingelheim.com/BIWebAccess/ViewServlet.ser?docBase=renetnt&folderPath=/Prescribing+Information/PIs/Atrovent+HFA/10003001_US_1.pdf
Barnes, op cit
Barnes, op cit
"FDA Approves Combivent Respimat (ipatropium bromide and albuterol sulfate) Inhalation Spray," FDA.gov, http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm274684.htm
*Picture with much appreciated permission from Inhalatorium.com

1960-2012: Evolution of asthma controller meds

2012-01-20T01:36:00.000-05:00

Previously I described the history of steroids for the use of asthma, and how inhaled steroids became the preferred method of preventing asthma. In this post I shall list the asthma controller medicines that have been used since the 1960s.

The following are asthma controller medicines past and present:

1. Beclomethasone: It hit the market in 1960 as the first inhaled corticosteroid. Over the years it was marketed under various names, such as Beclovent, Vanceril, Becloforte, and Beconaise. The initial inhalers were made with the chlorofluorocarbons (CFC) propellant.

2. Fenoterol: It was a non-selective long acting beta agonist that asthma patients were allowed to use at home. It was marketed as Barotek. It was introduced to the market in New Zealand in 1976. Shortly thereafter the asthma death rate soared in New Zealand to a rate significantly higher than other nations. Fenoterol overuse was blamed for the deaths, however, this was never proven. Some believe that poor education about asthma medicines encouraged some asthmatics to continue using the medicine instead of seeking help. The New Zealant asthma death rate declined slightly after warnings were incorporated into the package in 1981, yet the death rate in New Zealand continued to be higher than other nations. The death rate fell 50 percent in 1990. Despite the warnings, sales of the product remained consistent and actually increased slightly in 1989-90. (1) Despite consistent sales, the product was taken off the market in the 1995 due to the scare. The product was also available in Japan and Canada.

Intal Spinhaler

3. Chromolyn: It hit the market in as Intal, and was inhaled by using the Intal Spinhaler. It was the first dry powder inhaler to hit the market, and was prescribed soley to prevent asthma during the 1980s and 90s. It was a popular alternative to inhaled corticosteroids as an anti-inflammatory medicine. A capsule was inserted into the device, the inhaler was cocked and the capsule was crushed releasing the inner powder that was inhaled. One pretty significant side effect of the inhaler is the powder often produced a cough, and this sometimes exacerbated asthma The medicine was ultimately changed to an inhaler with the CFC propellant by the later 1990s. Due to decline in prescriptions of the medicine due to better asthma controller medicines, and due to the Montreal Protocol, the medicine was phased out by December 31, 2010.

Azmacort inhaler

4 Triamcinolome: It was introduced to the market in the early 1980s as Azmacort, and became another alternative to the various beclomethasone products It had a more pleasant taste than the other inhaled corticosteroids of the day, and was the first inhaler to come with its own built in spacer. The spacer assured proper use of the inhaler, and increased compliance. However, it was bulky and difficult to carry. Sales started to decline in the late 1990s due to long acting inhaled steroids that required fewer puffs, such as fluticasone After the declaration by the Montreal Protocol the medicine was phased out by December 31, 2010.

Tilade inhaler

5 Nedocromil Sodium: It was approved by the FDA and introduced to the market in 1993 as an alternative to Tilade It was an inhaler with the CFC propellant Since sales of this product declined by the late 1990s due to better asthma controller medicines on the market. After the Montreal Protocol set a timetable to ban the use of the CFC propellant in asthma inhalers, the product was phased out by June 14, 2010.

6. Flunisolide: It was introduced to the U.S market in the late 1990s as Aerobid. This turned out to be perfect timing for entry into this market, because in 1989 the National Heart, Lung and Blood Instute's (NHLBI) Asthma Guidelines were created. The guidelines recommended inhaled steroids as a top line asthma treatment, and sales of inhaled steroids skyrocketed, with Aerobid leading the way. Aerobid was the best selling inhaled steroid during the 1990s mainly because it had a stronger formula than triamcinolome and beclomethasone requiring fewer puffs to achieve the desired dose. However, due better inhaled steroids and the Monteral Protocol, the product was phased out by June 30, 2011

Aerobid inhaler

7. Fluticasone: It entered the market in 1996 as Flovent. Initially it was an inhaler with three doses to meet the needs of different patients, yet ultimately it became available as a dry powder inhaler via the spinhaler (similar to Advair spinhaler seen in picture although it was brown). The doses were: 44 mcg, 110 mcg, and 220 mcg. The medicine was initially an inhaler, but was eventually available as a discus with as a dry powder inhaler. It was the first attempt as marketing a dry powder inhaler since the Intal Spinhaler in the 1980s. This product was a success and is still on the market. Fluticasone was a stronger inhaled steroid that stayed in your system longer, and this meant only 2 puffs twice a day of the inhaler, or 1 puff twice a day of the discus. The medicine is still prescribed as an asthma controller medicine.

8. Salmeterol: It entered the market as Serevent in 1994, and became the latest long acting beta adrenergic (LABA) to enter the market. The medicine attached to beta 2 adrenergic receptor sites in the lungs and continued to release the medicine for up to 12 hours. All that was needed was two puffs twice a day. Ultimately the product was available as a dry powder inhaler as the spinhaler (the same as the flovent and later advair spinhaler. It was green). By 2008 some suspected the medicine was the cause of asthma related deaths and a black box warning was placed on the product. The NHLBI Asthma Guidelines ultimately recommended the medicine not be used by itself in the treatment of asthma. If asthma is bad enough that this medicine is needed, the guidelines recommended taking it with an inhaled steroid to control inflammation. The product is still available as a treatment for other lung diseases such as COPD.

Advair Discus

9. Advair: This is a combination drug with both Fluticasone and Salmeterol that was introduced to the market in the late 1990s and early 2000s as the Advair Discuss (purple). It was marketed as an asthma controller medicine to prevent bronchospasm and inflammation in asthmatic lungs to prevent asthma. Because it combined the two medicines and the frequency is one puff twice daily, it greatly improves compliance with asthma medicine (I can personally attest to this). Sales skyrocketed during the 2000s and it continues to be the top selling asthma controller medicine. Some fear the medicine is related to asthma deaths and a black box warning was placed on the packaging in 2006. I wrote about this in more detail here. The patent for Advair expired in the U.S. in 2010 and will expire by 2012 in most European countries. It's expected that soon generic products will enter the market which would increase competition and lower the cost of the inhalers (currently priced at over $100).

Foradil Inhaler

10. Formeterol: Introduced to the market as an alternative to salmeterol. It was marketed as Foradil in the U.S., and in other nations the brand names Oxeze, Atock, Atimos and Performist were used. The Foradil Aerolizer was approved by the FDA in 2001 as the dry powdered version of the medicine. The medicine is still on the market, although most asthma guidelines recommend not using this medicine by itself for asthma. According to the FDA.com, as of 2007 there were no FDA approved formoterol products on the market, however the product does continue to be marketed in other countries. It's currently marketed by AstraZeneca in other countries as the Oxis Turbohaler, and as the combination Symbicort inhaler.

11 Budesonide: The inhaled steroid solution of Pulmicort was introduced to the market in the early 1980s as the only inhaled steroid available as a solution for home use. Studies showed it was the safest and best corticosteroid solution. It was mainly prescribed for kids, however it's recommended for any asthmatics who requires inhaled steroids and has trouble coordinationg an inhaler. From what I can tell it has the same potency as Flovent. A Pulmicort Turbohaler hit the market in the late 1980s as the first corticosteroid as a dry powder inhaler. But it never caught on and in 2007 it was discontinued.

Symbicort inhaler

12. Symbicort: This basically works the same as Advair except the LABA is faster acting and appears to have a stronger cardiac effect (on me anyway). It's availabe as either a metered dose inhaler or dry powder inhaler via the Turbohaler. I know many asthmatics who love this medicine. So, once again, personal preference reigns. If one medicine doesn't work try another. Note: Some countries have adopted the Symbicort Smart program whereby you can use your Symbicort as a rescue inhaler. I wrote about this here.

13. Beclomethasone: I'm mentioning this again because the older CFC versions of this inhaler were taken off the market and replaced by an HFA inhaler which has been rebranded as QVAR. The medicine is the same, yet some studies show the smaller particle size allows the medicine to penetrate deeper into the lungs as compared with other inhaled corticosteroids presently on the market.

Symbicort Twisthaler

14. Mometasone furoate: It's the latest long acting inhaled corticosteroid to enter the market. It was approved by the FDA in 2008. It's a once a day medicine, or twice a day if need be, that was introduced to the market as Azmanex. It's a dry powder inhaler taken via the Azmanex Twisthaler. I have never tried this medicne, although I had to teach myself how to use the inhaler so I could teach how to use it to patients.

15. Dulera: It was approved by the FDA in June of 2010. It hit the market as an alternative to Advair and Symbicort. It containes Mometasone and Furosimide. Other than that it works similar to Advair and Symbicort. Whether one of these works better than the other is a matter of personal choice and physician preference. I trialed this medicine once and it make my heart beat like a jackhammer and I went back on Advair.

Singulair pills

16. Montelukast sodium: This product was introduced to the market in 1998 as Singulair. It was the first leukotriene receptor antagonist. What it does it it blocks the affects of leukotrienes and prevents them from causing inflammation and bronchospasm. Leukotrienes are released from mast cells during the allergic response along with histamine. While histamine causes inflammation of the respiratory tract, leukotrienes do this, but they mostly cause bronchospasm. So Singulair was marketed as a product to help allergic asthmatics. With insurance these pills cost about $1.00 each, or $30 for a month supply (as of this writing in January 2012). I took this medicine the past three years, but with my doctor's permission I just quit becasue I haven't noticed any results. My doctor said he's recommending all his asthma patients quit taking it.

17: Zafirlucast: This was another leukotriene receptor agonist admitted to the market as Accolate to compete with Singulair.

18. Zileuton: This was another leukotriene receptor agonist marketed as Ziflo. It was introduced to the market in 2007 and was discontinued in 2008 (you can read the discontinuation letter here). It failed to take off becaue the other options only had to be taken once daily, while this one had to be taken four times daily.

19. Omalizumab: This is the first medicine on the market to block the effects of IgE, an antibody that is responsible for the allergic response. The medicine is marketed as Xolair and consists of a series of injections. It costs $10,000 to $30,000 for an annual prescription, and for this reason it's only recommended for severe, persistent asthma (hardluck asthma) non responsive to other asthma remedies

References:

Beasley, Richard, Sankei Nishima, Neil Pearce, Julian Crane, "Fenoterol and Asthma Mortality," The Lancet, August 8, 1998, volume 352, Issue 9126, page 486

Asthma History Lexicon

2012-01-19T19:38:00.000-05:00

I realize there are many readers on this blog who aren't in the medical profession, so I've decided a few definitions are in order.

1. Bronchioles: The are the air passages in your lungs. The air you inhale moves through these tubes. They are often referred to as the bronchiolar passages or simply air passages.

2. Bronchiole muscles: These are muscles that wrap around the bronchioles. They are often referred to as bronchiolar muscles,

3. Bronchoconstriction: This is when bronchiolar muscles spasm and squeeze the air passages causing them to become narrow. This makes it so air has trouble moving past the constriction. This is the main component of an asthma attack.

4. Bronchodilation: This is when the air passages open up, or when broncoconstriction is reversed. This is what's necessary to reverse an asthma attack.

5. Beta 2 Adrenergic Receptors: These are receptors that line bronchiolar muscles. Stimulation of these causes bronchodilation. They are often referred to as B2 receptors.

6. Beta 2 adrenergics: This is medicine that sits on B2 receptors and cause bronchodilation. These are sometimes referred to as beta agonists, B2 agonists, front door bronchodilators, asthma rescue medicine, or rescue medicine. I prefer the term rescue medicine. Examples include epinephrine, metaproterenol , albuterol, and levalbuterol.

7. Acytylcholine: This is a neurotransmitter that sits on receptor sites on bronchiole muscles and cause bronchoconstriction.

8. Anticholinergic medicine: This is medicine that sits on receptor sites and prevent acetylcholine from causing bronchoconstriction. In this way, this type of medicine is a bronchodilator, or a back door bronchodilator. I prefer to refer to them as back door bronchodilators. Examples include Atropine, Ipatropium Bromide, and Tiatropium Bromide

9. Catahhr: This is an old term that means swelling of the respiratory tract that causes increased secretions. It's usually used to refer to inflammation and drainage of the nose, or simply hay fever. This is an ancient term that's hardly used anymore.

10. Chlorofluorocarbon (CFC): A liquified gas propellant used in used in asthma inhalers until the Montreal Protocol was signed in the late 1990s and a goal was set to ban the propellant to protect the ozone.

11. Hydroflouroalkane (HFA): A new propellant used in inhalers that is safe for the environment. Most inhalers on the market now use this propellant or are propellant free.

1800-1985: Asthma Cigarettes

2012-01-17T08:11:00.000-05:00

Elliot's Asthma Cigarettes*

So as you probably know by now by hanging out on this blog I had pretty bad asthma as a kid. One day I walked into my doctor's office and he said, "Look, if you ever decide to smoke cigarettes, just let me know and I'll put you out of your misery myself."

The irony of that was a few days later I visited the Manistee County Historical Museum in Manistee, Michigan. The museum is housed in the old A.H. Lyman Company building, which housed a pharmacy that was preserved. On the shelves were antique medicines, one of which said, "Asthma Cigarettes." What I saw was similar to what you see in the picture to the right.

Potter's Asthma Remedy*

If smoking was supposed to be so bad for asthma, I thought, why would doctors prescribe smoking cigarettes, and what was in them anyway?

Years later I learned the following about asthma cigarettes:

They didn't contain tobacco, but crushed and dried herbs from the nightshade family of plants called solanaceae, which included datura strammonium, atropa belladonna, and the hyoscyamus niger, and Lobelia inflata.
Such plants contained an alkaloid called Atropine that causes mild bronchodilation, and made breathing easier.
The idea smoking is hazardous to your health is a relatively new idea.

My quest took me all the way back to 4,000 B.C. which marked the dawn of the bronze age. Ancient city states of Sumeria and the empire of Egypt were in their infancy, and the discovery of papyrus and cuneiform soon allowed societies the ability to communicate from one generation to the next.

Kinsman's Asthma Cigarettes*

The Ancient Egyptians had plentiful access to atropa belladonna. It was a pungent smelling herb that grew to be about three feet high with oval shaped, pointed leaves that grew about three to six inches long with reddish or purplish flowers. (1)

Men and women experimented with this herb and discovered its poisonous effect which gave the plant the name deadly nightshade. Egyptians would pick the leaves, stems and roots and dry them under the hot sun, and crush what was left. The byproduct could be used in a variety of ways..

Encyclopedia.com describes how Egyptian women squirted drops in their eyes "for the allure given by large, black pupils: hence the name belladonna — ‘fine lady'." It made pretty eyes prettier and helped beautiful Egyptian women woo men.

Ad for Schiffmann's Asthma Cure (1899)*

Physicians used it as a remedy for just about any respiratory ailment. The dried and crushed herbs would be placed on bricks already heated on hot coals, and the smoke would be inhaled to provide temporary breathing relief.

However, there were risks for side effects, especially if too much was ingested or inhaled. Side effects included dry mouth, increased, dilated pupils, nausea and headache. Likewise, if taken in large quantities it caused hallucinogenic effects. Yet I imagine if you couldn't breathe the hallucinogenic effect may be just as beneficial as the breathing relief.

Kellogg's Asthma Cigarettes*

About 100 A.D. physicians in India had access to datura strammonium, a herb that also produces an unpleasant smell and grows to be about five feet tall with a pale green stem with spreading branches and puplish leaves coarsely sedated along the edges. Its flowers are white or purple. (2)

By early experiments ancient societies learned of its poisonous qualities, and hence comes the description of the plant. Datura comes from the ancient Hindu word for plant, dhatura. Stramonium is a New Latin word meaning thornapple. Strammonium originally came from the Greek word strychnos which means nighshade and mankos meaning mad. (3)

Other than thornapple, common names I've found during my research that refer to strammonium are jimsonweed, Jamestown weed, drowny thornapple, Devil's trumpet, angel's trumpet, mad apple, stink weed and tolguacha.

Like belladonna, the leaves, stems and roots were dried and crushed into a powder that was stuffed into pipes and inhaled. This was a remedy for diseases of the lungs or throat. Although, as with any member of the nightshade family, there were toxic side effects.

The famous Greek physician Hippocrates wrote about stramonium and belladonna, and we know they were used as an asthma remedies by ancient Greek and Roman physicians. Yet such wisdom was lost to western civilization during the dark ages of medicine, not to be reintroduced until 1802.

In that year British physician and asthmatic James Anderson visited India and enjoyed the mild breathing relief he obtained after smoking a cigarette containing stramonium. (4)

Anderson reported his find to his friend Dr. Sims in Edinbergh, who published a report in the Edinbrugh Medical and Surgican Journal about the benefits of smoking cigarettes containing the leaves of datura stramonium.

After this report asthma cigarettes became popular for the treatment of asthma in Europe and America. (5)

American Indians were introduced to another member of the nightshade family called lobelia inflata. They smoked it for asthma relief, and it's for this reason many refer to it as Indian Tobacco or Asthma Weed.

American physicians were introduced to lobelia and used it for asthma releif, yet they also used it to make some patients vomit. The idea here was that along with vomit toxins would be removed from the body to balance the humors and cure the ailment. For this reason it was often referred to as pukeweed and vomitwort. (6)

Atropine was finally derived from the belladonna plant in 1833. By 1867 Atropine was isolated by von Bezold. It was then determined to be a component alkaloid of the various nightshade plants found in India, including the datura strammonium, atropa belladonna, and the hyoscyamus niger (black henbane), and Lobelia inflata (7)

Ultimately it was learned that atropine is an anticholinergic agent in that it sits in the receptor sites of the neurotransmitter acytycholine and prevents it from causing bronchoconstriction (narrowing of the air passages in the lungs). In this sense it's often referred to as a back door bronchodilator (as opposed to epinephrine being a front door bronchodilator in that it causes bronchodilation).

Potter's Patient Inhaler (funnel device)*

In the mid 19th century asthma cigarettes started growing in popularity. Some cigarettes were prepared and sold by individual pharmacists. Some asthmatics would purchase the necessary ingredients and stuff them into their pipes, or roll them into cigars or cigarettes.

By 1879 a an asthma cigarette craze struck America and Europe. (8) More and more companies entered the market in an attempt to benefit off the plight of asthmatics. Belladonna, stramonium, lobelia, henbane, atropine, and even cannabis were packaged in cans and placed on shelves in pharmacies.

The products were marketed for just about any respiratory condition, including asthma, chronic bronchitis, whooping cough, cholera, croup, catarrh, and hay fever. The product could be stuffed into pipes or rolled into into cigars and cigarettes. In the 1880s technology progressed so some companies pre-rolled cigarettes and packaged them for the convenience of the asthmatic.

Asthma cigarettes from a variety of companies could be found on pharmacy shelves like the A.H. Lyman Company. According the Inhalatorium, the most famous brands were:

Potter's Asthma Cigarettes*

Schiffmann’s Asthmador
Blosser’s
Potter’s
Marshall’s
Kinsman’
Dr Guild’s green Mountain
Kellogg’s
Page’s
Regesan’s

In my studies the brand I've come across most often was Potter's Asthma Cigarettes, which you can see in the picture to the right or by clicking over to inhalatorium.com.

The main ingredient in Potter's cigarettes were stramonium, belladonna and atropine. The Inhalatorium notes that Potter's also had a variety of asthma remedies that included cigarettes, incense, pills and powders to be inhaled by Potter's funnel device

Potter's Asthma Pills*

The cigarettes continued to be popular even after the discovery of epinephrine in 1900 and as the solutions of epinephrine and atropine became options for home use with the invention of the mass-producible electric nebulizer in the 1930s.

Sales of asthma cigarettes stayed consistent because they provided breathing relief, were less expensive than those other options, and they were available without a prescription. Plus the nebulizers available were bulky, fragile and expensive.

Yet while asthma cigarettes were the preferred choice due to convenience and cost, that all changed in 1957 with the invention of the inhaler, and the release of the Medihaler-Iso and the Medihaler Epi. These inhalers provided instant relief, were relatively inexpensive, and easily carried in pockets and purses.

Easy to use & fast acting Medihaler (1957)

As sales of asthma inhalers went north, sales of asthma cigarettes went south. Yet despite the decline in sales, they were still a viable over the counter option until the early 1980s.

There were growing concerns at this time that teenagers were purchasing asthma cigarettes not for asthma relief but for their hallucinogenic effects. (9) So studies were conducted to confirm whether or not asthma cigarettes really worked, and whether they should be taken off the shelves.

By this time there were many other options for asthmatics, which included safer asthma rescue medicine such as Ventolin and Alupent, theophylline, and a refined and safer version of Atropine called Ipatropium Bromide (Atrovent). These medicines could also be delivered in preset doses via inhalers and solutions to be nebulized.

