Dr. Gail Brottman
Appearances
Health Chatter
Asthma
And they don't wheeze again necessarily because they just don't have those risk factors. There's another group of children Um, that, uh, is called our late onset wheezers, which this is more your typical asthma where, um, they don't really start wheezing until they're five to seven years old. They're more associated with, uh, developing allergies, seasonal allergies, sometimes food allergies.
Health Chatter
Asthma
Again, most of those kids, there's some family history, maybe not of asthma, but the parents have seasonal allergies or food allergies or something like that. And then there's the other group of children, which we call persistent wheezers, which these are the children that start wheezing when they're young, when they're babies.
Health Chatter
Asthma
Their parents have asthma, they have eczema, there's a lot of allergies. And these are the babies that really develop asthma. Anywhere from 70 to 85% of those children will develop asthma by the time they're age seven. Now, your question about sort of how does this go into adulthood? I think for and not practicing adult medicine. So I'm going to just qualify that.
Health Chatter
Asthma
You know, I think that things change actually quite a bit in adolescence. And this is where we see maybe there's some hormonal, you know, influence on what's happening in your airways or something like that, there are a fair amount of adolescents that will stop wheezing and actually not need to use their asthma controller medicine anymore.
Health Chatter
Asthma
And so maybe we would say they've kind of outgrown their asthma. I think that my experience, in my opinion, is that if you had asthma as a child, even though you don't have any current asthma symptoms, that if you are exposed to the right trigger, which is what our term is for something that will cause you to have asthma symptoms or an asthma attack, that you probably are going to waste.
Health Chatter
Asthma
And I think that gets into the air pollution. I mean, I think that that when you're talking about people who have sensitivities, right, where, you know, they're maybe, they only need to use their inhaler when they run. Like I'm starting to train for a marathon and I started to get short of breath and I couldn't figure out what was happening.
Health Chatter
Asthma
And then, oh yeah, I used to have asthma when I was younger. Right. Excuse me. So I think that I think that plays a role. The other piece of this, and I really, I can't speak a lot about this because again, I'm not an adult provider, but there also is something that is called the asthma COPD overlap syndrome, where adults who continue to have asthma
Health Chatter
Asthma
who maybe smoke or are exposed to some toxins in their workplace can actually go from having asthma to COPD at a younger age than would be expected for somebody to develop COPD. So there's a lot of research being done on this asthma COPD overlap syndrome. There's a lot of work being done on trying to figure out Why do these early wheezers stop wheezing?
Health Chatter
Asthma
Why do they wheeze in the first place and then why do they stop wheezing? So there's a lot of science happening, which is very exciting to give us a better idea of how to treat people with these conditions.
Health Chatter
Asthma
So asthma is, at least today, right this minute, asthma is not curable. But as we talked about, it is treatable. And that's with what I mentioned, the word controller medication, which is a medicine that actually decreases the swelling or inflammation in your airway. So Our controller medications, which usually come in the form of inhalers.
Health Chatter
Asthma
There are now some biologics, which are injections or IV medications that are used for people with more severe infections. But for your general population, what we're talking about is daily inhalers that someone would take to decrease the swelling or inflammation in the airways over time.
Health Chatter
Asthma
So that's a great question. And so it actually depends on the severity of your asthma and how often you're having symptoms. So it's very hard, especially in young children. So we cannot do lung function testing in young children. Actually, we can do it, but it's really tricky.
Health Chatter
Asthma
So I don't know if people are familiar with doing a breathing test where you blow into this machine and you keep blowing, blowing, blowing, blowing, and that actually measures how wide open your air tubes are, right? So if your air tubes are narrowed, by this swelling or inflammation, you would not be able to push as much air through.
Health Chatter
Asthma
And so the numbers on these pulmonary function tests goes down, right? So if your air tubes are like, swollen and you can only blow 50%, then that's a problem. And that means that there's a lot of swelling in those air tubes.
Health Chatter
Asthma
And if your lung function is only 50% of predicted, then you need to take a daily preventive medicine every day, even if you're not actively having what I would call an asthma attacks. I want to get back to one thing that you said earlier, which I think is really important, that people who have chronic asthma that have ongoing airway narrowing. can get really used to how they're breathing, right?
Health Chatter
Asthma
And so they may not feel short of breath, just walking around or sitting around, even though their lung function is not normal. The problem is, is if you're starting with air tubes that are 50% closed up,
Health Chatter
Asthma
you're the it's going to be that much easier if you get into some sort of trigger like smoke or bad air or something like that for you to have an asthma attack versus if you have air tubes that are 100% open or 90% open, right, the likelihood that you're gonna have an asthma attack is really, really decreased.
