WEBVTT - Ep 122 Asthma: A phlegmy episode

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<v Speaker 1>Hi.

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<v Speaker 2>My name is Lindsay and I wasn't officially diagnosed with

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<v Speaker 2>asthma until I was a teenager. But I do remember

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<v Speaker 2>when I was a kid having exercise induced asthma, but

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<v Speaker 2>just not knowing how to describe it. My asthma was

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<v Speaker 2>very well managed with just your standard preventative and albuterel

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<v Speaker 2>until my early thirties. Something changed, not sure what it was,

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<v Speaker 2>and then March of twenty twenty, I had my first

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<v Speaker 2>really bad exacerbation. Beforehand, it was just like I could

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<v Speaker 2>maybe have won maybe two exacerbations, if any, in a year.

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<v Speaker 2>So I got an oral steroids in March of twenty

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<v Speaker 2>twenty and I cleared up pretty fast usually that's how

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<v Speaker 2>it happens with asthma exacerbations. And I finished the course

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<v Speaker 2>of steroids, and then about a week later I started

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<v Speaker 2>having asthma symptoms again, and again I had to go

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<v Speaker 2>back to my doctor and get back on steroids.

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<v Speaker 1>And this happened pretty much every six weeks.

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<v Speaker 2>I would get on steroids and then finish my course

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<v Speaker 2>of steroids, and then gradually the symptoms would return. And

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<v Speaker 2>then with my first pominologists that I had, we were

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<v Speaker 2>kind of in a struggle between testing my blood levels

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<v Speaker 2>for the EOSINFL levels that they thought would be the problem,

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<v Speaker 2>and excess of usnfl's kind of aggravating things. But unfortunately,

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<v Speaker 2>I wasn't able to stay off of steroids for long

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<v Speaker 2>enough for them to get an accurate USINFYL count. So

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<v Speaker 2>it was kind of this, let's get off of steroids,

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<v Speaker 2>but then I would have an exacerbation. So that was frustrating,

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<v Speaker 2>and that happened throughout the spring and summer of twenty twenty.

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<v Speaker 2>I'm a paramedic, so it was extremely difficult at work.

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<v Speaker 2>Even when I wasn't having a full blown exacerbation, I

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<v Speaker 2>was having to wear masks and feeling very short of

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<v Speaker 2>breath with my patients, and I got very tired of

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<v Speaker 2>explaining that no, I don't have COVID, my lungs are

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<v Speaker 2>just trying to kill me.

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<v Speaker 1>So the exacerbations.

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<v Speaker 2>Were in tech. It would start off as shortness of breath.

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<v Speaker 2>I would get very short of breath for a few

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<v Speaker 2>days just with regular exertion. I would get winded climbing

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<v Speaker 2>a fight of stairs, I would get winded getting dressed,

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<v Speaker 2>and then eventually they would degrade until I was having

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<v Speaker 2>to take albuter all treatments regular albauter of all treatments

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<v Speaker 2>every two hours maybe, and then eventually we switched to

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<v Speaker 2>DUOEB and even the duo EB was only effective for

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<v Speaker 2>about four hours at a time. The worst, by far

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<v Speaker 2>was the sudden nocturnal dismea. I would be asleep and

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<v Speaker 2>then I would find myself awake, and then it would

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<v Speaker 2>be like it would feel like a train would just

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<v Speaker 2>hit me in the chest and I couldn't breathe, and

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<v Speaker 2>I would be scrambling to find my nebulizer and set

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<v Speaker 2>that up before I passed out. Basically, I did have

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<v Speaker 2>a little at home pul sac siminar. The lowest that

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<v Speaker 2>I ever saw my pulsacks go with seventy four percent.

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<v Speaker 2>That was, Yeah, that was scary, especially because I'm a

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<v Speaker 2>medical professional and I know what that means. And like

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<v Speaker 2>my head was swimming and pounding and I'm just trying

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<v Speaker 2>to work through that work of breathing to bring my

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<v Speaker 2>action levels up. I got into a pretty sticky situation

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<v Speaker 2>and as the exacerbation that landed me in the er

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<v Speaker 2>in October of twenty twenty, and in that er setting,

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<v Speaker 2>I actually found out that I was pregnant. That was

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<v Speaker 2>pretty scary. Things got pretty complicated because the normal course

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<v Speaker 2>of action at this point would just do be on

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<v Speaker 2>a low daily dose of steroids until we could figure

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<v Speaker 2>out what was going on and find a better treatment. However,

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<v Speaker 2>the implications of taking long term steroids while pregnant were

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<v Speaker 2>not great. There was a lot of complications that could

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<v Speaker 2>go along with that. Luckily, moving into the winter season,

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<v Speaker 2>my asthma is pretty mild, so I was able to

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<v Speaker 2>just kind of fuddle through take very short bursts of

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<v Speaker 2>steroids if I needed it, and that got me pretty

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<v Speaker 2>much through all the way to the spring right before

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<v Speaker 2>I delivered, where I inadvertently had an anaphylactic reaction to

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<v Speaker 2>something that I've never had an anaphyalactic reaction to before.

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<v Speaker 2>My palminologists at the time didn't say it was anaphylaxis,

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<v Speaker 2>but anaphylactoid and anaphylactoid reaction, I guess, so I don't

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<v Speaker 2>really know what the difference is, but either way, it

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<v Speaker 2>was very scary. So I ended up going on a

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<v Speaker 2>short burst of storids after that, and then I delivered

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<v Speaker 2>in June of twenty twenty one, a very healthy baby girl,

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<v Speaker 2>and I had another exacerbation immediately after I delivered, which

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<v Speaker 2>was rough. At this point, I was working with one

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<v Speaker 2>palminologist who had mentioned biologics before, but was nervous about

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<v Speaker 2>starting biologics to kind of change my immune system while

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<v Speaker 2>we were in the middle of a pandemic. I suffered

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<v Speaker 2>through about one more exacerbation with that palminologist, and then

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<v Speaker 2>I decided to get a second opinion. So I switched

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<v Speaker 2>palminologists and I was immediately allergy tested and then started

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<v Speaker 2>on the first biologic that they usually go to, called Dupixend.

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<v Speaker 2>Dupixend helped a bit. It's a monthly injection. It's a

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<v Speaker 2>monoclonal antibody that helped manage some of my symptoms to

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<v Speaker 2>the point where I was able to wean down from

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<v Speaker 2>the predna zone, but not all the way. So in

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<v Speaker 2>February of twenty twenty two, I started on a medicine

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<v Speaker 2>called Ficenra and that was wonderful.

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<v Speaker 1>That was an immediate difference.

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<v Speaker 2>I was able to wean off all of my predmo

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<v Speaker 2>zone just kind of stick to my regular albuterol and

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<v Speaker 2>my preventatives, and it's been great. I've been able to

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<v Speaker 2>get back to exercising. I don't feel like I'm suffocating

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<v Speaker 2>having to wear a mask at work anymore. So yeah,

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<v Speaker 2>it's been definitely a journey. Now we are working on

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<v Speaker 2>a kind of like a third biologic option because the

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<v Speaker 2>fsenra was supposed to be able to be weaned off

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<v Speaker 2>of it, but I've not successfully been able to be

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<v Speaker 2>weaned off of it. So we're going to try a

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<v Speaker 2>new medication called Nkala, which is supposed to control signus

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<v Speaker 2>polyps as well, So we'll see how that goes.

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<v Speaker 3>And yeah, that's it.

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<v Speaker 1>That's been my journey with asthma.

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<v Speaker 4>Oh my gosh, that sounds so scary.

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<v Speaker 3>I just.

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<v Speaker 5>I know, goodness, thank you so much for sharing your

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<v Speaker 5>story with us. I can't and imagine reliving that is easy.

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<v Speaker 4>Yeah, and just how like what a confusing time and

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<v Speaker 4>how like difficult and like long this process can be sometimes. Yeah, yeah, yeah,

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<v Speaker 4>thank you.

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<v Speaker 1>Hi.

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<v Speaker 3>I'm Aaron Welsh and I'm Aaron almant Updike.

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<v Speaker 4>And this is this podcast will Kill You. And today

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<v Speaker 4>we're talking about asthma. Yeah. I know we say this

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<v Speaker 4>a lot, but big topic is asthma. Even like I

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<v Speaker 4>think it was near the end of my research when

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<v Speaker 4>I came across a phrase that was in some two

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<v Speaker 4>thousand and six journal article in The Lancet that was like,

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<v Speaker 4>has asthma as a term outlived its usefulness, right, like like,

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<v Speaker 4>right is it? I guess we'll find out.

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<v Speaker 5>We'll find out.

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<v Speaker 3>I guess.

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<v Speaker 5>Yeah.

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<v Speaker 4>It is a very big topic. There's a lot of

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<v Speaker 4>it just feels very amorphous. So I'm curious to see

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<v Speaker 4>how it all goes.

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<v Speaker 5>I have a feeling at the end of this episode

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<v Speaker 5>it's going to still feel amorphous. But hopefully we can

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<v Speaker 5>like put some boxes around it. Maybe I don't know. Yeah,

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<v Speaker 5>I think so, we'll try.

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<v Speaker 4>Okay, but first things first, it's quarantiney time. It is

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<v Speaker 4>what are we drinking this week?

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<v Speaker 5>Well, nothing other than the inhaler. It works well on paper,

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<v Speaker 5>it does. Just go to our social media, you'll see

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<v Speaker 5>it written.

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<v Speaker 4>Uh huh uh huh you basically with the ale emphasize.

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<v Speaker 5>It's the inhale Wait, the inn ale er that's yeah,

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<v Speaker 5>really rolls off. The tongue.

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<v Speaker 4>Does not translate well to audio. That's okay, though, that

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<v Speaker 4>is okay.

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<v Speaker 3>What's in the inhaler erin it is based.

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<v Speaker 4>On a new drink new to me that my friend

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<v Speaker 4>actually told me about, called the spaghette. I don't know

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<v Speaker 4>it's provenance, but it is delicious. It's basically like a

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<v Speaker 4>cheap logger and you get a bottle, you drink a

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<v Speaker 4>little bit down, and then you pour in some apparol

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<v Speaker 4>and lemon juice and it's kind of like an apparol sprits.

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<v Speaker 5>But with cheap beer.

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<v Speaker 4>And I love it.

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<v Speaker 5>I it sounds delicious and I can't wait to try one.

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<v Speaker 4>And we will post the full recipe for this quarantini

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<v Speaker 4>as well as the non alcoholic polacy rita on our

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<v Speaker 4>website This Podcast will Kill You dot Com, as well

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<v Speaker 4>as on all of our social media channels.

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<v Speaker 5>Our website is this Podcast will Kill You dot Com.

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<v Speaker 5>Have you heard of it? Have you gone to there?

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<v Speaker 5>We have so many things there. Check it out. We've

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<v Speaker 5>got merch, we've got a good Reads list, We've got

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<v Speaker 5>there's so much more. We've got music, pipeline mobile, we've

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<v Speaker 5>got a Patreon.

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<v Speaker 4>You know what.

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<v Speaker 5>Just check it out.

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<v Speaker 4>Check it out right. There's actually a really cute new merch.

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<v Speaker 4>There's like a muscle tea.

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<v Speaker 5>I'm wearing it right now.

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<v Speaker 4>You are? You look great in it?

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<v Speaker 5>Oh?

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<v Speaker 4>Thanks? Okay, enough gathering. Should we get on to the

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<v Speaker 4>actual content of this episode.

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<v Speaker 5>We should let's all take a deep breath and a

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<v Speaker 5>quick break, okay, and get into it. So there are

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<v Speaker 5>various definitions of asthma that exist out there. They're all

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<v Speaker 5>probably slightly different based on which society or expert panel

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<v Speaker 5>or which set of guidelines you're looking at. But for

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<v Speaker 5>this biology section, the way that I decided to structure

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<v Speaker 5>it is just to jump into describing what asthma looks

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<v Speaker 5>like or feels like, what the symptoms are, because that

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<v Speaker 5>will inevitably lead us to the big question of this section,

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<v Speaker 5>and that really is what on earth are these underlying

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<v Speaker 5>causes or mechanisms of what we know of as asthma,

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<v Speaker 5>like what is going on in our bodies if we

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<v Speaker 5>are living with asthma? So let's get into it. I

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<v Speaker 5>think that asthma is a common enough condition that probably

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<v Speaker 5>everyone listening has heard of it and either has asthma

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<v Speaker 5>or knows someone with asthma personally. So when we think

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<v Speaker 5>of asthma, we probably have a picture in our mind

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<v Speaker 5>of what we think of. We might think of someone

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<v Speaker 5>who has these discrete episodes or asthma attacks where they

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<v Speaker 5>might have wheezing. Right, this sound in their airways like

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<v Speaker 5>a squeaking sound when they exhale. They might be really

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<v Speaker 5>short of breath, feel like they just can't catch their breath.

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<v Speaker 5>Maybe we think of someone who is coughing a lot

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<v Speaker 5>and just kind of can't stop coughing during these episodes,

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<v Speaker 5>or complains of a feeling of tightness in their chest,

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<v Speaker 5>like they just can't get enough air in because of

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<v Speaker 5>the feeling of this tightness, and we probably think of

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<v Speaker 5>this person using an inhaler of some kind, like a puff,

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<v Speaker 5>and then being able to breathe a little bit easier.

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<v Speaker 5>Maybe we think of someone who has to use an

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<v Speaker 5>inhaler before they can start soccer practice or run the

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<v Speaker 5>mile in pe because otherwise they get short of breath.

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<v Speaker 5>Or maybe we've actually seen or experienced a very severe

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<v Speaker 5>exacerbation where someone can barely get any air in their

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<v Speaker 5>wheezing so much that you can hear it across the

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<v Speaker 5>room without a stethoscope, and they have to go to

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<v Speaker 5>the emergency room for systemic treatment with steroids and breathing treatments.

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<v Speaker 5>And many of us might think of asthma as a

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<v Speaker 5>childhood condition that people outgrow and then no longer need

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<v Speaker 5>their inhalers. Once they're adults, and those kind of are

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<v Speaker 5>the symptoms of asthma. But as we'll see, not only

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<v Speaker 5>is asthma not only a childhood condition. It's a chronic,

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<v Speaker 5>potentially lifelong condition or one that can arise for the

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<v Speaker 5>first time in adulthood. But it's also a lot of

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<v Speaker 5>different things. So while these episodes all might sound similar,

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<v Speaker 5>there is a lot going on underneath the surface in

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<v Speaker 5>every different person that has asthma.

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<v Speaker 4>So is asthma as a term more like a collection

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<v Speaker 4>of symptoms rather than any like one path of physiological process.

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<v Speaker 5>Pretty much, Yeah, let's get into it, shall we. Yeah,

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<v Speaker 5>because we can talk about some of the path of physiology,

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<v Speaker 5>but as we'll see, yes, there's a lot of different

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<v Speaker 5>sort of pathways that get you to that same endpoint

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<v Speaker 5>where you have have these episodes with wheezing, shortness of breath,

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<v Speaker 5>chest tightness, et cetera. Right, m hmm okay, Yeah, So

0:14:07.640 --> 0:14:12.920
<v Speaker 5>on a very basic level, asthma is a chronic inflammatory

0:14:13.200 --> 0:14:17.520
<v Speaker 5>disorder that's affecting the airways right of our lungs, and

0:14:17.679 --> 0:14:23.000
<v Speaker 5>it essentially results in these episodes in widespread and uneven

0:14:23.240 --> 0:14:27.200
<v Speaker 5>constriction or narrowing of the small and large airways of

0:14:27.240 --> 0:14:32.320
<v Speaker 5>the lungs, and that results in obstruction of airflow, and

0:14:32.480 --> 0:14:38.520
<v Speaker 5>that constriction, that obstruction is usually reversible, either spontaneously like

0:14:38.560 --> 0:14:41.800
<v Speaker 5>with time, or with medications. Those inhalers that you see

0:14:41.800 --> 0:14:46.080
<v Speaker 5>people using or that you've maybe used themselves. That is

0:14:46.120 --> 0:14:50.760
<v Speaker 5>what causes the wheezing sound, right, is this restriction, constriction

0:14:50.880 --> 0:14:53.160
<v Speaker 5>of the airways and air trying to get out through

0:14:53.160 --> 0:14:57.040
<v Speaker 5>a very small opening. It's also what causes the shortness

0:14:57.040 --> 0:15:00.160
<v Speaker 5>of breath. You literally can't move air back and forth

0:15:00.200 --> 0:15:03.880
<v Speaker 5>because of how small these airways are. But that's a

0:15:03.880 --> 0:15:06.720
<v Speaker 5>pretty bare bones description. We don't do barebones. So let's

0:15:06.800 --> 0:15:10.040
<v Speaker 5>drill down as deep as we can on this podcast

0:15:10.120 --> 0:15:14.040
<v Speaker 5>into what's going on in asthma and in these asthma

0:15:14.120 --> 0:15:18.960
<v Speaker 5>attacks or exacerbations. So, like you alluded to, aerin asthma

0:15:19.240 --> 0:15:25.200
<v Speaker 5>is not just one thing. It's not one discrete pathophysiologic

0:15:25.360 --> 0:15:31.720
<v Speaker 5>process that's underpinning these exacerbations or these episodes. And it's

0:15:31.760 --> 0:15:37.600
<v Speaker 5>not just these episodes. All of the different pathophysiologic processes

0:15:37.600 --> 0:15:39.520
<v Speaker 5>that I'll get into at least a little bit of

0:15:39.560 --> 0:15:46.120
<v Speaker 5>detail of first start with an underlying chronic inflammatory state.