H.L. Elliot and J.L. Reid described in a 1980 article published in the British Journal of Clinical Pharmacy a study that concluded asthma cigarettes made of "herbal preparations containing Atropine-like alkaloids" were just as effective as using ipatropium bromide (Atrovent).

Dr. R. Schiffman's Asthma powder*

The researchers concluded that "an overdose of of asthma cigarettes is manifestly capable of producing pharmacological effects (hallucinations, delerium, tachycardia)." They also concluded that the dose of medication getting to the lungs is "variable and unpredictable."

Likewise, they noted that "In view of increasing evidence of abuse, there appears to be good reason to restrict availability of these preparations. Although a herbal cigarette might possibly be recommended for the asthmatic who insists on continuing to smoke," a majority of asthmatics would get just as much benefit with fewer side effects by using thier Atrovent inhaler. (10)

By 1985 asthma cigarettes were removed from the shelves of all U.S. Stores. Yet while being generally extinct in western nations, they are still available in some third world nations.

I will leave you today with a recipe for asthma cigarettes from the National Druggist, Volume 30, 1900:

(W.B.C. Cleveland Ohio) The following formula is one that the writer has used for several years occasionally, and has found effective and not unpleasant, provided that the cigarettes are used not to frequently, or to excess:
Strammonium leaves..........................8 parts
Green tea leaves............................8 parts
Lobella Leaves..............................6 parts
Plantain leaves.............................2 parts
Mince the leaves to a condition suitable to rolling in cigarette form, and moisten the mixture with cold saturated solution of potassium nitrate in water, dry thoroughly, and pack in air tight cans or jars. Lavel "Asthma Cigarette" mixure. Directions: When an attack of asthma is imminent take sufficient of the mixture to make one or two cigarettes of the ordinary size, roll in cigarette paper, and smoke slowly, inhaling the smoke as deeply as possible. If relief is not afforded by the first, a second cigarette should be used.

References:

"Belladonna," Encyclopedia.com, http://www.encyclopedia.com/topic/belladonna.aspx
"Plants poisonous to livestock," Cornell University's Department of Animal Science, http://www.ansci.cornell.edu/plants/jimsonweed/jimsonweed.html
"Plants poisonous to livestock," ibid
Sneader, Walter, "Drug discovery: a history, 2005, England, page 96\
Sneader, ibid
University of Maryland Medical Center, "Lobelia," http://www.umm.edu/altmed/articles/lobelia-000264.ht
Encyclopecia.com
"The Scarcity of Cubebs," The Chemist and Druggist," 1887, Feb. 26, page 268 of Chemist and Druggist: A Weekly Trade Journal, 1887, Vol. XXX, January to June 1887
Jackson, op cit, page
H.L. Elliot and J.L. Reid, "The Clinical Pharmacology of a Herbal Asthma Cigarette"British Journal of Clinical Pharmacy (1980, 10, 480-490)
* Picture used with permission from Inhalatorium.com. Check out the site for more picutures, ads and descriptions of asthma cigarettes and other asthma remedies.

1900-2012: History of steroid use for asthma

2012-01-09T17:32:00.026-05:00

So now in our quest through the anals of asthma history we come to corticosteroids. If we consider the discovery of Epinepherine to be the most important discovery as far as asthmatics are concerned, the discovery of cortisone must be considered the second greatest discovery of all time.

The discovery of cortisone occured the same year epinepherine was discovered in 1900. According to Barry E. Brenner in his history of asthma, "at that time Solis-Cohen prepared a crude extract of the adrenal gland and used it in the treatment of acute asthma." (1)

In the late 1930s it was isolated, and it was used successfully for the first time in 1944, according to Meriam-Webster dictionary. It was initially used to reduce inflammation for patients with rheumatoid arthritis, yet it was ultimately discovered that it would help reduce inflammation in the air passages of asthmatics. (2)

According to Answers.com, "Schering-Plough," cortisone was synthesized in 1949 by Merck & Co, yet through a series of legal loops Schering obtained access to cortisone information. This made it possible to make cortisone, and made it easily available to physicians. (3)

What you have to realize, however, is at this time asthma was believed to result in inflammation only during an asthma attack. Brenner explained that several studies were completed in the 1940s and 50s, and in 1955 prednisone was discovered as the first synthetic corticosteroid and marketed as an effective treatment for acute asthma symptoms. (4) Medicine.net reports that it was approved by the FDA in 1955.

Medrol Steroid Pack

Schering marketed prednisone as Metricorton in 1957. Paracort and Deltasone are other generic options on the market.

Another similar product is prednisolone which was also approved by the FDA in 1955. It was marketed as either Sterane or Delta-cortef, although is available under as variety of products such as Pediapred and Orapred as well as generic names.

Dexamethasone also entered the market in the 1950s as Decadron. Some believe this is a more potent steroid that lasts anywhere from 1-3 days in your system, making it ideal for kids who won't reliably take yucky tasting pills or solutions.

Dexamethasone was actually the first corticosteroid to be marketed as a solution to be nebulized, and this was shown to benefit asthmatics in studies done in the 1960s. (5)

Methylprednisolone was later marketed as a varient and marketed as Medrol and Solu-medrol. Medrol is the pill form and comes in what is referred to as a Medrol Steroid pack, or simply a steroid pack. If you're an asthmatic chances are you've been prescribed a steroid pack at one point or another.

The pack comes with five rows of 4 mg pills: 7 in the top row, 5 in the second row, 4 in the third row, 3 in the fourth row, 2 in the fifth row, and 1 in the sixth row. You take the top row on day one, the second row on day two and so forth. The idea is you take fewer pills each day to wean yourself off.

I often get asked what's the difference is between prednisone, prednisolone, and methylprednisolone. The answer is that they are simply the same or simlar products made by different companies. Some say that methylprednisolone has fewer side effects, yet that's like saying Albuterol is better than Xopenex, or snow is better than rain. In other words, which one a doctor prescribes is based on personal preference.

To treat acute episodes of asthma the medicine could be given as an injection, or the pill or liquid version could be taken at home.

Yet once you start taking steroids you had to slowly be weaned off. Your body produces corticosteroids, and if you take the pill form your body will think you have enough and stop production. For this reason, if you're given a high dose of corticosteroid medicine and then you stop cold turkey you leave your body with no corticosteroids and you'll die. So you must wean, and that was one of the nice things about the steroid pack. A doctor gave you a shot of Solu-medrol at the office and sends you home with a pack to wean you off.

Sales of systemic corticosteroids boomed during the late 1950s and 60s. It didn't take long for doctors to note a major problem with this medicine. There were certain individuals who had persistent or chronic arthritis or asthma who required steroids on a daily basis. Since there was little data on ideal dosing, some physicians prescribed high doses long-term for some patients. It soon became evident there were some severe consequences to such long term, and high dose use of systemic corticosteroids.

Beclovent Inhaler

Noting the success of the Medihaler-epi and Medihaler-iso, pharmaceuticals hoped to take take advantage of the booming inhaler market. In 1960 beclomethasone was introduced as the first inhaled corticosteroid by Allen & Hanbury, the makers of the Albuterol inhaler. (7) The product was marketed as Becotide in 1972, and the recommended dose was four puffs daily.

GlaxoSmithKline's version of beclomethasone was Vanceril, and Schering-Plough's version was Beclovent, and both were approved by the FDA for sale in the U.S. in 1982.

I was prescribed Vanceril from the late 1970s until 1985, yet from time to time other generic forms entered my home. (You can see a 1979 ad for Beclovent and Ventolin here.)

After the CFC propellants were set to be phased out in 1989, the hunt was on to find an environmentally friendly inhaler. 3M Pharmaceuticals developed an HFA version of beclomethasone called Qvar, and it was approved by the FDA in 2000. By 2001 GSK stopped production of Vanceril, and soon thereafter Schering-Plough ceased production of Beclovent.

Studies actually show that (aside from the spike in cost), this changeover might have worked to the advantage of asthmatics as the new version has been proven to get deeper into the lungs providing better distribution of the medicine (I wrote about this in more detail in this post).

However, according to Dr. H. Morrow Brown at Allergiesexplained.com, beclomethasone was almost written off as a useless medicine. Many doctors preferred to treat asthma by desensitization with allergy shots, and this was done with me.

I have the medical records to prove it. I remember getting allergy shots through the 1970s all the way until 1985. As some point you'd have thought my doctors would have caught on they weren't working, considering my asthma continued to get worse and worse instead of better.

So desensitization was a top line therapy for athma and inhaled steroids were relatively ignored by physicians until a study was reported in The British Medical Journal in 1971 and 1972 showing beclomethasone was effective in controlling asthma. (8)

Becotide Inhaler

This turned out to be a great achievement because the inhaled medicine is absorbed in the lungs where it's needed and very little gets in the system, as opposed to oral or injected steroids which cause systemic effects.

From the 1970s until the early 1990s systemic steroids were prescribed for severe episodes of asthma, and other than that acute episodes were managed by rescue medicine and inhaled corticosteroids like Becotide because side effect (although still expected), were believed to be far less than systemic steroids.

Perhaps as a result of this, between 1957 and 1985 the market for asthma inhalers (which also included bronchodilators) skyrocketed so that in 1985 asthma inhaler sales were 25 percent of the asthma prescription market (theophylline was also at 25 percent of this market).

The problem that remained until the early 1990 -- perhaps due to the 1950s scare -- was that doctors were still afraid that inhaled steroids used long term would produce the same side effects as systemic steroids. For this reason they were leary of prescribing them as an every day medicine, and recommended them for use only during an acute attack to limit side effects.

A second problem was that scientists had yet to discover that inflammation in the lungs wasn't just there during an acute attack, that it was chronic (always there). For both these reasons, corticosteroids -- either systemic or inhaled, were only prescribed for moderate and severe asthma, and rarely mild asthma.

Vanceril Inhaler

In the 1960s triamcinolone entered the market as Azmacort. In 1975 Schering-Plough introduced its version of beclomethasone as Vanceril. In the early 1980s Budesonide was introduced to the market as Pulmicort.

Studies showed Pulmicort was the safest and most effecteve nebulized corticosteroid. Decadron is sometimes given by aerosol in hospitals in the emergency rooms, but rarely, and usually not for asthma but inflammation of the throat. Pulmicort has earned the respect of physicians, and it's basically the only nebulized corticosteroid available for home use.

Perhaps my doctor had me trial all these at some point, yet the one I remember becoming friends with was the Vanceril inhaler. It was a little pink inhaler designed the same as the Ventolin inhaler. I have a note from my doctor following a 1981discharge from a local hospital after an asthma admission that says: "Use your Vanceril for two weeks, then use only when you have trouble breathing."

By 1985 my asthma continued to be high risk, and I was using my asthma rescue medicine several times daily. Sometimes I'd use my Ventolin inhaler in less than a week, and made several unscheduled doctor visits and emergency room for uncontrolled asthma. I survived this, yet many asthmatics did not.

My local doctor decided he couldn't help me, so I was shipped to National Jewish Hospital/ National Asthma Center (Now National Jewish Health). Doctors there were up to date on the latest asthma wisdom and weren't afraid to prescribe inhaled steroids.

The Azmacort inhaler with built-in spacer

Knowing my asthma was high risk, my doctor at NJH put me on Azmacort, and instructed me to take four puffs four times every day to control my asthma. I was not to stop taking it no matter what, even if I felt good.

The neat thing about this inhaler was it was the first inhaled steroid with a pleasant taste (at least I thought so). The only problem was you needed four puffs four times a day to equal two daily puffs of our modern inhaled corticosteroids.

This many puffs was a pain in the butt, but when I was compliant it worked like a charm. So long as I took my inhaled steroid every day there would be just enough steroid in my system to prevent an asthma attack.

By 1989 there were enough studies to confirm the approach NJH doctors used on me was the best way to treat asthma, and safest, that such experts set out to educate regional doctors of this approach. For this reason, the National Heart Blood and Lung Institute (NHBLI) created a group of asthma experts to develop guidelines for the management of asthma. The guidelines would help local doctors better manage their asthma patients.

Thus, in 1989 the NHBLI's asthma guidelines were created. The guidelines highlighted the following:

Asthma is often underdiagnosed
All asthmatics have some degree of chronic inflammation
A small amount of steroids in asthmatic lungs obtained from inhaled corticosteroids is often all that's needed to control this inflammation and prevent asthma symptoms.
The amount of steroid inhaled from an inhaler is very small compared to systemic steroids, and therefore side effects are rare and minimal at worse. Thus, the benefits far outweighed the risks for many asthmatics with uncontrolled asthma.
Thus, the emphasis for asthma treatment was changed from focusing on controlling acute asthma symptoms to preventing asthma from occurring by treating the underlying inflammation and preventing bronchospasm.
Inhaled steroids should be used daily to prevent asthma, and rescue inhalers should only be used when needed to treat acute asthma episodes.
Inhaled steroids are safe to use for mild asthma to prevent airway remodeling that may cause asthma to become moderate to severe.

Loaded with this new wisdom, physicians started prescribing inhaled corticosteroids more often. This helped many asthmatics better control their asthma, and use of rescue medicine declined. Now asthma experts refer to uncontrolled asthma as using rescue medicine more than twice in a two week period.

Greg Minton, in his book "Breathing Space" explained that after the release of the asthma guidelines sales of inhaled steroids soared, and flunisolide, marketed as Aerobid, lead the charge. Minton described that "in the first three months of 1991, prescriptions of Aerobid doubled those of the entire previous year. Aerobid was the fastest growing inhaled steroid on the market." (9)

At one point my regional doctor decided Azmacort wasn't good enough for me and he prescribed Aerobid as a replacement. I took two puffs of it -- just once -- and rejected it on the grounds the mist tasted like rotten mints. Surely Aerobid required fewer puffs, but I decided I'd rather puff away at the better tasting Azmacort.

By the late 1980s Pulmicort became the first dry powder inhaler on the market when the Pulmicort Turbohaler was introduced. I never used this inhaler on myself, although I have instructed it to patients from time to time. Considering the horibble taste, I can't fathom that Aerobid sold so well.

The market for inhaled corticosteroids proved to greatly benefit asthmatics not simply by controlling and preventing asthma, but by reducing unscheduled doctor visits, emergency room visits, hospital admissions, and the cost of treating the disease.

Other pharmaceuticals rushed to enter this market, and this brought about the longer lasting and more potent inhaled corticosteroids we use today. Fluticasone was introduced as Flovent in the 1990s and Mometasone furoate in the 2000s.

Interesting to note that each new inhaled steroid was a little more selective than the previous, and lasted a little longer. This is the main reason some of the older inhaled steroids have been phased out in favor of fluticasone, mometasone furoate, and other new ones on the market or in the oven. (10)

Advair entered the market in the late 1990s ad the first combination inhaler with a long acting beta adrenergic (rescue medicine) and an inhaled steroid. It was a combination of fluticasone and salmeterol. It quickly became the best selling asthma product because it controlled asthma and only required two puffs a day.

Symbicort and Dulera are similar products to enter the market. Since the patent for Advair expired in 2010 generic versions are expected to hit the market soon, and hopefully lower the price.

So you can see we have come a long way since cortisone was discovered at the turn of the century, since prednisone was discovered in the 1950s, and beclomethasone hit the market in 1972. While physicians were once hesitent to prescribe a daily dose of inhaled corticosteroids to control asthma, steroid inhalers have since become a top line therapy for preventing and controlling asthma.

Click here for more asthma history.

References:

Brenner, Barry E, ed., "Emergency Medicine," 1998, from chapter one "Where have we been? A history of acute asthma," page 18
Meriam-Webster dictionary, "Corticosteroid," http://www.merriam-webster.com/dictionary/corticosteroid
"Schering-Plough: Information," Answers.com, http://www.answers.com/topic/schering-plough-corp
Brenner, op cit, page 18
Schleimer, Robert P., et el, "Inhaled Steroids in Asthma," vol. 163, 2005, New York, page 5
"Schering-Plough: Information," op cit
Primary Care Respiratory Journal,"A brief history of inhaled asthma therapy over the last fifty years," Volume 15, Issue 6, December 2006, Pages 326-331
Dr. H. Morrow Brown at Allergiesexplained.com, http://allergiesexplained.com/
"Mitmann, Gregg, "Breathing Space: How allergies shape our lives and landscape, 2007, page 247 (a great read if you want to learn more about the history of asthma/ allergies)
Schleimer, op cit, page 45

1900-current: The evolution of asthma rescue medicine

2012-01-07T10:50:00.000-05:00

1944 ad showing glass epi vial

The evolution of asthma rescue medicine started in 1900 with the discovery of epinephrine. While it's considered one of the top 10 medical discoveries of all time, we asthmatics consider it THE best medical discovery of all time.

Since that infamous day in 1900, and the first use of the medicine on an asthmatic in 1903, asthma rescue medicine has morphed and taken a safer, more effective form. The evolution was slow and deliberate, offering many options for the asthmatic in distress.

Asthma rescue medicine is generally considered any fast acting bronchodilator used to end an asthma attack. Effects are generally felt immediately or within fifteen minutes. Routes of administration are either injection, or inhalation of aerosolized solution or inhaler.

Older asthmatics may remember some of these rescue medicines:

1. Epinephrine (epi): It was discovered in 1900 and made available to asthmatics in 1903. It generally came in ampules for to be drawn up and injected under the skin or intravenously. The medicine attached to B2 adrenergic receptors in the lungs to dilate the air passages, but it was also specific to B1 and A1 adrenergic receptors in the heart to cause vasodilation and speed up the rate and force of the heart. The medicine would generally relieve an asthma attack within five to 15 minutes, yet it only lasted one and a half to two hours. The medicine was a top line treatment for asthma until the early 1990s when Albuterol breathing treatments were proven to be equally effective and safer.

The current Isoproterenol vial, syringe and packaging

2. Isoproterenol: (being edited...)

Isopropyl Adrenalin was synthesized in 1903 as the first modification of epinephrine.

(Isoprenaline) was introduced to the U.S. market as Isuprel.

Also known as Isopropyl adrenaline. It was synthesized in 1903 and was the first modification of epinephrine. It's chemical composition was similar to epi, although it was specific to beta receptors, both B1 and B2. Therefore it still caused considerable cardiac side effects.

It offered a viable alternative to epinephrine, although it was only available as an injection until the 1930s when an aerosolized solution became available. Like epinephrine, it also only lasted one and a half to two hours.

It became available as an inhaler when the Medihaler-Iso was introduced in 1957. The medicine was a top line asthma prescription during the 1940s, 50s and 60s. Isuprel was in the medcart for respiratory patients in 1995, although the products were ultimately phased out due to safer bronchodilator options.

4. Aerolone: Cyclopentamine was an alpha receptor agonist and it was given with isoproteronol in a solution called Aerolone to limit the cardiac affects. The beta effect of isoproteronol would dilate the airway and the vasodilating effect of cyclopentamine would decongest the lungs. (1)

5 Isoetharine: It was first synthesized in 1936 introduced in Germany as Aleudrin in the 1940s It later entered the U.S. market as Bronkosol in 1951 as the first B-2 specific rescue medicine, and it was marketed as the first B2 specific aerosolized bronchodilator. It had a stronger beta effect and less of an alpha effect than epinephrine. Bronkosol had less of a beta 2 effect than Isopretoronol, yet it was more desirable because of the decreased cardiac affect. The medicine still only lasted one and a half to two hours. Like epinephrine and isoproerenol it was a top like bronchodilator for asthma during the 1940s, 50s and 60s.

6. Epinephrine: I must list the medicine once again because in 1956 the FDA approved the epinephrine inhaler which was marketed in 1957 as the Medihaler-epi. I wrote about this inhaler in more detail here.

1998 picture of epi products

7. Susphrine: This was epinephrine formulated in such a way that it lasted 6-8 hours. Doctors loved this because they could give you the shot of susphrine along with a systemic steroid. Then they could send you home knowing that by the time the susphrine wore off the steroid would kick in. It became an option for doctors in the 1960s and was commonly used throughout the 70s and 80s before it was phased out and ultimately taken off the market. Epinephrine and susphrine were used differently by different physicians. Some just gave you one or the other, and some recommended using epinephrine initially and then later giving susphrine for the longer action. I wrote more about susphrine here and here. I have a note from 1975 (I was 5) from my doctor when my family made a trip from Michigan to California that said: "This boy has chronic asthma and responds well to 0.5cc susphrine." Whenever I went to the hospital I would ask for this medicine. In 1991 I went to the ER and asked for it and the doctor said, "What's that." So you can see how quickly it was phased out once albuterol (see below)became popular in hospitals.

Brethaire inhaler

8. Terbulatine: Terbutaline was introduced during the 1970s as both an MDI and solution for nebulization and injection. In 1981 three brand names were approved by the FDA: Bricanyl, Brethaire, and Brethine. Other brand names since approved are Bricanyl or Brethaire. It lasted 4-6 hours, longer than epinephrine, isoetharine and metraproteronol (see below), the other rescue medicines available at this time. The MDI version of this medicine has been approved by the FDA, but the DPI versions are only available overseas.

It also had a stronger B2 effect than metraproteronol. By the 1980s it was the main alternative to metraproteronol, with the later being the more popular alternative. The medicine is believed to be as powerful as Albuterol, yet why it never caught on as a top line asthma remedy in the U.S. remains a mystery.