Health Chatter
Asthma
And so, you know, part of the way we determine, and this is especially for young children, about how much swelling is in the air tubes is by how often they have symptoms, right? And so it's really, really important for people to tell their healthcare provider that, well, no, I don't hear my kid wheezing every day, but they can't do gym, right? They can't run because they get short of breath.
Health Chatter
Asthma
Well, that's a symptom. Kids should be able to run and not get short of breath. Right. So it might not be that they're having asthma attacks where they're gasping for air or wheezing or sucking in or looking scary. Right. But those little symptoms are really, really important clues as to how open they
Health Chatter
Asthma
the air tubes are, and actually should guide your healthcare provider as to determining whether or not you need to have a daily preventive medicine, which we call an asthma controller, or, you know, just a rescue medicine before exercise. So it's really kind of looking at clues to see if we can tell how much swelling is. Again,
Health Chatter
Asthma
and I'm going to probably say this a million more times during our conversation, it's all about airway inflammation and how much is there, what's triggering it and how do we decrease it and in an, or in an effort to really control the asthma symptoms and prevent asthma attacks. All right.
Health Chatter
Asthma
Right. Well, and that's a great question, Stan. And we do this all the time, right? Because anesthesia is a risk for people with asthma, right? It's not only surgeries, but For example, dental procedures, right? We have pediatric dentists here at Hennepin that do amazing work on all different kinds of kids with all different kinds of respiratory issues.
Health Chatter
Asthma
And, you know, they need to make sure that these kids are breathing properly. before they're going to sedate them. Right, right. And again, it really gets back to trying to make an assessment of how somebody's lungs are functioning. At a point in time.
Health Chatter
Asthma
And we do a lot of visits like, you know, two weeks before, a month before a scheduled surgery to make an evaluation. And quite frankly, you know, I have told parents and surgeons that if I think that a child's lungs are not in optimal condition that they should, you know, put it off in the surgery because of the risk. And obviously, you know, it's not always elective, right?
Health Chatter
Asthma
We work at a level one trauma center here. And again, you know, I think it's really about trying to make an assessment of how much swelling is in those airways. How well is your asthma controlled? So there are actually, and people can look it up online.
Health Chatter
Asthma
If they look up asthma control test, this was a survey that was developed actually by a drug company called GlaxoSmithKline, but it's available in multiple languages. And It's actually, there's a test, asthma control test for ages four to 11 and for 12 and above. And it basically says, how often are you having symptoms, right?
Health Chatter
Asthma
And again, what we said was that the more symptoms somebody is having, and I'm not talking asthma attacks, I'm just talking, how often do you cough during the day? How do you get short of breath with normal activity? How often do you need to use your rescue or albuterol inhaler?
Health Chatter
Asthma
If your asthma control test score is less than 20, and if your child's asthma control test score is less than 20, their asthma is not well controlled. And again, it's getting back to the symptoms of airway inflammation,
Health Chatter
Asthma
Yes, yes. And, you know, and I'm going to sort of break this into a couple of different sort of ways to look at it. So really the, the, in the United States, the highest risk of asthma is in the Puerto Rican population. Interesting. In Puerto Rico. Yeah. And that I believe has to do with genetics, quite frankly. Okay.
Health Chatter
Asthma
So if you look at populations, Puerto Ricans by far have the highest risk of asthma of any of any
Health Chatter
Asthma
I'm calling them a population realizing that, you know, there are many, many, many different Hispanic, Latinx people with different, from different areas of the world and different genetics, quite frankly. And then the other populations that have higher prevalence of asthma, quite frankly, are African-Americans and also Native Americans, quite frankly.
Health Chatter
Asthma
And I think some of that is genetics, but some of that is basically due to differences in historical racism, in housing, in exposures to pollutants and exposure to tobacco. So there are genetics, I believe, that play a role. But I believe and I know for a fact that there are health disparities in our communities of color.
Health Chatter
Asthma
because of poverty, housing, and exposures to pollutants and things that really put people at higher risk for asthma.
Health Chatter
Asthma
So as with any, as with any chronic illness, There are multiple factors involved, as we talked about, right? And I think that the importance of having a public health approach to something like asthma is absolutely 100% necessary, right?
Health Chatter
Asthma
So it's, you know, it's, and let me just sort of go through the, I'm thinking about bubbles that all intersect, right, around somebody with asthma, if you can visualize that Venn diagram of bubbles, right? Yeah. So, you know, if you're talking about housing, right, that there needs to be some standards about housing. And if somebody, if people are living in poor housing conditions,
Health Chatter
Asthma
How do they evaluate that? Is there somebody available to evaluate that? Are there standards for that? That is actually, there are live links. This asthma state plan is really wonderful. The fact that they, it used to be a book, it probably still is a book, but it wasn't very useful as a book because nobody ever looked at the book.
