All About Asthma

Podcast Transcript

Raed Dweik:

Hello and welcome to the Respiratory Inspirations Podcast, I'm Raed Dweik, Chairman of the Respiratory Institute at the Cleveland Clinic. This podcast series of short, digestible episodes is intended for patients and families, and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary critical illness, sleep, infectious disease and related disciplines. We will share with you information that will help you take better care of yourself and your loved ones. I hope you enjoy today's episode.

Dr. Khatri:

Hello, everybody, this is Sumita Khatri. I'm a guest host for this episode of Respiratory Inspirations. Thank you for joining us. Today's topic is asthma, and we'd like to talk about this very common condition and what you can do about it, with two of my very great colleagues and friends, Dr. Emily Pennington, who is a pulmonologist and critical care physician, and quality director of our asthma center at Cleveland Clinic, and Dr. Roxana Siles, who's the codirector with me, of the asthma center. Thank you both for joining.

Dr. Siles:

Thank you for having us.

Dr. Pennington:

Yeah, happy to be here.

Dr. Khatri:

Glad. So, I just wanted to say, this is such an important topic, everybody knows what the word asthma is, but has a very, very different view of what it actually is. And we'll get to that in a little bit. But, you know, ultimately sometimes they say, you don't choose your career, but your career chooses you. So, I'm going to start with you, Emily, Dr. Pennington, I can't help but call you by your first name. Dr. Pennington, what about pulmonary medicine attracted you into this field, and then asthma specifically?

Dr. Pennington:

So, pulmonary was actually my favorite section of med school. And yeah, so, in medical school, we'd spend a few weeks on different organ systems, and pulmonary was by far my favorite section. I just loved learning about it and thinking through, you know, all the pathways and how the, everything in the lungs interacted. It was just, you know, my favorite area. So, that was the first time that I started thinking that I might want to do this for a career. And then I just kind of continued to pursue that throughout medical school doing extra rotations in pulmonary areas, just getting more experience with it. And then asthma for me came along the mentor, probably a little selfishly, the mentor that I wanted to work with happened to specialize in asthma, and so, I thought, well, that sounds pretty good. You know, I kind of wanted to just work with her.

So, I thought, well, let me just try this asthma. And my mom had asthma, so I was kind of around it. Growing up and saw what she went through, and I think that's just sort of what pulled me in. And then I think once I got more involved with asthma, I think what I really loved about it was the breadth of different patients that you work with.

Dr. Khatri:

Yes.

Dr. Pennington:

So, you know, for me, I only see adults, but still, I see 18- to 80-year-olds with asthma, and everything in between. And so, you really get a wide variety of experiences with patients and trying to help them be able to live their lives, go to school, go to work, you know, take care of their families and, you know, be able to manage their asthma successfully. And then I think, just from a scientific standpoint, I think there's so much exciting research going on in asthma right now and new treatments and all, that weren't available even a few years ago, that have really changed how we take care of our asthma patients and being able to allow them to live, fulfilling lives and be able to do what they want to do, the activities they want to do, and not be limited from their asthma.

Dr. Khatri:

Mm-hmm. That sounds like it's a gratifying as well as exciting career.

Dr. Pennington:

Yes.

Dr. Khatri:

And how about you, Dr. Siles? You've gone into allergy immunology, and with all of those pathways it says a lot about how intelligent you are. Tell us a little bit about what got you into this field and what keeps you here.

Dr. Siles:

So, I was, from residency, I was fascinated by the lungs. And in fact, I had, I was ready to start residency in, I should say, fellowship in pulmonary.

Dr. Khatri:

Oh, you kind of did, didn't you?

Dr. Siles:

When I did rotation in allergy immunology.

Dr. Khatri:

Oh.

Dr. Siles:

And wheat really fascinated me is that immunology is in every organ system.

Dr. Khatri:

Yeah.