Many physicians chose to use it only when a tolerance to other rescue medicines was suspected. The medicine is still used in Europe and rarely in the U.S. The solution is still available, yet terbutaline inhalers were taken off the U.S. market in 2001.

This was the first rescue medicine I was prescribed to put into my nebulizer when I was first admitted to the asthma hospital in 1985, although it caused my blood pressure to spike and I was soon switched to metaproteronol. If I was prescribed it any other time I have no recollection. I never used the inhaler.

Alupent inhaler

9. Metaproteronol: It was introduced to the market in 1961 as Alupent, Metaprel or Oriprenaline and aproved by the FDA in 1973. It was the first B-2 specific rescue medicine that lasted more than 4-5 hours. It was usually prescribed as needed every 4-6 hours, although many asthmatics will admit to using it much more frequently. The solution came in a small, dark brown bottle with a bright orange nipple adaptor to draw up the recommended 0.3cc of solution to mix with 0.3cc normal saline.

Yet other than that it's chemical composition was similar to isoproterenol and therefore it still had some strong cardiac effects. (2) It remained the bronchodilator of choice until Albuterol gained acceptance during the 1980s and early 1990s. In 2010 production of Alupent was discontinued.

This was the rescue medicine that I was given in breathing treatments in the 1970s and 80s during my ER visits. I was introduced to the inhaler in 1980 by my doctor, and I quickly fell in love with this inhaler. In 1985 I was started on regular breathing treatments of metaproteronol solution. I was switched to the albuterol inhaler in 1985, and albuterol solution in 1991.

Ventolin solution with nipple syringe

10. Albuterol: This was the first B2 selective agonist, and it was introduced as the Ventolin inhaler in 1968 by Allen & Hanburys. (3) It's referred to as salbutamol in some countries. It's a fast acting bronchodilator, with the full effect being felt in 15 minutes. The usual aerosolized dose is 2.5 mg or 0.5cc in 3 cc of normal saline. It lasts 4-6 hours and is generally prescribed for use every 4-6 hours. However, due to it's perceived effect and safety record, many asthmatics admit to using it more frequently. The Ventolin solution was not available until after 1987. I was introduced to it in the emergency room in 1991, and soon thereafter my doctor prescribed it for use at home.

While this solution was initially obtained in a small, brown glass bottle and injected into the nebulizer with a syringe (see picture to left), it's now available in single dose plastic amps (see below). This change was made due to infection control.

Plastic ventolin amps

The chemical formula is basically terbutaline with some adjustments. This was another great innovation because racemic albuterol is refined to the point it can provide instant asthma relief with very minimal side effects. Once the original patent wore out the product was Schering-Plough as Proventil. By 1999 the product was available as 17 unique brand names including Pro-Air, AccuNeb and Vospire. (4*)

Ventolin Rotohaler

The medicine was ultimately deemed to be so safe that it became the most popular asthma medicine during the 1980s and 1990s, and the most profitable asthma medicine ever. For home use the medicine was (and still is) prescribed to be used as needed by inhaler or nebulizer route every 4-6 hours. However, in emergency rooms the medicine was proven to be safe given as often as needed to make breathing easier.

Most asthma experts now consider Ventolin not only safer but just as effective as epinephrine for severe asthma episodes. For this reason, epinephrine is rarely used and susphrine has been taken off the market. Isoproteronol and Iseotharine were also phased out, and as of 2010 so too was Metaproteronol. Albuterol continues to be the cheapest and, many believe, most effective rescue medicine on the market. I still have albuterol solution available as a back-up mainly in case my inhalers run out and in case I need it. I still carry the inhaler around with me wherever I go and still use it regularly (although not as often as I once did).

Maxair Autohaler

11. Pirbuterol: The product was introduced in the 1980s, and was approved by the FDA in 1992 and marketed as Maxair. It's composition is similar to Albuterol, although it improves breathing in less than 5 minutes as compared with Albuterol's 15 minutes. The side effects are similar to Albuterol. (6)

The neat thing about Pirbuterol is it's available as an Autohaler. With this device the medicine is inhaled by force of the patient's breath instead of just being squirted out. This acts as a spacer and assures improved compliance with the device, and improves medicine deposition in the lungs for a greater effect.

Pirbuterol is currently set to be phased out by 2013 due to an FDA mandate to get all inhalers that use chloroflourocarbons (CFC) propellant off shelves. In fact, it's also for this reason Metraproterenol was taken off the market, along with several other inhalers. I used this inhaler only once, and that was when I forgot my albuterol inhaler and borrowed my good friend Todd's Maxair.

12. Bitolterol The early 1990s saw the marketing of Bitolterol as Tornalate, and it worked similar to epinephrine, isoproterenol, and esoetharine. It lasts 5-8 hours, was B2 specific, and also had a quick onset of 2-5 minutes. It was never widely accepted, and in 2001 production was stopped. (7) I never took this medicine that I know of.

Ventolin Rotohaler

13. Albuterol: I'm listing albuterol her twice mainly due to the Montreal Protocol which called for the phase out of chlorofluorocarbon (CFC) propellants in asthma inhalers.

A dry powdered inhaler version of albuterol was available during the late 1990s, yet it never caught on due to the high cost of production. A Rotohaler was also introduced but was discontinued because it contained the CFC propellant and simply never caught on.

In 1995 Salbulin was made available as the first albuterol rescue inhaler that was CFC free, made with the environmentally friendly hydroflouralkane (HFA) propellant instead. the Automir Autohaler and Ventolin Evohaler were then introduced to the market.

The first HFA version of Albuterol to be approved by the FDA was Proventil HFA in 1996. The makers of the product was 3M Health Care and the marketers were Schering-Plough. (*) This was significant because the product had already been approved by 23 other countries (****)

Since then all albuterol products have been converted to the HFA propellant. This ultimately resulted in a new patent and a spike in the cost of the medicine. In this way, Albuterol was re-branded as a new product, and this resulted in a spike in the cost of the medicine. (9) Actually, this is the inhaler I carry in my pocket today.

13. Levalbuterol: This medicine was introduced to the market as Xopenex in 1999. While Albuterol has an S-isomer and R-isomer in it's formula, levalbuterol only had the R-Isomer. Other than epinephrine, levalbuterol is the only single isomer bronchodilator on the market.

Initially, this was believed to make the medicine stronger than albuterol and with fewer side effects. The medicine was available in three doses: 0.35 mg, 0.63 mg, and 1.25 mg, all premixed in plastic amps with 3 cc of normal saline. Studies showed the 0.63 dose was simiilar in effect to the 2.5 mg dose of albuterol. The 1.25 mg dose was believed to last from 6-8 hours, meaning less medicine would be needed during the course of the day. (10)

Salespeople working for Sepracor had trouble convincing physicians it was any better than albuterol, so they attempted a unique strategy of trying to convince patients, nurses, and respiratory therapist, who would in turn convince doctors. The marketing plan worked, and now levalbuterol is preferred by many physicians.

However, more recent studies show it works similar to albuterol with the same side effects. Clinical experience with the two medicines show similar results. So which one works better is often left to the personal preference of the physician. However, levalbuterol continues to be under patent, which means it costs about $4.17 per amp while albuterol only costs about $0.75 an amp. For this reason, most hospital administrators recommend doctors stick with the old faithful and less expensive albuterol for most patients.

In my humble opinion, albuterol and levalbuterol are the same medicine. However, I also believe that once the patent for levalbuterol runs its course and the price comes down to earth, levelbuterol will replace albuterol as the bronchodilator of choice. A Xopenex inhaler was introduced in 2002. I've taken a few xopenex treatments just for fun, although I didn't notice any difference from albuterol other than cost. I have yet to use the xopenex inhaler.

Primatene Mist inhaler

14. Primitine Mist:: Wyeth and Armstrong (a subsidiary of Amphastar Pharmaceuticals) continues to makret an epinephrine inhaler marketed as Primitine Mist. It's able to stay on the shelves in pharmacies as an over the counter medicine because it has been grandfathered in, according to FDA.gov.

A 2005 National Health Interview Survey by the Centers for Disease Control and prevcention (CDC) determined that 7.7% of the U.S. population owned one of these inhalers, which would amount to about 23 million people.

Asthma experts have been trying to get the medicine off the shelves for years, and finally succeeded when the Montreal Protocol was signed mandating all CFC inhalers be taken off the market. Primitine Mist was finally discontinued as of December 31, 2011 as part of the Montreal Protocol's desire to get rid of CFC inhalers. This discontinuation did not effect non inhaler epiniephrine products.

An HFA epinephrine inhaler may soon be available, yet it's yet to be determined if this new inhaler will be allowed to be sold over the counter. Wyeth has since concluded that an epinephrine DPI is available but it's not a viable option at this time.

I used this inhaler only once. A friend gave me it because he didn't use it, and once my Alupent ran out I ran the Primitine Mist canister dry in about one day. It didn't work anything close to as well as Alupent, which explains the extra puffs. I probably ended up in the ER (because of bad asthma, not because of side effects to all those puffs, although I may have been a little stressed abotu side effects since I never used the medicine before). I have never used this inhaler since and wouldn't recommend it either. I wrote about this further here.

15. Combivent: This was an inhaler that combined both Albuterol and the anticholinergic Atrovent . It is commonly used for COPD patients during the 1990s and 2000s to prevent and treat symptoms. It was generally not recommended as a top line asthma medicine. The recommended frequency is 2 puffs every 4 hours as needed, or simply four times per day. Because it has Atrovent, it's not generally recommended for more frequent use (although many patients use it more often than recommended). Due to it's CFC propellant it's set to be discontinued as of December 31, 2013 Recently the FDA approved a new propellant free Combivent Respimat, and this will be available in the middle of 2012. I have never been prescribed this medicine.

16. Duoneb: It's a solution that combines Albuterol, Atrovent and 0.3 cc normal saline. It comes premixed in a plastic ampule. It's yet another option for asthmatics and other lungers when albuterol alone isn't enough to control asthma. I have never been prescribed this medicine, but give it regularly to my patients. This is a very popular medicine to give in hospitals for just about any respiratory ailment (and whether it does any good or not).

Click here for more asthma history.

References: (I'm presently working on modifing these references)

Rau, Joseph L., "Inhaled Adrenergic Bronchodilators: Historical Development and Clinical Application," at AARC.org (American Association of Respiratory Care, July, 2000, Vol. 45, number 7),
Rau, ibid
Rau, ibid
*Ahrens, Richard C., et all, "Therapeutic Equivalence of Spiros Dry Powder Inhaler and Ventolin Metered Dose Inhaler," Am. J. Respir. Crit. Care Med., Oct 1, 1999, vol. 160, No, 4, pages 1238-1243
"Allen & Hanbury's: Information," About.com, http://www.answers.com/topic/allen-hanburys
Rau op cit
Rau op cit
Murphy, Anna, "Asthma in Focus," 2007, page 122 *
*Ahrens, Ibid
Rau, op cit

****Barnet, Alt, "First Metered Dose non-CFC Inhaler approved by FDA," The Lancet, August 1996, vol. 348, Issue 9027, page 606

1957: The invention of the rescue inhaler

2012-01-05T07:40:00.000-05:00

When Americans unite and put their minds and imaginations together in a quest to obtain a united goal, anything can be accomplished. This was what occurred during WWII. While war is bad, it can bring about many good things. In this way, the metered dose inhaler -- the rescue inhaler you have in your pocket right now -- is a byproduct of war.

A 1957 ad for the Riker inhaler (a)

Allied troops fighting in the fields of Europe were often infested with bugs that caused Malaria. This was impeding the war effort.

To remedy this problem the U.S. Government hired researchers to come up with a bug repellent that would help allied soldiers attack bugs.

Lyle Goodhue and William Sullivans must have first looked to the past to find a solution. They would have learned that in 1790 pressurized aerosols were introduced in France to create carbonated beverages.

They would have learned that in 1837 the first spray can was made of heavy steal in Perpigna. The can had a valve in it that allowed it to create the spray. Several prototypes were tested in 1862, although nothing ever came of it. (1)

They would have learned that in 1927 a Norwegian man named Erik Rotheim patented the first spray can that was capable of holding pressurized contents and spraying them. It's now considered the forerunner of modern spray cans.

Goodhue and Sullivans then took these old ideas and combined them with ideas of their own and came up with a design capable of carrying a pressurized propellant called flurocarbon. The bug spray was added to the propellent and the spray can allowed for the bugs to be sprayed and killed.

So while the first spray cans were used to hold bug sprays during the war, the concept soon evolved to other products, such as paint and perfume. It was the perfume market that Riker Laboratories (a subsidiary of what is now 3M Pharmaceuticals) was thinking of when it started tinkering with this product. They wanted to create a spray perfume. (2)

Yet Riker researchers soon realized there was a demand by asthmatics for a convenient to use and portable spray can for asthma medicine. This was how the first inhaler came to fruition. In 1956 Riker inventors created the asthma inhaler market with a Medihaler-Epi that contained epinepherine and medihaler Iso that contained Isophrenaline.

The Riker inhaler was a major breakthrough. This product was incorporated with the first ever actuator with a one-way valve that allowed for the medicine and propellant to be sprayed in a uniform dose (a metered dose), and soon became known as the metered dose inhaler (MDI). The Medi-Iso delivered a metered dose of 0.15 mg and the Medi-Epi delivered a dose of 0.06 mg. The inhalers were easy to use, provided fast relief, and were easy to lug around. (2)

The design of this original inhaler was very similar to many of the inhalers we lug around today, such as the Ventolin inhaler. It could easily fit into a boy's front pocket or a mom's purse, and using it was as as easy as squeezing the actuator.

Electric nebulizers in the 1950s were large, bulky and made of glass. They were also expensive, so many asthmatics had less expensive nebulizers that required them to squeeze a bulb to aerosolize the medicine. Many asthmatics continued to smoke asthma cigarettes, insents, or other palliative asthma remedies.

So getting asthma relief was inconvenient when the medihaler was introduuced, and the relief given wasn't very good. So this was the market advertisers for Riker Laboratories aimed for when they started their first advertising campaign.

1956 ad for the Medihaler (b)

An old advertisement for the Medihaler (see image) used the inconvenience of these other devices as a marketing ploy:

Medihaler with your favorite bronchodilator:
No rubber bulbs to deteriorate
No breakage of costly glass nebulizers
No spilling of solution in pocket or purse

The Medihaler became an instant hit. It, coupled with the discovery of theophylline, caused the market for asthma medicines to boom.

Gregg Mitman, in his book "Breathing Space: How allergies shape our lives and landscapes," explained that between 1972 and 1985 prescription drugs in the United States showed a modest 7 percent increase in the number of prescriptions filled.

During the same period, prescriptions for asthma drugs increased 200 percent." The market for asthma inhalers was so bullish that other pharmaceutical companies raced to make their asthma remedies available as an inhaler. (3)

Mitman further explained that the sale of asthma inhalers alone (both beta adrenergics and others), accounted for "25 percent of all prescriptions dispensed for the treatment of asthma in 1985."

So it didn't take long at all for pharmaceuticals, doctors and asthmatics to catch on to the convenience of the rescue inhaler. Life for asthmatics changed forever, and for the better.

Click here for more asthma history.

References:

About.com, "History of spray cans," http://inventors.about.com/od/astartinventions/a/aerosol.htm (provides a good history of the spray can)
Brenner, Barry E, ed., "Emergency Medicine," 1998, from chapter one "Where have we been? A history of acute asthma," page 23
Mitmann, Gregg, "Breathing Space: How allergies shape our lives and landscape, 2007, page 237 (a great read if you want to learn more about the history of asthma/ allergies)

Pictures:

(a) Deco Dog, http://www.decodog.com/inven/medical2.html, you can purchase or check out old asthma inhaler ads here
(b) Deco Dog, ibid

1900-1960: Key developments in asthma

2012-01-04T16:50:00.000-05:00

The most productive years in the history of asthma medicine came between 1900 and 1960. Key developments in this era changed the way asthmatics live, and for the better

The developments were as follows:

1900: Epinephrine was discovered. I wrote about this here.

1903: Epinephrine was injected into the arm of an athmatic and, within minutes, an asthma attack was ended. This was the first recorded use of asthma rescue medicine.

1910: The first aerosolized epinephrine treatment was given. The nebulizer used was primitive -- by modern standards anyway -- but relief was felt almost immediately. This was the first recorded breathing treatment with a nebulzer.

1930s: The first mass producible electric nebulizer hits the market. Asthmatics now had access to fast acting rescue medicine in the comfort of their own home, and whenever they needed it. For the first time the asthmatic didn't have to hunt down a doctor with each asthma attack when relief was sought. I wrote about the history of nebulizers here.

1936: Isopretoronol was synthesized in 1936 as the first successful modification of epinephrine. (1)

1940s: Isoproteronol was marketed as Aleudrin in Germany

1948: The terms beta-2 Adrenercic is first described by Raymond Ahlquis. Beta 2 adrenergic receptors (B2) were discovered to line smooth muscles that wrap around air passages in the lungs. When stimulated, these receptors cause these muscles to relax and the airways to dilate. It's B2 stimulation by rescue medicine that ends an asthma attack. Since this discovery rescue medicine is sometimes referred to as beta-2 agonists, or simply beta agonists. (3)

1948: The terms beta 1 Adrenergic (B1) and alpha-1 adrenergics (A1) are described also described by Raymond Ahlquis. A1 and B1 receptors line heart muscle, and when stimulated the heart rate increases in rate and force. Epinephrine was found to be attracted to B1, B2 and A1 receptors. So this explained why the instant breathing relief came with side effects.

1948: Isopretoronol was learned to have a stronger B2 effect than epinephrine, yet it also had a strong B1 effect that caused the heart to speed up "even when administered via inhalation." So Isopretoronol still had to be used with discretion. (4)

1951: Isopretoronol was marketed as Isoprenaline in the U.S. It became yet another option via the nebulizer route, although, like epinepherine, it only lasted one and a half to two hours. (2)

1951: The first B-2 specific rescue medicine hits the market. The medicine was Iseotharine and it was marketed as Bronkosol and Isuprel. It had a stronger beta effect and less of an alpha effect. It was marketed as the first B-2 specific inhaled aerosolized bronchodilator. Bronkosol had less of a beta 2 effect than Isopretoronol, yet it was more desirable because of the decreased cardiac affect. The medicine still only lasted one and a half to two hours. (5)

1957: The first metered dose inhaler hits the market. Riker Pharmaceuticals introduced the Medihaler-Epi and the Medihaler-Iso which had epinephrine and isoprotoronol respectively. For the first time ever asthmatics had a handy little inhaler to carry with them wherever they went. The medicine provided instant relief from an asthma attack without the hassle of hunting down a doctor, or dealing with fragile and complicated nebulizers, solutions and hand held squeeze bulbs. I wrote about this in more detail here.

Click here for more asthma history.

References:

Brenner, Barry E, ed., "Emergency Medicine," 1998, from chapter one "Where have we been? A history of acute asthma," page 23
Rau, Joseph L., "Inhaled Adrenergic Bronchodilators: Historical Development and Clinical Application," at AARC.org (American Association of Respiratory Care, July, 2000, Vol. 45, number 7),
Rau, ibid
Rau, ibid
Rau, ibid

1858-1929: History of nebulizers

2012-01-04T16:42:00.001-05:00

While we asthmatics should consider epinephrine the greatest discovery in the history of medicine, the greatest invention may be that of the nebulizer and inhaler.

Ancient doctors as far back as 10,000 B.C had access to various herbal remedies for asthma-like symptoms, and as early as 5,000 B.C. they learned the best mode of delivery was inhalation. Yet the only methods they knew of were steam and smoke.

The Ancient Egyptians inhaled smoke from dried and crushed belladona burned on bricks. Ancient Indians burned cigarettes with dried and crushed strammonium. Insents were ultimately used as well.

As we travel forward to the mid 19th century not much has changed. Enter any random home and you'll quickly be able to tell if an asthmatic lives there by the bittersweet smell of smoke wafting through the doorway

Surely there were a few devices called nebulizers and inhalers at this time, yet they were large, bulky, fragile, hard to operate and very expensive. Operating them was often difficult and time consuming, and the medicine available wasn't much good anyway.

Sales-Giron and his portable nebuliser (1858)*

The first nebulizer was actually produced in 1858 by a French inventor named Dr. Sales-Girons. His nebulizer was unique in that it had a pedal that acted like a bicycle pump, and when pulled up air was forced through an atomizer and a mist was created to be inhaled. (1)

(A picture and good description of this first nebulizer can be seen here at Inhalatorium.)

One thing to note as we delve into the past here is that nebulizers of old came by varying names. Some were called atomizers, some nebulizers, and some inhalers.

The idea is that an atomizer refers to any device that converts a liquid to a fine spray. Likewise, nebulizers and inhalers create an aerosolized mist to be inhaled.

So sometimes atomizers were referred to as atomizers, sometimes nebulizers, and sometimes inhalers. Which name was used was left to the discretion of the inventor or marketer of the device. And while some were called inhalers, they were nothing like the inhalers we use today.

