Tyranny and Cruelty

By Brian J. Waldron|Sunday, August 01, 1993
The sound of asthma is eerie, like the wind whistling through a window on a lonely December night. The look is one of terror, born of the conviction that each breath could be the last. The feeling is overpowering: a clammy, heart-pounding, chest-tightening helplessness.

As I listened to Rosemary’s lungs one early morning a few years ago, I heard the expiratory wheeze that punctuated each breath as the airways clamped down, blocked by thick, tenacious mucus plugs. In her eyes I saw the look of fear mixed with a yearning for relief. As for the feeling, it was one I knew well. I did battle with asthma throughout my childhood, so looking at Rosemary was like looking in a mirror. I knew how asthma steals your breath away.

I knew how trying to suck air into your lungs feels like trying to suck a thick shake through a collapsing straw. I knew how the harder you struggle, the more the tube closes in on itself.

Rosemary knew, too. After all, she’d been going through the drill for 29 years. And her attack that day differed from the others only in the details. It started with a rough day at work, after which she’d gone to her health club to sweat out some of the stress. Then she’d showered, returned home, and gone to bed. At 4 A.M. she awoke coughing and short of breath; once she realized it wasn’t going to get better, she called me. Hello, Dr. Waldron? she wheezed, barely able to get the words out. I didn’t immediately recognize her voice, but I recognized its struggle and sense of urgency. This is Rosemary Martin.

I’d treated Rosemary for asthma several times before and knew her as a brittle asthmatic--the type of asthmatic whose attacks start with little provocation or warning and are difficult to treat. Obviously I didn’t want to waste any time. I’ll meet you in the emergency room, I said, and dashed over there.

An asthma attack is one of the most dramatic and acute medical maladies that either a doctor or a patient can face. Indeed, it was described in seventeenth-century medical literature as tyranny and cruelty. It is no less oppressive today: Rosemary and I are just two of 15 million Americans--about 6 percent of the population--who are afflicted with asthma. And asthma’s prevalence is on the rise. A recent Australian study documented a 141 percent increase during the past 25 years. In the last decade, the prevalence of asthma in the United States has grown by more than 60 percent. Why the numbers are growing is not exactly clear, but some doctors think the rise is related to an increase in indoor air pollution.

It was easy to diagnose Rosemary that morning. There were no specific diagnostic tests to help me, but I didn’t need any help. What I heard and saw when I examined her, my knowledge of her history, and my own history--which gives me, I believe, the ability to pick up the subtle nuances of a patient’s symptoms and her response to treatment--were all that I needed.

Rosemary and I had battled through enough of her asthma attacks that we had established a kind of routine. Although her condition was not critical when she arrived at the ER, I asked the nurse on duty, Mike, to immediately begin giving her oxygen through a nasal cannula, plastic tubing that carries the vital gas to the blood via two prongs that fit into the nostrils. To someone who’s never had an asthma attack, the cannula looks very scary: I was petrified the first time I had to be hooked up to one. But that fear hadn’t lasted long. I soon found that getting oxygen during an attack is a comfort. It’s as if the gas is going to somehow force open the stubbornly closed tubes in the lungs. That’s why I gave it to Rosemary: once the oxygen started flowing and I looked into her eyes, I saw hope and the recognition that help was on the way. She began to relax.

But Rosemary needed more than oxygen to get through this attack. We needed to stop the attack itself. Although no one really knows what initially causes asthma, it is known that many asthmatics become exquisitely sensitive to certain inhaled substances--substances that have little effect on a normal individual--and that this allergic type of response inflames the airways and obstructs the flow of oxygen. So Mike and I began to administer medications designed to accomplish two goals: open the breathing tubes and bring down the inflammation caused by the reaction.

There are a whole host of substances that can provoke an asthma attack: dust and dust mites, pollen, respiratory viruses, animal dander, smoke, occupational particulates and fumes, mold, aspirin and other medications, and food additives. Even emotions, like stress or overexcitement, may play a role. From the story Rosemary had wheezed out when she got to the hospital, I knew that one or more of these substances-- possibly the mold in the gym’s locker room--on top of a stressful day at the office could well have factored into this attack.