0:15:47.000 --> 0:15:50.160
<v Speaker 5>So in all people with asthma, there's an increase in

0:15:50.160 --> 0:15:53.920
<v Speaker 5>inflammation of the airways even in the absence of an

0:15:53.960 --> 0:15:59.080
<v Speaker 5>acute episode. So there's this chronic, low level inflammation that's

0:15:59.120 --> 0:16:03.000
<v Speaker 5>happening all the time, and then there are these acute

0:16:03.120 --> 0:16:07.120
<v Speaker 5>or discrete worsenings of that. That's what we call an

0:16:07.120 --> 0:16:12.880
<v Speaker 5>asthma attack or an exacerbation. These attacks tend to happen

0:16:13.000 --> 0:16:19.160
<v Speaker 5>with some kind of trigger smoke, exercise, allergens like pollen

0:16:19.360 --> 0:16:23.160
<v Speaker 5>or cat dander, very often a cold or a viral infection,

0:16:23.600 --> 0:16:26.280
<v Speaker 5>but it could even be just cold air. Really, it's

0:16:26.360 --> 0:16:31.600
<v Speaker 5>any number of things that cause a sudden increase in

0:16:31.600 --> 0:16:37.680
<v Speaker 5>inflammation and immune system activation that then causes inflammatory cells

0:16:37.720 --> 0:16:40.480
<v Speaker 5>and messengers and all this stuff being sent to the

0:16:40.520 --> 0:16:44.640
<v Speaker 5>airways that leads to both cells and debris in the area,

0:16:45.040 --> 0:16:48.840
<v Speaker 5>which that alone can cause some obstruction of the airways.

0:16:49.280 --> 0:16:52.320
<v Speaker 5>But in people with asthma, what this does is it

0:16:52.400 --> 0:16:57.080
<v Speaker 5>triggers a hyper reactivity of the smooth muscle cells that

0:16:57.200 --> 0:17:01.720
<v Speaker 5>surround our airways, and it causes those airways to constrict.

0:17:02.320 --> 0:17:07.680
<v Speaker 5>This again obstructs the airway. So it's these two things. Inflammation,

0:17:07.920 --> 0:17:12.679
<v Speaker 5>which is both an underlying chronic inflammation and episodes of

0:17:12.760 --> 0:17:18.600
<v Speaker 5>increased inflammation and smooth muscle constriction also called bronco constriction,

0:17:19.240 --> 0:17:22.639
<v Speaker 5>and that together is what causes the shortness of breath,

0:17:22.800 --> 0:17:25.520
<v Speaker 5>the wheeze, the chest tightness, all of these things that

0:17:25.560 --> 0:17:27.920
<v Speaker 5>we associate with asthma exacerbations.

0:17:28.520 --> 0:17:33.520
<v Speaker 4>Okay, I can wrap my head around, like the hyperreactivity

0:17:34.240 --> 0:17:38.680
<v Speaker 4>part of this leading to super inflammation. But where does

0:17:38.720 --> 0:17:44.159
<v Speaker 4>the smooth muscle constriction come in, Like why does that happen?

0:17:44.200 --> 0:17:48.119
<v Speaker 4>Does that happen under other circumstances? When is that like

0:17:48.359 --> 0:17:50.280
<v Speaker 4>is it too much of a good thing?

0:17:50.640 --> 0:17:55.520
<v Speaker 5>Kind of a deal? Yeah, it's a good question. So, yes,

0:17:55.720 --> 0:17:59.600
<v Speaker 5>our airways have smooth muscles so that they can expand

0:17:59.600 --> 0:18:03.719
<v Speaker 5>and contry at as needed. What happens in asthma is

0:18:04.640 --> 0:18:08.560
<v Speaker 5>a hyperactive response. If you think of like when you

0:18:08.840 --> 0:18:11.480
<v Speaker 5>get a tickle in your throat, or you inhale your

0:18:11.480 --> 0:18:16.960
<v Speaker 5>own saliva by accident and you cough, right, that cough response.

0:18:17.119 --> 0:18:20.440
<v Speaker 5>Part of what's happening in that is airways are constricting,

0:18:20.440 --> 0:18:24.040
<v Speaker 5>smooth muscle cells are being activated, right, that's a normal

0:18:24.160 --> 0:18:28.640
<v Speaker 5>physiologic response. What's happening in asthma is a hyper reactivity

0:18:28.720 --> 0:18:33.280
<v Speaker 5>to irritants or to triggers of some kind that's also

0:18:33.440 --> 0:18:37.320
<v Speaker 5>happening unevenly across all of the different small and large

0:18:37.320 --> 0:18:40.240
<v Speaker 5>airways in your lungs. So it's not like the whole

0:18:40.320 --> 0:18:42.680
<v Speaker 5>lung it's like patchy throughout the lungs.

0:18:43.080 --> 0:18:47.680
<v Speaker 4>That's really interesting, and it's like a sustained response to.

0:18:48.400 --> 0:18:51.399
<v Speaker 5>Such a good question erin So it's not like just

0:18:51.920 --> 0:18:54.719
<v Speaker 5>all of the airways and the lungs constrict and stay constricted.

0:18:55.040 --> 0:18:57.280
<v Speaker 5>But you can think of it as like this hyperactive

0:18:57.320 --> 0:19:00.720
<v Speaker 5>response happening throughout the lungs, and that is also going

0:19:00.800 --> 0:19:05.400
<v Speaker 5>to trigger more immune activity and inflammation. Right, So it's

0:19:05.440 --> 0:19:08.840
<v Speaker 5>like a it's more like a cycle, yeah, dominoes or cycles.

0:19:09.240 --> 0:19:14.000
<v Speaker 4>Okay, so why certain areas, Like is there any rhyme

0:19:14.119 --> 0:19:17.359
<v Speaker 4>or reason to which areas are constricted or have this

0:19:17.480 --> 0:19:19.440
<v Speaker 4>hyperreactivity or anything like.

0:19:19.359 --> 0:19:22.480
<v Speaker 5>That, not that I know of. Okay, Yeah, Yeah, it's

0:19:22.480 --> 0:19:25.040
<v Speaker 5>just sort of it's happening throughout the lungs and it's

0:19:25.720 --> 0:19:32.760
<v Speaker 5>patchy debris like mucus can be mucus cells, all of

0:19:32.760 --> 0:19:35.639
<v Speaker 5>the immune mediators that are coming to the quote unquote

0:19:35.680 --> 0:19:39.200
<v Speaker 5>rescue because of this trigger that we have to respond to, right,

0:19:39.840 --> 0:19:43.080
<v Speaker 5>all the cells that are there, it's just all that stuff,

0:19:43.920 --> 0:19:46.880
<v Speaker 5>And again this is not happening in the same way

0:19:47.000 --> 0:19:50.480
<v Speaker 5>in everyone, so it's not the same stuff in everyone.

0:19:50.600 --> 0:19:53.359
<v Speaker 5>There are a lot of different types of asthma and

0:19:53.400 --> 0:19:56.720
<v Speaker 5>they're classified in different ways. So in a clinical setting

0:19:56.800 --> 0:20:00.440
<v Speaker 5>like your doctor's office or whatever you might in here,

0:20:00.480 --> 0:20:04.560
<v Speaker 5>asthma classified by its severity. Is it an intermittent asthma

0:20:04.640 --> 0:20:08.679
<v Speaker 5>that really happens pretty rarely under very certain circumstances. Or

0:20:08.760 --> 0:20:11.480
<v Speaker 5>is it persistent? Is it kind of always there or

0:20:11.480 --> 0:20:15.280
<v Speaker 5>happens really often but can be controlled with medications. Is

0:20:15.280 --> 0:20:19.080
<v Speaker 5>it mild? Is it moderate? Or is it severe? But

0:20:19.680 --> 0:20:24.119
<v Speaker 5>those different definitions change based on what society's guidelines you

0:20:24.200 --> 0:20:26.159
<v Speaker 5>might be looking at. And by society, I mean you know,

0:20:26.400 --> 0:20:29.439
<v Speaker 5>like the Asthma Federation of this country or that country,

0:20:29.520 --> 0:20:36.360
<v Speaker 5>not like urgiety, yeah, high society, whatever. But on top

0:20:36.400 --> 0:20:39.199
<v Speaker 5>of those type of clinical definitions, there's also a lot

0:20:39.240 --> 0:20:43.280
<v Speaker 5>of other ways to classify asthma. There's allergic asthma, which

0:20:43.359 --> 0:20:47.520
<v Speaker 5>often coincides with things like you know, allergies, food allergies,

0:20:47.600 --> 0:20:53.080
<v Speaker 5>environmental allergies, exzema. Non allergic asthma, so not associated with

0:20:53.200 --> 0:20:57.800
<v Speaker 5>allergies or allergic responses. There's like cough predominant asthma. There's

0:20:57.960 --> 0:21:02.639
<v Speaker 5>eosynophilic asthma. There's extra size induced asthma, there's late onset asthma.

0:21:03.359 --> 0:21:07.240
<v Speaker 5>There's a lot. And these are sometimes called different phenotypes

0:21:07.359 --> 0:21:10.840
<v Speaker 5>of asthma. For anyone who hasn't taken general bio in

0:21:10.880 --> 0:21:14.080
<v Speaker 5>a while, a phenotype is like what you observe. It's

0:21:14.119 --> 0:21:18.040
<v Speaker 5>a set of like observable characteristics. So these are other

0:21:18.080 --> 0:21:22.560
<v Speaker 5>ways to classify asthma based on how it appears clinically,

0:21:22.600 --> 0:21:26.920
<v Speaker 5>how you seem. It's another system aside from just mild, moderate, severe,

0:21:27.000 --> 0:21:30.679
<v Speaker 5>and these can kind of go together. But none of

0:21:30.760 --> 0:21:34.440
<v Speaker 5>these ways of classifying get into the fact that within

0:21:34.560 --> 0:21:38.200
<v Speaker 5>and across each of these classifications there are in fact

0:21:38.359 --> 0:21:44.840
<v Speaker 5>different underlying mechanisms of that asthma. These are sometimes called

0:21:44.920 --> 0:21:49.359
<v Speaker 5>different asthma endotypes or different subsets of a disease that

0:21:49.400 --> 0:21:55.199
<v Speaker 5>are actually based on distinct pathophysiological mechanisms. On that, I

0:21:55.240 --> 0:21:58.000
<v Speaker 5>want to shout out a paper called Understanding the Immunology

0:21:58.040 --> 0:22:03.120
<v Speaker 5>of Asthma Pathophysiology by and Treatments for Asthma Endotypes from

0:22:03.160 --> 0:22:05.919
<v Speaker 5>twenty twenty, because not only does that paper highlight a

0:22:05.960 --> 0:22:09.159
<v Speaker 5>lot of the complexity of these different endotypes, and I

0:22:09.200 --> 0:22:12.320
<v Speaker 5>am not going to get into a lot of that complexity,

0:22:13.119 --> 0:22:17.359
<v Speaker 5>but it had this really great schematic diagram of some

0:22:17.560 --> 0:22:21.320
<v Speaker 5>of the possible mechanisms that underlie the development of these

0:22:21.359 --> 0:22:25.560
<v Speaker 5>different types of asthma, which you can all just call asthma,

0:22:25.600 --> 0:22:31.240
<v Speaker 5>really in a way that connects these seemingly disparate pathways

0:22:31.800 --> 0:22:35.160
<v Speaker 5>that all happen to lead to the same end result, right,

0:22:35.200 --> 0:22:40.960
<v Speaker 5>and that end result is chronic underlying inflammation and airway

0:22:41.119 --> 0:22:46.480
<v Speaker 5>hyper reactivity with certain triggers aka asthma.

0:22:46.600 --> 0:22:49.520
<v Speaker 4>It's so interesting because on the one hand, it seems

0:22:49.560 --> 0:22:53.919
<v Speaker 4>like you can break down asthma into so many discrete

0:22:54.080 --> 0:22:59.320
<v Speaker 4>types and in terms of phenotype like you said, or

0:22:59.400 --> 0:23:03.280
<v Speaker 4>the underlier mechanism or treatment or whatever. But at the

0:23:03.320 --> 0:23:06.919
<v Speaker 4>same time it's this big overarching thing. And at the

0:23:06.920 --> 0:23:12.320
<v Speaker 4>same time, treatment i assume is highly individual, where it's

0:23:12.400 --> 0:23:16.000
<v Speaker 4>like based on this person, Like you could have two

0:23:16.080 --> 0:23:20.960
<v Speaker 4>people that have allergic asthma, but they're maybe their triggers

0:23:20.960 --> 0:23:24.359
<v Speaker 4>are something different, and so then the management is different.

0:23:24.760 --> 0:23:28.360
<v Speaker 5>Well is it, Aaron Guse Right now? It isn't. And

0:23:28.480 --> 0:23:32.600
<v Speaker 5>that is such a good point, right, That is why

0:23:32.960 --> 0:23:38.520
<v Speaker 5>understanding these different underlying mechanisms matters because if all the

0:23:38.560 --> 0:23:43.399
<v Speaker 5>treatment is the same, then these underlying mechanisms are interesting

0:23:43.480 --> 0:23:49.360
<v Speaker 5>but don't necessarily matter. Right now, our treatment is based

0:23:49.400 --> 0:23:53.000
<v Speaker 5>on symptoms, and symptoms are things that you can see

0:23:53.400 --> 0:23:58.280
<v Speaker 5>and experience, right so treatment is based on how often

0:23:58.280 --> 0:24:01.520
<v Speaker 5>do you have exacerbations? Yes, maybe what are your triggers

0:24:01.520 --> 0:24:04.600
<v Speaker 5>will determine when you might use a treatment. But at

0:24:04.680 --> 0:24:09.200
<v Speaker 5>its core, the treatment guidelines are mostly the same for everyone,

0:24:09.240 --> 0:24:12.840
<v Speaker 5>based on the severity of your asthma, but not based

0:24:12.880 --> 0:24:17.399
<v Speaker 5>on any of these underlying mechanisms. So two people with

0:24:17.480 --> 0:24:20.480
<v Speaker 5>the same severity are going to end up falling on

0:24:20.520 --> 0:24:23.600
<v Speaker 5>the same treatment algorithm, even if they have totally different

0:24:23.640 --> 0:24:28.600
<v Speaker 5>types of asthma. How it stands today, but it doesn't

0:24:28.680 --> 0:24:32.119
<v Speaker 5>work the same way for everyone, and that's because the

0:24:32.200 --> 0:24:37.520
<v Speaker 5>underlying mechanisms aren't necessarily the same. So in asthma we

0:24:37.640 --> 0:24:42.240
<v Speaker 5>have now learned that understanding these disparate mechanisms is actually

0:24:42.280 --> 0:24:46.880
<v Speaker 5>really important because even though it ends with the same response,

0:24:47.640 --> 0:24:50.680
<v Speaker 5>the ways and pathways in which you get there, if

0:24:50.720 --> 0:24:54.880
<v Speaker 5>we can better target those, we can have individualized treatment

0:24:56.240 --> 0:24:58.879
<v Speaker 5>and then we can have better outcomes. Right now, we

0:24:59.040 --> 0:25:03.320
<v Speaker 5>have that for pretty small subsets of populations just based

0:25:03.359 --> 0:25:04.960
<v Speaker 5>on like what's available today.

0:25:05.680 --> 0:25:10.280
<v Speaker 4>Huh, It's like it's within reach. It's like you know

0:25:10.440 --> 0:25:13.840
<v Speaker 4>this now, now let's turn to application.

0:25:13.800 --> 0:25:15.880
<v Speaker 5>Right exactly? I think I think that's kind of where

0:25:15.880 --> 0:25:18.800
<v Speaker 5>we where we are and where we're going. So that's

0:25:18.800 --> 0:25:24.240
<v Speaker 5>like spoilers for later this episode. So that is kind

0:25:24.240 --> 0:25:26.800
<v Speaker 5>of the as much as we'll get into on the

0:25:26.920 --> 0:25:30.560
<v Speaker 5>nitty gritty of like these different mechanisms of asthma and

0:25:30.600 --> 0:25:35.000
<v Speaker 5>the types of asthma. If you want more real nitty gritty,

0:25:35.840 --> 0:25:39.199
<v Speaker 5>I will post plenty of papers for you. But the

0:25:39.240 --> 0:25:44.120
<v Speaker 5>other big question is like who gets asthma? Right? Right? Everyone?

0:25:44.160 --> 0:25:48.280
<v Speaker 5>What right? And everyone? What are these risk factors like?

