Anyone who has ever had or witnessed an asthma attack is unlikely to forget it, especially if the victim is a child. The asthmatic victim wheezes and struggles to breathe through blocked and constricted airways. Panic may set in as breathing becomes more and more difficult. Severe attacks can lead to loss of consciousness and even death. Watching a child fight for air is one of the scariest scenarios any parent can face -- and an increasing number of parents now face that situation every day.
Rates of asthma, particularly among children, have been rising steadily for the past two decades, according to the Centers for Disease Control and Prevention. In the United States alone, 4.8 million children suffer from asthma, a chronic respiratory disease characterized by wheezing, coughing and difficulty exhaling air due to inflammation and narrowing of the airways. About one-third of all pediatric emergency room visits are due to asthma, and the condition is one of the primary causes of school absenteeism, leading to an average of 4.6 days per student missed annually.
In 1999, the Washington Department of Health stated that asthma was approaching epidemic proportions in the state. Locally, statistics reported by the Spokane Regional Health District bear out the national and state trends. Of households in Spokane County with children under age 18, one in five have at least one child with asthma. Spokane hospital visits due to asthma reached a peak of 457 in 1999 for children under 18. Health district officials estimate that total annual asthma-related costs in Spokane County exceed $16 million.
Why the Increase? -- Theories explaining the rising asthma rates abound, but none has been proven. Concerned parents may suspect everything from childhood immunizations to environmental chemical exposure, but researchers have yet to assign blame definitively. Some observers have even cast doubt on the veracity of the numbers, arguing that the only reason asthma rates appear to be rising is because of improved medical technology and an increased willingness to diagnose breathing difficulties as asthma. Dr. Michael McCarthy, a local pediatric allergist and pulmonologist, says while there's some truth to these claims, the increases are real.
"I believe that part of the rise is spurious because we're diagnosing milder cases now," he explains. "But epidemiologists have been very careful to work with the statistics to weed out that factor and see that there is a real rise."
When rates of asthma first began to increase, many people suspected the cause was increasing air pollution and exposure to chemicals in the environment. But McCarthy sees problems with that argument as well.
"Changes in air pollution may be part of it, but that's not the whole story," he says. "Yes, the air is a lot dirtier now than it was a hundred years ago, but it's cleaner than it was 10 or 20 years ago, when the rates began increasing."
Because so many kids have tested positive for allergies to dust, mold and animal dander, allergists have long argued for a pristine home environment free of all germs and potential allergens. But the newest theory holds the opposite point of view. According to proponents of what's called the Hygiene Hypothesis, modern life has become too clean and antiseptic for our own good.
"The hygiene hypothesis says our homes are so clean now and there's protection from childhood diseases, so the immune system is not busy enough," McCarthy says. "Instead of fighting illnesses, it develops asthma and allergies. This is not a proven fact, but it's the leading theory right now." Supporters of the hygiene hypothesis point to studies showing lower asthma rates in children from rural areas who are, presumably, exposed to more animals and dirt than their urban counterparts.
Socioeconomic Factors -- Whatever's causing the rising asthma rates, children from low-income families tend to be at higher risk for asthma than their counterparts with more family resources. Because of Spokane's notoriously high rates of poverty -- nearly half of Spokane County children qualify for Medicaid services -- asthma prevalence locally is slightly higher than either state or national averages.
"Lack of access to regular health care services is one of the biggest factors for poor kids," says Lyndia Vold, manager of the Assessment/Epidemiology Center at the Spokane Regional Health District. "Children from low-income families also have higher exposure to asthma 'triggers' like dust, mold and smoke. There are often language and literacy barriers as well."
When low-income children don't have access to preventive care, they often end up needing high-cost emergency services, Vold says. From 1998 to 2001, Medicaid claims for asthma totaled more than $1.2 million in Spokane County. Public health nurses now work with high-risk families to coordinate between child-care providers, parents and physicians. In addition, the Inland Northwest Asthma Coalition works on outreach efforts to visit asthma-affected families in their homes.
While poverty may contribute to higher asthma rates in Spokane, we don't suffer from some of the environmental factors that plague other parts of the country. For example, our dry climate minimizes the population of dust mites, those nasty microscopic creatures that can thrive in bedding and carpets, munching away on sloughed-off skin cells and other organic components of dust. Spokane's asthmatics aren't home free, however.
"We have significant problems here with particulate pollution," McCarthy says, discussing the small particles that come from woodsmoke, grass burning and forest fires. These particles affect asthmatics whether their asthma is due to allergies. "About 70 percent of kids with asthma have allergies. We have a grass pollen season from mid-May to mid-July, and also outdoor mold allergies, despite the dry climate."
Some of the biggest threats to children with asthma come from inside the home. Much of our time is spent indoors now, in energy-efficient air-tight homes where allergens and other asthma "triggers" concentrate. Tobacco smoke leads the list of indoor hazards, but other problems include radon, combustion gases, pet dander and volatile organic compounds present in paints, cleaners, and perfumes.
Treatments -- Once a child has been diagnosed with asthma, the choice of treatment depends on the severity of symptoms. The most common and immediate treatment for asthma is an inhaled fast-acting bronchodilator such as albuterol, which is now referred to as a "rescue" medication. In recent years, physicians have moved toward daily preventive treatment with increasingly effective anti-inflammatory agents.
"Research indicates that with asthma there's inflammation of the airways that remains even when the episode is over," McCarthy explains. "If episodes are frequent, there's ongoing inflammation. And it probably causes harm."
Researchers have not proven that chronic inflammation causes permanent lung damage, he says, but the aim of newer treatment strategies is to reduce inflammation with daily preventive treatment.
"The most effective of these are the inhaled corticosteroids," he says. "There are some concerns with steroids at high doses, but at low doses they have generally high safety margins."
Despite the effectiveness of corticosteroids, some patients have reported effects including suppression of the immune system, hoarseness, weight gain and thrush, an infection of the mouth and throat. Milder anti-inflammatory agents such as cromolyn and a newer class of drugs called leukotriene modifiers may work for those whose symptoms are less severe.
Alternative and complementary therapies for asthma include acupuncture, acupressure, herbs, nutritional supplements, dietary modifications and homeopathy, although their effectiveness is debated by physicians. Regardless of therapy choices, most experts agree that regular exercise and a healthy diet can go a long way toward easing asthma symptoms. But all children with asthma must have regular access to health care services in order to minimize individual symptoms as well as societal costs, says the health district's Lyndia Vold.
"The key thing with asthma is access," she says. "If kids end up in the emergency room, that's not a cost-effective use of our community resources."
Publication date: 05/01/03