Dr. Siles:

And atopic diseases, you know, when you think about atopic diseases, they start early childhood with your atopic dermatitis and then you develop food allergies and allergic rhinitis, and then here you have asthma. And now we're learning more and more about EOE. So, again, immunology is everywhere. So, I think that is very exciting. When it comes to asthma, I, you know, I started with the clinic at a regional practice, where the pulmonologist I was working with had interest in interstitial lung disease. So, by default, he would just refer a lot of his Hispanic patients to me. And I realized how fascinating it was to see these patients. Because again, no two people are the same. Some are very challenging. But it's such a rewarding condition. We can really make a big impact in the quality of life of our patients. And I think that's why I, you know, continue to see asthmatic patients.

Dr. Khatri:

So, immunology, that's a big word. Can you sort of bring it down to, like, very lay language, what does that mean and what are common immune conditions, and what can you help them do about the immune conditions that they have, even outside of asthma.

Dr. Siles:

Yeah. Perfect. So, when we think about the immune system, you know, we all have an immune system to protect us from disease. But when the immune system does not work the way, it's supposed to, that's when we start developing different conditions. And so, you know, aside seeing allergies, which is an overdrive of the immune system, where the body is trying to fight the allergen, where compared to that to common variable immune deficiency, which is a condition in which the immune system is not working and not protecting against infectious disease. So, again, the immune system plays a different role and what is fascinating is that there's a lot of proteins that are involved in protecting you and taking care of you. So, again, there there's just a lot of different pathways. Inside that target different organs and different conditions. Yeah.

Dr. Khatri:

Yeah, we're so appreciative that there's so many new discoveries and how you keep up with it is very important. In the world of asthma, its immunology, someone might be predisposed to infections which might make their asthma worse too. So, how often are you seeing an immune condition, let's say like a immune deficiency as adding to asthma?

Dr. Siles:

So, immune deficiencies overall are not very common.

Dr. Khatri:

Right.

Dr. Siles:

The most common that we see is common variable immune deficiency. But that's one in 50,000 patients.

Dr. Khatri:

Hm.

Dr. Siles:

Or people. So, it's not very common, but absolutely, you know? Infections can certainly play a role and they could definitely affect asthma. I do have, I would say a handful of patients who have both conditions. And yes, it's a challenge, right? So, yeah, it's fascinating, but yeah, challenging and we can definitely make a big impact in patients' lives.

Dr. Khatri:

Yeah. It definitely shows how, for something like asthma, it's not just one solution. You have to think about what causes it, what's underlying it, try and take away that stimulus for that asthma getting worse. So, having a broad set of skills and knowledge really helps the patients get better. And so, you know for our patients out there, our listeners who don't have medical backgrounds, you know, what is asthma and what are its common features? You know we talked about the complex ones first, but, you know, in general, why do people think they don't have asthma?

Dr. Pennington:

So, asthma is a chronic inflammatory disorder in the airways in the lungs. The hallmark symptoms of it are shortness of breath, cough, chest tightness, a lot of patients will describe it as feeling like there's a rope around their chest. And then wheezing, which would be really kind of high-pitched noisy breath sounds, especially when you exhale. Then the other thing that's important about asthma is that the symptoms are variable, and so there's specific triggers for the symptoms, so it's not something that you necessarily have these symptoms all day, every day, but there's certain things that when you're exposed to it, that sets off your symptoms.

So, that could be exercise, it can be strong perfumes or cleaning smells, thunderstorms, rain, weather changes can do it. For some people it's that really hot, humid air or really cold air in the winter can set off their symptoms. But the specific triggers are kind of an important of asthma and your symptoms.

Dr. Khatri:

Yeah, people always seem to find an alternative reason for that cough. Or that clearing of their throat. And so, there is probably a misconception, and it probably fuels the fact that asthma is often underdiagnosed. What do you think, Dr. Siles?

Dr. Siles:

Absolutely. I think it's important to think about that no two people with asthma are the same. Some people may have daily symptoms, but some may only have symptoms when they're exposed to a cat, or after, you know, an infection, like we mentioned before. And you know, and some people may only cough and that's it, that's their only symptom. They don't have to wheeze or feel short of breath every single time. So, I think there is definitely a lot of under diagnosis because of that. And I think this is why we want to encourage those who have symptoms to seek formal evaluation. There are tests that can be done that can help confirm the diagnosis, and be able to treat it accordingly.