0:25:48.680 --> 0:25:51.479
<v Speaker 5>And I think a really interesting part of that question

0:25:51.600 --> 0:25:55.320
<v Speaker 5>from a public health perspective is is it inevitable that

0:25:55.359 --> 0:25:58.520
<v Speaker 5>a person is going to develop asthma if they are

0:25:58.560 --> 0:26:00.920
<v Speaker 5>a person who's going to develop as or is this

0:26:01.000 --> 0:26:06.840
<v Speaker 5>something potentially preventable? And I'm sure it will be no

0:26:06.960 --> 0:26:10.679
<v Speaker 5>surprise to you, AARIN or to listeners that we don't

0:26:10.720 --> 0:26:15.800
<v Speaker 5>know the answer to that question. Asthma is a multi

0:26:15.960 --> 0:26:21.000
<v Speaker 5>factorial disease, since we know now just how variable it

0:26:21.119 --> 0:26:24.639
<v Speaker 5>is and we're only in the relatively early stages of

0:26:24.720 --> 0:26:29.399
<v Speaker 5>really understanding all of that variability. We don't really know

0:26:29.760 --> 0:26:33.480
<v Speaker 5>and can't pinpoint this person's going to develop asthma, this

0:26:33.520 --> 0:26:37.400
<v Speaker 5>person's not. If we change these things about the environment,

0:26:37.440 --> 0:26:40.800
<v Speaker 5>we could prevent this asthma, but not this asthma. We

0:26:40.880 --> 0:26:43.760
<v Speaker 5>don't know that. But we do know that there are

0:26:43.880 --> 0:26:48.240
<v Speaker 5>both genetic and environmental factors that play into the development

0:26:48.359 --> 0:26:52.640
<v Speaker 5>of asthma. There are a lot of different potential genes

0:26:52.680 --> 0:26:56.280
<v Speaker 5>that could be involved, like a whole host of them,

0:26:56.800 --> 0:26:59.640
<v Speaker 5>and there's some thought that there might also be epigenetic

0:26:59.640 --> 0:27:03.040
<v Speaker 5>factor that are involved, because there's evidence that asthma is

0:27:03.119 --> 0:27:07.280
<v Speaker 5>more strongly maternally linked than paternally linked in terms of genetics,

0:27:08.080 --> 0:27:11.920
<v Speaker 5>but overall heritability is like between thirty five and eighty

0:27:11.960 --> 0:27:17.080
<v Speaker 5>percent depending on which study you read. And in terms

0:27:17.080 --> 0:27:22.000
<v Speaker 5>of environmental factors, there are so many it's.

0:27:21.800 --> 0:27:24.600
<v Speaker 4>Just like you could spend the rest of this episode

0:27:24.640 --> 0:27:27.320
<v Speaker 4>listing them and not even get close exactly.

0:27:27.920 --> 0:27:29.680
<v Speaker 5>And I know, Aaron, that you're going to get into

0:27:29.720 --> 0:27:33.679
<v Speaker 5>some of the fun hypotheses that have come out.

0:27:33.840 --> 0:27:37.360
<v Speaker 4>As to just just a tiny little sprinkling.

0:27:37.480 --> 0:27:40.159
<v Speaker 5>Yeah, that's good, that's good. That's all we need is

0:27:40.160 --> 0:27:43.679
<v Speaker 5>a sprinkle of some of those, but some things that

0:27:43.720 --> 0:27:47.240
<v Speaker 5>we know are real risk factors for asthma are things

0:27:47.320 --> 0:27:51.640
<v Speaker 5>like tobacco, smoke pollution right air pollution is a huge

0:27:51.720 --> 0:27:55.960
<v Speaker 5>factor in the development of asthma and also asthma exacerbations.

0:27:57.200 --> 0:28:01.200
<v Speaker 5>So there's a lot of just overall environmental changes that

0:28:01.240 --> 0:28:04.440
<v Speaker 5>can affect the development of asthma. And that's the large

0:28:04.480 --> 0:28:07.040
<v Speaker 5>part of why we see, as we'll talk about in

0:28:07.080 --> 0:28:11.520
<v Speaker 5>the current event section, such variation in asthma prevalence across

0:28:11.520 --> 0:28:12.040
<v Speaker 5>the globe.

0:28:12.560 --> 0:28:18.160
<v Speaker 4>There are so many layers to every aspect of asthma.

0:28:18.560 --> 0:28:21.399
<v Speaker 4>I know, and I have nowhere that I'm going with

0:28:21.440 --> 0:28:25.080
<v Speaker 4>that just saying that, But I do have a question.

0:28:26.680 --> 0:28:29.640
<v Speaker 4>So you talked about how for the most part, treatment

0:28:29.920 --> 0:28:34.800
<v Speaker 4>and management is more or less very similar, if not

0:28:34.880 --> 0:28:37.959
<v Speaker 4>the same, for most people. What is that treatment?

0:28:38.520 --> 0:28:41.000
<v Speaker 5>Great question. I'll talk a little bit more about this

0:28:41.200 --> 0:28:45.680
<v Speaker 5>in the current event section, but the basic, very basicness

0:28:45.960 --> 0:28:50.240
<v Speaker 5>is inhalers of some kind. Inhalers allow for medication to

0:28:50.240 --> 0:28:53.719
<v Speaker 5>be delivered directly to the lungs, so that's where we

0:28:53.760 --> 0:28:55.760
<v Speaker 5>want the effect of this medication to be. This is

0:28:55.800 --> 0:28:59.040
<v Speaker 5>a disease that's really happening in the lungs, so by

0:28:59.120 --> 0:29:02.640
<v Speaker 5>having an inhaled medication, you have pretty minimal systemic absorption,

0:29:02.720 --> 0:29:07.080
<v Speaker 5>which is good. There's two different major types of inhalers.

0:29:07.560 --> 0:29:11.680
<v Speaker 5>There's inhalers that mostly serve to broncho dilate, so they

0:29:11.800 --> 0:29:14.960
<v Speaker 5>relax the smooth muscle of those airways and open them

0:29:15.040 --> 0:29:19.160
<v Speaker 5>up right. All of those rescue inhalers that people think of,

0:29:19.480 --> 0:29:24.280
<v Speaker 5>those are usually really short acting broncho dilators, so they

0:29:24.480 --> 0:29:27.080
<v Speaker 5>turn on quickly and turn off quickly to just open

0:29:27.200 --> 0:29:31.040
<v Speaker 5>up your airways if you can't breathe for a short time.

0:29:32.040 --> 0:29:34.960
<v Speaker 5>Then there are longer acting versions of those that people

0:29:35.040 --> 0:29:41.040
<v Speaker 5>might use as controller medications. And then there are inhaled steroids. Steroids,

0:29:41.040 --> 0:29:44.320
<v Speaker 5>of course are anti inflammatory, so these are serving to

0:29:44.400 --> 0:29:48.800
<v Speaker 5>reduce the overall inflammation and immune activation that's causing a

0:29:48.800 --> 0:29:54.880
<v Speaker 5>lot of this underlying issue. More and more inhaled corticosteroids

0:29:54.960 --> 0:29:59.800
<v Speaker 5>have become the mainstay of asthma management. Even in mild asthma.

0:30:00.280 --> 0:30:05.959
<v Speaker 5>Used to be a probably over reliance on bronchodilators, and

0:30:06.040 --> 0:30:09.280
<v Speaker 5>now more and more it's inhaled steroids plus or minus

0:30:09.360 --> 0:30:13.880
<v Speaker 5>these bronchodilators. And I think that that makes sense when

0:30:13.920 --> 0:30:16.239
<v Speaker 5>you go back to what we just talked about with

0:30:16.760 --> 0:30:20.360
<v Speaker 5>the fact that this is an inflammatory disease. There's underlying

0:30:20.400 --> 0:30:24.200
<v Speaker 5>chronic inflammation even in people with mild or intermittent asthma,

0:30:25.040 --> 0:30:28.880
<v Speaker 5>and so anything that's just acting to bronchodilate is like

0:30:28.920 --> 0:30:31.520
<v Speaker 5>a band aid. It's treating the symptoms, but it's not

0:30:31.560 --> 0:30:37.280
<v Speaker 5>addressing that underlying immune dysfunction and inflammation. So the steroids

0:30:37.280 --> 0:30:41.240
<v Speaker 5>are doing a better job of that. But as I said,

0:30:41.480 --> 0:30:44.080
<v Speaker 5>especially as we understand more and more about these different

0:30:44.080 --> 0:30:47.680
<v Speaker 5>types of asthma, there are already and will likely continue

0:30:47.720 --> 0:30:52.600
<v Speaker 5>to be other, probably systemic options like monoclonal antibodies and

0:30:52.640 --> 0:30:56.560
<v Speaker 5>things like that, that are directly targeting the dysfunctional immune

0:30:56.600 --> 0:30:59.920
<v Speaker 5>cells involved. But we're not there quite yet.

0:31:00.520 --> 0:31:03.120
<v Speaker 4>I think it was in our lupus episode that we

0:31:03.240 --> 0:31:07.000
<v Speaker 4>talked about how long term use of steroids can be

0:31:07.560 --> 0:31:13.080
<v Speaker 4>not so great sometimes. Is that different for inhaled steroids

0:31:13.120 --> 0:31:15.320
<v Speaker 4>because it's so localized exactly.

0:31:15.360 --> 0:31:19.560
<v Speaker 5>That's why it's so important that it's inhaled and not systemic,

0:31:19.680 --> 0:31:22.840
<v Speaker 5>because you have very minimal systemic absorption. It's really just

0:31:22.880 --> 0:31:27.560
<v Speaker 5>like coding your airways and acting in those airways. Cool

0:31:27.760 --> 0:31:30.240
<v Speaker 5>very different than like taking a steroid pills.

0:31:31.160 --> 0:31:32.680
<v Speaker 4>Yeah, okay, that's interesting.

0:31:33.000 --> 0:31:34.400
<v Speaker 5>Yeah.

0:31:34.440 --> 0:31:38.280
<v Speaker 4>Although we know that asthma is not strictly a childhood

0:31:38.320 --> 0:31:43.400
<v Speaker 4>disease or disease of childhood, it does happen in children

0:31:43.480 --> 0:31:47.280
<v Speaker 4>and then go away. Do we know anything about why?

0:31:47.320 --> 0:31:51.640
<v Speaker 5>That is good question. I don't have an answer to

0:31:51.680 --> 0:31:54.200
<v Speaker 5>that question. It is possible that I just didn't read

0:31:54.200 --> 0:31:56.360
<v Speaker 5>the right papers and that there is a very good

0:31:56.520 --> 0:32:01.160
<v Speaker 5>answer to that question that I didn't find. So if

0:32:01.200 --> 0:32:03.760
<v Speaker 5>anyone has a better answer than what I'm about to say,

0:32:03.800 --> 0:32:06.520
<v Speaker 5>please do let us know. But I suspect a lot

0:32:06.560 --> 0:32:08.840
<v Speaker 5>of it just has to do with how much our

0:32:08.840 --> 0:32:12.840
<v Speaker 5>immune systems are still under development when we're little, and

0:32:12.960 --> 0:32:17.040
<v Speaker 5>our airways are also a lot smaller. Okay, So anything

0:32:17.080 --> 0:32:20.600
<v Speaker 5>that's causing obstruction or constriction, it's going to have a

0:32:20.640 --> 0:32:23.160
<v Speaker 5>greater effect when you're smaller and your airways are small.

0:32:23.520 --> 0:32:26.959
<v Speaker 5>And so a lot of kids have wheeze, and a

0:32:26.960 --> 0:32:30.960
<v Speaker 5>lot of that wheeze may never truly be labeled as asthma. Right,

0:32:31.000 --> 0:32:34.640
<v Speaker 5>they might get wheezing with every viral infection, but never

0:32:35.200 --> 0:32:39.480
<v Speaker 5>like meet the definition of asthma by whoever's defining it

0:32:39.560 --> 0:32:42.720
<v Speaker 5>in their region. And then they'll grow out of that

0:32:42.800 --> 0:32:45.520
<v Speaker 5>because their airways are growing and their immune system is,

0:32:45.640 --> 0:32:49.520
<v Speaker 5>you know, figuring itself out. That's the best answer that

0:32:49.600 --> 0:32:51.400
<v Speaker 5>I can give you. There might be a better one

0:32:51.440 --> 0:32:51.800
<v Speaker 5>out there.

0:32:52.120 --> 0:32:56.040
<v Speaker 4>Okay, Yeah, so I know that this next question, the

0:32:56.120 --> 0:32:58.960
<v Speaker 4>answer is probably it depends on what country or what

0:32:59.400 --> 0:33:04.840
<v Speaker 4>organization or whatever. But how is asthma diagnosed? Yeah, what happens?

0:33:05.120 --> 0:33:07.200
<v Speaker 4>What are the what are the diagnostic criteria?

0:33:07.440 --> 0:33:12.239
<v Speaker 5>Excellent question. So in some places it's diagnosed with what

0:33:12.280 --> 0:33:15.680
<v Speaker 5>are called pulmonary function tests, So that means you actually

0:33:15.720 --> 0:33:18.280
<v Speaker 5>have to like sit in this chamber and blow and

0:33:18.360 --> 0:33:21.800
<v Speaker 5>this tube and they measure the flows and blah blah blah,

0:33:21.840 --> 0:33:23.920
<v Speaker 5>and then on top of that, you have to give

0:33:24.000 --> 0:33:29.440
<v Speaker 5>a Bronco dilator and see if the values improve. Because

0:33:29.440 --> 0:33:34.240
<v Speaker 5>that tells us that it's a reversible process that really

0:33:34.280 --> 0:33:39.240
<v Speaker 5>helps distinguish asthma from something like COPD or chronic obstructive

0:33:39.240 --> 0:33:43.040
<v Speaker 5>pulmonary disease. So that's more like adults are more likely

0:33:43.080 --> 0:33:49.160
<v Speaker 5>to undergo that whole function pulmonary function testing process. In kids,

0:33:49.200 --> 0:33:51.080
<v Speaker 5>a lot of times they can't do those testing or

0:33:51.080 --> 0:33:53.600
<v Speaker 5>that testing is really difficult and just not available where

0:33:53.600 --> 0:33:56.760
<v Speaker 5>they live. So really it's based on those symptoms that

0:33:56.840 --> 0:34:00.680
<v Speaker 5>I talked about way at the very beginning, these episodes

0:34:00.720 --> 0:34:03.280
<v Speaker 5>of shortness of breath and wheezing, which is something you're

0:34:03.280 --> 0:34:08.200
<v Speaker 5>going to hear with a stethoscope, and that happen in

0:34:08.239 --> 0:34:10.560
<v Speaker 5>response to really any kind of trigger, doesn't matter what

0:34:10.680 --> 0:34:14.040
<v Speaker 5>the trigger is, and that will get better with some

0:34:14.239 --> 0:34:18.640
<v Speaker 5>of these medications in general. So I don't have in

0:34:18.680 --> 0:34:22.359
<v Speaker 5>front of me like the very specific this number of

0:34:22.680 --> 0:34:25.399
<v Speaker 5>episodes or of wheezing or anything like that, but that's

0:34:25.440 --> 0:34:28.960
<v Speaker 5>the general rule, and you don't have to have those

0:34:28.960 --> 0:34:32.239
<v Speaker 5>pulmonary function tests in order to make the diagnosis.

0:34:32.560 --> 0:34:36.120
<v Speaker 4>Okay, I feel like I saved all my questions for

0:34:36.160 --> 0:34:38.440
<v Speaker 4>the end somehow. But I do have another.

0:34:38.200 --> 0:34:39.600
<v Speaker 3>One, Okay, give it to me.

0:34:40.160 --> 0:34:43.960
<v Speaker 4>And that is the breakdown between mild, moderate, and severe.

0:34:44.239 --> 0:34:48.280
<v Speaker 4>Like what determines whether something is mild, moderate, or severe

0:34:48.320 --> 0:34:53.600
<v Speaker 4>is that the frequency or intensity of exacerbations. And question

0:34:53.800 --> 0:35:00.359
<v Speaker 4>part two is are there certain types of asthma that

0:35:00.400 --> 0:35:03.319
<v Speaker 4>are more likely to be severe or more likely to

0:35:03.360 --> 0:35:06.600
<v Speaker 4>be mild or is it super individual?

0:35:07.120 --> 0:35:12.920
<v Speaker 5>Excellent question. So again I don't have the exact numbers

0:35:13.000 --> 0:35:15.440
<v Speaker 5>in front of me in terms of mild, moderate, severe.