Health Chatter
Asthma
Right now it's online and he has live links to all these amazing resources. So if you have a question about, you know, okay, how do I look for asthma triggers in my house? Or is there somebody who could come out to look at my house? That's available on the state plan, right? The issue about provider education, right? I mean, there's a lot of providers that maybe, you know, I mean, for
Health Chatter
Asthma
don't really understand how to diagnose asthma in young children. And what is the appropriate medication? What are the new guidelines? That's available on the state plan. There are links for health care providers. Schools, for example, right? Our kids are in school all day. Do the school nurses know how to identify asthma? Are there triggers in school? What kind of medicines?
Health Chatter
Asthma
So there's links for the school nurses. Daycares. So again, I mean, taking a very global approach to multiple different agencies and venues that all are in some way involved in in touching, if you will, people with asthma. And this isn't just for children, this is for adults as well.
Health Chatter
Asthma
So asthma is a condition that many people have that causes swelling or the other word we use for it is inflammation in the airways. And what happens is when you get swelling or inflammation in your airways, your airways are the things that allow you to bring air and oxygen into your lungs and breathe the carbon dioxide out of your lungs. And so really they're just a series of tubes.
Health Chatter
Asthma
And so, you know, I think that really the goal is that it's not just, I mean, part of it is that you have to be diagnosed with asthma, first of all, and you have to get proper treatment. But, you know, if you're constantly exposed to, you know, allergies or mold or something like that in your home.
Health Chatter
Asthma
And if the, you know, you don't have an inhaler at school, or your workplace, you have like some toxic environment at your workplace, or, you know, all these things, all of these things have to come together in order to help control asthma. And quite frankly, you know, with the environmental pieces with
Health Chatter
Asthma
climate change and air quality standards and things like that, calling out redlining and where housing is along highways and asthma. prevalence along highways, all that information is on this website, right? Easily findable, easily findable, cool maps, but it really is going to help people advocate for improvements in each one of those sectors.
Health Chatter
Asthma
And so by having everybody work towards the same goal, Right. That's going to be what helps not only decrease the number of people developing asthma, hopefully, but also having asthma symptoms. And by decreasing the number of emergency room visits and hospitalizations from asthma, that is going to decrease the cost. Plus, let me ask you this from work.
Health Chatter
Asthma
Yeah. So this is again, and I, this is, this is the theme. If you want to talk about airway inflammation and swelling and irritants, I mean,
Health Chatter
Asthma
think about what happens when you get smoke in your um eyes um and your eyes start watering right that's your body's way of protecting itself right because you start tearing and it's supposed to rinse out your eyes you get you get stuff in your nose your nose starts watering you sneeze you get mucus because the job of your lining of your nose and the lining of your airways
Health Chatter
Asthma
is to try to keep stuff from getting way down in those little air sacs where the oxygen goes. And so what happens when you breathe in These small particles, you might see the term PM 2.5 or PM 10 or something. Those are particles, very tiny particles. The smaller the particle, the deeper into your lungs they can go. And again, it's an irritant and can cause swelling and mucus.
Health Chatter
Asthma
And again, it's the swelling and the mucus and the irritants that can cause you to have trouble with your asthma. So, you know, I think everybody can relate to that. You is that I have recently downloaded on my phone and I just pulled up my my cell phone here. I have recently downloaded it's called air now.gov.
Health Chatter
Asthma
And if the tubes get narrowed, it makes it harder to push air through. And that's basically what happens in people with asthma. The airways get swollen. You get extra mucus that builds up in the airways for a variety of reasons. And subsequently, it makes it harder to breathe.
Health Chatter
Asthma
And it's a free app that you can put on your phone, you put in your zip code, and it will give you The number for what the air quality is in your zip code and it tells you sort of what it looks like tomorrow, and I will tell you so for people who are sensitive that if it's all if the air if they. you know, if the air quality index, which is what it's called, is over 100, which is bad.
Health Chatter
Asthma
So the lower the air quality index, the cleaner the air is. So lower is better. Higher is terrible. If it's over 100, then we're recommending that, you know, kids with asthma limit their outdoor activities and for sure, like don't play soccer or football or tennis or.
Health Chatter
Asthma
I have, I have been telling people in my clinic, literally while they're sitting there and we're having our visit, I just say, just download this and you'll have it. It's very helpful. But, um, So, Stan, can I just circle back for a minute? I want to talk about two things, obviously. I know you have an agenda here, but I have an agenda here, actually, as an advocate for asthma, people with asthma.