Dr. Khatri:

Mm-hmm. So, I'm imagining that primary care providers would be the first ones to maybe detect that asthma may be an issue. And that is of course if somebody does have a doctor. So, I guess the question I have is, you know, if you're seeing a primary care physician, what are the right questions to ask, and if the physician is caring for you and you don't feel like they're getting better, like, how soon should they request specialty help? Dr. Pennington, would you like to take that on?

Dr. Pennington:

Yeah, I think that, you know, to keep in mind, is that if you're having these symptoms frequently, especially one of the things I see commonly in clinic is that patients who have needed steroids, like prednisone, you know, multiple times a year and they just kind of keep chopping, chocking it up to, "Oh, I just get bronchitis multiple times a year." And that often is actually asthma. And so, that's, I think, the time when you get these episodes where you get shortness of breath and cough and your primary care doctor says, oh, it's bronchitis and here's an antibiotic and steroids, when that's happening, you know, two, three or more times a year, that that's when it's time to question and say, hey, could this be asthma instead? And maybe I need to be on an inhaler to help control these symptoms and help prevent them from coming back. And then I think in terms of when to see a specialist, I think it's when, you know, maybe your primary care doctor has recognized that you could have asthma and has started you on an inhaler, but after a couple months, you're not really feeling better, you're still having frequent symptoms or needing steroids often, then that's the time to ask about seeing a specialist. Whether it be an allergist or a pulmonologist.

Dr. Khatri:

Mm-hmm. And how about for you, Dr. Siles? When you are seeing that there is a risk of under diagnosis, where is there a particular time period where that can be a problem? Is that early childhood? Is it teenage years? Is it when they're becoming adults? When is that risk area in somebody's lifetime when asthma can be happening and they're not getting the care they need or they're not seeking care.

Dr. Siles:

You know, asthma is a chronic condition. So, it's important to highlight, and some people do start having asthmatic symptoms in childhood. But others start having asthmatic symptoms in adulthood. It does affect more women than men, but again, it's important to recognize the symptoms that Dr. Pennington was mentioning, and also emphasize that, like she mentioned, bronchitis can be a sign of asthma. It doesn't have to be, you know, daily symptom.

Dr. Khatri:

Yes, yes. And also considering with insurance coverage and being under your parents' insurance, when a child becomes an adult, that seems to be another risk and as well as that, when women become pregnant. These are two certain areas that we always look at as, why did we drop the ball there? And for kids growing into adults, I wonder your ideas, Dr. Siles, and then, Dr. Pennington, I wonder about women who are pregnant or wanting to get pregnant, I'm seeing this crazy basically intention to do good, but them stopping their medication. So, I'd like to sort of dispel these myths and address these sort of choke points and danger zones. So, how about that transition to adulthood?

Dr. Siles:

Yeah, no, I think that's very important. And like you said, a lot of times, kids turn 18, they're off to college and then there they go. Or, they get a job and off their parents' insurance. So, I think transition of care is very important. Currently we're working on a pilot to address this important issue. And it boils down to partnership with our pediatric colleagues, to really assess how much they understand our disease, how well they're able to control the symptoms, but be able to almost pass the baton to the adult world. So, we're doing a formal introduction and a formal summary of what has been happening during childhood as we transition patients into adulthood. And I think that's very important so that people don't get lost in the system.

Dr. Khatri:

Yeah. And we're realizing this to be an issue. I just in the last year met this wonderful woman whose son had severe asthma, and he was controlled, and then he grew up and then he lost his insurance, and then because of lack of access to medications, he died of his asthma. I mean, the fact that people can die from asthma is an untold secret. And there's stigma and shame to having a chronic disease. And I want our listeners to hear that there's no shame in having a chronic condition, you did not do this to yourself. And we're here to help you. So, that's a lesson I just wanted to be stark about. And then also, our offspring, the new generations we're bringing to the world, right? And pregnant women with asthma, Dr. Pennington, your view on this, how can we do better? How can they do better?