Dr. Siegel inhaler (1872)

In 1864 Dr. Siegel invented Siegle’s steam spray inhaler that used the force of steam through a small tube to draw up the medicine and turn it into a vapour that is inhaled through a glass mouthpiece. The principle used here is similar to modern nebulizers, only now we use air instead of steam. (2)

Siegel's invention is often considered the beginning of nebulizer therapy.

There were various attempts at copying Siegel's nebulizer, yet neither Siegel's nor any of the others were effective enough to become popular among asthmatics. Again, the medicine available back then provided only minimal relief, and this fact probably made efforts to use these devices fruitless, and perhaps too expensive to make them worthwhile investments.

So the evolution of such devices was left at a standstill until the discovery of epinephrine in 1900. Now, for the first time ever, there was a medicine available that could end an asthma attack. The only problem now was the asthmatic in need had to seek out a doctor and have the medicine injected into a vein.

Silbe hand-held rubber bulb nebulizer (1940)*

Doctors also quickly learned that the systemic delivery in this way of epinephrine into your body caused significant side effects, such as full and bounding heart rate, increased blood pressure, and hyperactivity. The medicine also took several minutes to take effect. Entrepreneurs sensed an opening to a new market, and searched for a device to help asthmatics better deliver this medicine.

By 1910 epinephrine was available as a solution to be nebulized, yet nebulizers continued to be too expensive and too difficult to operate to be of much use. However, for those willing asthmatics, there were a few nebulizers available such as the:

Silbe Atomizer: A hand held nebulizer with a bulb syringe that had to be squeezed
Colossol Nebulizer: A glass nebulizer with a rubber squeeze ball

Glass Collosol Nebulator with rubber bulb*

Volatilizer Inhaler: Dr. Coulter's vaporizer and inhaler was called the champion Volatizer. It was steam powered and made of copper, brass and nickel plate. (2)

In 1929 various bulb syringe nebulizers (like this one) were available. The asthmatic would draw up some of the epinephrine from a small vial and mix it with some water in the nebulizer cup and then squeeze the bulb to create a fine mist that could be inhaled.

As you can guess, this took a lot of time, coordination, and even muscle strength to get an adequate amount of medicine aerosolized to do any good. I had a bulb to connect to my nebulizer cup back in 1985 to use in case of a power outage, and I tried it once just for kicks. It took forever just to get minimal results

1892 ad for Dr. Couilter's vaporizer & inhaler*

However, I suppose if that's all you had available, you'd squeeze that bulb as long as you had to. Yet we asthmatics yearned for something better, simpler, cheaper and easier to use. Aware of the possibility of a new market, many investors and inventors worked overtime searching for the ideal device.

By the 1930s asthmatics finally got what they yearned for when the first electric nebulizers hit the market. These nebulizers were a reasonable size, generally inexpensive and easy to operate. Asthmatics could now have access to epinephrine in the comfort of their own home right away when they needed it.

Aerosolized epinephrine worked faster, almost immediately giving the asthmatic relief from an asthma attack. Since it was inhaled instead of injected into a vein, side effects were significantly diminished. In this way, the invention of the electric, mass producible nebulizer was a godsend to asthmatics.

Adrenalin Inhaler used to nebulize epinephrine (1930s)*

Nebulizers have continued to evolve since then, yet the general concept has not changed.

Click here for more asthma history.

References:

Rau, Joseph L., "Inhaled Adrenergic Bronchodilators: Historical Development and Clinical Application," at AARC.org (American Association of Respiratory Care, July, 2000, Vol. 45, number 7),
Inhalatorium.com provides pictures and descriptions of antique nebulizers and inhalers
* Pictures used with permission from Inhalatorium.com. Check out the site for more antique nebulizers and inhalers.

1900: The discovery of epinephrine

2012-01-02T13:10:00.029-05:00

Epinephrine. It was the first asthma rescue medicine and the greatest medical discovery ever, at least as far as we asthmatics are concerned. This discovery spearheaded a quest that lead to the inventions of the rescue inhaler, nebulizer, and albuterol.

By the turn of the 20th century there were many theories about asthma, and there were many remedies available, yet which one to use was a crapshoot, and the relief obtained was palliative at best. Like in the ancient world, the best treatment for an asthma attack was the soothing hand upon your shoulder and reassuring words.

Jockichi Takamine (1854-1922)

Yet this all changed in 1900 when Jockichi Takamine discovered a hormone called epinephrine. Three years later, in 1903, the medicine was injected into an asthmatic who, within only minutes, was breathing easy. This was the first time ever that an asthmatic got instant relief by an asthma rescue medicine.

The medicine was originally marketed as Adrenaline. Doctors were quick to start prescribing it for their asthmatics in distress. Asthmatics, as you might imagine, quickly fell in love with the medicine.

Yet in order to get a shot an asthmatic had to seek out a doctor. For this reason many asthmatics continued to stick with their usual asthma remedies, which mainly consisted of asthma cigarettes and insents.

At this time many asthma experts believed asthma was caused by dilation of the vessels in the lungs. So it only made sense that the initial theory was that epinephrine made breathing easier because it constricted vessels in the lungs.

Yet another theory was that asthma caused the smooth muscles (bronchiolar muscles) that wrap around the lungs to spasm, and this caused the air passages to narrow. This was often referred to as the spasmotic theory of asthma. We now refer to it as bronchospasm.

In 1907 it was discovered epinephrine was a bronchodilator; that it made breathing easier by dilating the air passages -- known as bronchioles -- in the lungs It was therefore dubbed a bronchodilator. (1)

Regardless of the cause, the medicine made breathing easier, and that's all asthmatics cared about. Yet there were side effects. The vasoconstricting quality of the medicine caused blood flow to speed up and this increased blood pressure, and increased the force and rate of the heart. It also caused asthmatics to feel jittery, anxious and hyper.

And while it provided instant relief, this relief only lasted about an hour and a half to two hours.

So the quest was on to learn more about this medicine, to fine tune it to get rid of side effects, to make it last longer, and to discover better and faster modes of delivery. The race was on.

Click here for more asthma history.

References:

Rau, Joseph L., "Inhaled Adrenergic Bronchodilators: Historical Development and Clinical Application," at AARC.org (American Association of Respiratory Care, July, 2000, Vol. 45, number 7), pages 854-62
Rau, ibid
Rau, ibid

1200-1600: Asthma in ancient Korea

2011-12-29T16:18:00.000-05:00

If you were an asthmatic living in Ancient Korea you would have had to wait until the 13th century before you had any options available to you other than folk medicine.

Folk medicine was basic philosophies and treatments of various disease processes handed down from generation to generation to anyone interested in learning them. Remedies usually consisted of simple things such as concocting herbal remedies, applying ointments, drinking teas, or soothing massages. (1)

It was around the 12th and 13th centuries when medical philosophies of Traditional Chinese Medicine started to influence Korean physicians, which were recorded in various Chinese texts. Yet the first medical texts in Korea simply consisted of compilations of folk medicine, which up to this time was passed on only by word of mouth

It was in 1236 that all the folk medicine of the day was compiled into one treaties called "Hyang-yak kugup pang" or "Emergency Remedies of Folk Medicine." It's the oldest medical texts written by a Korean. (2)

At about the same time several other such treaties were compiled, including "Samhwaja hyangyak pang," or "Folk Remedies of Samhwaja."This was mainly a diagnostic guide. (3)

All the medical wisdom from these books were compiled in 1433 into "Hyangyak chipsong pang," or "Compilations of Native Korean Prescriptions." (4) Two centuries later, in 1610, Korean philosopher Ho Chun compiled all the medical wisdom up to his time in "Tongui pogam," or "Exemplar of Korean Medicine." (5)

Mark Jackson, in his book "On Asthma: The Biography," explains that Korean physicians believed asthma-like symptoms or coughing were caused by excessive eating, fear and shock. While folk medicine was the original treatment for any ailment, various remedies from Chinese medical texts worked their way into Korean medicine. (6)

While Traditional Chinese Medicine influenced Korean medicine, Korean texts were likewise respected in China. It wasn't until the 18th century that Eastern and Western civilizations shared medical wisdom.

Click here for more asthma history.

References:

WebMD, http://dictionary.webmd.com/terms/folk-medicine
Lee, Ki-baik, "A New History of Korea," 1984, Korea, page 171
Lee, ibid, page 171
Lee, ibid, page 171
Jackson, Mark, "Asthma: The Biography," 2006, New York, page 43
Jackson, ibid, page page 43

314-240 B.C.: Erasistratus founds school of anatomy

2011-12-28T20:04:00.000-05:00

Erasistratus (315-240 A.D.)

Ancient Greek and Roman life was so pleasurable that for the first time in human existence there was time to sit back and enjoy the finer things in life; to ask questions; seek for truths; devise theories; and learn.

Men became smarter in all walks of life, including medicine. At first medical theories were formed based on keen observation, and ultimately new ideas were created based on experience, such as actually cutting open a human to see what was inside, and see what various diseases did to the human body.

Erasistratis of Chios lived about 315-240 B.C. and is known by history as an anatomist and founder of the School of Anatomy at Alexandria, Egypt. He is generally known to follow the methods of Hippocrates before him, yet his work would later influence Galen.

Erasistratus was an anatomist who was so accurate at describing the human body that many of his descriptions are still used to this day. However, it wasn't until the writings of Galen some 350 years later that his descriptions were introduced to the medical world. (1)

One significant contribution to medicine and our history of asthma is the discovery by Erasistratus of the valves of the heart. Hippocrates had earlier noted the heart could not be diseased, but Erasistratus thought otherwise.

However, while he conducted his research it was believed the arteries contained air not blood. Blood wasn't described until the days of Galen.

This is significant to our history of asthma because over the next 2,000 years it would be learned that heart failure mimicks true asthma and was ultimately reclassified not as asthma per se but cardiac asthma. Cardiac asthma is now referred to as heart failure.

Another interesting thing about the life of Erastistratis is that, while he may not have known it at the time, his life marked the beginning of the fall of the once great empire that was Rome. In our study of the history of asthma Erasistatis is our last significant figure representing medicine in the Ancient Greek and Roman eras.

Click here for more asthma history.

References:

Parr, Bartholomew Par, M.D., "The London Medical Dictionary," 1809, London, Vol. 1, pagegs 425-5

500 A.D. Asthma in Ancient Japan

2011-12-27T15:10:00.000-05:00

Fuiwara no teika ( (1162-1241)

If you lived with asthma in ancient Korea and Japan your asthma may have been recognized, yet treatment would have been mainly supportive. It wasn't until the 6th century A.D. that Chinese medical ideals -- mainly in the form of the Nei Ching -- spread to these nations.

Chinese medicine was referred to as canpo in Japan, and asthma-like symptoms were referred to as zensoku as early as 700 A.D. (1)

The most famous asthmatic in Ancient Japan was Fujiwara no Teika who is considered one of the most famous poets in Japanese history. Legend has it that his poems became well read due to his cordial relationship with the Emporor Go-Toba (1180-1239).

Japanese children learned early that there were 404 different kinds of illnesses, and they learned of the various herbal formulas used as remedies, most of them indigenous to the region. One interesting remedy for asthma was by eating a potion containing earthworms dried under the sun, cooled and then boiled.

Most asthma remedies were similar to what was recommended by Traditional Chinese Medicine. So prior to the 6th century Japanese asthmatics would have been recognized although there wasn't much anyone could do other than offer support.

Yet if you were afflicted with breathing difficulties in the 6th century you would have had available to you many of the same treatments available to Chinese asthmatics, including Ma Huang, a very efficient bronchodilator.

Click here for more asthma history.

References:

Jackson, Mark, "Asthma: A biography," 2006, New York, page...

25 BC-50 AD: Celcus spearheads quest to define asthma

2011-12-26T07:46:00.000-05:00

So what would life be like for us asthmatics at the time of Jesus? From my investigations into this era I'd imagine the best remedy might simply be to tough it out, as many of the recommended remedies seem like they'd be worse than the disease.

Aurelius Cornelius Celsus

The second century A.D. was a very "fruitful era of literature and philosophy." (1) It is for this reason we have resources available to help us learn what was known about asthma at that time and the remedies to treat it. Among those influential in our quest to investigate the history of asthma are Pliney the Elder, Seneca the Younger and Aurelius Cornelius Celsus.

I will write about Pliney and Seneca later, yet for this post I would like to introduce you to Celsus, who was born of respectable parents, was well learned, and shared with us his wisdom through his many writings. He was a philosopher, physician, surgeon and a pharmacist. One author noted him to be so skilled at his crafts that he was "second to none." (2)

His writings are also known to be "diligent" and "attentive," yet many future biographers and historians have debated as to whether he really practiced what he preached. Some speculate that he never was a surgeon, let alone a physician. (3)

Celsus was born in Greece in 25 B.C. He was a stoic, which meant he did not believe in an after life. As an arch opponent of Christianity he wrote "The True Word," which was a well read attack on Christianity, a new philosophy in that era.

He wrote several other books as well, such as "A Treaties on Agriculture" and "A Treaties on Military Tactics." Yet what history most remembers him for is his "Treaties on Medicine." It is thanks to this work that we gain our first look at asthma during the time of Jesus.

As a medical writer Celsus emulated Hippocrates, and parts of his books are word per word transcriptions from the "Hippocratic Corpus." In fact, Celsus did this so often that one later author, Nicholas Mondaris, referred to him as the "Ape of Hippocrates." (4)

Treaties on Medicine

Yet he incorporated into his book the latest wisdom of his day, plus some of his own ideas. This is clearly evident in his writings on asthma.

When asthma was first defined by Hippocrates in 400 B.C., it was often difficult to distinguish between the causes of dyspnea, and therefore they were grouped under the umbrella term asthma. Thus, all that caused dyspnea were referred to as asthma.

Celsus, on the other hand, believed asthma was more than just dyspnea, and for this reason he provided us with our first description of asthma as more than simply a blanket term.

Celsus believed there were three thoracic disorders that resulted in difficulty of breathing, and they varied by their "degree of violence":

Dyspnea: Moderate, unsuffocative breathing without a wheeze; it's chronic
Orthopnea: Breathing only takes place in an erect position; it's acute
Asthma: Vehement breathing that is sonorous and wheezing; it's acute (5)

He was also the first to describe asthma as a specific condition involving constriction of the air passages in the lungs, and he was likewise the first to describe a wheeze. He described an attack of asthma this way:

(Asthma is caused by) the narrow passage by which the breath escapes, it comes out with a whistle; there is pain in the chest and praecordia, at times even in the shoulder blades, sometimes subsiding, then returning; to these there is added a slight cough."

His remedies were barbaric, and may have included any of the following:

Blood letting (common remedy for just about any ailment)
Milk (to relax the bowels)
Purging of the bowels with enemas (clysters) or injections if necessary
Hydromel (honey diluted in water
Head must be kept high in bed
Thorax relieved by fomentations (warm, moist medicincal compress)
Thorax relieved by hot cataplasms (a heated medical dressing, either dry or moist)
Malagma (lotion or salve) or iris ointment after fomentations and cataplasms (these act as emollients to soften skin to make chest movements easier)
Hydromel as a drink (mixture of water and honey)
Bruised root of capers has been boiled
Nitre or white cresses fried, bruised, then mixed up with honey and given as electuary (oral, by mouth)
Honey, galbanum, and turpentine resin boiled together and, when they are coalesced to the size of a bean, dissolved under the tongue daily
Impure sulfur or southernwood triturated together in a glass of wine and sipped warm
Fox's liver dried, hardened and pounded into a powder and sprinkled on a drink (such as wine)
Eating the fresh, roasted lungs of a fox (but you can't cook it with iron utensils)
Gruels (watery porridge) and mild food
Light austere wine
Sometimes a vomit (Emetics)
Anything that promotes urine (diuretics make you pee, but they probably believed they were full of poisons that caused the humors to be imbalanced)
Gentle walking (nothing more)
Massage (he referred to it as friction; it's done to move poisons around the body to balance the humors and to make breathing easier) (6)

While some of Celsus's remedies were later proven to have medical significance, most were simply palliative, and some were downright barbaric. Still, Celsus's ideas were studied and followed for many years after his death.

We asthmatics should be thankful to Celsus for spearheading -- although he didn't know it at the time -- a 3,000 year effort to define asthma as a disease of its own. You can decide for yourself if you'd have been satisfied with his remedies for your asthma...

... or if you'd have rather just stayed home and suffered. Let me know what you think.

References:

Celsus, Aurelius Cornelius, "De Medicina," translated by L. Targa, London, pages xiiv-xxiii, "The Life of Cornelius Aurelius Celsus," by J. Rhodius and translated from Almeloveen's Lugduni Batavorum, page xxi, xxii
Celsus, ibid, page xvii
Parr, Bartholomew Par, M.D., "The London Medical Dictionary," 1809, London, Vol. 1, pagegs 425-5
Celsis, op cit, page
Celsis, op cit, pages 259-61
Celsis, op cit, pages 259-61

62 B.C.: Seneca the asthma philosopher

2011-12-24T02:01:00.003-05:00

"What in fact makes people who are morally unenlightened by the experience of physical distress is their failure to acquire the habit of contentment with the spirit. They have instead been preoccupied by the body.. so do not go out of your way to make your troubles any more tiresome than they are and burden yourself with fretting." Seneca

Like the writings of Pliney the Elder, Seneca's writings became well read, and Seneca became one of the most well known philosophers. In one of his letters to Lucilius, a friend and correspondent of Seneca's, Seneca provided a description of asthma, although he doesn't use the term asthma.

Sculpture of Seneca by Puerta de Almodóvar in Córdoba, Spain

From his 54th letter to his friend Lucius (who also had asthma and catarrh), we get Seneca's description of asthma from "On Asthma and Death" as translated by Richard M. Gummere:

My ill health had allowed me a long furlough, when suddenly it resumed the attack. "what kind of ill-health?" you say. And you surely have a right to ask; for it is true that no kind is unknown to me. But I have been consigned, so to speak, to one special ailment. I do not know why I should call it by its Greek name; for it is well enough described as "shortness of breath." It's attack is of very brief duration, like that of a squall at sea; it usually ends within an hour. Who indeed could breathe his last for long? I have passed through all the ills and dangers of the flesh; but nothing seems to me more troublesome than this. And naturally so; for anything else may be called illness; but this is a sort of continued 'last gasp.' Hence physicians call it 'practising how to die." For some day the breath will succeed in doing what it has so often essayed (breath will succeed in doing what it is supposed to do).

In letter 65 he wrote about his and his friend Lucius's catarrh*:

"I am all the more sorry to hear about your constant catarrh, and the spells of feverishness that go with it when it becomes protracted to the point of being chronic, because this kind of ill health is something I have experienced myself. In its early stages I refused to let it bother me, being still young enough to adapt a defiant attitude to sickness and put up with hardships, but eventually I succumbed to it altogether. Reduced to a state of complete emaciation, I had arrived at a point where the catahhral discharges were virtually carrying me away with them altogether. On many an occasion I felt the urge to cut my life short there and then, and was only held back by the thoughts of my father who had been the kindest of fathers to me and was then in his old age. Having in mind now how bravely I was capable of bearing the loss, I commanded myself to live. There are times when even to live an act of bravery."

This was probably saying a lot back then, because I can imagine living in a state of shortness of breath. And I can imagine this coupled with the misery of allergies on top of that.

Yet I cannot imagine what those two ailments would be like when there was no cure and no remedy that really provided any relief. It must have been pure hell to live like that. I can understand how he might be compelled to think about just ending the misery right "there and then."

Yet life is special, and there are few who get to enjoy this special gift. Seneca realized this. He used his father to provide himself the courage to go on.

In letter 65 he described to his friend Lucius and what he did to survive the attacks of asthma and catarrh*.

"Let me tell you the things that provided me consolation in those days, telling you to begin with that the thoughts which brought me this peace of mind had all the effects of medical treatment. Comforting thoughts contribute to a person's cure; anything which raises his spirit benefits him physically as well. It was my Stoic studies that really saved me. For the fact I was able to leave my bed and was restored to health I give the credit to philosophy. I owe her -- and it is the least of my obligations to her -- my life. But my friends also made a considerable contribution to my health. I found a great deal of relief in their cheering remarks, in the hours they spent at my bedside and in their conversations with me. There is nothing, my good Lucius, quite like the devotion of one's friends for supporting one in illness and restoring one to health, and for dispelling one's anticipation of dread and death. I even came to feel that I could not really die when these were the people I would leave surviving me, or perhaps I should say I came to think I would continue to live because of them, if not among them; for it seemed to me that in death I would not be passing on my spirit to them. These things gave me the willingness to help my own recovery and endure all the pain. It is quite pathetic, after all, if one has put the will to die behind one, to be without the will to life.

Another remedy he later adds "is to turn your mind to other thoughts and in that way get away from your suffering. Call to mind things which you have done that have been upright and courteous; run over in your mind the finest parts that have been played. And cast your memory over the things you have most admired."

No potions. No magic. No herbs. Seneca might have been one of the first asthma experts to recommend, mainly due to his own experiences, the importance of relaxing to control your asthma.
Click here for more asthma history.