0:35:15.920 --> 0:35:18.440
<v Speaker 5>I will point all listeners who want to know to

0:35:18.760 --> 0:35:22.239
<v Speaker 5>and we'll link to the Global Initiative on Asthma or

0:35:22.360 --> 0:35:26.960
<v Speaker 5>GENA report, which is one of the main organizations that

0:35:27.360 --> 0:35:32.720
<v Speaker 5>defines these But it is based on how many exacerbations

0:35:32.719 --> 0:35:35.759
<v Speaker 5>you have, whether you've needed to be hospitalized or had

0:35:35.840 --> 0:35:40.720
<v Speaker 5>systemic steroids to treat an exacerbation, versus if your exacerbations

0:35:41.040 --> 0:35:45.400
<v Speaker 5>get better with just inhaled medications, because sometimes they're so

0:35:45.600 --> 0:35:48.800
<v Speaker 5>bad that you do need those systemic steroids to actually

0:35:48.840 --> 0:35:53.239
<v Speaker 5>calm down that inflammation and actually treat that exacerbation. So yeah,

0:35:53.280 --> 0:35:56.359
<v Speaker 5>at its core, it's about how many exacerbations and how

0:35:56.400 --> 0:36:00.799
<v Speaker 5>bad those exacerbations are. Okay, when we're talking about the

0:36:00.920 --> 0:36:04.800
<v Speaker 5>different classification to answer your question about our certain types

0:36:04.840 --> 0:36:09.400
<v Speaker 5>of asthma more likely to be severe, Yes, potentially, especially

0:36:09.440 --> 0:36:12.960
<v Speaker 5>adult onset asthma or late onset asthma is maybe more

0:36:13.040 --> 0:36:16.680
<v Speaker 5>likely to be severe than childhood asthma or asthma that's

0:36:16.719 --> 0:36:20.440
<v Speaker 5>been there since forever, and I'm sure that there are

0:36:20.520 --> 0:36:24.840
<v Speaker 5>other types that also are more likely to be severe

0:36:24.880 --> 0:36:29.080
<v Speaker 5>than others. Then there are also some people with asthma

0:36:29.160 --> 0:36:32.200
<v Speaker 5>that we maybe don't have a good classification for, but

0:36:32.239 --> 0:36:35.719
<v Speaker 5>that is very severe that we really don't have great

0:36:35.760 --> 0:36:39.200
<v Speaker 5>treatments for yet. And so I think that gets to

0:36:39.320 --> 0:36:42.080
<v Speaker 5>why it's so important that we really understand all of

0:36:42.120 --> 0:36:46.719
<v Speaker 5>the different underlying mechanisms, because there are people who have

0:36:47.360 --> 0:36:50.160
<v Speaker 5>very difficult to control asthma with severe symptoms that we

0:36:50.280 --> 0:36:52.920
<v Speaker 5>right now don't have great ways of treating.

0:36:53.520 --> 0:36:58.560
<v Speaker 3>Okay, yeah, so yeah, that's unless you have more question.

0:37:00.080 --> 0:37:02.000
<v Speaker 5>That's the biology.

0:37:03.320 --> 0:37:03.960
<v Speaker 3>Of asthma.

0:37:04.719 --> 0:37:06.839
<v Speaker 4>There's so much to it.

0:37:07.400 --> 0:37:10.319
<v Speaker 5>Yeah, and I probably didn't cover it all.

0:37:10.920 --> 0:37:14.600
<v Speaker 4>I mean it's impossible too though, like it even if

0:37:14.640 --> 0:37:19.360
<v Speaker 4>you did one type of asthma, let's say, like allergic

0:37:19.480 --> 0:37:22.200
<v Speaker 4>or allergy associated asthma or whatever. Yeah, how did they

0:37:22.239 --> 0:37:22.760
<v Speaker 4>even begin?

0:37:23.239 --> 0:37:26.399
<v Speaker 5>We'd be we'd be here all night erin, Yeah, we would.

0:37:27.040 --> 0:37:30.080
<v Speaker 5>So on that note of being here all night erin,

0:37:31.920 --> 0:37:34.919
<v Speaker 5>I'm guessing, I mean, have we had asthma since we've

0:37:34.960 --> 0:37:38.560
<v Speaker 5>been humans? Where did the again? I don't even know

0:37:38.600 --> 0:37:41.360
<v Speaker 5>how to ask, where did this come from? Like? What's

0:37:41.560 --> 0:37:43.640
<v Speaker 5>up with this? How about that?

0:37:43.640 --> 0:37:46.000
<v Speaker 4>That's that's a good way to put it. I don't know,

0:37:46.160 --> 0:37:50.400
<v Speaker 4>but I'll well, we'll try to get into it as

0:37:50.440 --> 0:38:21.359
<v Speaker 4>much as we can. Right after this break. The thing

0:38:21.680 --> 0:38:26.160
<v Speaker 4>that surprised me most about the history of asthma isn't

0:38:26.360 --> 0:38:30.200
<v Speaker 4>how far back and wide ranging the descriptions go. So, Aaron,

0:38:30.280 --> 0:38:34.080
<v Speaker 4>you asked, have we had this since we were humans?

0:38:34.680 --> 0:38:37.600
<v Speaker 4>First of all, yes, it's an ancient disease that's been

0:38:37.600 --> 0:38:41.359
<v Speaker 4>written about since ancient times, and we absolutely have had

0:38:41.360 --> 0:38:43.959
<v Speaker 4>it for as long as we've been humans, which makes

0:38:43.960 --> 0:38:47.440
<v Speaker 4>sense because other animal species can also have asthma. Like,

0:38:47.560 --> 0:38:48.800
<v Speaker 4>my gosh, get asthma.

0:38:49.120 --> 0:38:51.319
<v Speaker 5>I really wanted to ask you that question, and I

0:38:51.360 --> 0:38:52.239
<v Speaker 5>was afraid that it was a.

0:38:52.200 --> 0:38:57.879
<v Speaker 4>Silly question, and bil I definitely googled it, and that's

0:38:57.920 --> 0:38:58.880
<v Speaker 4>what Google tells me.

0:38:59.160 --> 0:39:03.200
<v Speaker 5>Oh my goodness, poor kitty cats. I know, I know,

0:39:03.600 --> 0:39:05.880
<v Speaker 5>how do you get an inhaler for a cat? You

0:39:05.920 --> 0:39:06.799
<v Speaker 5>need a nebulizer?

0:39:07.560 --> 0:39:11.640
<v Speaker 4>Sure, I don't know how at home management is for

0:39:11.840 --> 0:39:14.279
<v Speaker 4>cats with asthma. Maybe we have a lot of people

0:39:14.320 --> 0:39:16.480
<v Speaker 4>who are in the veterinary field that listen.

0:39:16.320 --> 0:39:19.280
<v Speaker 5>So yeah, please, it's so sad.

0:39:19.719 --> 0:39:24.000
<v Speaker 4>But the I forget where I was even going with this,

0:39:24.280 --> 0:39:28.719
<v Speaker 4>but that we've had it since forever. Oh yeah, yeah, yeah.

0:39:28.800 --> 0:39:31.680
<v Speaker 4>Another thing that did not surprise me, or it didn't

0:39:31.680 --> 0:39:35.680
<v Speaker 4>surprise me. The most about asthma, the history of it

0:39:35.719 --> 0:39:40.960
<v Speaker 4>is that asthma has undergone many revisions since these earliest descriptions, right, Like,

0:39:41.000 --> 0:39:43.560
<v Speaker 4>that's not that surprising. It started out as a disease

0:39:43.640 --> 0:39:48.200
<v Speaker 4>of humors, then of lungs, then of personality, then of allergy,

0:39:48.360 --> 0:39:51.640
<v Speaker 4>than as inflammation, and many other forms along the way,

0:39:51.719 --> 0:39:56.360
<v Speaker 4>sort of crisscrossing each other and happening simultaneously and borrowing

0:39:56.400 --> 0:39:57.120
<v Speaker 4>parts of each other.

0:39:57.560 --> 0:39:58.040
<v Speaker 5>Makes sense.

0:39:58.520 --> 0:40:02.040
<v Speaker 4>The thing that actually surprised me the most about the

0:40:02.120 --> 0:40:06.120
<v Speaker 4>history of asthma was how prominent a role the personal

0:40:06.239 --> 0:40:09.880
<v Speaker 4>experience of asthma played in the way that this disease

0:40:10.000 --> 0:40:14.280
<v Speaker 4>was written about, the attention it got, and in my view,

0:40:14.520 --> 0:40:19.279
<v Speaker 4>the greater sense of empathy that it invited. And this

0:40:19.440 --> 0:40:22.240
<v Speaker 4>is true for much of the history of this disease really,

0:40:22.719 --> 0:40:24.720
<v Speaker 4>or at least until we get to the early twentieth

0:40:24.760 --> 0:40:30.320
<v Speaker 4>century with the depersonalization of medicine as per usual. Basically,

0:40:30.360 --> 0:40:33.320
<v Speaker 4>this is my way of preparing you for the sizeable

0:40:33.440 --> 0:40:36.880
<v Speaker 4>number of sizable quotes that I've sprinkled in throughout the

0:40:36.960 --> 0:40:41.400
<v Speaker 4>history section one first hand account per century. Just kidding

0:40:41.400 --> 0:40:44.279
<v Speaker 4>that would be like a ridiculous amount a lot, but

0:40:44.680 --> 0:40:48.759
<v Speaker 4>I honestly probably could have given how many there are

0:40:48.920 --> 0:40:54.600
<v Speaker 4>which I think is really interesting and unusual.

0:40:55.000 --> 0:40:59.440
<v Speaker 5>Yeah, Is it just that a lot of people had

0:41:00.719 --> 0:41:03.319
<v Speaker 5>so or why? Why is that?

0:41:04.520 --> 0:41:04.800
<v Speaker 1>Yeah?

0:41:05.080 --> 0:41:07.680
<v Speaker 4>I think it just comes down to how prevalent it

0:41:07.920 --> 0:41:12.000
<v Speaker 4>was and how much it was a part of people's lives,

0:41:12.800 --> 0:41:14.000
<v Speaker 4>right because.

0:41:13.719 --> 0:41:15.719
<v Speaker 5>People were just like living with it on a day

0:41:15.760 --> 0:41:18.120
<v Speaker 5>to day. It wasn't this thing that came one time

0:41:18.880 --> 0:41:22.080
<v Speaker 5>and then killed you, right, Like a lot of diseases

0:41:22.080 --> 0:41:23.880
<v Speaker 5>we talk about, it's something that people lived with for

0:41:23.920 --> 0:41:24.640
<v Speaker 5>their whole lives.

0:41:24.960 --> 0:41:27.120
<v Speaker 4>Yeah, I think that the most similar one that we've

0:41:27.160 --> 0:41:30.719
<v Speaker 4>covered on the podcast is gout. But the other thing

0:41:30.840 --> 0:41:34.440
<v Speaker 4>too is that, like we've covered a lot of chronic diseases,

0:41:35.320 --> 0:41:40.359
<v Speaker 4>but it's also who is doing these medical writings, who

0:41:40.400 --> 0:41:43.000
<v Speaker 4>writes about it and was able to be a physician,

0:41:43.040 --> 0:41:47.520
<v Speaker 4>who was allowed to be a physician, Right, So, like endometriosis,

0:41:48.160 --> 0:41:52.600
<v Speaker 4>we could absolutely have had centuries worth the first hand accounts,

0:41:52.719 --> 0:41:53.680
<v Speaker 4>but we don't.

0:41:54.120 --> 0:41:57.800
<v Speaker 3>M this makes a lot of sense, yeah anyway.

0:41:57.520 --> 0:42:01.719
<v Speaker 4>But I think in terms of asthma, what these historical

0:42:01.800 --> 0:42:05.480
<v Speaker 4>first hand accounts show is that while there have been

0:42:05.840 --> 0:42:10.319
<v Speaker 4>enormous improvements made in terms of how it's treated or

0:42:10.400 --> 0:42:16.040
<v Speaker 4>understood or even defined, some things haven't changed I also

0:42:16.200 --> 0:42:19.280
<v Speaker 4>think that they're a good reminder in this day and age,

0:42:19.320 --> 0:42:23.600
<v Speaker 4>with medicine being so depersonalized and reduced to statistics and

0:42:23.719 --> 0:42:28.560
<v Speaker 4>charts and test results, to not discount the value of

0:42:28.640 --> 0:42:31.000
<v Speaker 4>personal stories, because I think that it can be really

0:42:31.440 --> 0:42:35.719
<v Speaker 4>important in well, first of all, just like recognizing that

0:42:36.560 --> 0:42:40.240
<v Speaker 4>patients are people, but also in how maybe this person

0:42:40.320 --> 0:42:45.280
<v Speaker 4>wants to manage their asthma and the things that exacerbate asthma. Anyway,

0:42:46.080 --> 0:42:49.400
<v Speaker 4>I should probably stop at this point philosophizing and you know,

0:42:49.480 --> 0:42:54.320
<v Speaker 4>talking about asthma and start talking about actually the history

0:42:54.480 --> 0:42:59.360
<v Speaker 4>of asthma, beginning with the ancient stuff, because the evolutionary

0:42:59.400 --> 0:43:02.040
<v Speaker 4>history of asma, like it's impossible.

0:43:02.400 --> 0:43:06.520
<v Speaker 5>Yeah, absolutely, yeah. Yeah.

0:43:06.600 --> 0:43:09.240
<v Speaker 4>So it feels like it's been a little bit since

0:43:09.320 --> 0:43:12.439
<v Speaker 4>I've gotten to say the word papyri or talk about

0:43:12.520 --> 0:43:16.560
<v Speaker 4>ancient Greece or China or India. So this is exciting.

0:43:17.400 --> 0:43:20.680
<v Speaker 4>The word asthma is actually from an ancient Greek word

0:43:21.000 --> 0:43:24.040
<v Speaker 4>that first made an appearance in the Iliad from the

0:43:24.080 --> 0:43:28.640
<v Speaker 4>seventh or eighth century BCE, in a scene describing the

0:43:28.680 --> 0:43:33.520
<v Speaker 4>Trojan leader Hector quote lying on the plane while about

0:43:33.600 --> 0:43:37.040
<v Speaker 4>him sat his comrades and he was gasping with painful

0:43:37.080 --> 0:43:42.640
<v Speaker 4>breath as Mahdi distraught in mind and vomiting blood. In

0:43:42.680 --> 0:43:46.560
<v Speaker 4>this context and for the few hundred years that followed,

0:43:47.160 --> 0:43:50.759
<v Speaker 4>the word asthma was used in Ancient Greece to describe

0:43:50.840 --> 0:43:55.560
<v Speaker 4>labored or painful breathing or gasping, especially as induced by exertion,

0:43:56.640 --> 0:43:58.759
<v Speaker 4>so you can find it a lot in descriptions of

0:43:58.840 --> 0:44:05.000
<v Speaker 4>battle or death scenes in epic plays or poems. But

0:44:05.080 --> 0:44:09.400
<v Speaker 4>by the time of Hippocrates around the fifth century BCE

0:44:09.880 --> 0:44:12.880
<v Speaker 4>or so, the word asthma had shifted to have a

0:44:12.880 --> 0:44:18.000
<v Speaker 4>more medical meaning, with a specific set of symptoms, causes, prognosis, treatments,

0:44:18.000 --> 0:44:23.000
<v Speaker 4>et cetera, a chronic condition rather than just solely an

0:44:23.040 --> 0:44:29.359
<v Speaker 4>acute attack, and in this recognition, ancient Greek physicians were

0:44:29.440 --> 0:44:33.520
<v Speaker 4>a bit behind the times. The Ebers Papyrus from around

0:44:33.560 --> 0:44:37.759
<v Speaker 4>fifteen fifty BCE includes a description of what is likely

0:44:37.840 --> 0:44:42.279
<v Speaker 4>asthma and treatments that ranged from your simple enema to

0:44:42.600 --> 0:44:46.680
<v Speaker 4>the application of various animal dung mixed with herbs. Just

0:44:47.280 --> 0:44:49.520
<v Speaker 4>spread that on your skin your skin.

0:44:49.920 --> 0:44:51.080
<v Speaker 5>What sure.

0:44:52.320 --> 0:44:55.720
<v Speaker 4>Asthma was written about extensively in ancient China as well,

0:44:56.200 --> 0:44:59.640
<v Speaker 4>with the earliest descriptions coming from around one thousand BCE,

0:45:00.480 --> 0:45:04.759
<v Speaker 4>including a mention of the plant mahuang, which was used

0:45:04.760 --> 0:45:10.080
<v Speaker 4>to treat asthma and in modern times has been used

0:45:10.200 --> 0:45:15.000
<v Speaker 4>to extract ephedrin, which has also been used to treat asthma.

0:45:15.160 --> 0:45:18.640
<v Speaker 4>So that's kind of that's kind of cool. Yeah, the

0:45:18.680 --> 0:45:23.880
<v Speaker 4>inhalation of stramonium from thorn apple or gymsen weed was

0:45:23.960 --> 0:45:26.680
<v Speaker 4>also used in modern times to treat asthma and was

0:45:26.719 --> 0:45:31.440
<v Speaker 4>also mentioned in some ancient texts. But anyway, asma was

0:45:31.520 --> 0:45:35.200
<v Speaker 4>widely written about across the ancient world, like in so

0:45:35.320 --> 0:45:38.839
<v Speaker 4>many different historical texts. It's kind of incredible, and I

0:45:38.880 --> 0:45:41.759
<v Speaker 4>think that just goes to show how prevalent it was

0:45:42.000 --> 0:45:44.880
<v Speaker 4>and how much interest there was in finding ways to

0:45:44.920 --> 0:45:51.360
<v Speaker 4>alleviate symptoms. And yeah, some of those treatments seemed a

0:45:51.400 --> 0:45:56.160
<v Speaker 4>bit questionable. You know, you've got your blood letting, your enemas,

0:45:56.280 --> 0:46:02.279
<v Speaker 4>your plasters to ease the chest, your diuretics, your emetic exercise, massage,

0:46:02.960 --> 0:46:07.160
<v Speaker 4>honeywater mead, eating the liver of a fox after it's

0:46:07.200 --> 0:46:10.520
<v Speaker 4>been dried and pounded and sprinkled into a cupful of wine,

0:46:11.239 --> 0:46:15.240
<v Speaker 4>or just eating the freshly roasted lungs of that fox. Oh, dear,

0:46:15.640 --> 0:46:22.040
<v Speaker 4>you know, just your standard treatments, standard standard, pretty pretty regular,

0:46:22.680 --> 0:46:25.480
<v Speaker 4>not to mention the dozens upon dozens of herbal remedies

0:46:25.520 --> 0:46:28.840
<v Speaker 4>and plant extracts which could be applied as tinctures, consumed

0:46:28.840 --> 0:46:32.360
<v Speaker 4>in a cocktail, and hailed so many ways to administer.

