History of Exercise Induced Bronchospasm

If you have asthma chances are you have exercise induced asthma (EIA), statistics show about 80% of asthmatics have it. Yet prior to 1966 few understood EIA.

I happened upon a book called "Allergy: Principles and Practice Volume II (5th edition, Elliot Middleton, editor, 1998) which, on page 953, so happened to have a good review of the history of EIA, which has actually since been changed to EIB (exercise induced bronchospasm). To learn more about EIB you can check out this link.

In upcoming posts on this blog you will get to know the asthma experts such as Sir Joh Floyer and Fredrick Hyde Salter that are mentioned below, for now all you need to know is they were physicians who helped shape the history of the disease you and I have: asthma.

E.R. McFadden, Jr, wrote the following history of EIA:

"EIA was formally brought to the attention of clinicians of the modern era in 1966. Actually, the association between strenuous exertion and the acute development of airway obstruction was originally recorded by Arateaus the Cappadocian in the first century AD.

It was then rediscovered in 1968 by Sir John Foyer, who was the first to point out the relationship between the level of ventilation and the severity of symptoms. In 1864, Salter (Fredrick Hyde Salter) recognized that the postexertional obstructive response could be accentuated if the exercise was performed in a cold environment. He too suspected the importance of the absolute level of ventilation achieved during exertion and suggested that the rapid passage of fresh and cold air over the bronchial mucous membrane could stimulate the airways either in a direct manner or by production of nervous system irritability (he believed asthma was a nervous disease). The importance of these thoughts were unrecognized until recently.

It wasn't until 80 years later, McFadden writes, that a man named Herxheimer published works on his theories about what EIA was. He actually believed that "hyperventilation during exercise was the key factor, but he reasoned that it brought about its effects through the constrictor action of airway hypocapnea (low CO2)."

When you breath fast you blow off CO2, and was believed to (through a series of reactions) to cause bronchospasm (airway narrowing). This was later disproven.

While others agreed with Herxheimer, some believed substances released from the muscles during exercise (such as lactic acid) were the stimuli that caused EIA. This theory, as well as the theory that low CO2 caused EIA, were found to be false in 1977.

What was not considered back then was temperature and humidity of the air inspired were important factors in the cause of EIA.

While scientists are still digging for all the facts about EIA, it appears we're pretty close. On a recent post at MyAsthmaCentral.com, I reported on the up to date definition of EIA. So here I quote myself:

"The best definition I could find came from this post at AAAAI.org, which notes exercise doesn't necessarily "cause" asthma, but that "hyperventilation (fast breathing) associated with exercise cools and dries the upper and lower airway resulting in the release of histamine and other substances that produce the bronchospasm (spasming of the muscles in the air passages in your lungs)."

Likewise, when an asthmatic exercises when the temperature is cold, and the air dry, "Hyperventilation of cold dry air produces a similar response."

In this way, asthmatics are more likely to have asthma symptoms when they exercise in cold, dry air.

Dr. Randolph also said it isn't so much the cold weather that triggers the asthma attack, but the fact that the air is dry. Asthmatic lungs have a diminished ability to humidify the air, and this triggers the asthma response. This has been proven via various studies.

AAAAI.org also notes it doesn't help that "During strenuous activity, people tend to breathe through their mouths, allowing the cold, dry air to reach the lower airways without passing through the warming, humidifying effect of the nose."

Actually, according to Dr. Christopher Randolph, a clinical professor at Yale University who was interviewed by The New York Time's, EIA is not quite the same as asthma. He notes the "'preferred term' in the scientific community for exercise-induced asthma is exercise-induced bronchoconstriction, or EIB."

So by default we'll probably continue to call it EIA, although it's actually EIB. And that's why I titled this post, "History of EIB."

Do nebs work better in hospitals than at home?

The asthmatic patient took the breathing treatment from me, and puffed on it for about five minutes. I could tell just by looking at her that her breathing was getting better.

When the treatment was finished she said, "Wow! I feel much better! Why is it that breathing treatments work so much better in the hospital than at home?"

I get similar questions or comments regarding this all the time. People think that home nebs don't work as well as when they are given in the hospital. But, to be honest, it's the same medicine, so it shouldn't work any better.

So that got me to thinking. I remember the same thing when I was a bad asthmatic years ago. I remember feeling short of breath until I took a treatment in the hospital. Why is that? Sometimes I felt better as soon as I entered the hospital.

In fact, to be honest, even to this day I might use my inhaler a few times during the day at home, and when I go to work I never even take it with me because I never need it. Or if I do need it I just wait and my breathing gets better on its own. Why is that?

