Vol.4 Issue 1

Asthma

We asked two clinicians with diverse approaches to patient care to discuss the management of a patient with asthma. The participating clinicians were:

Donald Novey, MD – Dr. Novey is the medical director of the Center for Complementary Medicine, Advocate Medical Group, Park Ridge, Illinois

Carrie Murphy, LAc – Ms. Murphy is a faculty member at the Pacific College of Oriental Medicine, Chicago, Illinois

CASE STUDY

Michael is a 12-year-old African American boy who was diagnosed with asthma when he was three years old. He has coughing episodes less than twice per week that are accompanied by SOB. He does not experience nocturnal coughing. His mother identifies coughing/SOB triggers as physical activity, stress, exposure to cats and cigarette smoke, and “colds.” There are no pets in the house and no family members smoke. Mite-proof covers are used on Michael's mattress and pillow. He is currently managed with a low-dose inhaled corticosteroid in combination with a long-acting, selective beta2-agonist bronchodilator (Advair 100/50), 1 puff BID, and albuterol two puffs prn. You perform a spirometry in the office and obtain a forced expiratory volume after one second (FEV1 ) of 88% of predicted value.

Michael wants to try out for his school's basketball team next month and his mother is concerned that the physical activity will exacerbate his symptoms. Both she and Michael are reluctant to change his medication because they feel that his control is “good” and he has had no asthma-related hospitalizations in the past two years. They ask you if there are any “non-drug” treatments that he can begin now to minimize the likelihood of an exacerbation during the stress of his tryouts. Michael's mother is also concerned that he may be under a good deal of stress trying to juggle his academic responsibilities with his commitment to a sports program.

Moderator: Ms. Murphy, how would you manage this patient?

Ms. Murphy: This is an ideal case for Traditional Chinese Medicine (TCM). Michael is stable and has a clear diagnosis. He has been successfully managed with Western medicine and is being closely monitored. Shortness of breath is a hallmark symptom of deficiency of the Lung energy. This is an obvious statement, which is rare in Chinese medicine. In this case, it is clear that the lungs function under normal circumstances, but not under pressure. Stressors such as environmental toxins, physical activity, emotional stress, and “colds” trigger the attacks. A healthy pair of lungs can handle these stressors, Michael's cannot.

In TCM, we take colds very literally. We consider these infections to be an invasion of an external cold wind trying to blow its way into the body. This may sound strange, but remember that TCM predates the discovery of germs. Modern TCM practitioners understand that our forebears recognized that an external agent was attacking the body, and so they employed a metaphor from nature to attempt to explain the phenomenon they saw. They also observed that certain people were strong enough to fight off these cold winds, and others were not, thus conceiving of the modern concept of immunity. The first line of defense is called the wei qi, or defensive qi, which waits at the surface of the body to guard against external invasions. Both the wei qi and the surface of the body are said to be ruled by the lung, so a “cold” presents a double whammy for a patient with deficient lung energy. This is because lung deficiency leads to diminished immunity against infection, and because the first organ to be attacked by the infectious agent (or cold wind) is the one that is also the weakest. Asthma may be diagnosed in many different ways in TCM, but in this case I am quite sure the first order of treatment would be to strengthen and tone the lungs.

One approach for strengthening the lungs is acupuncture. Acupuncture is the stimulation of clearly defined points along energy lines on the body using very small gauge needles. There are many points that strengthen defense and immunity, tonify the lungs, and release cold wind attacks from the exterior. Weekly treatments beginning immediately and lasting throughout tryouts and the basketball season would help Michael's lungs deal with the stress of physical activity. Acupuncture would also help Michael deal with the emotional stress of tryouts and competitive play. Finally, by strengthening the Lung energy, we are strengthening his immunity, and preventing the colds that trigger attacks. Michael's mother could get a few treatments herself. It must be terrifying to know that your baby just stops breathing sometimes, and over the years that has probably taken a toll on her as well. A second modality that I would employ is called cupping. Cupping employs glass cups whose insides are heated to create a vacuum inside the cup. These cups are then placed at strategic locations along the back. I really can't explain in biomedical terms how this is helpful, but it is an astonishingly effective treatment for inflammation in the lungs, possibly by drawing the inflammation to the surface, and then pulling it out. Cups leave non-tender bruise-like marks which fade over the course of a few days.

Moderator: Dr. Novey, what would your plan of care for this child entail?

Dr. Novey: The complementary medicine response to this patient begins with the understanding that current therapy is maintained until alternative methods prove effective.

Before I begin to address treatment approaches, I always ask the patient if they are aware that CAM approaches cost money and are often not covered by insurance. If the patient is not able to afford non-reimbursed CAM therapies, I then must limit my approach to reimbursed therapies and medications, and diet/lifestyle modification strategies.