When an asthmatic is first exposed to such a substance, an antibody called immunoglobulin E is released from a type of white blood cell. This antibody then latches onto the surface of other immune system cells. At this point the asthmatic’s overreactive system is primed. When the antibody encounters the offending substance a second time, it signals these immune cells to unleash a number of chemicals to fight against the invader. These chemicals’ purpose is to get more blood and more white cells to the site of the attack, and in their zeal they cause blood vessels in the lungs to dilate and become leaky. The airways become filled with cellular debris and mucus. Other substances call extra white cells to the area and aid them in wiggling through the walls of the leaky vessels and into the surrounding tissues. Cells that line the airways begin to slough off, adding to the obstruction. In short, these substances perpetuate the inflammation that is typical in an asthma attack. They can also have a second, more direct, effect. A group of substances called the leukotrienes, for instance, causes some of the smaller, peripheral airways to tighten.

Because Rosemary had long suffered with asthma, she kept certain medications at home, including terbutaline--one of several drugs I could prescribe for her that allow smooth muscle to relax, opening the airways. In fact, when she first awoke wheezing, she had inhaled some terbutaline. But her continued gasps for breath made it clear that it hadn’t done the trick. So I began to give her more terbutaline through a nebulizer--a machine that aerosolizes the drug, mixing it with a saltwater solution so it can get down the airways more easily. The nebulizer is about twice the size of your average lunch box, a distinct contrast to the inhaler she used at home, which was a tube barely larger than a lipstick.

If you want, you can take the nebulizer home with you, I said to Rosemary, laughing and nodding toward her shoulder bag. That looks big enough to hold it. She rolled her eyes in response but barely wheezed a laugh as feeble as my nervous joke. She clearly needed more help, so I asked Mike to draw and inject 0.3 cc’s of epinephrine--adrenaline--under her skin.

Epinephrine stimulates the sympathetic nervous system, one of the two arms of the body’s autonomic nervous system, which controls our involuntary reactions. The sympathetic nervous system is responsible for the fight-or-flight reaction that enables us to either confront or escape a perceived threat. The heart beats faster and more efficiently. Blood is shunted away from the digestive organs in favor of skeletal muscles that could help us run away. The lungs expand and their airways dilate to allow for the maximum flow of oxygen into the bloodstream.

In Rosemary’s case, the combination of exercise and a stressful day at work had really fired up this system. As she began to relax, the other arm of the autonomic system--the parasympathetic nervous system--took over. Its job is to calm the body down: slow the heart rate, allow food to get digested, and constrict the airways. It’s possible that because of the stress Rosemary was under, this system overcompensated and kicked into overdrive. In addition, when Rosemary lay down in bed that night, acid from her stomach may have traveled the wrong way up the digestive tract into the esophagus and stimulated the vagus nerve, which is part of the parasympathetic system. So the parasympathetic system would have continued sending out airway-constricting messages even after they were clearly no longer needed. (Interestingly, this acid backwash phenomenon is the reason so many asthmatics experience their symptoms at night--some doctors think the backwash can be so severe that the acid travels into the lungs themselves.)

By giving Rosemary epinephrine, I was hoping to override the parasympathetic system by turning on the sympathetic system. But when I listened to her chest, I heard a lot of wheezing and little air movement. Looking up, I nodded to Mike, who had anticipated my next request by drawing an additional dose of epinephrine. He quickly injected it.

It soon became apparent that I still wasn’t getting the response I wanted. So I turned to two other drugs that can be used to treat a severe asthma attack: theophylline and cortisone. Theophylline is yet another dilator, caffeine’s chemical cousin. Cortisone works by reversing the inflammatory response and quieting the airways, making them less responsive to all those allergic stimuli. I gave these to Rosemary through an intravenous line.

Though helpful, the drug combination acted like a triple espresso. Rosemary was almost instantly wired and became even more anxious. When I touched her, she was trembling.

I knew how she felt. I remember the shots of epinephrine I got during an attack when I was a child. Within seconds I was breathing more easily. But at the same time, my heart began to race and pound against my chest. I hugged myself, trying in vain to make it stop, to keep it inside. But I knew I wouldn’t really feel any better until the epinephrine filtered out of my body.

Back then, doctors regularly prescribed pills with sympathetic system stimulants to keep the airways open and help prevent further attacks. These pills sometimes contained extra ingredients that were supposed to sedate the patient and offset the anxiety provoked by both the stimulants and the asthmatic attack itself. Well-intentioned though they were, they didn’t work. Instead, they used to send me on a drug roller coaster--the sedatives made me want to sleep, but I wasn’t able to because the stimulants gave me palpitations and made me tremble.