Health Chatter
Asthma
I want to talk about two things. I want to talk about communication with diverse communities, because I've been here at Hennepin Healthcare for 31 years now. As of July 1st, this has been my lifelong career to work with communities of color and try to help address health disparities around any respiratory issue, but obviously asthma is my passion. And I think that
Health Chatter
Asthma
one of the challenges, and really, honestly, this is where the community needs to help step up to help itself, is that, you know, and I'm just, you're a straightforward person. I'm just gonna call this out. There's a lot of mistrust with communities of color and the healthcare system. I mean, that's historical.
Health Chatter
Asthma
It's, it's, it's well founded for good reasons which we're not going to talk about today, but it does exist. And so I think that in community in communications, especially with communicating
Health Chatter
Asthma
about chronic conditions, about chronic medications that people might be a little afraid of or, you know, use the word steroids and people think of the Olympics and bulk up steroids and oh my gosh, and they're terrible. And so there needs to be communication from community members who really can help advocate
Health Chatter
Asthma
to other community members that asthma is a controllable disease, that it does not have to be limiting, that if you have questions about medications, that you should ask your healthcare provider, that if there are trust issues with the person that you're seeing, you need to just see somebody else. I work very closely.
Health Chatter
Asthma
In fact, I also have a clinic at North Point, which has been a great advocate for the community of color in North Minneapolis. So I think that from a public health perspective also, how people hear things and who the message is coming from is absolutely critical. And so I'm just going to put that out there if people want to know what they can do to help, right?
Health Chatter
Asthma
It is really find some trusted members of the healthcare community, community health workers, again, the strategic asthma plan has some resources, but for the Native American community, I think that having peers talk about this in a straightforward way and really advocate that this is something that you or your child does not have to suffer with because there is help.
Health Chatter
Asthma
And the other piece that I want to really advocate for is that once people get connected with a trusted health care provider, that they need a written asthma plan. And the reason is exactly what you said. Like, well, what if somebody is walking around and all of a sudden they have an asthma attack? What do they do? Right.
Health Chatter
Asthma
And and once somebody gets connected with a health care provider that's helping them actively manage their asthma, much like diabetes. Right. What do I do if my blood sugar goes high? Well, you take this much more insulin. What do I do if I'm having more asthma symptoms? We have asthma plans that are written very specifically and they look like stoplights, right?
Health Chatter
Asthma
So we have a green zone, meaning go. This is your daily asthma medication. This is what you do in the yellow zone. If you're starting to have more asthma symptoms, these are the medications that you take as your rescue medicines.
Health Chatter
Asthma
In the red zone, if your symptoms aren't getting better, if your child is having more symptoms of respiratory distress, this is what you do before you call 911 or go to the emergency room, right? And I will tell you that having the appropriate knowledge, right?
Health Chatter
Asthma
This is again about communication, knowledge and understanding of what the different medicines do and when they should be used, that this can make all the difference in the world for a parent who's at home on a Saturday night and their child starts wheezing and they're like, oh my gosh, the clinic's closed. What do I do? And so they have the medication and the tools. to start helping their child.
Health Chatter
Asthma
It's again, it's like having Tylenol at home or ibuprofen, right? What if you have a fever? Oh, well, we're just going to give them some Tylenol, right? So again, having a plan, understanding about what to use when can really, really make a big difference for, you know, I think you bring up a, you bring up a great
Health Chatter
Asthma
Well, I just, and I just want to make a comment about what you said about asthma being debilitating, Stan, because I think it's really, really important for people to understand that we have really good treatments for asthma now. And There are Olympic athletes that have asthma like gold medal winning Olympic athletes.
Health Chatter
Asthma
Michael Phelps has a famous swimmer and Jackie Joyner Kersey, who was one of the world's fastest women runners has asthma. And so I just, I just want people to know that while, you know, asthma can be a problem,
Health Chatter
Asthma
and definitely can cause difficulty with breathing and you get uncomfortable and things like that, that it really doesn't have to be debilitating and it doesn't have to become a disability, especially in adulthood, if it's treated early. and treated properly. And so that's where I come in as a pediatric pulmonologist.
Health Chatter
Asthma
I think that it's really important for children to have a diagnosis of asthma made as early as possible. And I think one of the challenges for pediatricians, family physicians, is that there are other things that can cause babies and young children to wheeze. As we know, viruses can cause wheezing that are self-limited, that are not asthma. But when you have children
Health Chatter
Asthma
who have recurrent episodes of wheezing, especially between colds, right? So if you're having wheezing with a runny nose and a cold and your child is in daycare, then your pediatrician or your family doctor is going to say, Oh, yeah, it's probably just a respiratory viral illness. It'll be fine.
