There is no doubt that within the last three decades we have witnessed a striking increase in asthma deaths. The International Consensus Report on the Diagnosis and Management of Asthma, issued recently by the National Institutes of Health, reflects the views of most conventional chest physicians in laying the blame squarely on “underdiagnosis and inappropriate treatment” (shorthand for not enough steroids). But this is hardly an adequate explanation for the strange harmlessness of the same condition a couple of generations ago, when diagnosis and treatment were primitive and steroids weren’t used.Most concern about asthma drugs has focussed on the group called beta-agonists. After the upsurge in asthma deaths in the mid 1960s, there was a general perception among the public that asthma inhalents were dangerous; drug consumption fell and mortality fell. By the mid 1970s physicians had regained their confidence with the new generation of “safe” bronchodilators and prescription rates started rising again, to be followed shortly by death rates (Recent Advances in Respiratory Medicine Vol 4, 1986, 1-11).

Many autopsies have been carried out on patients who have died of asthma. Two types of picture emerge. The most common is of widespread plugging of bronchi and bronchioles the airways leading to the lungs with thick mucus, often so thick and hard that it cannot be sucked up with a pipette but has to be cut with a knife. Embedded in the mucus are numerous inflammatory cells (neutrophils and eosinophils), together with clumps or even sheets of epithelial cells (cells which normally line the inner surface). These patients have usually died in hospital after several days or weeks of increasingly aggressive treatment (J Allergy Clin Immunology 1987, 80: 415-6). On the other hand there are those who die unexpectedly, in their homes or at work, and in these cases the airways are often empty on post mortem, having relaxed after death from the tight and sudden broncho-constriction that was the presumed cause of death (J Allergy Clin Immunology 1987, 80: 415-6).

The wheezing of asthma is caused by narrowing of the bronchi and bronchioles. This is caused by inflammation. Inflammation is the body’s defence and repair mechanism for coping with “insults” from the environment such as germs, harmful chemicals, extremes of heat and cold, radiation and trauma.

Allergy, in immunologist’s terminology, is an immunologic process that leads to inflammation. In other words allergy is one of the body’s natural protective mechanisms. Asthma itself must be protective in some way against some insult.

When the Highways Department decides to repair a stretch of motorway, it closes some of the carriageways and considerable congestion results while the repairs get done and traffic simply has to stop or use another route.

The bronchi may be looked upon in the same light. For repairs to be carried out on an air tube, it may have to be narrowed or completely stopped for a while. Total airflow is of course restricted, although the chest has considerable spare capacity. Although the amount of air passing through that stretch of bronchus may be reduced, its velocity and turbulence are increased (The Lancet 1989, ii: 836-7), giving rise to a “scouring” action that would encourage the mucus (and any particles or chemicals trapped therein) to become detached from the inner wall of the bronchus and be forced up towards the throat.

This effect would be seriously compromised by any drug which permitted the secretion of mucus but prevented it from being carried away (by preventing, the bronchoconstriction that sets up the scouring).

Beta-agonists certainly would be expected to do this, and at first sight it would seem that we must support the belief of most chest physicians that steroids should be used more aggressively, since steroids suppress inflammation. But there are four main snags to the use of steroids: (1) steroids, even the inhaled variety, are just too dangerous (Br Medical Journal 1990, 300: 1548-51); (2) they don’t always work (Clin Exp Allergy 1992, 22: 315-7) as for instance when the inflammation is caused not by an immune reaction but by direct toxicity and (3) not all mucus secretion is caused by inflammation. It can also be stimulated directly by certain plant toxins called lectins (The Lancet 1978, i: 585-6), abundant in pollen grains and other allergenic particles (J Nutr Med 1991, 2: 45-64).

Steroids also wouldn’t be expected to stop mucus secretion but merely prevent the mucus from being coughed up. The mucus would stay in the airway, getting drier and stickier.

And even if we could find the perfect drug, that entirely suppressed not only inflammation but also mucus secretion so that mucus plugging and asthma fatalities were abolished, it would still in theory leave the body open to pollen and mite toxins, which would probably exert effects on distant, non pulmonary sites and might be even worse.