*Campbell, Robin, Lucius Annaeus Seneca, "Letters from a Stoic: Epistulae morales ad Lucilium, " Penguin, 1969, letter LXXVII.

"There then are your remedies."

1281-1348: Xi defines asthma for China

2011-12-23T16:06:00.000-05:00

The next person to make a significant impact on the flow of asthma wisdom through Ancient China was InZhu Dan Xi (also known as Zhu Zhenheng).

He lived from 1281-1348 A.D, and was born to a medical family. He believed his family received poor medical care when he was young, and therefore became determined to learn about medicine. (1)

He believed over indulgence depleted the essence of yin and caused chronic diseases. His most significant recommendation was temperance. (2)

He continued to describe diseases as an imbalance of the humors as was described in the Nei Ching some 2,000 years earlier, and as described in Ancient Egypt and Western Civilizations.

InZhu Dan Xi (1281-1348)

Xi is often regarded as the first Chinese physician to provide a modern description of asthma. He combined chuan and Xiao to come up with chuan xiao, which many historians believe is similar to the Western world's description of asthma. (3)

From this time on Chinese physicians believed Chuan xiao was caused by an imbalance of yin and yang, which are polar opposites, and "obstruction to the flow of Qi by phlegm in the airways, according to Mark Jackson in his book "Asthma: The Biography."

Ma Huang continued to be a common therapy for the treatment of any respiratory ailments along with "Qi supporting" liquorice and gypsum decoction, "Yin syndrome asthma was treated with Yin Returning elixer." (4)

Since Ma Huang was a much better bronchodilator than any western treatment for asthma, Chinese asthmatics had it at least a little better off than their contemporaries in the rest of the world, or so one might imagine.

Click here for more asthma history.

References:

Beijing Medical Museum of TCM
"Chu Tan-chi [Zhu Danxi/Zhu Zhenheng; 1280-1358 A.D.," Chinese Medicine History, http://www.taijichinesemedicine.com/zhudanxi.htm
Jackson, Mark, "Asthma: The Biography," 1998, New York, page 41
Jackson, ibid, page 41

150-219: The Chinese Sage of Medicine

2011-12-22T11:45:00.000-05:00

Zhang at work

If you had asthma in China prior to the 3rd century A.D. your doctor may have recommend a remedy of drinking a bitter tasting tea made from dried stems of the Ma Huang plant.

This remedy made your breathing better, and your cough often subsided too. The trick was your physician would have to remember it and the formula to concoct it.

You see, there were few books with medical wisdom for your physician to reference. Most medical knowledge, especially regarding herbal remedies, were passed on from one generation to the next to anyone who wanted to learn about it.

This all changed around 220 A.D., and it all changed because of a war that causes a virus to strike the village of a man named Zang Zhong Jing (also known as Zhang Ji).

Legend has it he was 50 when two-thirds of his village died of a fever in a short span of ten years, and that inspired him to become an expert on ancient medical text, such as the Nei Ching and the Hippocratic Corpus.

This resulted in him writing a medical book that helped shape Chinese medicine, and resulted in him becoming well known to the Chinese medical community by giving birth to Traditional Chinese Medicine. (1)

His book was called "Shanghan Zabing Lun" which translates in English to "Treatise on Cold Pathogenic and Miscellaneous Diseases." It's a compilation of the medical wisdom from all those who lived before him.

Yet his book was lost in a war, and was not available until 1065 when the rulers of China saw a need for these old books and formed the Bureau for Collation of Medical Books of the Song Dynasty. Wang Shu-He collected what he could of Zhang's writings and recompiled them into two books he called the "Shang Lun," which translates into "Treaties on Cold Induced Fevers."

The two books were:

Shan Han Lun (On Cold Damage), a compilation of herbal remedies to treat infectious diseases that cause a fever
Jinkui Yaolue (Essential Prescriptions of the Golden Coffer), which records his clinical experiences

These books describe methods of diagnosing, treating, and monitoring the effect of treatment. He recommended the importance of using the pulse not only to diagnose as Huang Ti recommended 1000 years earlier in his book "Nei Ching," but to monitor the course of treatment.

He was also the first to mention artificial respiration. And he also recommended forcing water down a person's throat who attempted suicide by poisoning to bring up the poison, and this is a technique similar to what is used in hospitals today. (3)

Like Hippocrates, Zhung recommended against the practice of physicians taking advantage of patient naivety for the purpose of making a profit. He noted that some physicians concocted bogus formulas and sold them as viable remedies. He berated this practice and encouraged good medical ethics.

So his books were very helpful to Chinese physicians and their patients. Yet of most importance were the formulas he calculated for collecting and concocting herbal remedies for many of the ailments of his day, especially those that are contagious and cause fevers like what wiped out his village.

One of the neatest things about Zhang's herbal formulas is that many are still used to this day, and many have even been proven by science to be effective remedies. This includes as description of asthma-like symptoms in Jinkui Yaolue and a formula for creating a remedy using Ma Huang. He described breathlessness or panting as chuan, and wheezing as xiao. (2)

His works have earned him the respect of Chinese Historians as one of the best physicians of all time, so much so that he's often referred to as the sage of medicine. Actually some consider him to be a god, and others believe his existence was merely a legend.

While revered in China, his works also influenced and forever changed the way medicine was practiced in Japan, Korea, Vietnam and Mongolia. Many of his formulas for herbal remedies are still used as effective treatment for many ailments, and many have even been proven effective by modern scientists.

He's such a significant "legend" that his books continue to be required readings for any student of Traditional Chinese Medicine. (4)

(Considering this fame, little is known about his life, nor exact dates associated with his life. It's estimated he lived from 150-219 A.D, yet many historians continue to debate these dates.)

Click here for more asthma history.

Selin, Helaine, ed., "Encyclopedia of the History of Science, Technology, and Medicine in Non-Western Cultures," 1997, Netherlands, page 893
Jackson, Mark, "Asthma: The Biography," 1998, New York, page 41
Selin, Op. Cit, page page 893
"Chinese Herbal Formulas and Application," chapter 1, page 31

100 A.D.: Asthma in Ancient India

2011-12-21T09:50:00.000-05:00

If you lived with asthma in India during the first century your illness would have been recognized by physicians, who -- if you had access to them -- would prescribe a variety teas and inhalants to ease your suffering.

Ayurveda was a school of medicine in Ancient India and Sri Lanka. The Caraka Samhita is a a two volume medical book compiled by Caraka, physician to the King Kanishka in Sanskrit around the first century A.D. The book is full of descriptions of diseases and remedies supposedly from the Hindu god Brahma to the Vedic sage Atreya. (1)

Indian mixing a remedy from the Caraka Samhita (a)

It provides a description of Tamaka Swasa, with swasa meaning breathlessness. It's a condition that closely resembles our modern description of asthma such as wheezing, shortness of breath, increased phlegm and coughing (kawa). When severe it may result in sweating, trouble lying down and trouble speaking. (2)

Tamaka Swasa is believed to be caused by cooling of the body that results in an imbalance of the bodily humors that ultimately results in excessive phlegm that blocks the air passages. (3)

The condition was believed to be aggravated by cooler or humid environments. Some foods, such as milk, was believed to increased phlegm and may also have contributed to worsening asthma.

Recommended treatment mainly consisted of methods to balance the humors and warm the body, and might have included:

Steam
Inhaled Cinnamon
Castor bean oil
An insect resin
Tumeric
Arsenics
Inhaling strammonium (belladona)
Herbal ointments (4)
Leaves of Camellia sinensis served as a tea
Adhatoda visaca

Datura and strammonium would have given the asthmatic some relief from an attack. It was introduced to the modern world in the early 19th century and became a popular asthma remedy mainly in the form of asthma cigarettes.

In 1888 the mild bronchodilator theophylline was derived from the Camellia Sinensis. Theophylline was proven to benefit asthma in the 1950s and became a top line asthma remedy in the 1970s and 80s.

Adhotoda visaca is a shrub that stinks so bad goats won't go near it, hence the name was derived from the term for goat, adu. The leaves, roots or flowers of the plant were fixed in various forms and used to improve a cough and help with phlegm expectoration. It therefore was used to help remove excessive phlegm from the body to balance the humors. (5)

Ayurvic advice for asthmatics may also have included an improved diet, adequate sleep, rest, exercise and massage to ease the mind. It was believed relaxation and improved social and living conditions enhanced the healing process.

Ayurvic medicine is a philosophy of medicine that has continued to modern times in India adn , although with many advances. Many of the treatments recommended, particularly yoga, are still considered to be an alternative therapy for treating asthma to this day.

Click here for more asthma history.

References:

Jackson, Mark, "Asthma: The Biography," 2009, New York, page 44
Brenner, Barry E, "Emergency Medicine," 1999, page 2
Hahn, Mark, Marcia C. Inhorn, "Anthropology and public health: Bridging differences in culture and society," 2009, New York, page 80
Brenner Barry E, op. cit., page 2
Premila, M.S., "Ayurvic Herbs," 2006, page 86

Photo:

(a) AyurvedaDosha copyright 2011 from aruvedadosha.com

My asthma used to anger my mom

2011-12-15T14:51:00.000-05:00

My daughter's experience with the asthma beast last night reminded me of my own childhood experience.

My wife made a neat observation: "Some parents might actually be annoyed when their daughter woke up at midnight coughing and crying and acting restless. They might have been annoyed because they wouldn't have known their child was having an asthma attack. They might have thought their daughter was just being a brat and keeping her parents up."

I think my wife was surprised by my response. I said, "I think that happened to me. With no disrespect to my parents because they weren't medical professionals and they didn't have asthma. But my mom used to wake me up when I was coughing and make me lie on my side. Then I'd fall asleep and an hour or so later she'd be waking me up again because I was coughing. She'd make me lie on my side. It got to the point that to this day I can't sleep lying on my back. She had no clue my coughing was probably due to asthma. I couldn't breathe and she was mad at me.

"I will never let that happen to any child of mine. I don't want my two asthmatic daughters to have that scar."

I tried to discuss this with my mom once in a matter of fact way and she outright denied it. She might honestly not remember. And she might have done so in a completely innocent matter.

It doesn't matter to me. I was just curious. I have an awesome mom and she was always there. So I don't mean to make my mom look bad. It's just something that she did that left a scar. Yet it's something neat to write about.

If any of my fellow asthmatic followers ever had a similar experience please leave a comment below.

My 3 YO daughter's second asthma attack

2011-12-14T20:33:00.002-05:00

So my reserved 3 YO daughter was fine when I came home from work last night, yet right around bed time she started coughing, retracting and with my stethoscope I heart inspiratory and experiatory wheezes. She was tight and her words were short and choppy.

I gave her a treatment. It benefited her, yet she was still tight with wheezes. I had a distinct feeling it was going to be a long night. An hour later she was distinctly bad again and I gave another treatment. She fell asleep in my arms, and when I set her in bed he head bobbed up and down on the pillow from her bodies effort to suck in air.

Remembering my experience sitting up all night suffering from asthma and my parents not realizing what it was, I didn't want my daughter to go through the same thing. So I didn't think I'd fall asleep. Yet I must have. At 11:30 I was awake and heard no coughing. For a moment I though we had made the right decision not to go to the ER. Yet then the coughing started. Then...

"Mommy and Daddy," she yelled in a panicked voice. I picked her up and she was unhappy I was around. She was agitated. She didn't know what she wanted. She was retracting and audibly wheezing. It was an easy call. My wife got out of bed, snuggled our daughter in the recliner, and we made the decision it was time to go in for another steroid shot.

This time one of our regular doctors was working. She was great. Here's what she charted:

child tends to have wheezing and over the past few weeks has been wheezing more frequently and was on oral steroids at one point. over the past 2 nights she has been wheezing to the point of requiring breathing txs at home. tonight she took pulmicort for the first time and this seemed to make the wheezing worse. mom brought in for further eval. due to her sob. dad has a hx of severe asthma and is a resp therapist at the hospital here. FREQUENT NONPRODUCTIVE COUGH, DIFFICULTY BREATHING. Seen by pediatrician earlier in day for same reason. active/playful/smiles, age appropriate attention, good eye contact, no apparent distress, not irritable, not lethargic Temperature: 98.6, Heart Rate: 140, Respiratory Rate: 48, Pulse Oximetry: 97, Weight: 28 (unable to get vitals previous visit). x-ray normal. child given 2 xopenex nebs upon arrival and decadron im. after third neb child was much improved. she had a p ox of 97% on ra and was talking well. retractions were gone. will give prelone for home and discussed close follow up. scripts: Prednisolone (Prelone) 15 Mg/5 Ml Syp 25 Mg OR DAILY (note: Errors are the doctors. I did not correct grammatical errors).

This doctor is one of our regulars and she also has kids, so that helped a great deal. My daughter must have sensed she was a good person, because she actually let her assess her. This just goes to show that if you're good in your approach you can even get the most reserved kids to cooperate in the ER. Common sense, you know, goes a long way.

The doctor also said that decadron has a tendency to last longer than solumedrol, sometimes up to three days. She said that's why she prefers to use it with kids, especially kids who don't like to take nasty taking prednisone pills.

At 3 a.m. my wife arrived home and she went to bed while I stayed up with my sweety. HM was hyped up from all the medicine and was marching around the living room chanting a hundred words a minute. Finally she asked me if I'd lay down with her, and before my head hit the pillow next to hers she was sound asleep.

Today she was back to normal. This was a much better ER experience than three weeks ago. It shows how smooth things can go when you respect the parent. Or, it shows how smooth things can go when the parents and doctor use common sense.

My 3 YO daughter's first asthma attack

2011-12-13T20:15:00.000-05:00

So I picked up my daughter's medical records today from her ER visit On Nov. 27. My wife took her -- my little reserved 3-year-old -- to the ER that day because of an exacerbation of asthma. It was clear to me it was asthma, although I can tell from what the arrogant and condescending doctor wrote she didn't necessarily agree.

Here's what the doctor wrote on the chart::

"Child has had cough and difficulty breathing for two weeks. Mother is RN and father Respiratory therapist and they have been giving her xopenex and albuterol every two hours at home since 0300 today. She has not been diagnosed with asthma. Mother states "she hates people." Mother has called their pediatrician and report was called to ED to avoid drawing blood on the child.

"Duoneb times two and worked to get cooperation to take steroid. After second neb still with wheeze inspiratory (scant) and full exp cycle. CXR neg. Solumedrol given IM and RX pediapred and atrovent for home. Mom is RN and Dad is resp therapist. They have home nebulizer and expressed preference to continue treatment at home.

Responds well to DuoNeb howevr still wheezing. Added steroid and to send home on Albuterol and Atrovent neb and PO Pediapred.

I think it's pretty clear the doctor was irritated my daughters pediatrician called with recommendations on how to treat my daughter. It was actually more us than our pediatrician. My wife and I are minimalists, and we know by our clinical experience that ER doctors have to order a bunch of stuff just to cover their butts.

Figuring my daughter's asthma is similar to mine, she didn't need a bunch of labs and an IV. All she needed was the steroids. I also had this distinct feeling this doctor wanted to admit my daughter too. The doctor was also not one of our regular doctors, which may explain the poor attitude.

And guess what. The steroids worked great.

Related links: My daughter's asthma attack and the arrogant doctor

The truth shall make your asthma better

2011-12-10T15:01:00.000-05:00

I was on the job as an RT at Shoreline for only three months when I had an asthma attack so bad I was taking treatments every hour. I went to the ER and was admitted.

Sahara was a coworker of mine. She took care of me when I was a kid, and I was looking forward to her coming to visit me. After I was a patient for several days she finally came, and instead of sympathizing with me she lectured me instead. She said:

"You did this to your self. Every time I see you you're eating a Big Mac or a Whopper and you keep gaining weight. You take poor care of your health and that's why this happened. You did this to yourself."

I was so ticked at her I couldn't wait for her to get out of my room. I told my other coworkers about what she said and they agreed she was a jerk. I barely spoke to her the next two years unless I was giving report. Yet eight months after that lecture I started working out. I also started eating well. I lost 35 pounds and was feeling great.

Since then I've continued to try to eat well and exercise and since then my asthma has been much improved. So improved, as a matter of fact, that I haven't spend a day as an inpatient for asthma since that visit.

So that got me to thinking: Sahara did me a favor by lecturing me. Instead of sympathizing with me and allowing me to continue on the wrong path she took the bold step and told me I was a fool for the way I was living.

This goes to that old saying that the truth hurts before it makes you better. For the lecture that set me on a path to becoming a Gallant asthmatic, I thank you Sahara. Thanks Sahara.

Thanks to my Brother Bobby

2011-12-09T14:47:00.000-05:00

My brother Bobby once told me I was a useless piece of skin because I was sitting on the couch one afternoon when he wanted me to play baseball. "Come on, Rick, we need one more person."

I wouldn't budge. What he didn't know because I wouldn't tell him was that I didn't want to play because I was sick and tired of not being able to breath. I was feeling sorry for myself that I had asthma.

A few years later, however, I didn't give him a chance to say such a thing to me. I played football even during an asthma attack. I even remember it was Thanksgiving and I kept running in every 5-10 minutes during the second half to use my nebulizer.

And while you might thing that was stupid of me, I thank him for that. Instead of allowing me to use my asthma as an excuse he encouraged me to do something. Because of him I became competitive. Thanks to him I stayed active, something we asthmatics should all do.

Thanks, Bob, you moron.

Is it LAZY or ASTHMA?

2011-12-08T14:14:00.001-05:00

My brother called me a worthless piece of lazy skin once because I couldn't play football with him. Yet little did he know I was sitting on the couch watching TV because I couldn't breathe. That was over 30 years ago.

Mom and I sat in a Chinese restaurant with two steaming hot cups of tea between us. She said, "You were a good kid. The only thing I remember getting mad at you about was your messy room."

We laughed as we reminisced about some of our fights. Once mom took an entire drawer and dumped it onto my floor. She wouldn't let me leave the room until the entire thing was clean. I wish now that she would have taken a picture of it, because you wouldn't be able to see any surfaces.

When we were finished laughing I reminded mom of one other moment I remember better than all those fights. "We were sitting at the kitchen bar after dinner. Dad and my brothers were gone, so it was just you and me. You said, 'John, I've decided I shouldn't get mad at you about your room anymore. I was thinking that you spend more time in your room because you have asthma. Instead of hanging out with your friends and your dad you become involved in creative projects in your room. You draw and collect baseball cards. Creative people are messy.' You said that, and it meant a lot to me.'"

"I said that," she said, smiling.

"Yeah," I said, "And then you yelled at me about my messy room again." We laughed.

I think my mom had a point. Even now as I look around at my desk I see a clutter of papers. My desk at work is clutters, so it my car and so is my locker. They aren't filled with a bunch of junk, they are filled with papers and books and things I've written ideas on for writing.

There's this old saying: A cluttered desk equals a cluttered mind. Instead of doing things I've filled my mind with clutter. In a way, I wonder if this is the reason so many asthmatics report being anxious. The more you think the more you have to worry about. Asthmatics tend to do a lot of time thinking.

There are times I feel lazy. I have felt lazy the past two weeks since I had an asthma attack cleaning my basement. I am afraid to participate in any cleaning activity, so my house is sort of a disorganized mess. So instead of cleaning I spend my time here on this blog.

There's another saying that my dad used to say a lot when we were kids. He said that if it weren't for lazy people nothing would ever get invented. An example he gave was Louis Sands, a local lumbering millionaire who lived in the late 19th century and early 20th.

He made a fortune chopping down trees and floating them down the river to the Louis Sands sawmill. He had a sleigh he rode in the winter and he didn't want to get out of the sleigh to open the gate to his mansion on 5th street. So he invented this thing where as soon as the sleigh rode over this ramp the gate automatically opened. It, in essence, was the first garage door opener.

He invented it because he was too lazy to get out of his sleigh. Yes indeed, lazy has produced a ton of inventions. The horse carriage was invented by a person who was too lazy to walk, and so was the car. The airplane was invented by someone too lazy to drive. The lighter was invented by someone too lazy to take the effort to light a match.

So lazy isn't so bad after all. Lazy has made the world a better place for everyone. So the next time someone calls you lazy, just remind them of all the good things that have come about because of lazy people.

I jokingly reminded my brother of what he said to me 30 years ago and he apologized.

"Yet you were right about one thing," I said, "You were right that I am lazy. I'm a lazy asthmatic. And that's not such a bad thing."

Reminders...

2011-12-03T14:12:00.001-05:00

Reminders are good...

You still have asthma, it's just been in hybernation
Your daughter still won't take her asthma medicines, which your reminded of as she starts wheezing and coughing again
You still like working nights even though you've been on days the past two years
Your boss is not your best friend, even though she's been kissing your butt lately
Christmas shopping isn't easy, even though you knew what to buy months ago

Is worsening asthma linked to anxiety?

2011-12-02T00:37:00.001-05:00

So I've noticed increased asthma symptoms lately. In October I had a pretty severe asthma attack at hunting camp and I've had two since that time. Of course my daughter and two of my coworker friends have been having trouble too lately, so perhaps there's something in the air.

Yet something else I've been thinking about also lately is there's been an increase amount of stress in my life too. Now that I'm working days my job is twice as hard, and the workload is triple of what it is when I work nights.