Dr. Pennington:

Yes, I think a very common misconception is that when women are pregnant, they are afraid to take any medication. Understandably so, you know, they don't want to do anything to hurt the fetus, but I think the very clear message is, is that uncontrolled asthma is far more dangerous for you and baby than being on your inhaler. So, it's really important that you stay in your inhalers, that you talk to your obstetrician, and if you do have asthma, you can also ask to get a pulmonologist involved during your pregnancy, that can help answer any questions that you have about your inhalers and what's safe to take and what you shouldn't take, and just making sure that your asthma is well controlled during pregnancy. Because it is true that some women during pregnancy, that their asthma will become more severe, more difficult to control. And so, it's important that we stay on top of that and we make sure that you're still doing well all through your pregnancy.

Dr. Khatri:

Mm-hmm. Thank you. Thank you for that very important point. And all of this takes a village, doesn't it? I mean, nobody should feel alone in their journey to health or isolated. And also, you know, you have very well-meaning friends and family who will be giving you all sorts of advice. (laughs) And then, I would ask you to just seek medical care and see what works. And so, I wondered, Dr. Siles, what have you seen work? What can parent of children, what can family members of adults, do to help support the person that needs to get care for their asthma?

Dr. Siles:

So, I think the most important thing family members can do is understand the condition, understand that it is variable and that it's chronic. Meaning it's not gonna go away, it's gonna come and go. And there's definitely important tools to help minimize the disease. So, some of the things would be, avoid triggers. So, if you're a smoker, you know, we want you to quit. And it might, not necessarily impact your health, but the health of those around you. If there are, you know, stay up to date with vaccines. As we said, infection can increase the risk of asthma. The other thing to do is just understand what each inhaler is intended to do and how to use it correctly, and understand an asthma plan. Understand when to use your inhalers, when to seek help, when to start, when to go to the emergency department if needed. I think that those are important things to think about.

Dr. Khatri:

Absolutely. I mean, to the point of the environment, not just helping the person who's smoking with asthma quit. Don't smoke around them either. And don't smoke at all. Quit together. And everyone's better for that. And you know, when it becomes an emergency, when somebody's having an asthma attack, they can't help themselves. They are struggling to breath, so you need to come into action, family members and friends, to help them get the care they need, and call for help if you're not seeing it. Don't wait too long. And how about you? What have you seen that would work for, you know, in a community for family members and friends to support someone with a chronic health condition like asthma?

Dr. Pennington:

Yeah, so, I think just, you know, reminding, um, their family members to make sure they're using their inhalers that they're prescribed. I think one of the challenging things about inhalers is, it's not a pill that you can put in your weekly pill box and just take out every morning with the other ones. And so, it takes a little bit more, you know, commitment to make sure that you're using it every day, and some of them are twice a day medication. So, family members can help with that. Helping to make sure that they get to their appointments. And then I think one of the other things you hear sometimes is I think patients are embarrassed to use their rescue inhaler in public if they need to use it, and just sort of making them feel comfortable that, hey, it's okay if you're having some breathing problems. And you need to use your inhaler and that's perfectly fine. And just making sure to help support them if they are having symptoms and they need help.

Dr. Khatri:

I appreciate that very much. That stigma is certainly there. People want to be strong and I don't know if it's a gender issue or a societal issue or a cultural issue, but whatever it is, it, you have to take care of yourself first. So, another thing, we were talking about environmental tobacco smoke, which is, just people being around smokers, that secondhand smoke. Self-smoker, is if you smoke yourself, secondhand smoke, someone's smoking near you, third hand smoke, it's people may not be smoking around you, but there's enough on their jackets or the carpets where they live that's just being off gassed and that can be just as dangerous from a standpoint of worsening asthma than anything else. So, we talked about tobacco smoke quite a bit already, but how about, would you like to address the outdoor air quality, Dr. Pennington? And then I'll turn to you for indoor air quality, Dr. Siles.

Dr. Pennington:

Yeah, outdoor air quality is really important, and it's something that if you pay attention to weather reports in the summer, that they'll talk about there being a poor air quality day. And that has to do with just it being a really hot, humid day. So, you end up with more ground level ozone, more you know, air contamination, and that just makes it harder to breathe. And so, it's on those days that you want to try and stay inside in some air conditioning, keep the windows closed to try and decrease that exposure to that air contamination as much as you can, and to maybe keep your activities to more sedentary things and not, you know, be outside, trying to do exercising outside and things like that that might make your symptoms worse.