0:46:33.800 --> 0:46:37.600
<v Speaker 4>Even though there's this huge variety in the types of treatments,

0:46:37.800 --> 0:46:41.960
<v Speaker 4>like from roasted fox lungs to enemas, their purpose was

0:46:42.120 --> 0:46:45.440
<v Speaker 4>largely the same thing, to restore balance in the body.

0:46:45.920 --> 0:46:48.840
<v Speaker 4>At the time. In ancient Greece, the humoral theory of

0:46:48.880 --> 0:46:52.000
<v Speaker 4>disease predominated. And I know I've mentioned this in so

0:46:52.080 --> 0:46:54.560
<v Speaker 4>many episodes, but in case this is someone's first time

0:46:54.600 --> 0:46:59.400
<v Speaker 4>tuning in first, welcome second. The humoral theory of disease

0:46:59.680 --> 0:47:03.000
<v Speaker 4>was a essentially this idea that there are four bodily humors,

0:47:03.520 --> 0:47:06.600
<v Speaker 4>and an imbalance in one of those humors, like too

0:47:06.680 --> 0:47:11.440
<v Speaker 4>much or not enough, is what led to disease. Treatment

0:47:11.520 --> 0:47:15.439
<v Speaker 4>then was focused on restoring that balance. In the case

0:47:15.480 --> 0:47:19.760
<v Speaker 4>of asthma, an excess of FLEM was to blame, specifically

0:47:19.800 --> 0:47:23.120
<v Speaker 4>as the phlem moved from the brain to the chest.

0:47:23.480 --> 0:47:31.360
<v Speaker 5>I feel like excess of FLEM is a lot of diseases, oh, yeah.

0:47:29.640 --> 0:47:34.440
<v Speaker 4>I mean when you only have four humors.

0:47:34.360 --> 0:47:37.800
<v Speaker 3>Right, you can do the math on Yeah, how many?

0:47:38.520 --> 0:47:40.359
<v Speaker 4>Is it? Like? Four times, three times, two times one?

0:47:40.400 --> 0:47:43.520
<v Speaker 4>I'm not sure how you do that. That's my air

0:47:43.600 --> 0:47:46.200
<v Speaker 4>and math. I don't know.

0:47:46.400 --> 0:47:47.239
<v Speaker 3>I really like it.

0:47:50.239 --> 0:47:54.160
<v Speaker 4>But for asthma, like, why was there more flem? That's

0:47:54.239 --> 0:47:58.319
<v Speaker 4>a reasonable question. It has a thousand different answers. Right,

0:47:58.920 --> 0:48:01.919
<v Speaker 4>Maybe it's because you than a dry climate, or maybe

0:48:01.920 --> 0:48:04.520
<v Speaker 4>it was a certain season, or maybe you had a

0:48:04.560 --> 0:48:07.560
<v Speaker 4>certain personality that just led you to have more phlegm.

0:48:08.480 --> 0:48:11.800
<v Speaker 4>Maybe you were a certain age. Really, it could be anything.

0:48:13.000 --> 0:48:17.640
<v Speaker 4>And this flemy explanation for asthma hung around for about

0:48:17.719 --> 0:48:21.400
<v Speaker 4>one thousand years in one shape or another, and continued

0:48:21.440 --> 0:48:25.319
<v Speaker 4>to influence how European physicians viewed the disease through the

0:48:25.360 --> 0:48:30.920
<v Speaker 4>seventeen hundreds. But of course it wasn't just phlem equals asthma.

0:48:31.200 --> 0:48:35.200
<v Speaker 4>Asthma was recognized to be incredibly varied in its presentation

0:48:35.680 --> 0:48:39.400
<v Speaker 4>and severity, with most cases thought to be mild, but

0:48:39.880 --> 0:48:44.120
<v Speaker 4>others recognized as severe and even life threatening. And here

0:48:44.160 --> 0:48:48.800
<v Speaker 4>we come to our first ancient first hand account. Ooh,

0:48:49.000 --> 0:48:53.719
<v Speaker 4>so the ancient Roman philosopher Seneca had asthma and he

0:48:53.920 --> 0:48:59.560
<v Speaker 4>described his disease in around the first century CE. Quote.

0:49:00.040 --> 0:49:03.880
<v Speaker 4>It's onslaught is a very brief duration, like a squall.

0:49:03.960 --> 0:49:07.360
<v Speaker 4>It is generally over within the hour. One could hardly,

0:49:07.560 --> 0:49:10.760
<v Speaker 4>after all, expect anyone to keep on drawing his last

0:49:10.800 --> 0:49:14.840
<v Speaker 4>breath for long could one. I have suffered every kind

0:49:15.000 --> 0:49:19.440
<v Speaker 4>of unpleasant or dangerous physical complaint, but none is worse

0:49:19.520 --> 0:49:23.880
<v Speaker 4>than this, not surprising, for anything else is just an illness,

0:49:24.120 --> 0:49:27.600
<v Speaker 4>while this is gasping out your life breath. That is

0:49:27.600 --> 0:49:31.560
<v Speaker 4>why doctors call it a quote rehearsal for death, since

0:49:31.680 --> 0:49:34.680
<v Speaker 4>eventually the breath does what it has often been trying

0:49:34.719 --> 0:49:35.040
<v Speaker 4>to do.

0:49:35.719 --> 0:49:40.200
<v Speaker 5>End quote. WHOA right? That sounds awful?

0:49:40.960 --> 0:49:41.560
<v Speaker 2>I mean.

0:49:42.880 --> 0:49:47.359
<v Speaker 4>Yeah, yeah, and that tracks it tracks right like that?

0:49:47.960 --> 0:49:52.200
<v Speaker 4>You could you could imagine someone describing that today.

0:49:52.600 --> 0:49:57.600
<v Speaker 5>I have seen that, Yeah, yeah.

0:49:56.440 --> 0:50:00.959
<v Speaker 4>But yeah, I mean yeah, first century CE. I could

0:50:00.960 --> 0:50:04.360
<v Speaker 4>probably spend the rest of the history section actually in

0:50:04.440 --> 0:50:07.040
<v Speaker 4>the first century CEE, not really, but like at least

0:50:07.080 --> 0:50:11.239
<v Speaker 4>in ancient times, talking about how asthma was perceived and

0:50:11.280 --> 0:50:15.239
<v Speaker 4>written about in the ancient and medieval world. But I

0:50:15.280 --> 0:50:18.120
<v Speaker 4>should probably move on to when we started suspecting that

0:50:18.200 --> 0:50:21.480
<v Speaker 4>it wasn't just about the phlegm coming from your brain.

0:50:22.600 --> 0:50:25.680
<v Speaker 4>I only mentioned a few specific writings or scholars, but

0:50:25.760 --> 0:50:30.279
<v Speaker 4>the ancient world gave us truly an abundance of descriptions

0:50:30.320 --> 0:50:34.120
<v Speaker 4>of asthma in its varying forms, the range of symptoms,

0:50:34.160 --> 0:50:38.360
<v Speaker 4>prognosis patterns, and development treatments, even the first connection with

0:50:38.480 --> 0:50:43.120
<v Speaker 4>hay fever by al Razzi, medieval physician from Iran. But

0:50:43.880 --> 0:50:46.680
<v Speaker 4>what I think stands out the most about asthma in

0:50:46.719 --> 0:50:51.240
<v Speaker 4>the ancient world is how consistent these writings were across

0:50:51.280 --> 0:50:55.680
<v Speaker 4>the globe. It came down to balance. At its core.

0:50:56.239 --> 0:51:00.160
<v Speaker 4>Asthma was thought to be caused by an imbalance, and

0:51:00.320 --> 0:51:05.120
<v Speaker 4>treatment focused on restoring that balance, largely through herbal remedies

0:51:05.239 --> 0:51:10.319
<v Speaker 4>or lifestyle changes like diet, exercise, and reducing stress. But

0:51:10.360 --> 0:51:12.080
<v Speaker 4>like I feel like it's not often that we see

0:51:12.120 --> 0:51:15.360
<v Speaker 4>such agreement across right the ancient worlds. I thought that

0:51:15.440 --> 0:51:20.240
<v Speaker 4>was interesting. So this idea about humoral balance in asthma

0:51:20.320 --> 0:51:23.800
<v Speaker 4>persisted through much of the Renaissance. But it's also around

0:51:23.800 --> 0:51:26.719
<v Speaker 4>this time that we start seeing people recognizing that that

0:51:26.880 --> 0:51:30.040
<v Speaker 4>might not be all there is to it. One of

0:51:30.080 --> 0:51:34.480
<v Speaker 4>these people, Juan Baptista van Helmont, in the late fifteen

0:51:34.520 --> 0:51:39.239
<v Speaker 4>hundred's early sixteen hundreds who had asthma rejected the Hippocratic

0:51:39.280 --> 0:51:42.759
<v Speaker 4>idea that asthma was caused by phlegm descending from the

0:51:42.800 --> 0:51:46.840
<v Speaker 4>brain to the lungs. He was like, no, it's definitely

0:51:46.880 --> 0:51:49.800
<v Speaker 4>not a nervous condition from my brain. I can feel

0:51:49.800 --> 0:51:54.680
<v Speaker 4>it in my lungs, specifically in the contraction of them.

0:51:55.440 --> 0:51:58.799
<v Speaker 4>And in any case, if Hippocrates was right, then there

0:51:58.800 --> 0:52:03.480
<v Speaker 4>would be better treatments by now, and Van Helmont would

0:52:03.480 --> 0:52:07.400
<v Speaker 4>be proven right and Hippocrates wrong not too long after

0:52:07.560 --> 0:52:10.799
<v Speaker 4>with anatomical demonstrations showing that phlegm from the brain to

0:52:10.840 --> 0:52:12.839
<v Speaker 4>the lungs did not seem to be at the root

0:52:12.880 --> 0:52:15.520
<v Speaker 4>of this disease. And I think it's pretty cool that

0:52:15.640 --> 0:52:19.000
<v Speaker 4>Van Helmont used his personal experience to question the dogma

0:52:19.080 --> 0:52:24.680
<v Speaker 4>of the time. But he wasn't right about everything. He

0:52:24.760 --> 0:52:27.680
<v Speaker 4>believed that asthma could be sorted into types, one that

0:52:27.719 --> 0:52:32.239
<v Speaker 4>affected women and one that affected everyone with guess where

0:52:32.239 --> 0:52:36.720
<v Speaker 4>the women only asthma came from, Oh, dear quote foul

0:52:36.800 --> 0:52:39.880
<v Speaker 4>or stinking vapors ascending from the womb to block the

0:52:39.920 --> 0:52:45.520
<v Speaker 4>pores and the lungs. I'm sorry, I just had to

0:52:45.560 --> 0:52:48.440
<v Speaker 4>throw that in. It was too good to pass up.

0:52:48.960 --> 0:52:52.600
<v Speaker 3>I Oh god, it's great.

0:52:53.040 --> 0:52:53.880
<v Speaker 4>It's good stuff.

0:52:55.560 --> 0:52:59.440
<v Speaker 5>Foul or stinking vapors, stinking vapors.

0:53:02.880 --> 0:53:05.960
<v Speaker 4>By the end of the Renaissance, the concept of asthma

0:53:06.160 --> 0:53:11.320
<v Speaker 4>had undergone a pretty big shift from this flemy nervous

0:53:11.320 --> 0:53:14.920
<v Speaker 4>disease to one primarily of the lungs, and this would

0:53:14.960 --> 0:53:18.759
<v Speaker 4>continue to be refined as anatomical dissections increased in the

0:53:18.760 --> 0:53:22.040
<v Speaker 4>seventeen hundreds and eighteen hundreds. But before I move on,

0:53:22.360 --> 0:53:25.080
<v Speaker 4>let me hit you with another first hand account, this

0:53:25.120 --> 0:53:29.440
<v Speaker 4>one from physician Thomas Willis, as in the Circle of Willis.

0:53:29.800 --> 0:53:31.720
<v Speaker 3>Oh wow, that's exciting.

0:53:32.280 --> 0:53:36.680
<v Speaker 4>So this is from the seventeenth century quote among the

0:53:36.719 --> 0:53:40.000
<v Speaker 4>diseases whereby the region of the breast is wont to

0:53:40.040 --> 0:53:44.239
<v Speaker 4>be infested if you regard their tyranny and cruelty, And

0:53:44.400 --> 0:53:48.480
<v Speaker 4>asthma doth not deserve the last place, For there is

0:53:48.560 --> 0:53:52.239
<v Speaker 4>scarce anything more sharp and terrible than the fits here

0:53:52.320 --> 0:53:56.600
<v Speaker 4>of the organs of breathing, and the precordia themselves, which

0:53:56.640 --> 0:54:00.319
<v Speaker 4>are the foundation and pillars of life, are shaken by

0:54:00.360 --> 0:54:04.840
<v Speaker 4>this disease as by an earthquake. For breathing, whereby we

0:54:04.960 --> 0:54:07.960
<v Speaker 4>chiefly live, is very much hindered by the assault of

0:54:07.960 --> 0:54:11.399
<v Speaker 4>this disease and is in danger or runs the risk

0:54:11.480 --> 0:54:13.040
<v Speaker 4>of being quite taken away.

0:54:13.920 --> 0:54:16.320
<v Speaker 5>Wow, yeah, Okay.

0:54:16.760 --> 0:54:20.200
<v Speaker 4>As we move into the seventeen hundreds and eighteen hundreds,

0:54:20.560 --> 0:54:24.120
<v Speaker 4>physicians were making small adjustments to their understanding of the

0:54:24.160 --> 0:54:27.440
<v Speaker 4>path of physiology of asthma, to the borders around the

0:54:27.480 --> 0:54:31.760
<v Speaker 4>definition of the disease, distinguishing it from things like bronchitis,

0:54:32.400 --> 0:54:37.040
<v Speaker 4>recognizing the wide variety of symptoms and presentations, and leading

0:54:37.080 --> 0:54:40.120
<v Speaker 4>many to wonder whether these all truly fit under one

0:54:40.160 --> 0:54:43.919
<v Speaker 4>disease name, because we're still wondering that. But the thing

0:54:44.080 --> 0:54:47.560
<v Speaker 4>is kind of like in the way that you were

0:54:47.560 --> 0:54:52.560
<v Speaker 4>talking about how our increased understanding of the different mechanisms

0:54:53.400 --> 0:54:59.319
<v Speaker 4>that underlie different types of asthma hasn't yet translated into treatments.

0:55:00.480 --> 0:55:03.600
<v Speaker 4>This similarly, like all of this information, all of this

0:55:03.760 --> 0:55:07.680
<v Speaker 4>knowledge that we had gained by the eighteen hundreds about asthma,

0:55:08.360 --> 0:55:12.319
<v Speaker 4>it didn't lead to any improvements in any sort of

0:55:12.360 --> 0:55:16.880
<v Speaker 4>relief for people who had asthma, and if anything, quality

0:55:16.920 --> 0:55:20.120
<v Speaker 4>of life was actually at risk of getting worse for

0:55:20.239 --> 0:55:24.520
<v Speaker 4>people with asthma who lived in cities or worked in factories.

0:55:24.640 --> 0:55:29.359
<v Speaker 4>As the Industrial Revolution was underway, which isn't to say

0:55:29.360 --> 0:55:32.840
<v Speaker 4>that people didn't try to alleviate their symptoms during this time.

0:55:32.920 --> 0:55:35.120
<v Speaker 4>If you went to ten different doctors, you could get

0:55:35.120 --> 0:55:40.000
<v Speaker 4>handed one hundred different prescriptions, all promising complete symptomatic relief,

0:55:40.440 --> 0:55:43.320
<v Speaker 4>none actually delivering on that promise, even if they appeared

0:55:43.360 --> 0:55:47.080
<v Speaker 4>to do so, because asthma is so idiosyncratic, like you

0:55:47.160 --> 0:55:51.359
<v Speaker 4>talked about yep, so it's not I mean, it's really

0:55:51.360 --> 0:55:53.719
<v Speaker 4>not that surprising. I think some of these doctors were

0:55:53.760 --> 0:55:58.280
<v Speaker 4>probably just looking to make a quick buck, being like, oh, yes,

0:55:58.360 --> 0:56:00.239
<v Speaker 4>this is how you do it, or people who made

0:56:00.239 --> 0:56:03.760
<v Speaker 4>patent medicines. But I think other people were like maybe

0:56:03.760 --> 0:56:07.759
<v Speaker 4>one time you prescribed like, oh, eat the liver of

0:56:07.920 --> 0:56:10.640
<v Speaker 4>the snake, and then your asthma would go away, And

0:56:10.680 --> 0:56:16.000
<v Speaker 4>then maybe it did randomly just not associated with the

0:56:16.080 --> 0:56:18.680
<v Speaker 4>liver of a snake or any reptile or animal, but

0:56:19.160 --> 0:56:22.880
<v Speaker 4>just because it went away, but then you believed. But

0:56:22.960 --> 0:56:27.800
<v Speaker 4>other people were certainly just peddling not just non helpful,

0:56:27.880 --> 0:56:34.480
<v Speaker 4>but potentially harmful quote unquote cures such as asthma specific

0:56:34.560 --> 0:56:39.479
<v Speaker 4>cigarettes that contained various compounds. Yeah, I know, it's enough

0:56:39.560 --> 0:56:42.560
<v Speaker 4>to just make your cringe. So this is from an

0:56:42.600 --> 0:56:48.879
<v Speaker 4>advertisement for Potter's Asthma Cure. Oh gosh, quote, You know

0:56:48.920 --> 0:56:52.759
<v Speaker 4>how exhausting asthma is. You know how prostrated you are

0:56:52.840 --> 0:56:56.560
<v Speaker 4>by an attack? Year after year you have suffered in

0:56:56.600 --> 0:57:01.080
<v Speaker 4>this way. The slightest thing brings on the dread paroxysms

0:57:01.239 --> 0:57:04.880
<v Speaker 4>of coughing, and the perpetual fear of an attack coming

0:57:04.920 --> 0:57:08.320
<v Speaker 4>on makes life a misery. Not only is the attack

0:57:08.400 --> 0:57:11.319
<v Speaker 4>painful and prostrating, but the loss of time during your

0:57:11.320 --> 0:57:14.600
<v Speaker 4>absence from business is another serious item in the account.