There's also been a lot of pressure from my boss to do all these extra projects, such as I'm a Neonatal Resuscitation teacher and I'm a member of the Keystone Committee. Plus I'm a commissioner on the local township commission and I was -- by default -- nominated as the chairman. So there's a lot of stress there.

Now is it all a coincidence that my asthma started acting up as all this stress stacked up? That's possible. Yet there is also a ton of evidence that links increased stress and anxiety with asthma I can't help thinking about it.

A case in point was mentioned by Andrew Harver and Harry Kotses in their book "Asthma, Health and Society," (2010, New York, page 315). They mention several studies that link asthma with anxiety and depression, and that link increased stress with worsening asthma.

I've mentioned on this blog a few times that I'm not afraid to say I have social phobia. I've been diagnosed on more than one occasion with anxiety disorders. I've been treated too. Something I'd like to delve into at some point in the future is my medical records where my psychologist when I was a kid wrote how I had anxiety and how it made my asthma worse.

If you met me you may never know it. I'm not the kind of person who sits in a corner. Obviously, otherwise I wouldn't have been elected to the commission, and I wouldnt be chair. And I wouldn't be able to be a teacher in front of classes. Perhaps therapy helped me there. Or perhaps common sense helps me there.

Now I wouldn't want to bore you with the details nor embarrass myself for that matter, yet I think this is significant because these studies match up almost to a tee with my own experience with asthma and anxiety and stress and depression. Coincidence? Perhaps. Yet I think the evidence is stacked too high to ignore it.

And of course there's no way of knowing whether increased stress and anxiety results in worse asthma or the other way around. Yet I'm digressing. I'd like to get back to the book I mentioned above and the studies.

I'm just going to quote the book here and then I'll leave it at that and you can tell me what you think. Of course we know that the link between asthma and psychosocial disorders goes all the way back to written records way back in 200 B.C.

"The late 19th century and early 20th century William Osler viewed asthma as a 'neurotic affection' in which imbalances of the nervous system and emotional factors played a fundamental role. Since then a growing # of studies have provided evidence of a link between various psychosocial factors and asthma. Data from both clinical and community settings suggest that psychiatric disorders, and mood and anxiety disorders in particular, are disproportionately more prevalent among asthmatics relative to the general population. Point prevalence rates of anxiety disorders (eg. panic disorders, general anxiety disorder and social phobia) and mood disorders (eg. major and minor depression disorder) are especially high among asthmatics, ranging from 16-25 percent for anxiety disorders. One recent study indicated 31% of asthmatics meet criteria for one or more current mood (20%) or anxiety (23%) disorder. Rates of certain disorders (i.e. panic disorders and major depressive disorder) are as much as six times more prevalent among asthmatics relative to the general population.

He also notes the following:

Studies also link increased psychological stress to increased asthma morbidity
Studies observed symptoms of anxiety and depression have been associated with increased asthma severity, increased use of ER visits, increased symptom reporting, poorer PFTs, and lengthier hospital stays
Increased anxiety results in poorer adherence to medicine, etc. (this was my problem back when I was admitted to the asthma hospital in 1985)

Henry Hyde Salter was a doctor who wrote several articles and a book in the mid 19th century, and he was convinced that certain stimuli (dust, stress, etc.) stimulated the obdulla oblongota and a message was sent down the pneumogastric nerve to the bronchiole muscles causing them to spasm. This was why he termed asthma a nervous disorder. He made this theory mainstream.

The nervous asthma theory made it through great medical minds like William Henry Osler and Frances M. Rackemann, and wasn't debunked until the late 1950s. Still it was followed by many doctors until the 1980s.

Yet I still believe there is some truth to the asthma neurosis theory. I denied it when I was 15 and my psychologist told me I had an anxiety disorder. I denied anxiety. I denied it all. Yet the wiser 40 YO me knows better. I'm convinced the allergic response doesn't just cause inflammation of the air passages, that it also causes inflammation somewhere in the brain that results in anxiety, social phobia and/or depression.

That's the Rick Frea theory. Increased inflammation in anywhere, when it lasts long enough, becomes permanent. This is what asthma is, so experts now beleive. So could there also be inflammation somewhere in the brain? We don't know?

I do PFTs on myself every month at work for fun. I've noticed my FEV1 had dropped some in the past year, the same time stress has increased. If you look at the flow volume loop you can see the obstructive pattern on expiratory portion of the loop. So is this a result exposure to too many other asthma triggers like dust and campfires, or is there some phychosocial issue going on?

I may be way off base and you can tell me so if you want. Yet it's interesting anyway. It's just a frivolous though perhaps.

How to get kids to take systemic steroids?

2011-12-01T22:31:00.001-05:00

Now I certainly hope you didn't click on this post thinking I was going to provide tips on how to get your kids to take their medicine. This post is exactly the opposite. If anything, I'm seeking advice.

Yet I don't think there really is any way to coax a three-year-old to take a steroid liquid, or a steroid pill, both of which taste -- to put it into the words of my daughter Mrs. L. -- "Yucky!"

The steroid shot worked the best. That shot cured her. On Monday she took the liquid. On Tuesday she said it was, "Yucky!" Yet she drank it. On the third day she refused. On the 4th day she refused.

It's not like you can force a liquid down a kid's throat, because they have the ability to spit. Then there's the concept of traumatizing a kid. I'm of the belief if you force a medicine down their throats you'll compromise any future effort to get them to trust you to take any medicine.

Yet I could be wrong. I probably am wrong. What I do know is during her nap today she was coughing again, something she hadn't been doing since the shot on Sunday. And when she woke up she was wheezing and tight. And she willfully took a breathing treatment, something she only does when she needs one.

So that brings us back to the steroid. How do you get a kid to take a steroid? Dave the pharmacist is going to give us some steroid pills, and the idea is maybe we can crush them and put them in Mrs. L's applesauce.

Yet Mrs. L. is a light and picky eater. Hm mm. We'll just have to wait until this plays itself out. It would be all the easier if some asthmatic dad didn't give the girl his bad asthma genes.

My daughter's asthma attack, and the arrogant doctor

2011-11-30T01:32:00.000-05:00

My daughter, Mrs. L, all three years of her, was introduced to the asthma beast this past week. She required a breathing treatment a few weeks ago and it worked like a charm. Yet last weekend the asthma beast struck with a vengeance.

She woke up in the night coughing. I gave her a breathing treatment and it seemed to work. Yet the next night she was up crying. I entered her room and she was sitting up in bed. It didn't take much convincing for her to let me carry her to the living room.

The nebulizer -- the community nebulizer for my family -- was already set up next to the recliner I set in with her. I grabbed an amp of Albuterol and squirted it in, and revved the machine to life. You can always tell when a kid benefits from a bronchodilator because she sits through it.

Yet the treatment did little to relieve her coughing. I sat up with her for an hour watching some old cartoon I can't even recall what it was. Quite frankly I don't think she did either. In fact, we didn't even have the sound on. The vision of a toon was all that was needed to placate my daughter.

I was emotionally into this, because I could remember vividly sitting up in bed all night long when I was a kid not being able to breathe, and my parents had no clue. It's not like they didn't care, they just didn't know. I didn't want my child to have that scar, so I doted her.

The next day, Sunday, my wife or I had to give her a breathing treatment every few hours. She probably could have used one more frequently. Yet it was enough for us to realize she needed more than bronchodilators: she needed systemic steroids.

Her doctor was out of town, so that posed a problem. If she was in town we would have called her and she would have written a script for prednisone. She knows me and my wife. She knows I'm an RT and a lifelong asthmatic. She knows we have a pharmacy here and everything except steroids to keep an asthmatic full of fresh air. Yet she was out of town.

Dr. B. is a new doctor and I've worked with her enough to be impressed with her. Yet she said she wasn't familiar with Mrs. L enough to just prescribe something over the phone. So she recommended we take her to the ER.

This posed a dilemma. Surely we had no problem taking her to the ER, but my wife and I both know that a trip to the doctor's office usually results in an assessment and a quit treatment of the cause of the problem. Then you go home and that's that. You get better.

Yet if you go to the ER they have to do a bunch of stuff just to cover the butt of the doctor. Labs will be drawn, an x-ray will be given, and an IV will be put in. We mentioned this to Dr. B. and she said she'd call the ER doctor with her recommendation.

Great! Or so we though. The ER doctor was pissed that Dr. B called her. The ER doctor was condescending and arrogant to my wife. She said something like, "It doesn't matter what your doctor said. I'm here and I'm assessing your daughter. I have to do what I think is needed. Dr. B. is not here."

My wife said she wanted to walk out the door right there. If her daughter didn't need the steroids right now that's what she would have done. And this is the hospital I work at. The nurses tried to take a pulse ox on my daughter's food, and my daughter said, "Go away! Leave me alone!"

My wife said, "Why don't you guys leave and I'll get a pulse on on her finger."

Yet they insisted on getting a pulse ox on her foot. Here my daughter, my shy daughter who is deathly afraid of people, has five nurses holding her down to get a pulse ox. My daughter cried and fought vehemently. Good for her. I wish she would have fought harder.

The doctor peeked her head in at this time and said, "Well, she's crying. So she must be breathing fine." My wife responded, "Wait for her to stop crying and you'll see she's retracting and her fingers are blue."

The doctor left. The nurses left. My wife got a pulse ox reading in about 2 seconds once they were out of the room. My daughters oxygen saturation of 82%. That's not good. And this all happened in triage. When she finally got to her room my wife had to fight off the impulse of the doctor to insist an IV and labs be drawn. Yet my wife stubbornly resisted. I am proud of her. "All she needs is steroids," my wife insisted.

The doctor was pissed. She listened to Mrs. L. with her stethoscope. She said, "She's wheezing. She has inspiratory and expiratory wheezes. Inspiratory wheezes are the worse kind. You should have come in sooner. If you need to give treatments every two hours you need to come to the ER."

My wife rebutted her comment: "We did come to the ER." And she probably thought, "You dumbF#$@!" I know my wife thought that because I know my wife. Yet I bet that doctor would doubt me.

The doctor prescribed a steroid drink, and my wife said Mrs. L. won't drink it. The doctor said, "We'll mix it up in a pop and she won't even know the difference." My wife said, "She's never had a pop in her life, so she probably won't even know what pop is. She won't drink that."

So you can see this made for an interesting visit. Finally my wife said, "She's not going to drink this stuff. Let's just give her the shot and get it over with." Five nurses held Mrs. L. down, and she didn't even fight. Later that night she said to me at home, "Daddy, I got a shot and I didn't even cry." She smiled. She smiled because she knew the shot made her better.

Yet. Steroids work on asthmatics in my family. We don't need labs and xrays and IVs and all that unnecessary stuff. Surely if the steroids didn't work you can look for something else.

My wife said the nurses were great. Later I talked to one of these nurses about that doctor, and she said the doctor has to cover her butt. Yet I said, "A doctor should also respect the wishes of the parent. A parent knows her child more than a doctor does. Not to disrespect the wisdom of that doctor, yet she really needs to respect the parents, especially when the parents are a nurse, and an RT who is a lifelong asthmatic. It's not like there's no experience here. We're not your typical ignorant parents."

This is exactly the reason I never go to the ER when my asthma acts up. The last time I was an ER patient they took me off my theophylline and almost killed me. Eight days later a different doctor put me back on my theophylline and I miraculously got better. So if you have asthma, and you know what works for you, and the doctor wants to do something totally different, who's right?

That steroid shot gave my daughter almost instant relief. She ran around the living room that night the way I'm accustomed to seeing her, all happy and cheerful. In the end, that's what's most important. As far as the rotten ER doctor, she was a rental doctor and both my wife and Dr.B. reported her arrogance to the powers that be.

Thank God for asthma hybernation

2011-11-24T10:11:00.001-05:00

Thank God for asthma hibernation. This awkward disease has a way of hiding in the sand for years making it's owner think the beast has left the building. Then just as you think it's gone WHAM! it hits you like a mack truck smashing into a possum on an expressway.

Thank God for asthma hibernation. It made for five good years. It made for five hunting camps. It made for five years of emptying boxes and moving furniture in the basement. It meant five years of raking leaves. It means five years of playing catch with my son. It means five years of rolling in the grass with my younger kids.

Yet asthma hibernation has it's own dark side, and this can be deadly for some. Because by not showing it's ugly head you might think the asthma beast is gone forever, and you enjoy yourself too much. You spend time around your allergens. You tempt the beast this way. There's this old rule that you never mess with a sleeping giant.

Thank God for the sleeping giant. Yet while surely you should enjoy the days when it's gone, you should never tempt it. You shouldn't stand by the fire at hunting camp, inhaling the fumes and scents, even though that's what everyone else does. You can't because the beast may strike. The beast did strike.

Thank God for the sleeping giant. Yet while surely you should clean your basement, you should limit yourself to a few minutes on the job as opposed to working until the job is done. Because in doing this your allergies struck, and then it hit your lungs. And then it wiped you out.

Thank God for asthma hibernation. Thank God the beast goes away for a while. Yet we also thank God for the medicine in the cabinet that can make the beast's tail loosen up its squeeze on your air passages.

Thank God for that five year old thralling pill that finally gave me my breath back last night. Those three continuous breathing treatments didn't do a thing. The panic was real. The anxiety was real. Yet that five year old pill, the one you weaned yourself off of after 30 years of chronic theophylline dependence, was staring at your face. "Why not? What do you have to lose?"

It went down. You laid down to get some rest, hoping, praying you'd fall asleep -- eventually. You sit high up on the pillow, concentrating on each breath. The breaths didn't go in all the way. Dyspnea. Air hunger. panic. Calm. Calm. You try to convince yourself

Than, 30 minutes later, unexpectedly, it came in all the way. Did it really happen. You inhaled again, the asthmatic did. He inhaled. It went in again. A feeling of euphoria ensued like he knew he could never explain to someone who didn't have this disease. The 5 year old theophylline pill worked. It worked. Sleep came. Rest. Rest.

The next day you could feel the allergies. Your eyes are sore and red. Your chest burns from all the heaving of each breath the night before. Yet you feel joy knowing the breaths came in. Air. Fresh air. What a joy. Yes. We asthmatics will never take air for granted, as others do.

Thank God for air. Thank god for the ability to breath it. Happy Thanksgiving.

1710 to 1790: William Cullen the nosologist

2011-11-22T21:40:00.013-05:00

As we enter the 18th century in our history of asthma we can see that the personal opinion of the so called asthma expert started to take a back seat to scientific theory. One of the first to base his asthma writings on studies he performed was William Cullen.

According to Encyclopedia Britanica he was born in 1710 to the lawyer of the Duke of Hamilton in 1710. In 1734 to 1736 he studied medicine at the University of Edinburgh, and it was here that he became interested in chemistry. In 1736 he started a medical practice in his home town of Hamilton and lectured on science at the University of Glasgow.

William Cullen (1710-1790)

He quickly earned himself a good reputation. In 1741 he married and had children who would also earn fame. Throughout most of his adult life he would study natural medicine, and was particularly interested in scientifically classifying diseases. He thus became a nosologist.

He believed that most diseases were fostered by some kind of disorder of the nervous system, and that the muscle was "a continuation of nerve." This belief affected his description of asthma, it's causes, and the remedies to treat and prevent it.

Still, when it came to asthma, he found the task of classifying it as a disease, and distinguishing it from other forms of dyspnea, to be a major challenge. The main reason was because most physicians of his day were stuck on the idea that all or most shortness of breath was asthma.

Cullen became one of the first asthma experts to base his beliefs, or at least try to confirm them, based on studying signs and symptoms of that disease while a person was alive, and comparing it with what he saw in autopsy. This would become a common trend followed into the 19th century.

The fact that he saw defining asthma as a challenge can be observed by the following quote from 1794:

"The term asthma has been commonly applied . . . , even by many . . . specialists, to every case of difficult breathing. ... By not distinguishing it with sufficient accuracy from other cases of Dyspnea, they have introduced a great deal of confusion into their treatises on this subject."

He then writes in his book, "First lines of the practice of the phych****," that asthma "may be most properly applied, and should be confined, to a cafe of difficult breathing that has peculiar symptoms, and depends upon a peculiar proximate cause which I hope to assign with sufficient certainty."

He likewise notes that even while some authors have defined asthma as spasmotic asthma, they have not distinguished the term from other forms of dyspnea. Cullin would propose that the term asthma be used to denote spasmotic asthma alone, and not other conditions that cause shortness of breath.

Thus, in his 1772 book "synopsis Nosologiae Methodicaei*," he defines asthma as:

Difficult respiration recurring at intervals, with sense of stricture in the breast, respiration performed with a wheezing noise; difficult cough at the beginning of the fit, sometimes none, free towards the end; and often with copious discharge of mucus."

In his book, "The first lines of the practice of the psychic****(page 397)," he describes asthma as "spasmotic, constriction of the muscular fibres of the bronchiae: which not only prevents the dilation of the bronchiae neccessary to a free and full inspiration, but gives also a rigidity which prevents a full and free expiration like many other convulsive and spasmotic affections is readily excited by a turgescence of the blood, or other cause, of any unusual fulness and distention of the vessels of the lungs (inflammation?)"

He also noted the following "facts" about the diseas****:

It's hereditary
It seldom occurs early in life, and hardly to the time of puberty, or after it
It effects both sexes, but most frequently the male
I have not observed it to be more frequent in one temperature or another
It does not seem to depend upon any general temperment of the whole body, but a particular constitution of the lungs alone (it's not psychosomatic?)
It frequently attacks... but hardly ever continues to be repeated for some length of time without occasioning an emaciation of the whole body
Attacks are generally in the night or toward the approach of night (yet occassionally in the day)
It comes about suddenly
It may go into remission
It is there for the person's whole life
Returns happen with different circumstances with different persons
Fits are more frequent in the summer
It may threaten immediate death, seldom occasions it
Many persons have lived long under this disease
Seldom entirely cured
It effects each person differently
Each patient has unique external triggers

The following are the signs and symptoms of asthma****:

Sudden dyspnea
Tightness of of stricture across the breast
A sense of straightness of the lungs impeding inspiration
Desire to get into an erect position
Desire for free and cool air
The difficulty of breathing goes on for some time
Both inspiration and expiration are performed slowly
With a wheezing noise
Speaking is difficult and uneasy (in violent fits)
Often some propensity to coughing, but it can hardly be executed
Sometimes the pule is increases
Sometimes fever (usually with increased pulse)
If urine is voided early it's usually with little colour or odour
If urine voided late it's usually of a high color and sometimes deposits a sediment
Sometimes the face is flushed and turgid, more commonly pale and shrunk
After long continuance, it often ends in a hydrothorax
Occasionally some aneurism of the heart or great vessels (it thereby proves fatal)

Even after some sleep and the breathing becomes easier and easier, the following signs and symptoms may continue for some time:

Feels some soreness across chest
Cannot breathe easy in horiontal posture
Can hardly bare any motion of his body
In afternoon has uneasy flatuency of his stomach
Unusual drowsiness
Difficulty of breathing returns toward evening
May occur for several nights
Followed by remission (especially after coughing up copious sputum)

These symptoms may continue for many hours, "then a remission takes place by degrees; the breathing becomes less laborious and more full, so that the person can speak and cough with more ease, and, if the cough brings up some mucus, the remission becomes immediately more considerable, and the patient falls into a much wished for sleep."

Causes are generally unique from person to person. The following are what Cullen would describe as asthma triggers, or things that cause the disease to be "readily excited"****:

External heat (weather or warm chamber)
Warm bathing
Summer weather (particularly dog days)
Changes of weather (especially sudden colder to warmer)
Full meal
Air in stomach
Exercise (or whatever else can hurry the circulation of the bloos)
Cold
Excitement of nervous system, as by passions of the minds
Odors
Smoke
Dust

He wrote that while the disease cannot be cured "by our art" the patient "can escape the disease by escaping the occasional or exciting causes, which I have endeavered to point out above."

He observes the disease is seldom cured and therefore he "cannot profile any method of cure which experience has approved as generally successful." However, he does propose some remedies that his observations have shown to be successful during an accute attack or to prevent such an attack.

The remedy generally depends on the cause of the symptoms. From here he classifies asthma into three groups**:

1. Idiopathic: Without manifest cause, or being accompanied with other disease

2. Symptomatic: From erruption or other acrid effusion being repelled

Two varieties:

Gouty (asthma arthriticum): I believe here he's referring to asthma that results from swelling of the air passages. He calls it gouty becasue it mimics the inflammation from gout or arthritis.
Syphilitic (asthma venereum): Again, this is possibly referring to inflammation in asthma being similar to that of syphilis.

3. Other asthma dyspneas and orthopnea symptomatic of cardiac and pulmonary difficulties and obstructions (what we might now refer to as heart disease, heart failure, heart attacks, etc.) or what we might refer to as cardiac asthma)

Thus, if asthma arrises from "difficult transmission of the blood through the vessels of the lungs (swollen broncheolar muscles), threatening suffocation, the best remedies are noted below.