Asthma, like other forms of inflammation, is actually a natural self cleaning and repair mechanism for the bronchi.

Experiments with pollen grains and housedust mites showed a startling degree of toxicity (Allergy 1983, 38: 477-486) causing inflammation. But eventually the immune inflammation drives the whole particle and soluble products out of the body (though at the cost of causing symptoms). We must therefore be very cautious about using drugs that prevent this natural defence mechanism.

It is the doctors who have turned asthma into a killer. Any drug, that effectively reverses constriction and inflammation of the airways, renders the patient more susceptible to the direct toxic effects of the particles and chemicals that the inflammation was trying to remove, and therefore is likely to increase mortality.

Breathing problems also affect people who are very allergic to some types of shellfish, nuts, medications and insect bites. These people can suffer an allergic reaction called anaphylactic shock. This reaction begins within minutes of exposure to the substance causing the allergy. During this type of allergic reaction, the airways narrow, making it difficult to breathe. Soon, the heartbeat races and blood pressure drops. Anaphylactic shock can be fatal if a person is not treated within 15 minutes.

Breathing problems from some things may require emergency care.

In children they include:

• Wheezing (see page 263)
  
• Croup, a virus with a “barking cough” common in young children (see page 255)
  
• Diphtheria, which is a very contagious throat infection
  
• Heart defects children are born with
  

• Severe allergic reactions
  
• A face, head, nose or lung injury
  
• Carbon monoxide poisoning
  
• Harsh chemical burns in the air passages
  
• Epiglottitis, which is inflammation of the flap of tissue at the back of the throat that can close off the windpipe
  
• Choking (see page 298)
  
• Drug overdose
  
• Poisoning (see page 322)
  
• Asthma (see page 76)
  
• Bronchitis (see page 81)
  
• Pneumonia (see page 369)
  

• Emphysema (see page 348)
  
• Congestive heart failure
  
• Heart attack (see “Chest Pains” on page 150 and “Coronary Heart Disease” on page 343)
  
• Blood clot in a lung
  
• Collapse of a lung
  

• Avoid allergic substances or agents that induce asthma, if you have it.
  
• Do not walk, run or jog on roads with heavy automobile traffic.
  
• If you have a gas furnace, install a carbon monoxide detector.
  
• Never leave your car running in a closed garage.
  
• Make sure immunizations against childhood diseases, especially diphtheria, are up-to-date. This is part of the Diphtheria, Tetanus, Pertussis (DTP) vaccination. (See “Immunization Schedule” on page 18.)
  
• If you smoke, quit.
  
• Keep small objects a child could choke on out of reach and do not give gum, (especially bubble gum), nuts, hard candy, or popcorn to children under 5 years old.
  
• Lock up all medications and poisonous substances so small children can’t get to them.
  

Has breathing stopped and is there no pulse?
Has breathing stopped, but there is a pulse?
Has breathing stopped due to choking on an inhaled object?
Are there signs of anaphylactic shock? Difficulty breathing Swollen tongue, eyes, or face Unconsciousness Difficulty in swallowing Dizziness, weakness Pounding heart Itching, hives
Are any of these problems present with difficulty in breathing? Signs of a heart attack such as chest pain, pressure, or tightness; pain that spreads to the arm, neck or jaw; irregular pulse. Serious injury to the face, head, or chest Signs of a stroke such as blurred or double vision, slurred speech, one-side body weakness or paralysis Signs of drug overdose such as drunkenlike behavior, slurred speech, slow or rapid pulse, heavy sweating, enlarged or very small eye pupils
Is it so hard to breathe that the person can’t talk (say 4 or 5 words between breaths) and/or is there wheezing that doesn’t go away?
Is blood being coughed up?
Does the difficulty in breathing occur with a cough in a baby and does it make the baby unable to eat or take a bottle?
Are any of these signs present? Breathlessness at night or at rest Pink or frothy phlegm being coughed up and/or A high fever along with rapid and labored breathing
Is a green, yellow, or gray mucus being coughed up?