Here's my theory. I could be wrong, but then again, I could be right. As with most of medicine, it's based on theories, and my theory of why tx's work better in hospital as outside is that inside the hospital you are away from your allergens. Whatever "triggered" your asthma attack is not here.

Hence, your asthma symptoms seem to go away. Or, the treatment seems to work better.

Asthma Past and Future

When I was growing up the lone asthmatic among four brothers with normal lungs, I was forced to explore the world in a unique way. Instead of just going with the flow and enjoying what life offers, I was forced to think, and to choose my own path.

I'm not implying people without asthma don't think, but when you are forced to sit in your room while your brothers are out in the woods hauling wood, you either read or you sulk. When you're up all night due to your asthma, you either think or you go insane. I'm not particularly fond of insanity, so thinking grabbed me.

I imagine that's how I found myself in the blogosphere writing about things most people choose to take for granted (like Freedom and air), or simply ignore (like history). Ah, history. So many of us just take do simply take it for granted or ignore it. Yet, without a firm grasp of the past, we are doomed to repeat it. What great historian came up with that famous line?

As I was lying awake, gasping for breath, trying to decide whether to wake my parents up (or how long to suffer before I woke them up?), I remember thinking about what life would be like before the puffer. What would it be like to have been Teddy Roosevelt and having to have your dad take you for a buggy ride just to get some fresh AIR.

So, starting soon on this blog, I will be exploring the asthma past, and eventually the asthma future. What was it like to live with asthma 1,000 years ago, and what will it be like 1000 years in the past? Ah, are you curious as I am?

When I first started writing about the history of asthma I could find nothing on the subject. After three years of surfing the net, and digging through dusty, musty library journals, I have found some very interesting information. In the coming days here on this blog, I will share my new wisdom.

Bare with me, as it will take me a little time to organize and make this history and interesting and pithy. As you may well know from my past posts about asthma's past, I like to make complex, lawyer-like material and make it simple.

Now, that said, March is chock full of medical renewal courses for your humble RT here, so writing will be sparse. But once that is done, check back here now and again for a spoonful of asthma history and future to go along with asthma wisdom.

Headaches

I don't know if it has something to do with all the medicine that I'm on, or the fact asthma causes some degree of stress, or the fact that I'm forced to be "unique" because of asthma, or due to anxiety, or sinus problems, or allergies, or wimpiness or what. But, I sometimes get these terrible headaches, and I have one right now.

Actually I have dulled it with an Ultram, but it's still there. I woke up at 2 a.m. with this headache so bad there was no way I was going to go back to sleep, so I got up and took two 500 mg Tylenol. I have to take that much, because one never quite cuts it.

I knew this was not a Tylenol headache, though. Yet I had to try it. I had to try something before I took an Ultram. I had to because once I take an Ultram, once it kicks in, I have to write. Doesn't that sound weird. Yep! Ultram relaxes me to the point, puts all these ideas in my head, and I have to put them on paper. I've written some good stuff while on Ultram.

Ultram dulls or gets rid of my headaches no matter how bad, it's the first drug I have ever taken that gives me at least some degree of relief. However, even though it is not an opiate, and my doctor says it's safe to use it and work, it gives me the feeling that about three cups of coffee gives me, although without the side effects such as shakiness and such. It just makes me feel euphoric, and happy.

So, Ultram is a good medicine. Like I wrote above, I always take something else first, and if that works I don't take the Ultram. However, the neat thing about Ultram is that I don't have to worry so much when I get a headache. It used to be that I would get headaches so bad that I'd have to almost take something for it prophylactically. Seriously.

In fact, I would take ibuprophen for a while, and when that quit working, I'd switch to Tylenol, and when that quit working, I'd switch to ibuprofen, and so forth. I even tried extra strength medicines such as Exedrin, although after a while, that quit working too. Then I went on an aspirin kick.

In December of 2008 I woke up one morning throwing up blood, and yes, it was coming out the other side too. Sorry to gross you out there, but that's what happens when you get a GI bleed. My wife and doctor were convinced I had an ulcer, and that it was exacerbated by the fact I was thinning my blood with Asprin at the time.

So, that was when my doctor prescribed Ultram.

Now I put myself on the spot, and I feel I have to back up a bit and explain something. When I was a kid I was the anxious, often depressed type of kid. Again, I don't' know if that had something to do with asthma or not. I don't know if that had something to do with the fact I was slowly realizing I was unique, not much of a socializer, had to do things different, couldn't hang out with the guys so much in the woods, in the baseball fields, and such. You know, that causes stress for a kid. And, worse of all, I was severely bullied as a kid in school.