Health Chatter
Asthma
But if these are recurrent episodes of wheezing where you're seeing that when your child is running and playing that they get short of breath, they seem like they're really not able to catch their breath. Maybe they just sit down and say, I'm tired. I don't want to run anymore. That's not normal for kids, right? Maybe grownups are lazy or whatever. Kids are not lazy.
Health Chatter
Asthma
And I say that with all seriousness. So, excuse me, it's important that if the child has recurrent, and I'm underlining recurrent, episodes of wheezing or shortness of breath or a cough that won't go away, especially when they're not sick,
Health Chatter
Asthma
Those are symptoms of childhood asthma and, you know, there's sort of a urban myth, maybe it's a medical myth that children under the age of five cannot be diagnosed with asthma and actually that's not true. You can diagnose asthma in young children.
Health Chatter
Asthma
Um, but at that point, that's where I come in as a lung specialist for children, where if, uh, if your primary care provider isn't sure if it's asthma, then, you know, people might want to say, Hey, uh, can you refer me to a specialist? Because I just feel like this is more than a cold or recurrent viral infections. And so I think that's really important for people to know.
Health Chatter
Asthma
It was epinephrine. They gave you a shot of epinephrine or known as adrenaline.
Health Chatter
Asthma
So very fortunately, and I've been actually doing this for quite a long time as well. But a long time ago, we really didn't have a lot of good asthma medicines. And more importantly, we didn't really understand that the key component of an asthma attack, if you will, was actually swelling of the airways.
Health Chatter
Asthma
And really what we thought asthma was, was just that the muscles that are around the air tubes in your lungs were just squeezing tight. And so the adrenaline would relax those muscles. And so that's why we used it. We also used to use a medicine called theophylline, which we don't really use anymore. But what happened with a lot of really good medical research over the years
Health Chatter
Asthma
is now we have a more specific medication that is administered either in an inhaler or a nebulizer that is very specific to relax the muscles. This medication is called albuterol. And we call that a rescue medicine. But the most important thing is that now when somebody is having an asthma attack, we know that albuterol is just a temporary relief.
Health Chatter
Asthma
It's kind of like giving Tylenol for a fever, right? So that Tylenol is not treating the cause of the fever. It's just treating the symptom. And that's what albuterol does. It just relaxes the muscles and that we know now what's important to do when somebody is having an asthma attack is to also give them a medicine to decrease the swelling. And typically those are medicines called steroids.
Health Chatter
Asthma
Um, you might've heard the, uh, name prednisone or prednisolone or decadron or dexamethasone, but those medicines need to be used together because if you just use the rescue medicine or the albuterol or even the epinephrine, right, the epinephrine would wear off and then they'd have to give it again. Right. Because again,
Health Chatter
Asthma
it wasn't treating the swelling, which is really causing the airway narrowing over a period of time. And so that's really changed this whole idea of airway inflammation or swelling has really totally changed the whole frame shift of how we treat asthma.
Health Chatter
Asthma
And I think, again, that's really, really important for people to understand that by addressing these chronic issues in the airways with asthma controller medicines that would be taken daily to decrease the swelling, you can prevent those asthma attacks. And that's really, really key.
Health Chatter
Asthma
Well, that's a really good question. And actually, I don't know that I have a good answer because really our understanding of asthma as it develops in childhood, that you have this swelling in your air tubes that may not always be terrible. It kind of can get worse and better over time. What we do know that there are different,
Health Chatter
Asthma
groups, let's just say, of children that have asthma and those relate to risk factors. And let me just explain that briefly. So we understand that asthma runs in families, right? So I don't know if your parents had asthma or allergies, but we know For example, I have very curly hair. My mother had curly hair. My daughter has curly hair. I have freckles.
Health Chatter
Asthma
So we know that many, many, many things in our body are determined by genetics and asthma is really no different than that, right? And so if you have a genetic predisposition because of family history, If you yourself have allergies or eczema,
Health Chatter
Asthma
basically you're more likely to not grow, outgrow asthma as an adult, really because of all of those other factors that are playing into the airway inflammation, right? There are a group of children, which we unfortunately call early wheezers. We treat them like asthma because they respond, but these are babies age zero to three
Health Chatter
Asthma
that wheeze a lot with viral infections, sometimes between viral infections, that their parents do not have asthma, they don't have allergies, they don't have asthma, they have no risk factors whatsoever, right? But they wheeze and they act like asthma and they actually stop wheezing by the time they're three to five years of age.