It should be noted here that instead of basing his asthma remedies on his own experience, Cullin performed studies. Based on his research, he determined the following remedies for asthma:

Blood letting (less and less necessary as disease progresses)
Emollients (empty stomach is beneficial)
Moderately laxitive glysters (have been found to give considerable relief)
Gentle vomits by emetics (flatuency of stomach are frequent attendants, and very troublesome for asthmatics, used to prevent and treat asthma) (more useful in winter than summer****)
Acids and neutral salts to treat asthma fits excited by turgescence of blood (also recommended by Floyer "On the Asthma."
Ether (an antispasmotic found to give relief but not long lasting)
Opium (Best antispasmotic has been found effectual and safe)
Good diet
Gentle exercise (riding horseback, going in a carriage, sailing,
Flowers of zinc**

The following he proved to not work:

Purging (seldom found to relieve vessels of thorax)
Blistering between shoulders or on breast (rarely found it useful)
Fetid gums (an antispasmotic proved not to work and be sometimes hurtful)
Musk (antispasmotic not properly tried)
Liquors (few asthmatics can bear strong, warm, tepid drinks because it weakens nerves of stomach)
Tea
Coffee
Emetics***** (The effects of full vomiting cannot be durable, nor its operation be conveniently repeated, so full vomiting cannot always be employed to prevent the recurrences of the... spasm)

Of interesting to note is Cullen's opinion about opium. He may have been the first to describe the use of antiispasmotics to relieve a fit of asthma, and he said that in pure asthma opium has been proven to work, and when it hasn't worked he beleives the reason is because the dyspnea was probably not caused by spasmotic asthma but some other cause.

If asthma is of the pure spasmotic form opium may be used opium may be used "both to prevent and to moderate fits with great advantage. However, with other forms of asthma "where the disease depends upon turgescence of the blood in the lungs, opium can hardly be used with safety.***"

He adds that, "even when the disease is of the catarrhal kind (nasal inflammation), if it be fit to use opium to relieve the catarrh, it may be likewise employed to relieve the asthma depending upon it. But I must conclude by remarking, that in both the spasmotic and catarrh asthma, I have frequently employed opium in moderating the disease; but have never found it to prove an entire cure of it***."

Yet he concluded asthma in the "pure spasmotic form" worked quite well according to his studies.

Click here for more asthma history.

*Cullen, William, "Nosology: or, a systematic arrangement of diseases, by classes, orders," London, 1800
**Jackson, Mark, "Asthma, Illness and Identity," The Lancet, Volume 372, Issue 9643, Pages 1030 - 1031, 20 September 2008
***Cullen, William, Benjamin Smith Barton, "Professor Cullen's treatise of the materia medica," Philadelphia, 1812, page 175
****Cullen, William, "The first lines of the practice of psychic," Vol. III, Edinburgh and London, 1784, pages 387 to 410
*****Cullen, William, "A treaties of the Materia Medica," Vol. II, Edinburgh, 1889, page 469

Other readings:

Cullen,William,"The Edinburgh practice of physic, surgery, and midwifery" Vol. II, London, 1803

I think I can... I know I can...

2011-11-16T03:38:00.000-05:00

Like the little Engine that could...

I think I can be patient today
I think I can go a week without complaining
I think I can lose 15 pounds by January
I think I can be a better husband
I think I can be a better dad
I think I can be a better coworker
I think I can be a better respiratory therapist
I think I can spend more time with my 13-year-old
I think I can be a more active American
I think I know what I'm talking about

Like the little Engine that could...

I know I can be a good dad
I know I can be a good husband
I know I be a good teacher
I know I can spend more time reading
I know I can get myself in better shape

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

1138 -1204 A.D.: Maimonides writes asthma book

2011-11-15T07:04:00.012-05:00

Maimonides (1138-1204 A.D.)

While few may know this, the Muslums may be credited as saving ancient Greek and Roman medical theories for modern times. This is because while the Western world was engulfed in the dark ages, the Eastern world was full of rising societies.

Europeans were so busy feuding amongst themselves and destroying towns and libraries, the Muslims were growing a society in Arabia and Spain. In essence, through their travels, the Muslums brought Greek and Roman medical wisdom to Spain.

Maimonides was not a Muslim but a Jew who lived from about 1138 to 1204 AD. He was among the most famous writers, physicians and philosophers of his day. He was born in Muslim controlled Spain and learned from his father, who was a Jewish teacher and Rabbi.

Fred Rosner, in his book "The medical legacy of Moses Maimonides" explained that Maimonide's father, Maimon, instilled in him an interest in the sciences and philosophy. He was blessed with a mixture of Ancient Greek, Roman, Medieval Arab and Hebrew wisdom of all ages. (1)

Despite all his writings, he left very little along the lines of opinions about everyday life, so we know little about his life and personality. (2)

He was born during the the time of the crusades where Christians traveled to the Holy land to free the city of Jerusalem from the Muslims, who captured the Holy lands from the Bryzantines in 638 A.D. In order to avoid religious persecution in Spain, Maimonide's family fled Spain and ended up in Fez, Morocco.

While in Morocco, Maimonide's became an avid reader of many of the medical writings obtained from the ancient Greek and Romans, particularly those of Hippocrates and Galen.

He later wrote that Galen observed Hippocrates to be wrong in many areas of his writings. But instead of saying, "Hippocrates was wrong," he would cover for Hippocrates, even to the point of changing Hippocrate's meaning, or crediting the error to other writers and not Hippocrates himself.

The family ended up in Egypt, and this is where Maimonide's skill as a physician took off. The author's of Emergency Medicine write that "he became appointed as the physician to the great Saladin and then became physician to the Saladin's son, Prince Al Afdal Nur ad Din ali, when the Prince assumed the throne at age 40 in 1193." (3)

Maimonide's wrote a lot during his lifetime, and most of his books were written to someone who requested some type of medical advice. For example, in the last 14 years of his life he was asked by the Prince to provide some advice on how to live with his asthma. Maimonide wrote to him that asthma was usually started with a cold and advanced to shortness of breath.

Maimonides ended up writing his "Treaties on Asthma," where he recommended against trying any magical cures for any ailments, and any such remedies should treat the cause as opposed to just the symptoms. Treatment should also be based on age of the patient and the season, as the disease might be seasonal.

He wrote that ultimately during the course of (an asthma attack) the patient later gasped for air and coughed up a wad of phlegm.

Rosner explained that Maimonides might have been the first to describe psychosomatic medicine when he wrote how a patient who is "mentally agitated" causes his physical well-being to suffer and eventually he becomes physically ill. (4)

Rosner wrote that Maimonaides also adds that "gaiety and joy gladden the heart, and stimulate the blood and mental activity. Excessive indulgence in the pursuit of pleasure, however, is injurious to one's health. The avoidance of illness induced by such excesses is by conducting oneself according to ethical and moral principles."

He likewise noted that asthma usually starts as a cold during the rainy season. However, modern historians aren't sure if Maimonide's description is asthma or some other similar malady.

He's also perhaps the first to describe how city air pollution may be the cause of asthma. He writes:

"Town air is stagnant, turbid, and thick; it is the natural result of its big buildings, narrow streets, and garbage... Air winds carry stealthily inside the houses and many become ill with asthma without noticing it. Concern for clean air is a foremost rule in preserving the health of one's body and soul."

He recommended many herbs to be inhaled and was the first to recommend chicken noodle soup as a remedy for breathing trouble.

Aside from chicken soup, his remedies included:

Clean air
Healthy eating (he recommends eating certain foods and avoiding others)
Healthy drinking
Controlling emotion (was this an early reference to psychosomatic asthma?)
Exercise
Rest
Sleep
Wakefulness
Excretion
Retention of wastes
Bathing
Massaging
Avoid gas producing foods (causes bloating)
Chicken soup (acute asthma only and only if patient is afebrile)
Moderate exercise prior to eating
No exercise right after a meal
Dry months
Small quantities of wine
Enemas to cleanse the bowels (induce bowel movement and to drain thick juices)
Emetic (severe cases only)
Aromic herbs (to fortify the brain and dry out any humidity therin)
Emetics to cleanse the stomach (cause vomiting)
Sleeping after bathing is good, yet bath water should be warm and contain salt
Various compound remedies (5)
Travel to dry regions
Moderation of sexual activity (6)

He advises against the following common "excessive" remedies from other physicians because they "involve strenuous physical and emotional exercise.":

Sexual intercourse
Blood letting
Hot baths
Urine stimulation (such as diuretics)
Purgation (never on healthy people because it doesn't preserve health)
Sleeping immediately after meals is harmful
Washing with cold water after meals is harmful
Excessive bathing during acute attacks (due to wet climate created)
Opiates (except in severe cases (7)

Possible triggers:

Wet seasons
Excessive drinking
Pollution (8)

Maimonides makes a point to emphasize what Hippocrates noted years earlier, which is to put your life in the hands of someone who bases his wisdom and remedies on scientific training as opposed to someone who treats based on superstition or faith. Worded another way: Science is better than quackery.

Likewise, in many instances it may be better to do nothing than to risk greater harm to the patient.

References:

Rosner, Fred, "The medical legacy of Moses Maimonides," Chapter 2, "A Treaties on Asthma," page 13
Yellin, David, "Maimonides," Israël Abrahams, Jewish Publication Society of America, Philadelphia, 1903, page 3
Brenner, Barry E, editor, "Emergency Asthma," 1998, New York, page 13
Rosner, op cit
Rosner, op cit
"Asthma History -- Through the Ages," Medical News Today
Roster, op cit
Roster, op cit

What is the blog "Hardluck Asthma" all about?

2011-11-14T14:24:00.001-05:00

Your humble question: If you were in an elevator and someone asked you about your blog, what would you tell them?

My humble answer: On my Hardluck Asthma blog I write about what it's like to live with asthma. What are the day to day challenges of being an asthmatic? I also write a lot about the history of asthma. I try no write from a unique perspective of the disease as to not make my blog a repeat of other asthma blogs, although I sometimes fail at that. I have three other blogs, and this one is my ME blog. This is where I get to write about me, my asthma, and how it effects me personally. I also spend some time writing my asthma story, or what it was like living with asthma when I was a kid. I had it bad, so bad in fact that I once made over 17 visits to an ER one year, and once spent six months in a hospital. I like to write about that and a whole lot more asthma stuff.

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

Heed the warnings on asthma medicine

2011-11-13T10:04:00.000-05:00

Task for the day: Open a book. Point to a page. Free write for 10-15 minutes on that word or passage. Post without editing if you can.

My response: I'm looking at a page in "Asthma: The Biography," by Mark Jackson. This is a remarkably thorough read about the history of asthma. The page I'm looking at discusses fatal asthma.

In the 19th century many doctors wrote that they rarely ever observed any one dying of true asthma. It was a disease that caused some suffering for a few days, yet usually let up eventually. My asthma is like this. I have an attack, it can be terrible, yet in a few days I know I'll get better whether or not I take medicine for it. The difference between now and the 19th century is today we have medicine to relieve our suffering. No one should have to suffer from a bad asthma attack anymore.

Yet no one died from asthma back then. That changed in the 20th century. It changed when epinepherine was used to treat asthma in 1900. Asthma deaths spiked again after the rescue inhaler was invented in 1952, and the first long acting rescue medicine was invented in the 1970s.

The first impression of asthma doctors was to blame the same medicine that helped asthmatics. They believed the medicine was killing asthmatics. The main cause of death was considered to be due to the cardiac effect of the medicine. This usually resulted when patients would abuse the medicine.

I think this may have contributed to some deaths, yet I think these scientists got it all wrong. I think the reason asthma deaths started to rise in 1900 is because more people were diagnosed that weren't previously diagnosed. I think one of the reasons is that you had medicines to help asthmatics if they were diagnosed.

Even recently Advair is blamed for killing some asthmatics. Yet I don't think that medicine would kill a fly. The medicine in Advair is no different that ventolin, it's just the longer acting version of ventolin. I've used an entire inhaler of Ventolin plus taken extra hits on my Advair and still survived.

I think the reason Advair gets blamed for asthma deaths is because the EMTs arrived at the person's home and saw the Advair clutched in the hands of the asthmatic. So the Advair was given the blame for the death. Yet the true reason was because instead of calling for help the asthmatic relied on the medicine. The medicine wasn't working, but by the time the patient realized this it was too late.

So I believe the reason for the rise, at times, in asthma deaths is due to lack of education. It has little to nothing to do with the medicine. And I think that black box warnings on such inhalers, or taking them off the market, does more harm than good. It prevents asthmatics from getting the medicine they need to help them.

So thus is my unedited rant.

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

Do asthmatics have a barrel chest?

2011-11-11T14:00:00.000-05:00

Your humble question: Do asthmatics have a barrel chest?

My humble answer: During an acute exacerbation of asthma you will have air trapped in your chest, and this can give you a barrel chest.

What is a barrel chest: The mayo clinic defines it best: The term describes a rounded, bulging chest that resembles the shape of a barrel. Barrel chest isn't a disease, but it may indicate an underlying condition.

Is a barrel chest permanent: When I was a kid I often was told I had a barrel chest, but I do not have one now. For asthmatics it's only temporary until the asthmatic attack is resolved and the excess air is allowed to escape from your chest. In this way, part of the definition of asthma is that it is completely reversible, either with time or medication. However, patients with emphysema may have permanent lung destruction that results in air being permanently trapped in the lungs. This may result in a permanent barrel chest.

If it's not broke don't fix it.

2011-11-11T10:07:00.000-05:00

I love blogging. I love blogger for providing me with access to blogger for free. I think the gift of blogs is among the greatest give ever to both the writer and anyone who loves to read, learn and share ideas in the arena of ideas.

There are some people who want to tax profits made on blogs. There are many who want to tax profits made on the Internet. Yet all the money I make on my blog goes right back into my blog. It's a minuscule profit at best, and taxing blogs would make it so fewer people would share ideas.

So if it ain't broke, don't fix it. Leave the Internet alone.

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

How to improve charitable givings

2011-11-10T09:13:00.000-05:00

Your humble question: What do you consider to be the best way to get people to become more involved in the community? What do you think needs to be done to get people to donate more of their time and money to help those in need?

My humble answer: I'm going to get a little complicated here, yet bare with me.

Statistics show that in the 1980s charitable givings increased by the greatest margin in U.S. history. The reason for this was, I believe, is because the top marginal tax rate was cut from about 70 percent to about 20 percent. Plus regulations were slashed. People had more money left over in their paychecks when their bills were paid, and this resulted in more money available to donate.

I believe that one of the best ways to increase charitable givings is to allow people to keep more of the money they earn. This would entail cutting back on government regulations that cut into the profits of companies (small and large) and provide them with more leeway to either hire more workers or provide better benefits and pay.

I believe that this would also improve the value of the dollar. When someone earns a dollar and 50 cents goes to taxes, that leaves only 50 cents left to pay the bills. After the bills are paid, that might leave that person or company with only 20 cents to spend in the marketplace.

In this way, while a dollar might have bought a loaf of bread in 1980, it would only purchase a quarter of a loaf of bread in 2011. This is referred to as a reduction in the value of the dollar. So instead of a buck buying one loaf of bread, it takes four bucks to purchase a loaf of bread.

What this means is that the dollar travels less. It purchases less goods and services. With a dollar that went further, this would allow people with more money to save and invest in such things as charities. So, by improving the value of the dollar, charitable givings would increase.

This whole process starts by cutting back on entitlement programs, cutting taxes, and freeing companies and individuals from all the regulations that act as a disincentive to do anything.

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

Tooting my own horn

2011-11-09T09:48:00.000-05:00

Your question: As a health activist you are a front-facing leader. What do you imagine you look like to your readers? What qualities do you possess. It's ok to toot your own horn today -- you hav efull permission to indulge. And don't hold back.

My humble answer: I think the best description of my writing comes from my good friend and former co-worker Jane Sage. She put it best when she wrote:

"First of all, John doesn't see himself as a health activist. He sees himself more of as a philosopher. He comes up with ideas for others to use in their activism. His is a fun, pithy writer. He's to asthma what Mitch Album is to the sports column. Album is a pithy, fun sports writer. He was the most award winning sports writer of his era, winning sports columnist of the year for over a decade. Rick's readers see Rick as having the ability to make complex things about asthma simple. His readers also see me as having a knack for finding humor and optimism in an otherwise life altering disease we call asthma. If there was an annual award for best lung blog, Rick would most surely win."

For the above I am most truly humbled.

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

1633 to 1714: Bernardino Ramazzini

2011-11-08T18:54:00.039-05:00

Hippocrates was the first to write about a possible link between asthma and occupation. Yet Bernardino Ramazzine was an Italian physician who defined occupational asthma as a common industrial lung disease.

Ramazzine was born in Carzi in 1633 and studied medicine at the University of Parma where he first became interested in occupational diseases. He was the professor of practical medicine at the University of Moderna from 1682 to 1700 where he was appointed chair of theory of medicine.

Giuliano Franco and Francesca Franco, in their article, "Bernardino Ramazzini: The Father of Occupational Medicine," in the (Am J Public Health. 2001 September; 91(9): 1382), write that it was during this time he extensively studied workers in various industries, he observed their working conditions, the symptoms they complained about, and the questioned them about their illnesses.

It was in 1700 that the first edition of his book, " De Morbis Artificum Diatriba " was published and the results of his work discussed. One common industrial symptom was shortness of breath and caobservation of workers of several occupations describing dificulty of breathing as a result of their work.

Yet it must be noted that while he described it as asthma, it's also possible a good portion of the patients may have suffered from other lung ailments, such as farmer's lung or pneumoconiosis, also.

He recognized the following professions as possibly causing asthma:

Bakers from (wheat and rye flour)
Mill workers (grain dust)
Farmers (animal dander)
Gilders
Tinsmiths
Glass workers
Tanners
Stonecutters
Ragmen
Runners
Professors (fumes and gasses)
Horseback riders (dust)

Bernardini Ramazzini ((1633-1714)

Based on his recognition of asthma and other diseases that might be caused as a result of certain jobs, Ramazzine is considered by many to be the father of occupational therapy. Likewise, due to his recognition of asthma that resulted from exercise, he is also often referred to as the first to describe exercise induced asthma, and the father of sports medicine.

Tova navarra in his 2003 book "Encyclopedia of Asthma and Respiratory Disorders," wrote that Ramazzini was the first physician to recommend to doctors that they ask their patients complaining of shortness of breath and cachectia with questions, such as, "Where do you work?"

Ramazzini recognized a link between inhaling fine particles at work and "shortness of breath and cachectic and rarely reached old age." He generally defined individuals with such a disorder as suffering from an occupational hazard.

While occupational asthma is now considered to be the cause of 10 percent of asthma cases, it wasn't until recently that occupation, and more specifically occupational asthma, was considered a legitimate type of asthma.

Click here for more asthma history.

3 facts and 1 lie about me

2011-11-08T03:33:00.000-05:00

The following are three facts about me and one lie. Can you tell which one is the lie?

1. I once spent six months in a hospital
2. I once had a "code blue" called on me
3. I once was in the hospital 14 times in one year
4. I was once put on a ventilator

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

So what slows me down?

2011-11-07T09:20:00.000-05:00

Your humble question: Is there anything that gets you down and slows down your writing? Is there anything in your life that simply gets you down, burns you out, or makes you sad? If so, what do you do about it?

My humble answer: I tend to be a worrier. Ever since I was a little kid I let things whirl around in my head too long. I think about conversations I had and what I should have said. I usually don't remember names and faces, but a conversation is something I never forget. This, I suppose, is good because it makes for good writing material. Yet sometimes I mull things over so much that it causes some anxiety. In the past this caused a passive aggressive behavior on my part, but after some counseling (way back in 1985 when I was at the asthma hospital) allowed me to control this.

On a similar note, I also have anticipation anxiety. There could be something I want to do, like teach a class about oxygen 101, yet I have this desire to be the best I can be so much that I worry about it. The same thing about the commission I'm a part of. I have a meeting once a month in which I am the chair, and I want to be the best chair I can be. So I find myself researching Robert's Rules of Order before every meeting, and then I mull it over and over in my head if this is something I want to do. I sometimes convince myself I don't want to do it any more. Yet during the meetings I love it. During class I love it. I suppose in a way this is what makes me such a good teacher/writer.

To remedy this problem is that I twist it around and make it an advantage. I know that by the time I enter a classroom, or a meeting hall, that I'm the most prepared person in the room. I also know that what I described above is common among responsible persons.

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

I'm a writer not an activist

2011-11-06T21:51:00.000-05:00

I do not consider myself to be a health activist. I am a blogger and that's it. I share my opinions. I like to consider myself a person who thinks of ideas that other people can act on. I would consider myself a philosopher if anything.

If I was an activist, however, I would change the health care industry to where the costs were lower and health care was affordable to everyone, including those -- especially those -- who do not work.

I hate it when an asthmatic comes to me and say he can't afford his asthma medicine, and therefore he ends up with unfortunate asthma, which is asthma as a result of not being able to afford asthma medicine.

Advair is one of the best asthma medicines in the world (and Symbicort and Dulera). These medicines work to prevent asthma, yet they cost over $100 if you don't have insurance. They cost over $30 with insurance.

The reason medicine like Advair cost so much has nothing to do with the pharmaceutical industry, so I hate it when people come up with solutions that involve fixing prices. That's not the solution. Al that will do is punish the people who create the medicine that we so much need.