So, needless to say, those things caused me stress. And, sometimes I wonder if that caused me to get these severe headaches when I was a kid. I remember my doctor prescribing one medicine after another for me to take for the headaches, and none ever worked.

This brings me to the asthma hospital in 1985. While there, yet again, I had bad anxiety. One of the major problems of the asthma hospital was severe homesickness that often had to be dealt with among the kids. I was no exception. So home sickness anxiety, coupled with the anxiety that already existed, coupled with the fact that I'm not much of a socializer and was among socializers, and away from my family, and away from my mother of whom I was attached (you hear that a lot about asthmatics, that they get attached to their mothers).

So, needless to say, I got severe headaches there too. And, since I was in a hospital, and the doctors wanted to make as much money off me as they could (a little humor there), they tested me for head problems. They had me see a psychologist, had me run through a series of tests such as an EEG, and the end result was that I was normal.

At one point while I was at the asthma hospital I participated with other kids and a specialized trained nurse on how to relax. I do plan on writing about this in more detail later on this blog. The psychologist, counselor, and the relaxation classes changed me quite a bit. I actually turned into an equanimitous asthmatic (equaniminous is not a real work, but I like it). I am cool, calm and such even during the worse attacks, and I'm better capable of dealing with life in general. When my asthma attacks, I do what I was taught in these classes, and I'm telling you, it works.

However, I digress. I quit getting headaches for a while. Yet, now that I'm an adult, I get those things terribly at times. I never said anything to my doctor. I didn't mean not to say anything, it's just that I never related it to anything other than just normalcy.

Yet, when I ended up in the hospital with a GI bleed, my secret was out. Well, it really wasn't a secret because I didn't intend on not telling my doctor, it's just that I never thought of it unless I had a headache. You know how that is I'm sure. The last thing I wanted to do was take yet another pill.

So, here I am, up at 6:00 in the morning, writing. I'm writing with a dull headache, numbed by the powers of the Ultram. Is it an asthma related headache? I may never know. And, quite frankly, you can thank the Ultram for this post.

Two-years old and all alone in a hospital crib

This has nothing to do with asthma, yet I'm going to report it off to you anyway. I had a 2-year-old kid I was just scheduled to give a breathing treatment. He was actually diagnosed with pneumonia, and doesn't need the treatment, but that's beside the point.

The reason I mention this here is because the kid, when I entered the room, was crying. He kept saying over and over, "Mommy! Mommy!" Yes. He wanted his mommy. He wanted the one person he is most attached to. And yet, she was no where to be found. Once the child was admitted, she went home.

So, after I gave my treatment, I sat with the kid. I put on a cartoon on the TV, and I talked to him. It took a while, but I eventually had him calmed down. Then I sat with him for a while, as he snuggled with his little stuffed puppy.

This kind of reminded me of when I was two and my parents left me in a hospital all alone. Yes, I was 2 years old in 1972, and my parents left me alone. There was a policy back then that parents weren't allowed to stay in the hospital after hours, so once visiting hours were over, they had to go home.

I remember a room where a bunch of hospital cribs, which were actually metal cages, were all lined up. I was put in one, and the side was raised. I remember standing up, all sad, as my mom and dad said good-bye. I remember them slowly walking to the door, looking back, and then exiting the door.

I also remember mom and dad looking in the little slit of a window on the door. They stood there a while, and then left. I was sad. I remember the nurses coming in every once in a while to put something in my bottom. I didn't know it then, but it was probably the temperature probe.

I was in the hospital because I had bad eyes, and the doctor was going to operate in the morning. I had a wandering eye, and the doctor had to tighten a muscle or something. Surgery may not be needed for this in 2010, or if it is, it would be an out patient procedure, but back in 1972 I had to stay the night for whatever reason.

I remember after the surgery, having a patch over my eye. I kept trying to take it off, so the doctors actually wrapped my head so I couldn't do it. I also remember leaving the hospital. I don't remember mom being there, but she probably was. She probably stayed in the hospital to do paper work or something while dad took us kids out to the car.

I remember my older brother Bobby, my younger brother David walking along side me. I was in a wheelchair, being pushed by dad, or, perhaps if my memory fails me, maybe it was a nurse. Regardless, I remember my brothers (one or both) wanting to ride in the chair, and dad saying something like, "Rick's the sick one. He gets to ride in the chair today."