0:57:15.000 --> 0:57:17.560
<v Speaker 4>And that is why you would give anything for a

0:57:17.600 --> 0:57:20.840
<v Speaker 4>remedy that would afford you prompt and certain relief and

0:57:20.960 --> 0:57:24.400
<v Speaker 4>freedom from attacks. That is why you ought to know

0:57:24.480 --> 0:57:29.080
<v Speaker 4>about Potter's Asthma cure, because it gives relief, instant relief.

0:57:29.640 --> 0:57:33.680
<v Speaker 4>Potter's Asthma smoking mixture is purely herbal in its composition,

0:57:34.080 --> 0:57:36.320
<v Speaker 4>and it may be smoked in a pipe either with

0:57:36.600 --> 0:57:40.320
<v Speaker 4>or without ordinary tobacco. Oh no, all that has to

0:57:40.360 --> 0:57:43.080
<v Speaker 4>be done to prevent the paroxysm of asthma is to

0:57:43.240 --> 0:57:46.960
<v Speaker 4>draw the smoke well into the lungs and bronchial passages,

0:57:47.480 --> 0:57:49.720
<v Speaker 4>and relief will immediately be obtained.

0:57:49.880 --> 0:57:51.840
<v Speaker 5>Oh gosh, Oh dear, I.

0:57:51.920 --> 0:57:56.040
<v Speaker 4>Know, I know people swore by these.

0:57:56.560 --> 0:57:58.600
<v Speaker 5>Mixing them with their tobacco and their pipes.

0:58:00.240 --> 0:58:03.440
<v Speaker 4>So like Potters was one of many what we're in

0:58:03.600 --> 0:58:05.720
<v Speaker 4>these right there, Like you could add tobacco or not

0:58:05.760 --> 0:58:08.600
<v Speaker 4>add tobacco. So I found a paper that actually did

0:58:09.120 --> 0:58:11.360
<v Speaker 4>like a chemical analysis of what was in some of

0:58:11.400 --> 0:58:14.600
<v Speaker 4>these asthma cigarettes, okay, And they found in the brand

0:58:14.600 --> 0:58:17.040
<v Speaker 4>that they looked at, which might have been Potters, I'm

0:58:17.040 --> 0:58:22.280
<v Speaker 4>not sure, leaves from Detura stramonium aka thorn apple, gimson weed,

0:58:22.400 --> 0:58:26.840
<v Speaker 4>Devil's trumpet, et cetera. You know, like toxic stuff. But

0:58:27.000 --> 0:58:30.840
<v Speaker 4>this paper also found that these compounds may have had

0:58:30.920 --> 0:58:37.960
<v Speaker 4>a slight broncho dilator ability, but like certainly not enough

0:58:38.160 --> 0:58:42.360
<v Speaker 4>to warrant. Probably it was like it major lungs inflamed

0:58:42.360 --> 0:58:44.360
<v Speaker 4>and worse, and then it lessened it a bit.

0:58:44.440 --> 0:58:49.400
<v Speaker 5>I don't know, Aaron, you remember our Belladonna episode? Oh yeah, okay,

0:58:49.440 --> 0:58:54.919
<v Speaker 5>way back when. So Jimson weed is related to belladonna, right,

0:58:55.120 --> 0:59:03.120
<v Speaker 5>and has the similar compounds in it, which include muscarinic antagonists,

0:59:03.720 --> 0:59:07.640
<v Speaker 5>which in fact are bronchodilators. So it probably did make

0:59:07.720 --> 0:59:10.600
<v Speaker 5>people feel a little bit better. That's one of the

0:59:10.680 --> 0:59:13.760
<v Speaker 5>types of medicines that we actually use today, although we

0:59:13.840 --> 0:59:18.200
<v Speaker 5>tend to use beta agonists more than muscarinic medications for asthma.

0:59:18.360 --> 0:59:21.640
<v Speaker 5>But yeah, so it probably did help, but also had

0:59:21.680 --> 0:59:23.360
<v Speaker 5>a whole bunch of other things in it and are

0:59:23.400 --> 0:59:26.600
<v Speaker 5>not specific to lungs and so would have systemic effects,

0:59:26.880 --> 0:59:32.520
<v Speaker 5>et cetera. So not recommended to soak gimson weed or

0:59:32.560 --> 0:59:36.200
<v Speaker 5>anything not. But I could understand why that would make

0:59:36.240 --> 0:59:37.080
<v Speaker 5>people feel better.

0:59:37.600 --> 0:59:41.240
<v Speaker 4>Yeah. Well, and along the same lines, apparently things like

0:59:41.360 --> 0:59:45.040
<v Speaker 4>opium which were also prescribed, that could also have worked,

0:59:45.440 --> 0:59:50.160
<v Speaker 4>you know, to help relieve some of the as an

0:59:50.160 --> 0:59:52.480
<v Speaker 4>anti spasmotic is what this says.

0:59:52.640 --> 0:59:55.400
<v Speaker 5>Yeah, and as like a pain reliever, but also it's

0:59:55.440 --> 0:59:58.480
<v Speaker 5>going to decrease your respiratory rate. So that sounds like

0:59:58.600 --> 1:00:00.160
<v Speaker 5>a bad combination.

1:00:00.240 --> 1:00:03.640
<v Speaker 4>Yeah it I think. Yeah, some of these came with

1:00:03.720 --> 1:00:05.920
<v Speaker 4>their own suite of problems, right, even if they did

1:00:06.000 --> 1:00:08.640
<v Speaker 4>help a little bit. Yeah, but what's the cost here?

1:00:08.720 --> 1:00:08.880
<v Speaker 3>Right?

1:00:08.920 --> 1:00:09.919
<v Speaker 5>They'll make you feel better?

1:00:10.440 --> 1:00:15.520
<v Speaker 4>Yeah, But inhalation of things in general became super popular,

1:00:15.680 --> 1:00:21.720
<v Speaker 4>from carbolic acid to the aforementioned stramonium. Animas were a

1:00:21.800 --> 1:00:27.040
<v Speaker 4>long standing option, something called the milk diet MMM. Caffeine

1:00:28.040 --> 1:00:34.000
<v Speaker 4>nose cauterization, all kinds of things, none of which provided

1:00:34.040 --> 1:00:38.240
<v Speaker 4>any long term relief. The frustration people felt must have

1:00:38.320 --> 1:00:42.520
<v Speaker 4>been huge. Right here was this disease on which treatise

1:00:42.600 --> 1:00:45.680
<v Speaker 4>after treatise had been written, which had been known about

1:00:45.800 --> 1:00:48.960
<v Speaker 4>for thousands of years, for which hundreds of treatments had

1:00:48.960 --> 1:00:53.160
<v Speaker 4>been tried out, that affected so very many people, and

1:00:53.240 --> 1:00:56.880
<v Speaker 4>yet nothing like nothing.

1:00:57.440 --> 1:00:58.000
<v Speaker 5>Yeah.

1:00:58.120 --> 1:01:03.240
<v Speaker 4>The famous French novelist Marcel Proust wrote extensively about his asthma,

1:01:03.400 --> 1:01:09.040
<v Speaker 4>which dominated his life. Quote and ever since that moment,

1:01:09.280 --> 1:01:12.240
<v Speaker 4>up to today and until I don't know when in

1:01:12.280 --> 1:01:17.160
<v Speaker 4>the future, I haven't stopped choking and having incessant attacks.

1:01:17.560 --> 1:01:20.040
<v Speaker 4>And that is why, although you were in my thoughts

1:01:20.080 --> 1:01:23.760
<v Speaker 4>practically all day long, I haven't written. I haven't had

1:01:23.800 --> 1:01:25.240
<v Speaker 4>the courage to take up my pen.

1:01:27.000 --> 1:01:28.600
<v Speaker 5>Wow. Yeah.

1:01:28.640 --> 1:01:31.320
<v Speaker 4>He spent a large portion of his life trying as

1:01:31.360 --> 1:01:34.560
<v Speaker 4>best he could to avoid any environmental pollutants that seemed

1:01:34.600 --> 1:01:37.840
<v Speaker 4>to trigger his asthma, even lining his bedroom walls with

1:01:38.000 --> 1:01:41.400
<v Speaker 4>cork to prevent pollen and perfumes from coming in.

1:01:41.720 --> 1:01:42.200
<v Speaker 5>Wow.

1:01:42.480 --> 1:01:45.440
<v Speaker 4>Yeah. So at this point I feel like I've been

1:01:45.480 --> 1:01:48.800
<v Speaker 4>talking about the history of asthma for about twenty five

1:01:49.080 --> 1:01:52.880
<v Speaker 4>thirty minutes or so, and we've covered about a couple

1:01:52.960 --> 1:01:57.440
<v Speaker 4>thousand years, and in many ways, I feel like we're

1:01:57.760 --> 1:02:01.840
<v Speaker 4>kind of right at where we started. It's like, yeah,

1:02:01.880 --> 1:02:06.760
<v Speaker 4>it's hard to breathe sometimes, right, and the lungs are involved,

1:02:07.080 --> 1:02:15.160
<v Speaker 4>and there's fronco constriction or whatever. Like yep, if you

1:02:15.240 --> 1:02:18.360
<v Speaker 4>read like I had in my early draft of notes,

1:02:18.760 --> 1:02:22.600
<v Speaker 4>two descriptions of asthma, one from the first century CE,

1:02:22.840 --> 1:02:25.520
<v Speaker 4>so when like around the time of Seneca when he

1:02:25.600 --> 1:02:29.840
<v Speaker 4>wrote that, and another from the early eighteen hundreds, so

1:02:29.920 --> 1:02:35.320
<v Speaker 4>like seventeen hundred years apart, and they are eerily similar,

1:02:35.400 --> 1:02:38.360
<v Speaker 4>like it's describing the same exact thing. And I don't

1:02:38.400 --> 1:02:42.440
<v Speaker 4>know why that just strikes me so much, because it

1:02:42.520 --> 1:02:45.040
<v Speaker 4>seems like, Okay, we got a pretty good handle on

1:02:45.120 --> 1:02:50.200
<v Speaker 4>what this looks like. And yes, we made some improvements

1:02:50.240 --> 1:02:53.160
<v Speaker 4>in terms of like our understanding that it's the lungs

1:02:53.320 --> 1:02:57.960
<v Speaker 4>and not the brain or your personality, although stereotypes persisted

1:02:58.200 --> 1:03:03.440
<v Speaker 4>still persist to this day, you know, but treatment is limited. Yeah,

1:03:03.480 --> 1:03:08.040
<v Speaker 4>that's putting it mildly, I think, But yeah, in all

1:03:08.160 --> 1:03:11.600
<v Speaker 4>this time, it just maybe this is harsher to me,

1:03:11.640 --> 1:03:16.760
<v Speaker 4>but there just doesn't seem to be very much progress made.

1:03:17.040 --> 1:03:20.800
<v Speaker 4>But finally, now that we're in the late eighteen hundreds,

1:03:21.680 --> 1:03:23.760
<v Speaker 4>fortunately all that is about to change.

1:03:24.200 --> 1:03:25.440
<v Speaker 5>Right although slowly.

1:03:26.600 --> 1:03:31.080
<v Speaker 4>Germ theory offered the idea that perhaps asthma was directly

1:03:31.200 --> 1:03:35.160
<v Speaker 4>caused by a pathogen, like a pathogenic infection, but that

1:03:35.200 --> 1:03:38.800
<v Speaker 4>didn't really amount to anything. Even though throughout this people

1:03:38.840 --> 1:03:41.840
<v Speaker 4>did recognize that some cases of asthma could result from

1:03:42.000 --> 1:03:46.400
<v Speaker 4>or be exacerbated by respiratory infection. But it was when

1:03:46.520 --> 1:03:50.200
<v Speaker 4>autoimmunity and allergy began to be studied, especially at the

1:03:50.240 --> 1:03:52.800
<v Speaker 4>cellular level, that a bit more of the puzzle was

1:03:52.800 --> 1:03:56.840
<v Speaker 4>put together. Researchers had long recognized that asthma often co

1:03:56.920 --> 1:04:01.000
<v Speaker 4>occurred with conditions like hay fever and egzema, but how

1:04:01.040 --> 1:04:05.280
<v Speaker 4>they were connected was still an open question. Then, in

1:04:05.320 --> 1:04:10.000
<v Speaker 4>the early nineteen hundreds, concepts of anaphylaxis, allergy, and hypo

1:04:10.080 --> 1:04:15.960
<v Speaker 4>and hypersensitivity were introduced, and physiologist Samuel Meltzer observed that

1:04:16.120 --> 1:04:21.920
<v Speaker 4>asthma bore a strong resemblance to anaphylaxis. Quote the theory

1:04:22.040 --> 1:04:26.439
<v Speaker 4>is here offered that asthma is an anaphylactic phenomenon. That is,

1:04:26.480 --> 1:04:30.960
<v Speaker 4>that asthmatics are individuals who are sensitized to a specific substance,

1:04:31.040 --> 1:04:34.400
<v Speaker 4>and the attack of asthma sets in whenever they are

1:04:34.520 --> 1:04:41.480
<v Speaker 4>intoxicated by that substance. We know now that that's not

1:04:41.560 --> 1:04:47.880
<v Speaker 4>the complete picture. Of course, We're still working on our knowledge,

1:04:47.960 --> 1:04:51.440
<v Speaker 4>and asthma throughout the twentieth century would undergo many paradigm

1:04:51.520 --> 1:04:54.440
<v Speaker 4>shifts and how it was understood or in the different

1:04:54.520 --> 1:04:58.600
<v Speaker 4>like models of asthma as a disease. But this was

1:04:58.720 --> 1:05:01.640
<v Speaker 4>a big step forward in finally putting together like a

1:05:01.680 --> 1:05:05.120
<v Speaker 4>cellular framework almost for what was going.

1:05:04.880 --> 1:05:06.840
<v Speaker 3>On, like a mechanistic connection.

1:05:07.320 --> 1:05:13.640
<v Speaker 4>Yeah, exactly. This new understanding of asthma didn't immediately translate

1:05:13.840 --> 1:05:18.560
<v Speaker 4>into improvements in patient experience. Those would come about pretty

1:05:18.560 --> 1:05:22.880
<v Speaker 4>shortly though, but almost immediately. It did lead to improvements

1:05:22.920 --> 1:05:25.920
<v Speaker 4>in managing the condition in the form of the first

1:05:26.040 --> 1:05:30.800
<v Speaker 4>vacuum cleaner, which was invented and patented in nineteen oh

1:05:30.880 --> 1:05:35.000
<v Speaker 4>eight by James Murray Spangler, a janitor from the US

1:05:35.080 --> 1:05:39.480
<v Speaker 4>who also happened to have asthma. What Yeah, so he

1:05:39.560 --> 1:05:42.520
<v Speaker 4>developed the vacuum to try to reduce his exposure to

1:05:42.640 --> 1:05:45.720
<v Speaker 4>dust at work, which had long been thought to contribute

1:05:45.760 --> 1:05:49.480
<v Speaker 4>to asthma irritations. Even before the link to allergy was made.

1:05:50.040 --> 1:05:52.760
<v Speaker 3>Huh, Yeah, that's so cool.