To calm Rosemary, I put my hands on her shoulders as if I could absorb the shudders. We’ll get you through this, I said slowly and firmly. We’ve done it before. She nodded shakily and silently. I had told her about my own struggles with asthma, and in some way it made me able to offer her another level of assurance--a sort of proof that I understood what she was dealing with because I’d been there. But despite this--and despite the fact that we both knew the choreography of the treatment--the asthma, the sleeplessness, and the side effects of the medications, let alone simply being in a hospital, overwhelmed my words and her reason.

So once I’d done my best with pharmaceuticals, I decided to turn to osteopathic manipulations. Doctors of osteopathy--like me--look at illness as a disequilibrium in the body and believe that through musculoskeletal manipulations we can achieve an anatomical balance that will help the body heal itself. To the uninitiated, osteopathic manipulations may seem like nothing more than a vigorous massage and a lot of back thumping. But I know that they can do a world of good for a patient. The massage and the thumping actually loosen the mucus plugs and help drain secretions. They increase blood flow to the chest muscles so the muscles don’t get tired as easily. They take pressure off the nerves that innervate these muscles so there is less chance of a dangerous muscle spasm. They align the joints where the ribs meet the vertebrae and the vertebrae themselves meet, thus helping the ribs move more efficiently in and out. And, because the nerves of the sympathetic nervous system run parallel to part of the spine, the massage and thumping stimulate them as well and can thus help open the airways.

For the patient, however, the most important part may be the actual touching. Rosemary, who was used to these manipulations, visibly relaxed as I began. There’s no denying the impact of therapeutic touch. This sort of laying of hands by physician onto patient is immensely comforting. It establishes trust and accelerates healing.

But it soon became obvious that this still wasn’t enough. Despite the oxygen, drugs, and manipulations, Rosemary was responding slowly, if at all. I had no choice but to check her into the hospital to monitor her condition closely and properly manage and administer her medications. Luckily, that’s as far as it had to go. Within a day or so I was sure that she wouldn’t require the more aggressive support of a respirator. And after five days in the hospital she was ready to go home. But before I let her go, we sat and carefully reviewed the instructions for the medicines she would have to continue taking. Anti-asthma agents are extremely potent, both in action and side effects. Theophylline, epinephrine, and other drugs to boost the sympathetic nervous system can overdo their job and cause cardiac arrhythmias or heart failure. Cortisone, given over a long period of time, can cause ulcers, cataracts, hypertension, osteoporosis, or even psychiatric symptoms. Though such reactions are fortunately rare if the patient is carefully monitored, these drugs, if not taken properly, can be worse than the disease.

They were for my patient Linda, a woman with whom I’d once had a similar talk. When I was an intern, Linda came to the hospital twice. The first time was in the summer when, like Rosemary, she was admitted for asthma that just wouldn’t respond to her usual medications. That was when we had our talk. The second time was eight months later, when she took an overdose of her theophylline. I recognized her immediately as she lay comatose on a stretcher. When I picked up the emergency room chart to review what had happened, my heart froze. I saw my name on the empty medicine bottle as the prescribing physician. Her sister told me that Linda had been despondent over a lost love. It’s possible that this emotional upset had triggered an asthma attack and she overdid the self-medicating. Or could her overdose have been a deliberate suicide attempt? I never found out the answer to that question. What I did find was that the level of theophylline in her blood was more than three times what it should have been. And none of our emergency measures could help. We transferred Linda to a better-equipped hospital for a type of dialysis called charcoal hemoperfusion, which is supposed to remove the drug from the blood. It’s the treatment of choice, but in this case it didn’t work. Linda died within 24 hours.

It was partly because of Linda, of course, that I was so careful with Rosemary, despite her years of experience with asthma. While she was in the hospital, I kept track of the levels of drugs in her blood until I had determined an optimal dosage. And as I discharged her, I made her promise that she would come back in two weeks to have the dosage checked yet again.

Since that attack, Rosemary has done quite well. Her blood levels are fine, and she has not had to be hospitalized for another attack. But though she’s beaten it time and again, she has a healthy respect for her disease. So do I.
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