Dr. Khatri:

Yeah, and I think when there's high air contamination levels, you can have some acute worsening over the next couple days, because it makes you more susceptible to other irritants like allergens. But there's also a certain slow, slow, drip, drip continual exposure to air contamination as well as any other agent that sort of has a cumulative effect. So, really being thoughtful about air quality, and then I guess all of us just doing our part to make the air quality better is something that we should all be thinking about. So, there's acute but there's a chronic exposure issue as well, right? And then Dr. Siles, so indoor air quality. This is something you probably talk about a lot with your patients.

Dr. Siles:

Yeah.

Dr. Khatri:

What would you like to share?

Dr. Siles:

Well, you know what, when you think about allergens, the most common allergens in the home are dust mite in animals. And certainly, outdoor allergens include pollens and those can be seasonal. And depending where you live, the pollen seasons may vary. But as far as indoors, when it comes to dust mite, important things are that they live in mattresses and also live in pillows. And it doesn't matter how clean your home is, we all have dust mites in our home. So, using dust mite encasements can make a big difference. If you have pets, keeping pets out of the bedroom. Air purifiers can certainly help. If we can reduce the amount of carpet, that can help eliminate some of these allergens. But, you know, I think what is very important for the listeners to understand is that that 60 percents of patients with asthma have allergies. And skin test is the best way to assess for allergies. And getting to know your triggers is what's very important to understand what you can do in your own home to make things better. And when it comes to outdoor allergens, watching those pollen reports can make a difference also. But again, I think skin tests can certainly help guide avoiding your triggers.

Dr. Khatri:

Mm-hmm. I think now more than ever people are really becoming addicted to furry friends at home. Are you seeing a lot of that? And how do you counsel before somebody might consider getting a pet and what pet to get. I know this is a tough question that I'm sure you're asked a lot.

Dr. Siles:

Absolutely. So, we did a survey many years ago. And a lot of people felt that they would get rid of their allergist before they get rid of their animals. So, what we do know is, compared to past years, you know, where people would have just one dog, now we're seeing multiple pets.

Dr. Khatri:

Oh, boy.

Dr. Siles:

Cats, dogs. You name it, right?

Dr. Khatri:

Mm-hmm. Rats, I've heard, too.

Dr. Siles:

Yes. Yes. And all these can definitely make a big impact in people's health. Again, allergy testing can help guide, but if you're thinking about getting a pet, sometimes it's easier to know ahead of time.

Dr. Khatri:

Right.

Dr. Siles:

Because once the pet's introduced into the home, we do appreciate that it becomes part of the family. But again, I can't emphasize enough that that makes, it plays a huge role in your health, and it can lead to increased flare ups, emergency room visits, hospital stays. So, we cannot underestimate our furry friends. But we're happy to help. And you know, there are treatments for allergies, including allergy shots that can make a big difference, but again, we would have to make sure, evaluate and decide what's the best therapy for you.

Dr. Khatri:

Mm-hmm. So, it sounds like avoiding the issues is not a good idea, but perhaps being proactive and getting knowledge, knowledge is power, and then you can adjust your pet tendencies.

Dr. Siles:

Absolutely.

Dr. Khatri:

Ahead of time, before you've developed an attachment. Thank you for that.

Dr. Siles:

Yeah. And I would just add that there's no such thing as a hypoallergenic pet. So, you know, definitely there are studies that have found in the same litter that one animal would have a lot more dander compared to another. And they were all labeled as hypoallergenic.

Dr. Khatri:

Oh, dear.

Dr. Siles:

I would just caution those about hypoallergenic pets.

Dr. Khatri:

Well, that's a conundrum for sure. We'll come back to that topic again when you've figured it out for us. Yes. Dr. Pennington, one of the things that I often hear people say, and even in common language, you know, I had asthma but then I grew out of it. Is there any such thing as growing out of asthma?

Dr. Pennington:

Not exactly. You can certainly find that your symptoms become less severe over time or for the most part go away, but you're still gonna, you know, if we did a biopsy of your lungs, we're probably still gonna see some changes related to that asthma that you had in your airways and everything. And you're still probably gonna be a little more susceptible to prolonged coughs after you have viral infection. And it's also possible that some people find that, you know, their asthma can vary over time. And so, it, they might have several years where it's much milder, and then it starts to flare up again and you start to notice you're having more symptoms.