If we consider pure economics 101, if the demand of a product goes up, and the supply stays the same, the price will go up. This is what has happened to the healthcare industry. In the 1960s when there were no government regulations on the healthcare industry people could see a doctor and pay for it out of pocket.

Yet since then many government regulations have been made, and welfare has been created. What this did is make health care free for many people. When something is free what do people do? They take advantage of it. So, instead of staying home and dealing with a simple cold on their own, these folks inundate emergency rooms.

Yet what's free to one person someone still has to pay for, and the people who pay for it are the rest of us who use health care services. Every time we go to the ER, for example, we not only pay for our visit but we pay for those who got it for free. Thus, we are paying more than what should be the market price.

Likewise, as the supply of patients increases due to government programs and regulations (hospitals aren't allowed to turn any patient down), and the number of nurses and doctors stays the same, the price of this care will go up to those who pay. It's simple economics 101.

I would like to create a health care system where everyone can go to the hospital and be able to at least somewhat afford it. Surely we should take care of the people who truly need medical services -- including those who can't afford it. But government involvement in the health care industry has resulted in skyrocketing prices. I would like to stop this.

5 things that have changed my life

2011-11-05T20:57:00.000-04:00

Your humble question: What are five things that have changed your life? For the better? For worse?

My humble answer: This is a great question. I'm going to focus on things that changed my life for the better. Some of the things I list here may have been very difficult events, and even horrible events at the time, yet in the end they all resulted in changing me for the better.

1. Horible asthma: As a kid I endured many long and agonizing nights suffering from hardluck asthma. Many days were spend in ERs and hospital beds. Yet I took it in stride as best I could, and in the end it made me what I am today. I actually wrote about it here and here.

2. National Jewish Health: By January 1985 my asthma became so bad I was admitted to National Jewish Hospital/ National Asthma Center (now National Jewish Health) for six whole months. It was fun at times, yet often very challenging. It was events that occurred here that made me what I am today, especially all my talks with counselors and physiologists.

3. Getting fired: I was hired as a journalist at a small town newspaper. It was my lifetime dream to become a journalist because I loved to write, yet once I got this job it was like my mind went blank. It didn't help that I was fresh out of school and I was in charge of the newspaper. In essence I was hired to do a job that was way over my head, and after three months I was let go. That event hit my confidence hard, yet in retrospect it was that event that made lead me to the job I was meant for -- a respiratory therapist.

4. Getting a job as an RT: If it weren't for all the events above I never would have become an RT. In a way, getting a job of respiratory therapist was my fate -- respiratory fate. It was because of this job that I met my wife. It was through this job I created this blog. It was through this job that I created a wonderful family and group of friends.

5. Meeting my wife: I always wanted to write, yet even though I had tons of time I never did. Then I met my wife, got a job as an RT, had kids, and even though I had hardly any time, with her encouragement, I created my blogs. My wife disciplined me. She made me the modest RT.

So there you have it. It was those five events that made me who I am. If it werent' for bad asthma as a kid I never would have spent time at National Jewish. If not for that experience I never would have become an RT. If I never would have become an RT I never would have met my wife, and my blogs never would have come to be.

How does smoking effect bronchodilators?

2011-11-05T13:53:00.000-04:00

Your humble question: How does smoking effect bronchodilators?

My humble answer: Smoking will have no effect on how a bronchodilator (like Albuterol and Xopenex) works. However, smoking can make asthma worse, and smoking can also do further damage to your lungs and cause and worsen COPD. So if your smoking further damages your lungs, this may make it so the albuterol has less effect, or may make managing your lung disease more difficult.

What happens after you press publish?

2011-11-04T20:53:00.000-04:00

Your question: So you've been blogging for a long time now. You have more than three blogs you seem to keep up to date. What do you do after you publish a post? Do you tweet it immediately? Do you continue to edit? Do you admire your work?

My humble answer: Great question. First of all I think it should be known I write because I love to write. I love my blogs because they are the few things in my life I feel I have complete control over (most of the time anyway). Yet another interesting thing about the way I write blog posts is I rarely write the same day something is posted. Usually I get in a writing mood one day a week, or two, or three. It's on those days where I sit and write all the ideas that have piled up in my head. Often during the course of the week I take notes as I'm working. Sometimes I come up with ideas when taking a shower, or when I wake up in the night, and I take notes. So one day a week I sit down and create posts. Then I set them to be scheduled for a certain date.

There is this sense of pride when I look at my blog and read my daily post. I usually do reread it to make sure it's saying what I intend, although usually by the time it's published that job (and any editing) is completed. Although quite often these days, in the hustle and bustle of life, I am too busy to get a chance to admire my work. So you can see, for this reason mistakes may be made. In essence, in this way, I may actually write something I might intend to one day take out so I don't get in trouble by what I say, or don't offend. If I had an editor this would be his job.

Another neat thing about blogging is many bloggers like to promote their blog posts through emails (spam), Facebook or Twitter. I do some of this, but for the most part I like my writing to stand on it's own. I believe if something I write is worth reading people will find it on their own.

I love my blog and I'm proud of my work. Usually I just leave it at that.

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

Dear 18 year old me

2011-11-03T13:22:00.000-04:00

Today as part of my effort to participate in HHBPM 30 health posts in 30 days I will write a letter to my 18 year old self.

Dear Rick Frea

11-3-2011

Hi. I am the future you. Through the magic of the Wellsphere Time-iMail machine I have been told this letter will be distributed to you on your 18th birthday. I've decided this would be a great opportunity for me to provide you with some tips.

First of all, call National Jewish Health and send for your medical records. This is important because in the future you will want to write about your story, and you will require your medical records.

Your future self -- that's me -- sent for these records, yet all he received was 34 paraphrased pages. NJH destroys your medical records after 25 years, so don't wait. Send for them now before they are destroyed.

Another thing I want you to do right now is sit down and write your asthma story while it is still fresh in your head. Don't worry about grammar and spelling and style, just write down your story. You can sandpaper your story in the future, because you will become a pretty darn good writer.

Also, make a copy of your story "Escapes from the Lost." I say this because by the time you turn 24 you will lose this story and have to rely on your memory to rewrite it in the future. Make a copy now and put it someplace safe.

Don't worry so much about your dreams that have yet to be answered. Yet keep praying and don't be afraid to step out of your comfort zone. Likewise, don't worry about what people think about you. Be yourself and be happy with who you are.

Other than that, I'm not going to give you any further tips because both the good things and the bad things that happen in your life make you -- me -- who I am. You will use your experiences -- the good and the bad -- to create some great writings. Be yourself, have fun, and rest assured your most important prayers -- like the ones you made at NJH -- will come true.

Your friend:

Riok Frea

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

1649-1734: John floyer upholds the supernatural

2011-11-02T14:22:00.017-04:00

Sir John Floyer

The early 18th century centered around a struggle by Western men who were losing their enchantment with the old world and increasing curiosities about the truth obtained by scientific progress and thought. John Floyer was born into this world in 1649 and he rejected it.

In fact, it was because he rejected it that he became one of the most interesting and popular personalities of his generation. He put forth a defense against modern logic and a defense for Ancient ideas, yet at the same time he provided a stunningly accurate description of asthma based on his own experience and experimentation

Floyer lived at about the same time as Jean Baptiste van Helmont and Thomas Wilson, yet it was Floyer's ideas regarding asthma that were more readily accepted by his generation. The reason was partly because Floyer had asthma and he used his own experiences to describe the disease. Yet also because he disregarded science and accepted old superstitions that were popular, while the other two endorsed science.

It's true. Floyer rejected the ideas of van Helmont and Wilson and other "quacks" because they "know little of Anatomy, and the Nature of Animal Humours." Likewise, Floyer accepted the ideas set forth by Hippocrates and Galen that all diseases were caused by some external poison that caused an imbalance of the humors: black bile, yellow bile, phlegm and blood. (1)

Floyer's Treaties of the Asthma (a)

Since this was the accepted dogma of the day -- the paradigm that mankind was stuck in at the time -- Floyer's ideas were much easier for other physicians to accept.

Floyer was born in 1649 in the small town of Staffordshire, England, the same year as the execution of Charles I. He suffered from asthma as a child and through much of his adulthood, and it was because of this he would later take up the study of this disease. (2)

He received his medical degree from Oxford in 1680. Shortly thereafter he returned to Lichfield which was only a few short miles from his birthplace and became an important member of the British society, and he was even knighted by James II in 1686. (3)

Floyer's A History of Cold Water Bathing

He was an ardent supporter of cold water bathing, and in n 1701 he published "A History of Cold Bathing: Both Ancient and Modern." He would often recommend this book to his many patients including his asthmatic patients. (4)

In 1682 Andreas Cleyer's Specimen medicinae Sinicae introduced the West to the ancient Chinese method of counting a pulse to diagnose diseases. Floyer liked this idea, and he expanded it and made taking a pulse a routine task when assessing a patient. (5)

To make the task easier he invented a "pulse watch" that had a second hand that ran for one minute. Alex Sakula, "Sir John Floyer's A Treatise on Asthma (1698)," wrote that one of the reasons this "pulse watch" was so important for his study was because he believed that each disease was associated with a specific pulse. (6)

He wrote about his watch in "The Physician's Pulse Watch" volume 1, in 1707. You can read about it in more detail here. The pulse watch was advanced many times even during Floyer's own life, and it soon became a popular site to see your neighborhood physician with a pocket watch. The practice of taking vitals, a pulse and respiratory rate, became commonplace.

The art of watching the hands of a watch revolve is often attributed to Sir John Floyer.

In 1698 he published his book A Treatise of the Asthma. In this book Floyer became the first asthma expert to make the case for asthma as a separate disease from other lung disorders. He also divided asthma into four parts, which are basically broken down as:

Floyer's A Treaties on Asthma (1698)

1. Symptoms (a history of the fits) or the asthmatic attack. It's generally based on his scientific description of bronchospasm:

The attack usually begins at one or two of the Clock in the Night
The breath if very slow (early sign)
Fullness of stomach (early sign)
A slight headache (early sign)
Sleepiness (early sign)
Feeling rigid
Feeling stiff
Feeling inflated (head seems to be filled with Fumes or Serous Humour)
Began to suck in breath
Straitness of breath, seems to be for want of an easie Inspiration
Urge to sit in an erect Posture, that the weight of the viscera may pull down the diaphragm
Enlarging of the breast during inspiration
Muscles of inspiration strive and labour more vehemtly
Muscles of expiration cannot easily perform the Contraction of the Thorax, being hindered by the Stiffness or Inflation of the Membranes in the Thorax
Expriation is easier than inspiration
Expriation is very slow, and leisurely (and wheezing)
The patient can not cough, sneeze, spit or speak freely
The diaphragm cannot contract itself to move downward
Bronchi and trachea has its membranes and nervous fibres contracted which results in wheezing (mainly expiratory)
Muscular Fibres of the Bronchia and Vesiculae of the Lungs are contracted adn that produces the Wheezing noise, which is most observable on expiration
Convulsive cough before fit (inconsiderable)
Phlegm is spit up (inconsiderable)

2. The nature of asthma as he saw it, which is basically based on Galanic principles:

A flatulent slimy Caccochymia which is bred in the stomach, and creates inflation there, and gives an effervescence in the blood and an inflation in the membranes in the lungs
At 2 a.m. the Chyle is more plentiful in the blood.. and the viscid Chyle and Lymph will not easily circulate through the lungs of the asthmatics
The Asthma is a High, Slow, Rare and Laborious Respiration, which depends immediately on the inflation of the Membranes of the Lungs by Windy Spirits, rarefied or propelled through the Glands of the Brain, either by external Accidents or periodic Febrile Effervescence (bubbling) of the Blood.

3. Triggers (Accidental causes) or lifestyle causes or factors that precipitate an asthma attack:

Great heats or cold
violent motions of the body or mind
Excess in eating and drinking
Venereal Pleasures
Heat of the bed
Changes of the weather to rain
Snow
Change in weather from frost to thaw
Alteration of clothes
Changes of the air at spring and fall (change in barometric pressure)
Moist air (dry air is good for the asthmatic)
Heat and smoke of from fires
Fumes
Perfumes
dust
Strong liquors and food
Exercise
Anger (makes humours more viscid)
Fear
Shouting
Excessive study (upset the spirits)
Any strong smells (candles put out, Smoak of tobacco, winie fermenting, soap making, burnign metals, etc.)
Sadness makes humours more viscid

4. Treatment (The cure of the fit) and preventative measures:

Cold water bathing
Light diet (fasting on day of attack with a light diet thereafter)
Gentle Exercise
Bleeding (performed in small quantities, but only in extreme cases)
Blisters (Applied to limbs and shoulders)
Narcotics/ opiates (if induced by sleep 'when nerves are filled with windy spirits'/ induce sleep)
Abstinance of anger or shouting
Emetics (to induce vomiting/ if excessive may bring on asthma/ monthly vomiting recommended)
Feather in throat (another option to promote expectoration of viscid sputum
Oxymel of squills (to induce expectoration)
Clysters (laxitives) or Purges (violent purging should be avoided, but regular purges are recommended)
Late sitting up (staying up late)
Avoid extreme climate changes
Febrifuges and Sudorifics to help fevers that accompany the asthma
Diuretics such as millipedes and woodlice

Floyer was not a fan of other more modern remedies for asthma that were prescribed by other physicians of his day. In fact, he flat out rejected many of them, and instead preferred the more supernatural remedies such as those proposed by Hippocrates and Galen.

Floyer described respiration as "preparing the blood or air vessels by tumours or by injury to the muscles of respiration or to the 'spirits, moving those Muscles.'"

He describes asthma this way:

When the Muscles labour much for Inspiration and Expiration, through some Obstruction, or compression of the Bronchia, &c. we properly call this a Difficulty of Breath: But if this difficulty be by the Constriction of the Bronchia, 'tis properly the periodic Asthma: And if the Constriction be great, it is with Wheezing; but if less, the Wheezing is not so evident; the Pulse being stopt in the Asthma Fit, the Respiration is Rare."

Then he describes two forms of asthma:

1. Continued: Dyspnea was the result of other diseases such as dropsy, empyema, tubercles in the lungs, thoracic tumors, abdominal tumors, and spinal conditions such as scoliosis. He used continued the way we use chronic, meaning that the "asthma" is always there. We now know this is not really asthma but other conditions

2. Periodic: This is bronchial constriction due to "windy spirits" occurring after fevers, catarrh (nasal inflammation or what we now call allergies or hay fever), and hypochondriacal fits or as what he referred to as "flatulent slimey cacochymia, which is bred in the Stomach."

Floyer described his own asthma as periodic, and it is this type of asthma that covers the majority of his Treaties on Asthma. Floyer noted that continued asthma is known to take the life of the asthmatic, yet most people with periodic asthma lived a normal life span. However, periodic asthma did take a life from time to time.

Floyer became the first to describe seasonal asthma. Floyer wrote how he kept a "diary of his disease, out of what I can give a more true Account than if I had now recollected what has long since passed."

He observed that he never had any problem with his asthma while he was at Oxford, yet when he returned to Staffordshire he "usually visited with a severe Fit or two. The air of a Town makes the Fits more severe when they happen; but I do not think the Asthmatic so much expos'd to the Accident of the Weather in a City, as in the Country."

He noted that his asthma was worse in the summer than winter, and worse during "the change of the moon." Barometric pressure can also affect asthma, he proposed, and that is why he recommended changes in weather as a probable cause of asthma.

He may also have been the first to describe how tobacco fumes from smoking cigarettes may trigger an asthma attack, yet his reasoning for this is quite supernatural:

"During the Fit of the Asthma, the Smoak of Tobacco is so offensive that it very much straitens the Breath, if it be smoaked the first Day of theFit, and much endangers a Suffocation. There are many Asthmatics that cannot bear the smell of it; therefore its Foetor is injurious any time, its Heat thickens the Phlegm and rerefies their aerial Spirits, making them restless; all the good it can do is to discuss the Windiness after the Fit abates, and to help the coughing up of Phlegm."

Floyer may have been among the first to note that very few people die of an asthma attack, and that between such attacks the asthmatic can live a relatively normal life. He wrote:

"I have met with some Asthmatics who have been so for Fifty years, as they informed me, and yet in tolerable Health without any considerable Decay of their Lungs, or Disability to perform their usual Employments; which I oft reflect on to encourage my patients, and myself, who yet can study, walk, ride, and follow my Employment, eat, drink, and sleep, as well as ever I could; neither am I yet sensible of any Decay in my Lungs."

Sakula noted that while Floyer's acceptance of Galanic principles would later be proven false, "his treatise shows that he was familiar with the multifactorial basis of asthma -- heredity, occupation, atmospheric pollution, hypersensitivity, infection, exercise, and psychological influences."

Because his theories about medicine were more readily accepted by society in the 17th century, Floyers is often given credit as the first to define asthma as a disease of it's own, more specifically as a disease of bronchospasm, even while this wasn't true. Regardless, he did play a significant part in defining asthma.

Floyers would die on February 1, 1734, yet his teachings would be studied by physicians for the next hundred years, and his practice of measuring a pulse and respiratory rate became a common medical practice that is still used to this day.

Click here for more asthma history.

References:

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Sakula, Alex "John Floyer: A Treaties on Asthma," Thorax, 1984, 39: 248-254
Floyers, John, "A Treaties on Asthma," 1698, London, pages

Photos:

(a) Photo compliments of http://www.nlm.nih.gov/hmd/breath/breath_exhibit/Asthma/IIIAa1.html
***Photo compliments of http://193.62.111.58/broughttolife/themes/science/measurement.aspx

My asthma TV show

2011-11-02T11:51:00.000-04:00

In my dream world my characters Joe Goofus and Jake Gallant will be the stars of a new cartoon aptly titled Hardluck Asthma: The adventures of Joe Goofus and Jake Gallant.

It will be both a fun and educational cartoon on Nickelodeon featuring the voices of Michael J. Fox and Jake Gallant and yours truly as the voice of Joe Goofus. I figured most of us are more realistically goofus asthmatics, and therefore I insisted on being the asthma goofus.

The cartoon features the two contrasting characters, both boys, who both have hardluck asthma. The premise of the cartoon is one or both of the boys faces an obstacle regarding his asthma, and goofus usually makes some decision that gets him into trouble. Sometimes the decision is irresponsible, yet quite often it's doing something that any normal kid might do.

Jake Gallant usually makes the "perfect" decision, although he still has trouble with his asthma. In the cartoon he usually takes on the role of trying to help Joe decide what to do when he faces his consequences of his decisions, such as the decision to rake leaves or to go to hunting camp with his dad even though he knows both those things usually lead to an asthma attack.

In my favorite episode Joe Goofus has a test at school, and in order to not have to take the test he doesn't take his controller medicines for a week and runs outside in the cold. In this way he becomes the Actor Asthmatic, or the asthmatics who fakes his asthma our of convenience.

Jake Gallant and Joe Goofus primary function is to teach children that they are not alone in living with asthma, and teach them basic skills on how to live with this disease. It also focuses on teaching kids what to do and what not to do in order to prevent asthma symptoms.

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

My future asthma book

2011-11-01T10:27:00.000-04:00

I do see a book in my future. I've started three books, and some day I plan to put them together and get them published. I have a nonfiction book and a fiction book I'm working on. Yet my nonfiction book would be relevant to to this blog because it's about asthma.

I've already written chapters of my book on the RT Cave and at MyAsthmaCentral. I've been trying to write about every aspect of asthma in a pithy (short and sweet) fashion. Some day I'd like to take my writings and put them together in a simple, easy to read book.

I want my asthma story to be in the book, yet I don't want that to be the main focus. I simply want to show how I suffered from the disease, how I survived, and how asthma made me what I am today. Yes, you can live a normal life and have asthma too.

Yet I also want to make asthma an easy disease to understand? What is asthma? What causes it? What triggers an attack? What's the history of asthma?

Here is an idea I've created for my future book jacket. It actually comes from one of my posts:

Living through an asthma attack is never fun. The good news is asthma can be controlled, and you can live a normal life with it. That in mind, and since we have to live with it anyway, no point in saying, "Why me?"

Based on my experience from being a lifelong asthmatic, I have discovered seven benefits of having asthma -- and no, I am not referring to using it to get out of gym class or work.

I have also used my professional and personal experience to create eleven different types of asthmatics, such as the Jake the gallant asthmatic and Joe the goofus asthmatic. You might be like Joe, yet chances are you might find you have more in common with Mr. Goofus than you think.

Hardluck Asthma provides the inside scoop of what it's like to live with asthma, and how you too can cope with this disease. Besides, it's also good to know that you are not alone in having to deal with asthma.

One thing I'm not so good at is creating titles for my future book. Here are some ideas I have:

My Hardluck Asthma Story
Living with asthma
How to have fun with asthma
The truth about asthma
An asthma guide: How to survive asthma
How asthma benefited my life
Fun with Asthma: A definition, a history, a life

Those are just some ideas, yet I'm not sure I like any of them. If you have any ideas let me know in the comments below. If you have an idea for a book, let me know about that too in the comments below.

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J