I remember the car. It was a station wagon with brown and white wooden side panels. That's the memory. That's how I remember it. And, yes, I was only two.

I told my memory to my mom once when I was a 10 or so, and she confirmed it. Yet, I brought it up a few years ago to her, and she said what I described was not how it was. She said my brothers wouldn't have been there, and stuff like that. However, I think my memory is accurate, as it happened to me, and mom didn't have a need to remember it the way I did.

Anyway, sitting there with this kid kind of reminded me of this episode, when I was a kid left all alone in the hospital. It's episodes like this that give me empathy for kids, especially kids that are left alone by their parents in a hospital, and the kid is all sad.

The kid was calm, staring at me, the ceiling, and occasionally getting lost in the movements of the cartoon on the TV, and I was hesitant to leave him all alone. Yet, remembering that I tolerated it somehow when I was a kid, I was certain this kid would do just fine. Perhaps, as it may have done me, strengthening him somehow.

Unique Asthma and common sense

I've been lucky all my life to have doctors who pretty much let me do what I want. While I've had pharmacists question my inhaler use in the past, I have never had a doctor tell me to quit using it so much.

Now I'm not saying my doctors aren't concerned, just that I've been fortunate to have doctors that understand that not all asthmatics fit into the "guidelines." Sure most asthmatics shouldn't need to use their rescue inhaler more often than once or twice in a two week period, but some asthmatics -- like me and perhaps you -- need it more often.

I wrote about how I was a bronchodilatoraholic (well, I suppose, once you're a bronchodilatoraholic you always are) once or twice on my other blogs, and I have had people email me to tell me my asthma is out of control if I use it as much as I claim. When, in fact, my asthma is controlled. Thus, rescue inhaler frequency isn't always an indicator of asthma control.

My family members who have seen my asthma first hand (my wife, my mom and dad when I was growing up, my brothers, grandparents, uncles and aunts, coworkers and the like) never question that I'm taking my inhaler. They never say things like, "Golly gee, don't you think you're using that a bit much!"

In fact, my doctors are the same. It's called common sense. Like with any other thing in life, nothing goes according to the plan. You can't go to doctor school expecting every time you have an asthmatic you can give the exact same analysis, the same medicine, and expect the same results. Why? Because in the real world, people have unique asthma

And, thankfully, people in my life, including my doctors, have always had a certain level of common sense not to make me feel uncomfortable about my inhaler overuse, my bronchodilatoraholism. However, I usually don't give them the chance, since puffing was usually done in private.

Today I couldn't care less, but when I was a kid I felt stupid enough using that darn thing. I wrote about it recently on this blog how carrying that thing in my pocket in itself was embarrassing. And, to use it in front of people, only generated looks and questions I didn't want to deal with.

So, understanding that perhaps, my doctor never questioned me. Perhaps the common sense part of his brain understood that Rick Frea has unique asthma. He has asthma that does not fit into the textbook.

And, when you have unique asthma, you need to treat it in a unique way. When you're short of breath, you test that rescue inhaler more often than you should. Then you realize the relief you get from it is worth any side effects that might transpire (Side effects are pretty minimal anyway).

Thankfully, most of the doctors I've had are wise to this fact. Considering I'm the worst asthmatic most of my doctors (minus the doctor's I had at the asthma hospital) ever treated, I often wonder how they obtained such patience with my asthma.

Common sense, people. It comes down to common sense. Either you have it or you don't, because it cannot be taught.

Allergies suck worse than asthma

I have had asthma and allergies my entire life. While I bet many asthmatics might disagree with me on this, I think having allergies is far worse than having asthma.

Yes, I did say that. I think allergies suck. Asthma is actually easier to control than allergies. Even after I was on Advair and finally had my asthma under control, the allergies continued to irritate the crap out of me.

Sure there are allergy shots, but those things did nothing for me but sting my arm once a week for three years.

Sure there were antihystamines and decongestants and nasal sprays, but if I'm around one of my allergens, those only took the edge off of that annoying feeling you get in your sinuses and nose. You sneeze. You get a runny nose. You feel down right miserable.

I'd rather have an asthma attack. A worse case scenerio for asthma is you have to go to the ER. Yet, even in the ER, there is nothing they can do for allergy symptoms.

This did change, however, with the invention of Singulair. Man that drug is awesome - for me anyway. Advair really helps too. Now I can actually be around something I'm allergic to and survive -- like during this flare up.

With Singulair my asthma flares still occur if I'm exposed to my allergens, although the flares are not near as bad as they used to be.