And then after a few years, it kind of calms down again and it can kind of go back and forth like that for some people. And then for other people, they kind of continue to have symptoms and it's not something that necessarily goes away completely for them. And kind of along those same lines I'll add is another misconception, is that adults can't get asthma. And that's not true, that adults can develop asthma even if they never had a problem as a kid. That's something I hear commonly in clinic when I'm telling somebody for the first time that they have asthma, and they say, well, I never had problems as a kid, and you say, well, unfortunately you can still develop as an adult. And that's still possible. But yeah, kids don't completely grow out of it, but certainly a lot of them find that their symptoms become less severe over time.

Dr. Khatri:

Mm-hmm. Yeah. So, that speaks to the very different types of asthma there are. I mean, asthma is not one condition, it's ... we often call it the asthmas. Like, there's different types of asthma that show up and, you know, truly, if you come for care, what asthma specialists do is really find the type of asthma that you have, so that your care can be customized. And knowledge is power, you can come speak to your physician, your provider, you can have a great relationship or just a good relationship. But you might want to seek other sources of literature or sources for more knowledge that's, you know, convenient for you. What would you recommend, Dr. Siles?

Dr. Siles:

So, we're fortunate in the field of allergy to have great patient resources. If you go to AAAAI.org, that's the American Academy of Allergy, Asthma and Immunology. There are great resources both in English and Spanish, not only about allergies but also about asthma. There's also information about the latest forms of therapies for asthma, and how to use inhalers. So, I would encourage those to visit that website. There's also great information at the ACAI.org. So, again, there's great information in both of those sites. And certainly, the asthma center website at Cleveland Clinic, it's a great resource with links to various patient information and certainly a phone number to reach one of us.

Dr. Khatri:

Yeah, perfect. How about you, Dr. Pennington, what would you suggest?

Dr. Pennington:

Yeah, I'd also throw in there the American Lung Association has some really great resources and they have videos that I actually tell my patients about all the time for how to use inhalers. So, if you're ever at home and can't remember, you know, how you're instructed to use an inhaler, you can always find those videos online. To help you.

Dr. Khatri:

Mm-hmm. Wonderful. So, this whole session was meant to be informative to people we would like to serve, and we'd like to help empower and help you have the resources. And I'm hoping that for the listeners, that this did accomplish that. Do know that here at our asthma center, we're available for you. And more importantly, you know, some parting thoughts, perhaps, you know, if there was something that we could do better, you let us know. But, you know, from our standpoint, I'll give my practice sort of pattern. One of the things that I really value when I see patients is hearing their stories from start to finish, because somewhere in the story is the clue as to what will help your condition get better. And then we work on solutions together. What's your secret sauce, Dr. Pennington?

Dr. Pennington:

I think, you know, I always like to remind patients that, you know, that we can help you get better. And I think a lot of asthma patients sometimes get used to, like, this is how I live, and I need my rescue inhaler several times a week, and that's normal. And I always tell my patients that's not normal. And that we can do better for you and help you feel better so you're able to live your life and do the activities you want to do and not feel like you're constantly trying to grab that rescue inhaler to find some relief.

Dr. Khatri:

Yes. How about you, Dr. Siles?

Dr. Siles:

I think with the management of asthma, it's a true partnership between the patient and the physician or our APPs to really make a difference in your life. Our goal is to be able to do what you want to do and stay out of the hospital, stay out of the emergency department. But what's most important is that you're able to feel good. And feel that you're not impaired by having asthma.

Dr. Khatri:

Yes. So, we want to treat your asthma so you forget you have asthma.

Dr. Siles:

Exactly.

Dr. Khatri:

But you got to stay on your medications. So, with that, I'd like to thank the both of you, my friends and colleagues, my partners in the asthma center. And to you, my listeners, our listeners. And I hope this was helpful for you, and this ends this episode of Respiratory Inspirations. Thanks for joining.

Raed Dweik:

Thank you for listening to this episode of the Respiratory Inspirations Podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @RaedDweikMD.