1:05:53.240 --> 1:05:56.600
<v Speaker 4>But the first treatment that showed real promise for asthma

1:05:56.720 --> 1:06:01.360
<v Speaker 4>came in the form of allergy shots nineteen hundreds. Many

1:06:01.440 --> 1:06:05.000
<v Speaker 4>researchers had considered and discarded the idea that pollen or

1:06:05.040 --> 1:06:10.200
<v Speaker 4>bacterial toxins directly caused asthma, but they started to wonder

1:06:10.240 --> 1:06:15.280
<v Speaker 4>whether the same principles used in preventing infectious diseases could

1:06:15.320 --> 1:06:19.880
<v Speaker 4>work on allergic disorders. Anti serum didn't really seem to work,

1:06:20.160 --> 1:06:26.040
<v Speaker 4>but what about vaccines. In nineteen eleven, researchers John Freeman

1:06:26.160 --> 1:06:29.840
<v Speaker 4>and Leonard Noon at a London inoculation department published their

1:06:29.880 --> 1:06:33.680
<v Speaker 4>findings from a study where they vaccinated volunteers who had

1:06:33.720 --> 1:06:39.440
<v Speaker 4>hay fever with increasing doses of pollen, and their findings

1:06:39.640 --> 1:06:43.919
<v Speaker 4>were amazing, So amazing that they encouraged researchers to try

1:06:44.040 --> 1:06:49.920
<v Speaker 4>desensitization as it's called, on asthma, using various preparations like

1:06:50.040 --> 1:06:56.480
<v Speaker 4>animal danders, dust, bacterial vaccines, et cetera. Desensitization grew to

1:06:56.520 --> 1:07:00.640
<v Speaker 4>be extremely popular into and beyond World War Two. Oh

1:07:00.680 --> 1:07:03.440
<v Speaker 4>and it seems to me like this gave hope to

1:07:03.520 --> 1:07:09.600
<v Speaker 4>so many researchers, greatly increasing interest in asthma and leading

1:07:09.600 --> 1:07:12.720
<v Speaker 4>to the formation of groups like the Asthma Research Council,

1:07:13.200 --> 1:07:18.280
<v Speaker 4>which brought together clinicians, scientists, philanthropists, and people who had asthma.

1:07:19.120 --> 1:07:21.640
<v Speaker 4>The work of these organizations not only broke new ground

1:07:21.720 --> 1:07:26.240
<v Speaker 4>in asthma research or improvements in treatment, but also in

1:07:26.280 --> 1:07:31.120
<v Speaker 4>bringing that treatment and other resources to people with asthma. Then,

1:07:31.400 --> 1:07:34.640
<v Speaker 4>in the mid twentieth century, the development of steroids for

1:07:34.760 --> 1:07:40.680
<v Speaker 4>use in Inhaler's revolutionized long term management for asthma, and

1:07:40.720 --> 1:07:44.600
<v Speaker 4>epidemiological studies and new lung function or cellular tests to

1:07:44.680 --> 1:07:48.880
<v Speaker 4>assess asthma revealed patterns in who was most likely to

1:07:48.920 --> 1:07:52.080
<v Speaker 4>develop the disease, the role of family history, which environmental

1:07:52.080 --> 1:07:56.480
<v Speaker 4>triggers could cause the most problems, and so on. There

1:07:56.560 --> 1:08:00.280
<v Speaker 4>was an incredible amount of progress made in the first

1:08:00.320 --> 1:08:03.640
<v Speaker 4>fifty years of the twentieth century. It's it's amazing, and

1:08:03.960 --> 1:08:06.600
<v Speaker 4>we have made more since then. But I do think

1:08:06.640 --> 1:08:09.840
<v Speaker 4>that one key thing was left behind, or at least

1:08:10.160 --> 1:08:12.160
<v Speaker 4>that's the sense that I got in doing the research

1:08:12.240 --> 1:08:16.639
<v Speaker 4>for this, and that's the personal experiences of people with asthma,

1:08:17.040 --> 1:08:19.599
<v Speaker 4>which up until then had been a key feature in

1:08:19.640 --> 1:08:24.040
<v Speaker 4>writings about the disease, like, even as medicine was becoming

1:08:24.080 --> 1:08:27.400
<v Speaker 4>depersonalized in the late nineteenth century and it became more

1:08:27.439 --> 1:08:31.920
<v Speaker 4>about the measurement and more about statistics, asthma was still

1:08:32.280 --> 1:08:38.360
<v Speaker 4>viewed largely as a very individual disease. This person's asthma

1:08:38.400 --> 1:08:42.000
<v Speaker 4>is exacerbated by this this person developed it at this age,

1:08:42.040 --> 1:08:45.439
<v Speaker 4>this person had their asthma is more severe.

1:08:45.520 --> 1:08:46.200
<v Speaker 5>You know, it was.

1:08:46.320 --> 1:08:51.160
<v Speaker 4>Incredibly varied, and I think that recognition in that variation

1:08:52.200 --> 1:08:57.759
<v Speaker 4>was really important, even if it didn't translate necessarily into treatment.

1:08:58.000 --> 1:09:02.599
<v Speaker 4>I don't know, but I think that it's interesting because

1:09:02.800 --> 1:09:06.880
<v Speaker 4>you can ask the question like what is asthma for you?

1:09:07.280 --> 1:09:10.800
<v Speaker 4>What is happening during your asthma attack? How did this

1:09:10.920 --> 1:09:16.040
<v Speaker 4>treatment provide relief? And you could answer those questions by

1:09:16.080 --> 1:09:19.880
<v Speaker 4>saying how it actually felt for you, like how does

1:09:19.920 --> 1:09:22.320
<v Speaker 4>asthma change your day to day life? Does it, does

1:09:22.360 --> 1:09:26.880
<v Speaker 4>it not? What is happening during an exacerbation for you?

1:09:26.960 --> 1:09:29.599
<v Speaker 4>What does that feel like? How does this treatment work

1:09:29.600 --> 1:09:32.479
<v Speaker 4>compared to this treatment? Or you could answer all those

1:09:32.560 --> 1:09:37.240
<v Speaker 4>questions by describing the cellular mechanisms, the path of physiological response,

1:09:38.280 --> 1:09:42.160
<v Speaker 4>and that second way was becoming had become much more

1:09:42.280 --> 1:09:45.960
<v Speaker 4>the norm in the twentieth century, and of course asthma

1:09:46.040 --> 1:09:48.160
<v Speaker 4>is not unique in this, but I do think that

1:09:48.240 --> 1:09:51.559
<v Speaker 4>shift is really striking, and I think that's especially so

1:09:52.479 --> 1:09:56.000
<v Speaker 4>because it was happening around the same time that cases

1:09:56.040 --> 1:09:59.720
<v Speaker 4>seem to be on the rise. So it's hard to

1:09:59.760 --> 1:10:03.320
<v Speaker 4>say how the prevalence of asthma changed over the course

1:10:03.320 --> 1:10:08.160
<v Speaker 4>of history, considering that diagnoster criteria have been extensively revised

1:10:08.520 --> 1:10:12.800
<v Speaker 4>and statistics didn't really exist until fairly recently. But it

1:10:12.840 --> 1:10:16.920
<v Speaker 4>seems pretty clear that cases of this disease have increased

1:10:17.040 --> 1:10:20.840
<v Speaker 4>throughout the twentieth century. Is this increase real, It's a

1:10:20.920 --> 1:10:24.960
<v Speaker 4>first question. I mean, it could be in part inflated

1:10:25.240 --> 1:10:29.519
<v Speaker 4>due to changes in how asthma is diagnosed and being

1:10:29.560 --> 1:10:33.200
<v Speaker 4>able to reach more people to make more diagnoses, But

1:10:33.439 --> 1:10:38.639
<v Speaker 4>that doesn't explain all of it, Like there's a real increase.

1:10:40.040 --> 1:10:45.800
<v Speaker 4>What's driving it then, worsening air quality or increasing exposure

1:10:45.840 --> 1:10:50.200
<v Speaker 4>to pollutants possibly those had long been linked to asthma

1:10:50.240 --> 1:10:57.080
<v Speaker 4>development or exacerbation. An increase in dust mites from more carpeting, Sure,

1:10:57.200 --> 1:11:04.719
<v Speaker 4>that seems reasonable. Yeah, more pollen from changing agricultural practices, Sure,

1:11:05.240 --> 1:11:12.760
<v Speaker 4>why not something else? Probably. The bottom line is that many,

1:11:12.800 --> 1:11:16.759
<v Speaker 4>many things are likely contributing to the rise in asthma cases,

1:11:17.479 --> 1:11:20.759
<v Speaker 4>and also that the drivers are probably not the same

1:11:21.080 --> 1:11:28.360
<v Speaker 4>across the entire globe. As always, it's complicated, But there

1:11:28.439 --> 1:11:31.200
<v Speaker 4>is one idea that people have gotten really excited about

1:11:31.280 --> 1:11:34.760
<v Speaker 4>as an explanation for this rise, and that is a

1:11:34.880 --> 1:11:36.240
<v Speaker 4>hygiene hypothesis.

1:11:36.680 --> 1:11:38.519
<v Speaker 5>Couldn't we could not, We couldn't not.

1:11:39.479 --> 1:11:43.360
<v Speaker 4>The hygiene hypothesis is this idea introduced in the nineteen

1:11:43.400 --> 1:11:47.599
<v Speaker 4>seventies and refined in the nineteen eighties that says that

1:11:47.680 --> 1:11:51.320
<v Speaker 4>by growing up in a more sanitized environment with less

1:11:51.400 --> 1:11:55.080
<v Speaker 4>dust and dirt and dander and lower exposure to pathogens

1:11:55.160 --> 1:11:59.120
<v Speaker 4>overall than in past millennia. This is also more specific

1:11:59.160 --> 1:12:03.400
<v Speaker 4>to people living in industrialized countries, that our immune systems

1:12:03.439 --> 1:12:07.760
<v Speaker 4>aren't getting the proper training that they used to and

1:12:08.560 --> 1:12:14.120
<v Speaker 4>end up being overactive or improperly sensitized. This has been

1:12:14.200 --> 1:12:17.400
<v Speaker 4>used to explain the apparent rise in allergic diseases and

1:12:17.479 --> 1:12:22.519
<v Speaker 4>autoimmune disorders. The hygien hypothesis isn't the first to claim

1:12:22.720 --> 1:12:25.040
<v Speaker 4>that our modern lives may have come at the cost

1:12:25.080 --> 1:12:29.520
<v Speaker 4>of increasing certain diseases. Since the eighteenth and nineteenth centuries

1:12:29.560 --> 1:12:32.320
<v Speaker 4>at least, asthma has been thought of as a quote

1:12:32.360 --> 1:12:37.719
<v Speaker 4>unquote disease of civilization. In the late seventeen hundreds, physician

1:12:37.840 --> 1:12:41.040
<v Speaker 4>Thomas Withers wrote about what he perceived as a rise

1:12:41.120 --> 1:12:45.400
<v Speaker 4>in the prevalence of asthma. Quote. The greater irritability and

1:12:45.479 --> 1:12:48.800
<v Speaker 4>weakness of the constitution in these days may in some

1:12:48.880 --> 1:12:52.840
<v Speaker 4>measure account for the greater frequency of the asthma, especially

1:12:52.880 --> 1:12:56.520
<v Speaker 4>if we add the inventive genius and the rapid progress

1:12:56.560 --> 1:12:59.960
<v Speaker 4>of mankind in all the various arts of modern luxury

1:13:00.080 --> 1:13:07.360
<v Speaker 4>and refinement. So that's like the prequel hygiene hypothesis.

1:13:07.439 --> 1:13:08.320
<v Speaker 3>Yeah, it really is.

1:13:09.200 --> 1:13:12.400
<v Speaker 4>His advice was essentially to toughen up or quote unquote

1:13:12.439 --> 1:13:16.519
<v Speaker 4>cast off the effeminacy of the present times, abandoned the

1:13:16.600 --> 1:13:18.240
<v Speaker 4>destructive luxury of heat.

1:13:19.040 --> 1:13:22.679
<v Speaker 3>I I oh my goodness.

1:13:23.040 --> 1:13:26.240
<v Speaker 4>Yeah. And he wasn't the only one. A few decades later,

1:13:26.400 --> 1:13:29.960
<v Speaker 4>physician Henry Hyde Salter, who also happened to have asthma,

1:13:30.360 --> 1:13:33.360
<v Speaker 4>wrote that quote the rich might be really more liable

1:13:33.400 --> 1:13:36.759
<v Speaker 4>to asthma than the poor, from a more irritable, nervous

1:13:36.840 --> 1:13:40.320
<v Speaker 4>organization engendered by the state of hyper civilization in which

1:13:40.360 --> 1:13:45.920
<v Speaker 4>we live end quote hypercivilization. Yeah, okay, anyway, so the

1:13:46.000 --> 1:13:49.760
<v Speaker 4>hygiene hypothesis, it's different. It's a bit more mechanistic, it's

1:13:49.760 --> 1:13:52.559
<v Speaker 4>a bit based more in biology than just a general

1:13:52.760 --> 1:13:56.160
<v Speaker 4>sense of feeling. But I do think that the parallels

1:13:56.200 --> 1:14:01.519
<v Speaker 4>are kind of funny there. The hygiene hypocthesis is a

1:14:01.560 --> 1:14:06.640
<v Speaker 4>really interesting and exciting idea. But is there any evidence

1:14:06.720 --> 1:14:10.000
<v Speaker 4>that asthma is caused by a lack of exposures to

1:14:10.120 --> 1:14:15.920
<v Speaker 4>antigens in early childhood. It's hard to say. So I

1:14:16.080 --> 1:14:18.880
<v Speaker 4>dug a little bit into the literature, mostly looking at

1:14:18.960 --> 1:14:23.920
<v Speaker 4>refuse and like retrospective is hygien hypothesis still an appropriate

1:14:24.760 --> 1:14:31.200
<v Speaker 4>model for asthma or whatever? And it's mixed right. There

1:14:31.240 --> 1:14:35.320
<v Speaker 4>are studies showing that kids who were exposed to farms

1:14:35.400 --> 1:14:38.800
<v Speaker 4>or raised near farms had lower rates of asthma than

1:14:38.840 --> 1:14:42.799
<v Speaker 4>those who were not, for example, But at the same time,

1:14:43.240 --> 1:14:47.080
<v Speaker 4>rates of asthma are increasing in children who live in

1:14:47.120 --> 1:14:51.920
<v Speaker 4>conditions of poverty in North American cities. Long term exposure

1:14:51.960 --> 1:14:56.000
<v Speaker 4>to things like cockroaches and dust mites is associated with

1:14:56.120 --> 1:14:57.280
<v Speaker 4>the development of asthma.

1:14:57.920 --> 1:14:59.559
<v Speaker 5>So cleaner is.

1:14:59.680 --> 1:15:03.639
<v Speaker 4>Should be better, but it's also not better, Like maybe

1:15:03.640 --> 1:15:06.760
<v Speaker 4>it depends on the specific antigen or the timing of

1:15:06.840 --> 1:15:10.200
<v Speaker 4>exposure or all of that could change depending on season,

1:15:10.320 --> 1:15:17.200
<v Speaker 4>or geography or individual genetics. There is no consistency with

1:15:17.320 --> 1:15:23.640
<v Speaker 4>the hygiene hypothesis, and there's a lot of contradictory evidence,

1:15:24.960 --> 1:15:27.120
<v Speaker 4>don't get me wrong, Like, I think this is a

1:15:27.160 --> 1:15:33.640
<v Speaker 4>really fascinating framework to think about early immune system development

1:15:33.760 --> 1:15:37.920
<v Speaker 4>and how that sets our immune system on a certain

1:15:38.040 --> 1:15:42.479
<v Speaker 4>course for the rest of our lives. But at this

1:15:42.680 --> 1:15:47.400
<v Speaker 4>point it seems that the studies that investigate its role

1:15:47.520 --> 1:15:51.760
<v Speaker 4>in asthma are not very consistent.

1:15:53.160 --> 1:15:56.400
<v Speaker 5>Yeah, I think too. There's also been maybe like a

1:15:57.240 --> 1:16:02.000
<v Speaker 5>combining or a shifting of this idea of just allergen

1:16:02.360 --> 1:16:08.679
<v Speaker 5>exposure with also microbiome exposure, which kind of yeah, yeah,

1:16:08.760 --> 1:16:09.160
<v Speaker 5>I know.

1:16:09.720 --> 1:16:13.000
<v Speaker 4>Like the whole thing was reminding me of like I mean,

1:16:13.120 --> 1:16:15.760
<v Speaker 4>and it is entangled with microbiome, but I was just

1:16:15.960 --> 1:16:23.640
<v Speaker 4>absolutely these sound so cool conceptually, but right we're not, like,

1:16:23.920 --> 1:16:27.400
<v Speaker 4>maybe we just don't have the studies yet to show

1:16:27.640 --> 1:16:32.280
<v Speaker 4>specifically enough. Yeah, which isn't to say that like there

1:16:32.360 --> 1:16:35.679
<v Speaker 4>aren't specific instances that could be Oh, if you had

1:16:35.720 --> 1:16:38.760
<v Speaker 4>been exposed to a dog, you know, if you touched

1:16:38.800 --> 1:16:41.800
<v Speaker 4>the dog out of a concrete fifteen days old or something, Yeah,

1:16:41.920 --> 1:16:44.759
<v Speaker 4>instead of a cockroach. Like, how does it all fit together?

1:16:45.120 --> 1:16:47.760
<v Speaker 4>I think we're a long way from I am knowing

1:16:47.760 --> 1:16:48.479
<v Speaker 4>the answer to that.