• Wear a face mask that covers the nose and mouth, when outdoors. Most hardware stores carry inexpensive ones.
  
• Don’t smoke. Avoid secondhand smoke. This applies to anyone with breathing difficulties.
  
• Install an electronic air filtering system or use an air purifier in your home, especially in the bedroom. Tests show that air filters help clear the air of allergy-causing agents.
  

Breathing problems can be avoided or lessened if you:

• Do not rake leaves that have been on the ground for awhile. Molds and mildew grow on leaves after they’ve been on the ground for a few days.
  
• Keep your basement dry, well ventilated, and well lit. Use dehumidifiers and exhaust fans to reduce moisture in the air.
  
• Get rid of house plants.
  
• Avoid barns, chicken coops, damp basements, and attics.
  

See also: “Asthma” on page 76, “Bronchitis” on page 81, “Common Cold” on page 83, “Coughs” on page 85, and “Flu” on page 87.

Adults: Conscious Victim


1. Choking is indicated by the Universal Distress Signal (hands clutching the throat).

2. If the victim can speak, cough or breathe, do not interfere.

If the victim cannot speak, cough or breathe, give abdominal thrusts (the Heimlich maneuver).

Reach around the victim’s waist. Position one clenched fist above navel and below rib cage. Grasp fist with other hand. Pull the clenched fist sharply and directly backward and upward under the rib cage 6 to 10 times quickly.

In case of extreme obesity or late pregnancy, give chest thrusts. Stand behind victim. Place thumb of left fist against middle of breastbone, not below it. Grab fist with right hand. Squeeze chest 4 times quickly.

3. Continue uninterrupted until the obstruction is relieved or advanced life support is available. In either case, the victim should be examined by a physician as soon as possible.

If Victim Becomes Unconscious


1. Position victim on back, arms by side.

2. Shout for “Help”. Call 9-1-1 or the local emergency number.

3. Perform finger sweep to try to remove the foreign body.

4. Perform rescue breathing. If unsuccessful, give 610 abdominal thrusts (the Heimlich maneuver).

5. Repeat sequence: perform finger sweep, attempt rescue breathing, perform abdominal thrusts, until successful.

6. Continue uninterrupted until obstruction is removed or advanced life support is available. When successful, have the victim examined by a physician as soon as possible.

7. After obstruction is removed, begin the ABC’s of CPR, if necessary.

Conscious Infant (Under 1 year old)


1. Support the head and neck with one hand. Straddle the infant face down over your forearm, head lower than trunk, supported on your thigh.

2. Deliver four back blows, forcefully, with the heel of the hand between the infant’s shoulder blades.

3. While supporting the head, immediately sandwich the infant between your hands and turn onto its back, head lower than trunk.

4. Using 2 or 3 fingers (see illustration for finger position), deliver four thrusts in the sternal (breastbone) region. Depress the sternum 1/2 to 1 inch for each thrust. Avoid the tip of the sternum.

5. Repeat both back blows and chest thrusts until foreign body is expelled or the infant becomes unconscious.

ALTERNATE METHOD: Lay the infant face down on your lap, head lower than trunk and firmly supported. Perform 4 back blows. Turn infant on its back as a unit and perform 4 chest thrusts.

Unconscious Infant


1. Shout for help. Call 9-1-1 or the local emergency number.

2. Perform tongue-jaw lift. If you see the foreign body, remove it.

3. Attempt rescue breathing.

4. Perform the sequence of back blows and chest thrusts as described for conscious infant.

5. After each sequence of back blows and chest thrusts, look for the foreign body and, if visible, remove it.

6. Attempt rescue breathing. Repeat steps
4 and 5.

7. If foreign body is removed and victim is not breathing, begin the ABC’s of CPR.

Conscious Child (Over 1 year old)


To dislodge an object from the airway of a child:

• Perform abdominal thrusts (the Heimlich maneuver) as described for adults. Avoid being overly forceful.
  

• Do not perform blind finger sweep in children up to 8 years old. Instead, perform a tongue-jaw lift and remove foreign body only if you can see it.