Before epinephrine in the 1930’s and antihistamines and cortisone in the 1950’s, patients suffered and died from this disease whose description goes back to the time of  Hippocrates. Since the 1950’s, and especially in the last 20 years, excellent new medications have become available for treatment: better bronchodilators, cromolyn sodium (intal) and tilade,  inhaled corticosteroids, better antihistamines, and most recently  the leucotriene receptor  antagonists.  But, in spite of these developments, bronchial asthma has developed into a worldwide epidemic, with increasing rather than decreasing  mortality.

Why?  We don’t  know all the answers.  But some we do know.

No. 1: Bronchial Asthma remains the most underestimated and under- treated serious disease in this country today.  It is  underestimated by patients and under- treated by physicians, despite having become the media disease of the last few years; and despite clear and useful National medical consensus treatment guidelines which are reportedly used by only 20 to 30 percent of physicians.

No. 2:   Increased urbanization and increased poverty in America have led to large concentrations of Americans (especially children) living in borderline housing infested with cockroaches, mice and dust mites.  This situation concentrates potent allergens in close quarters.

No. 3 The oil crisis of the 1970’s led to the subsequent construction of  “energy-efficient buildings” that produce and concentrate indoor air pollution, both allergenic and toxic, in an environment of poor air circulation.

No. 4: Of the elements of increased air pollution, one with a special significance relates to the massive increase in truck transport in the last 20 years.  It has been found that diesel fumes, in particular, promote in all of us an increase in the production of  IgE, the human antibody specifically responsible for allergic reactions.

No. 5: The phenomenon of women (mothers)  entering the workplace, and the consequent warehousing  by both parents of their children in incubators of disease called day-care centers, has multiplied the  well-known relationship between  viral respiratory diseases and bronchial asthma, especially  respiratory-syncicial virus and some influenza viruses.

No. 6: There is some evidence that the frequency and severity of particular “asthmogenic viruses” is increasing, producing increasingly common “post- viral hyper -reactive airways syndrome”  in allergic and non allergic patients alike.

No. 7 Smoking has not decreased, but rather has shifted from some adults and elderly citizens  to many stupid youth of our society.  Nor has there been an improvement in the gross insensitivity of smokers regarding the documented  effects of secondary smoke on those around them - including children in their households (a form of child abuse with  long-term medical  effects on those children).

No. 8: There is evidence that the common patient overuse of bronchodilators such as albuterol, as well as the over-reliance by physicians on these medications-especially in emergency rooms-may be producing a desensitization to these medications, and may even be sensitizing the bronchial tree, producing paradoxical worsening of bronchospasm.

No. 9: The love affair of Americans with their dogs and cats, given free rein throughout the house, has clearly worsened the problem of indoor air pollution, and particularly that of indoor air allergens.  Dog, and especially cat  proteins, are among the strongest allergens known.

There are very likely other mechanisms operating in this matter  that we do not yet recognize.  Nevertheless,  the problem is not a great mystery; and much can be done to promote a reversal of this trend.

A) Patients should consider any persistent cough, wheeze, or shortness of breath as a serious problem warranting medical care, and quite possibly specialty medical care.

B)  Physicians should rise to the challenge of treatment by using the many modalities now available, guided by National consensus statements on the subject.  They should recognize, belatedly and in some cases grudgingly, that immunomodulation in the form allergy imunotherapy should be standard treatment for the majority of cases of established bronchial asthma (in most cases allergically based).   Among the reasons, relating to better clinical control and the potential for desensitization  and “cure”, there is evidence that the remodeling (scarring) that develops with time in under-treated asthmatics and chronic bronchitics  may not be avoided or reversed even by the proper use of inhaled corticosteroids.  Thus, the importance of treating immunologic causes.

C) Anything that will improve the availability of proper health care for children will help greatly.  This includes issues of cost, physician availability (including a return to charity work), and greater responsibility of parents to seek such care for their children.

D) All energy-efficient buildings, especially schools, should be made to conform to reasonable and effective air quality guidelines.  This would generally require  nothing more than increased ventilation and greater volume of fresh air intake.

E)  It is  long past the time when the trucking industry and its diesel fleets must be brought under the same air quality requirements  as relate to auto exhaust.  Those trucks belching black smoke not only stink-they’re killing us.

F) The problem of children in day -care centers and the consequent impact of infectious diseases is tough, given the new economic facts of life.  But parents should seriously consider the trade-offs in health when planning their economic needs.

G) More research should be devoted to viral respiratory illnesses, especially regarding “asthmogenic” viruses.  Meanwhile, a  vaccine for RS virus, currently under study, would help substantially.

H)  What more can be said about smoking, a dirty, deadly habit that can be broken, if the common sense and the will are there.  Your physician now has good tools to help.

I) Until more research clarifies the suspicion regarding the overuse of bronchodilators by patient and physician, rescue medications like short- acting  bronchodilators  should be used  “as needed” rather than regularly.  Long- acting bronchodilators (like serevent) should be used-if at all-only at bedtime.  And emergency room physicians should rethink their almost total reliance on prolonged use of such agents to treat acute asthmatic attacks, precisely when these patients often present already having overused their medications.  Other treatments are available to add to the treatment mix: atrovent, terbutaline, theophyllin, and even epinephrine, in addition to corticosteroids.

J) Pets in any allergic household should be restricted totally out of the sleeping quarters, and also out of rooms where the patient spends  more than a very short time per day.

Is the incidence of disease and death from bronchial asthma rising? Yes. Is it a mystery? No. Can something be done about it? You bet! And the informed patient is in the best position to seek out and to demand proper care.  Remember, for your health care, choose... don’t settle.

GS