Inherent in this approach is also communication with the patient's physician, often in the form of a consult letter, informing him or her of the patient's visit with me, my assessment, and intended plan. This simple courtesy of communication not only informs the other physician, who may not be aware that the patient has sought other opinion, but also educates in other available approaches. This may encourage direct patient referrals from that physician for CAM approaches in the future.

For this discussion, I will assume the mother is uncertain as to whether she could pay for services or not. She asks me to describe what I would do in the best of circumstances. It would be as follows.

The issues in this patient are mild controlled asthma with triggers. The peak flow 88% of predicted is in the “green zone,” indicating good control. However, as the boy is still experiencing cough and dyspnea occasionally, he is still at the mercy of triggers. The triggers can be divided into environmental, exercise-related, viral upper respiratory infections, and emotional stress. Each of these needs to be addressed in turn.

Environmental triggers first require environmental modification. In a 12-year-old boy, it is often up to the parents to provide this protection. Although there are mite-proof covers on the boy's bed and pillow, the description says nothing about other dust traps, such as carpet on the floor in the bedroom and in the rest of the house, and the type of furnace filter. Removing carpet in the bedroom is a very effective reducer of dust triggers. Methods for cleaning the house air involve either changing the furnace filter every three months, installing a HEPA filter, or better yet, installing an electrostatic air filter. The parents can try to avoid visits to houses with cats or smokers. I counsel avoidance but not abstinence, as total restriction becomes socially isolating, not a good idea at this boy's pre-teen age.

Exercise is a known trigger and should not be avoided. Until we control his asthma with other CAM approaches, I recommend him to use his albuterol MDI 30 minutes before exercise. That will immediately reduce his exercise-induced asthma response.

Viral URI's can be reduced with some simple measures. The first is simply good hand washing, not a natural event in the life of a 12-year-old boy. I would counsel hand washing before eating or handling food. This is an excellent strategy for reducing frequency of viral URI's in all age groups. Additionally, I would review his diet by taking a 2-week food diary and reviewing it. Reducing junk foods and sweets and increasing healthy meals and snacks often improve resistance to common colds. If he gets colds frequently, I would also place him on a high quality general multivitamin, preferably one with a good spectrum of trace elements. I would not use Echinacea or Astragalus for URI prevention as they can cause mild immunosuppression with prolonged use.

I often recommend a one-month trial of dairy product restriction for those who contract colds frequently. This does not help all patients, but when it does, the effect is noticeable.

Emotional stress needs to be addressed in several ways. The most common-sense way is to examine his schedule and see where there is flexibility. Youth sports programs are now more demanding than ever, and the stress is very real. This patient needs to consider if this group activity is right for him, or if another sport might be less demanding. For this boy, playing on the basketball team may clearly be his dream, and nothing short of trying will help him to see what he can or cannot do.

If he experiences anxiety from his classes, and these trigger asthma episodes, I would recommend mind-body therapy consisting of stress reduction training and possibly brief psychotherapy.

Nontraditional treatment choices for him consist of homeopathy and traditional Chinese medicine, focusing on Chinese herbal therapy. Both can assist with asthma, but to me, homeopathy is the better choice in his age group. It requires less visits, is easy to administer and, in my experience, has a very good track record for patients with atopy.

To summarize, I would immediately recommend premedicating his exercise sessions with an albuterol MDI. This will let him start his sports and buy us time to try the CAM approaches. I would work on the dust issues in the home, and exposure at the homes of his friends. I would check and correct his diet and suggest a multivitamin and a trial of dairy restriction. I would request a classical homeopathy evaluation. I would also use his desire for participation in a sports program to motivate him to learn discipline and time management, trading some other leisure activities for study time. This will give him the valuable opportunity to learn how to prioritize his activities and gain confidence in pursuing his goals.

As an afternote, if the above methods are unsuccessful, my preference is to switch from Advair 50/100 to Singulair 10 mg daily in an attempt to avoid daily exposure to inhaled steroids.

Moderator: Ms. Murphy, Dr. Novey identified a number of lifestyle and environmental modifications that he would recommend. Are there any additional lifestyle modifications that you would recommend?

Ms. Murphy: I agree with Dr. Novey that dietary modification is an important aspect of Michael's care. As much as possible, he should avoid dairy, sugar, and refined white flour. These foods promote the build-up of mucus, which inhibits proper lung function. Apples and pears are excellent for the lungs, as they moisten, strengthen, and repair lung tissue. They can also be a great aid to those trying to quit smoking. Lastly, grief is an emotion that damages lung function. There is nothing in the case about Michael's father. Perhaps he lost his Dad at a young age, and has some unresolved grief about that. Perhaps it was some other loss that he went through, or that his mother went through and he internalized. If there is an issue like this, family counseling with a therapist or clergy person can be a great benefit. Just as the lungs take in air and let it go, they are also responsible for letting go on a grander scale. When we recognize and honor the way our patients' histories and emotional lives affect their physical health, it becomes possible to help the whole person heal.