1:16:49.000 --> 1:16:51.080
<v Speaker 5>I think it's I think how it fits together though,

1:16:51.120 --> 1:16:54.519
<v Speaker 5>is what's the interesting part about it, because I think

1:16:54.600 --> 1:16:58.200
<v Speaker 5>from the diversity of data that we have, it's very

1:16:58.200 --> 1:17:02.080
<v Speaker 5>clearly not one thing right. It's never going to be

1:17:02.200 --> 1:17:06.200
<v Speaker 5>one exposure or lack of one exposure, and we don't

1:17:06.320 --> 1:17:09.880
<v Speaker 5>understand necessarily what all of those exposures are, which I

1:17:09.920 --> 1:17:12.960
<v Speaker 5>think is why it's so interesting. Like even with pets,

1:17:13.000 --> 1:17:16.599
<v Speaker 5>it's like dogs, you know, reduce the risk of asthma

1:17:16.680 --> 1:17:19.880
<v Speaker 5>more than cats, but like cockroaches increase it. And this

1:17:19.960 --> 1:17:22.800
<v Speaker 5>in that sense, I mean, it's just it's, yeah, there's

1:17:22.880 --> 1:17:25.840
<v Speaker 5>a lot and it's interesting. But I agree, we don't

1:17:25.880 --> 1:17:29.240
<v Speaker 5>have the data to say that this is true versus

1:17:29.280 --> 1:17:31.080
<v Speaker 5>not true or anything like that.

1:17:31.160 --> 1:17:34.720
<v Speaker 4>This is not the answer. And I don't think that

1:17:34.840 --> 1:17:38.759
<v Speaker 4>most of the people who study the hygien hypothesis believe

1:17:38.840 --> 1:17:41.400
<v Speaker 4>that it is the answer. I think that they're using

1:17:41.439 --> 1:17:43.400
<v Speaker 4>it in the way that they should, which is like, hey,

1:17:43.439 --> 1:17:48.120
<v Speaker 4>this is a really interesting frameworkwork.

1:17:47.600 --> 1:17:51.639
<v Speaker 5>Yeah, to test, to test, to investigate exactly, Yeah, Yeah,

1:17:52.120 --> 1:17:53.680
<v Speaker 5>that's the point of a hypothesis.

1:17:55.520 --> 1:17:55.920
<v Speaker 3>It is.

1:17:58.960 --> 1:18:01.760
<v Speaker 4>But yeah, I mean I think that it does hold

1:18:01.760 --> 1:18:04.679
<v Speaker 4>a lot of promise, and I think that's probably where

1:18:05.120 --> 1:18:10.240
<v Speaker 4>at least one area of research for asthma is probably

1:18:10.439 --> 1:18:16.840
<v Speaker 4>pretty active. Speaking of which, Karon, where do we stand

1:18:16.880 --> 1:18:18.439
<v Speaker 4>with asthma today? What's going on?

1:18:19.120 --> 1:18:21.920
<v Speaker 5>I can't wait to tell you all about it right

1:18:21.960 --> 1:18:54.320
<v Speaker 5>after this break. We'll start with some possibly quite depressing statistics.

1:18:54.680 --> 1:19:01.599
<v Speaker 5>All right, One paper that I read said estimated that

1:19:01.800 --> 1:19:06.240
<v Speaker 5>in the UK, a child is admitted to the hospital

1:19:06.640 --> 1:19:11.800
<v Speaker 5>due to an asthma exacerbation every twenty minutes. What that

1:19:11.920 --> 1:19:14.800
<v Speaker 5>was my exact response and what I wrote? What with

1:19:14.920 --> 1:19:20.519
<v Speaker 5>three question marks? Oh my gosh, so frequent and so many.

1:19:20.680 --> 1:19:27.200
<v Speaker 5>I was astounded. Worldwide, it's estimated by the Global Asthma

1:19:27.240 --> 1:19:31.839
<v Speaker 5>Network and other organizations that at least three hundred million

1:19:31.920 --> 1:19:37.679
<v Speaker 5>people are living with asthma across the globe. And because

1:19:37.720 --> 1:19:41.880
<v Speaker 5>asthma is a chronic disease, even if it does go

1:19:42.040 --> 1:19:47.120
<v Speaker 5>away in adulthood, it's still a chronic disease for kids

1:19:47.640 --> 1:19:54.320
<v Speaker 5>and for adults. There are over twenty million disability adjusted

1:19:54.439 --> 1:20:00.880
<v Speaker 5>life years attributed to asthma across all ages. Globeobally, So

1:20:01.280 --> 1:20:05.919
<v Speaker 5>twenty one million disability adjusted life years every year globally,

1:20:07.000 --> 1:20:10.880
<v Speaker 5>and it's ranked thirty fourth among the leading causes of

1:20:11.080 --> 1:20:18.400
<v Speaker 5>burden of disease. So that's huge. It's massive. And while

1:20:18.479 --> 1:20:22.640
<v Speaker 5>asthma is a rare cause of death, thankfully, it is

1:20:22.760 --> 1:20:27.759
<v Speaker 5>responsible for deaths every year. The Global Burden of Disease

1:20:28.120 --> 1:20:32.479
<v Speaker 5>Collaboration estimates that in twenty nineteen, almost five hundred thousand

1:20:32.560 --> 1:20:36.320
<v Speaker 5>people died from asthma. That's more than a thousand people

1:20:36.360 --> 1:20:38.920
<v Speaker 5>a day across the globe. Oh my gosh, I know

1:20:39.600 --> 1:20:45.519
<v Speaker 5>it's it's way worse than I thought. And like you mentioned,

1:20:45.920 --> 1:20:50.280
<v Speaker 5>incidence has been increasing globally, though there has been some

1:20:50.439 --> 1:20:55.880
<v Speaker 5>evidence of potentially plateauing incidents in higher income countries. In

1:20:55.920 --> 1:21:01.280
<v Speaker 5>some high income countries, and it likely is environmental factors

1:21:01.280 --> 1:21:04.440
<v Speaker 5>that contribute to a lot of these discrepancies in prevalence

1:21:04.479 --> 1:21:08.519
<v Speaker 5>as well as this increasing incidence and prevalence overall, but

1:21:08.840 --> 1:21:12.879
<v Speaker 5>like we said, we really don't know what those factors

1:21:12.920 --> 1:21:18.480
<v Speaker 5>are in detail. If we look at the US specifically,

1:21:19.920 --> 1:21:22.960
<v Speaker 5>about twenty five million people in the US are living

1:21:22.960 --> 1:21:27.160
<v Speaker 5>with asthma. Over six million of those are kids. That's

1:21:27.200 --> 1:21:30.680
<v Speaker 5>about eight percent of the US population, which is a

1:21:30.720 --> 1:21:33.639
<v Speaker 5>lot of people, a lot of people. And a really

1:21:33.680 --> 1:21:37.320
<v Speaker 5>important part of asthma in the US specifically is that

1:21:37.400 --> 1:21:43.040
<v Speaker 5>it disproportionately affects black kids, especially as well as those

1:21:43.160 --> 1:21:46.680
<v Speaker 5>living below the federal poverty line in the US. So,

1:21:46.840 --> 1:21:52.120
<v Speaker 5>while asthma is a disease that can and does affect anyone,

1:21:53.200 --> 1:21:58.400
<v Speaker 5>it has a disproportionate effect on vulnerable segments of populations,

1:21:58.960 --> 1:22:04.280
<v Speaker 5>largely because of environmental exposures and systemic inequities that have

1:22:04.400 --> 1:22:10.760
<v Speaker 5>existed throughout our country's history that have contributed to these disparities.

1:22:11.040 --> 1:22:13.000
<v Speaker 5>So I think that's a really important part is that

1:22:13.040 --> 1:22:16.200
<v Speaker 5>there's really no evidence that any of these disparities are

1:22:16.520 --> 1:22:22.480
<v Speaker 5>genetic based their environmental and structural right. The other aspect

1:22:22.680 --> 1:22:26.960
<v Speaker 5>is that asthma is a chronic condition that's not always

1:22:26.960 --> 1:22:31.639
<v Speaker 5>easy to manage and sometimes very expensive, and so there's

1:22:31.680 --> 1:22:35.920
<v Speaker 5>also discrepancies in access to healthcare for diagnosis and in

1:22:36.000 --> 1:22:40.639
<v Speaker 5>access to medications as well. Yeah, and I did want

1:22:40.680 --> 1:22:42.720
<v Speaker 5>to say one thing erin because you talked a lot

1:22:42.760 --> 1:22:45.640
<v Speaker 5>about this individualization, and I know that I said that

1:22:45.680 --> 1:22:48.920
<v Speaker 5>treatment is kind of the same, and that is true

1:22:49.120 --> 1:22:51.040
<v Speaker 5>in that we use like kind of a handful of

1:22:51.080 --> 1:22:57.120
<v Speaker 5>medicines for asthma in general, but the individualization of each

1:22:57.360 --> 1:23:00.559
<v Speaker 5>person's asthma treatment is still a thing, and it's actually

1:23:00.560 --> 1:23:04.880
<v Speaker 5>called an asthma action plan. So access to someone who

1:23:04.960 --> 1:23:08.160
<v Speaker 5>can help develop an asthma action plan is actually really

1:23:08.200 --> 1:23:13.120
<v Speaker 5>really important and is associated with much better outcomes, reduced exacerbations,

1:23:13.160 --> 1:23:18.200
<v Speaker 5>reduced hospitalizations, et cetera. So that all contributes to these

1:23:18.320 --> 1:23:21.559
<v Speaker 5>huge disparities that we see, especially in the US, right

1:23:21.560 --> 1:23:26.840
<v Speaker 5>across the globe as well. So obviously there's a lot

1:23:26.880 --> 1:23:29.519
<v Speaker 5>of work to be done when it comes to asthma,

1:23:29.640 --> 1:23:33.840
<v Speaker 5>not only to better understand maybe the genetics that underpin it,

1:23:33.960 --> 1:23:39.680
<v Speaker 5>the environmental risk factors differentiating these different endotypes or phenotypes

1:23:39.760 --> 1:23:43.600
<v Speaker 5>or whatever, all of the different types of asthma. It

1:23:43.640 --> 1:23:47.040
<v Speaker 5>wouldn't be surprising to me if this does end up

1:23:47.120 --> 1:23:50.840
<v Speaker 5>leading to either splitting of this diagnosis or at least

1:23:51.600 --> 1:23:55.719
<v Speaker 5>specifying these diagnoses right where you have really more specific

1:23:55.800 --> 1:24:00.640
<v Speaker 5>definitions of asthma and therefore different and more in visualized

1:24:00.680 --> 1:24:03.920
<v Speaker 5>treatments beyond just how do you use your inhaler for

1:24:04.040 --> 1:24:10.599
<v Speaker 5>your specific action plan, but along those lines and with

1:24:10.720 --> 1:24:14.200
<v Speaker 5>regards to treatment and the future of treatment, I wanted

1:24:14.200 --> 1:24:16.960
<v Speaker 5>to mention something. Shout out to my friend and colleague

1:24:17.000 --> 1:24:21.920
<v Speaker 5>Kat who brought this article to my attention. That is

1:24:21.920 --> 1:24:27.200
<v Speaker 5>a really important part of how we decide on medications,

1:24:27.479 --> 1:24:30.760
<v Speaker 5>and we, as like a whole medical community, decides on

1:24:30.920 --> 1:24:38.640
<v Speaker 5>medications for chronic, often lifelong diseases. The recent guidelines that

1:24:38.680 --> 1:24:41.880
<v Speaker 5>came out of GINA, the Global Initiative for Asthma, These

1:24:41.880 --> 1:24:44.280
<v Speaker 5>are kind of like big time global guidelines that a

1:24:44.320 --> 1:24:48.639
<v Speaker 5>lot of different countries use. And these treatment guidelines very

1:24:48.680 --> 1:24:53.160
<v Speaker 5>strongly endorse using a combination of inhaled steroids like I

1:24:53.240 --> 1:24:57.920
<v Speaker 5>mentioned and a short acting broncho dilator, but they specifically

1:24:58.000 --> 1:25:03.479
<v Speaker 5>endorse this combination of one type of bronchodilator and one

1:25:03.600 --> 1:25:06.799
<v Speaker 5>type of inhaled cortico steroid, which happens to be found

1:25:06.920 --> 1:25:10.400
<v Speaker 5>in combination in a drug called Symbacourt in the US,

1:25:10.800 --> 1:25:15.400
<v Speaker 5>which is made by a company called Astrosenica, which happened

1:25:15.439 --> 1:25:18.240
<v Speaker 5>to have two point five billion dollars in sales of

1:25:18.280 --> 1:25:23.960
<v Speaker 5>this drug in twenty twenty one, and twelve of the

1:25:24.080 --> 1:25:29.679
<v Speaker 5>seventeen members of the GINA board have received payments from

1:25:29.840 --> 1:25:30.519
<v Speaker 5>this company.

1:25:30.600 --> 1:25:34.959
<v Speaker 4>Astrasenca not doesn't seem like it should be okay.

1:25:35.920 --> 1:25:40.320
<v Speaker 5>Now, the GINA guidelines more strongly recommend this drug this

1:25:40.439 --> 1:25:45.360
<v Speaker 5>combination than a couple of other guidelines that have less

1:25:45.520 --> 1:25:50.559
<v Speaker 5>fewer board members that have received payments from Astrosenca. But

1:25:51.640 --> 1:25:56.519
<v Speaker 5>what I'm saying is not necessarily that people are being

1:25:56.560 --> 1:26:01.439
<v Speaker 5>corrupted by these payments. The problem here is that if

1:26:01.479 --> 1:26:04.160
<v Speaker 5>you look at a Cochrane review from twenty twenty one,

1:26:05.040 --> 1:26:08.080
<v Speaker 5>four of the five studies that were included in this study,

1:26:08.120 --> 1:26:13.679
<v Speaker 5>which in fact showed that using this combination of inhaled

1:26:13.680 --> 1:26:19.800
<v Speaker 5>corticosteroids and a bronchodilator had better outcomes than using short

1:26:19.840 --> 1:26:23.880
<v Speaker 5>acting bronchodilators alone. The data is pretty clear from these

1:26:23.920 --> 1:26:28.200
<v Speaker 5>studies that that leads to better outcomes. But four of

1:26:28.360 --> 1:26:31.400
<v Speaker 5>five studies that were included in this Cochrane review were

1:26:31.479 --> 1:26:42.640
<v Speaker 5>funded by AstraZeneca. I mean, so it's not necessarily inherently

1:26:42.960 --> 1:26:47.439
<v Speaker 5>bad that the pharmaceutical industry is financing these studies. These

1:26:47.479 --> 1:26:50.679
<v Speaker 5>studies are important. They're integral to be able to develop

1:26:50.720 --> 1:26:53.880
<v Speaker 5>better treatments and to know is this treatment going to

1:26:53.880 --> 1:26:57.200
<v Speaker 5>be better than what we have currently. The problem is

1:26:57.240 --> 1:27:01.439
<v Speaker 5>not only these conflicts of interest, in that these studies

1:27:01.439 --> 1:27:04.719
<v Speaker 5>were funded by these companies. The guidelines are being written

1:27:04.760 --> 1:27:07.719
<v Speaker 5>by people who are getting money from these companies based

1:27:07.720 --> 1:27:10.800
<v Speaker 5>on the studies that were funded by these companies. But

1:27:11.800 --> 1:27:14.680
<v Speaker 5>it's also that we don't have any other studies of

1:27:15.160 --> 1:27:19.600
<v Speaker 5>similar medications to actually compare to. Right there are a

1:27:19.680 --> 1:27:22.679
<v Speaker 5>lot of other combinations of these two types of drugs

1:27:22.680 --> 1:27:25.640
<v Speaker 5>that exist, but right now we only have data that

1:27:25.680 --> 1:27:30.360
<v Speaker 5>says this particular one that we have studied, because we

1:27:30.479 --> 1:27:34.080
<v Speaker 5>paid for it, because we made it is the best,

1:27:34.479 --> 1:27:35.960
<v Speaker 5>So that's the one that we should.

1:27:35.760 --> 1:27:41.760
<v Speaker 4>Use, you know, And also considering that it's a chronic

1:27:42.200 --> 1:27:44.200
<v Speaker 4>use medication.

1:27:44.240 --> 1:27:47.519
<v Speaker 5>Exactly exactly, this is something people are going to be

1:27:47.520 --> 1:27:51.080
<v Speaker 5>buying every month, right for their whole childhood or their

1:27:51.080 --> 1:27:54.519
<v Speaker 5>whole life. And again I'm not saying that there's not

1:27:54.680 --> 1:28:00.880
<v Speaker 5>data that this medication absolutely reduces exacerbations, reduces hospitalizations, proves outcomes.

1:28:02.000 --> 1:28:04.600
<v Speaker 5>The problem is that when we only have data on

1:28:04.680 --> 1:28:09.080
<v Speaker 5>this one specific combination from this one company, how do

1:28:09.120 --> 1:28:12.200
<v Speaker 5>we then make a decision about how to treat not

1:28:12.320 --> 1:28:15.519
<v Speaker 5>only everyone who doesn't have access to this one specific

1:28:15.560 --> 1:28:19.479
<v Speaker 5>medication by this one specific company, but also how do

1:28:19.560 --> 1:28:22.960
<v Speaker 5>we compare that and make sure that we're funding studies

1:28:23.000 --> 1:28:25.840
<v Speaker 5>that are non biased to compare that to all of

1:28:25.840 --> 1:28:30.360
<v Speaker 5>the other drugs that already exist, right, right, And I

1:28:30.520 --> 1:28:33.080
<v Speaker 5>just wanted to mention that and bring that up because

1:28:33.120 --> 1:28:37.320
<v Speaker 5>I think it's a really important part of chronic disease,

1:28:37.760 --> 1:28:41.360
<v Speaker 5>especially right, like you mentioned, Aaron, this is a disease

1:28:41.360 --> 1:28:44.200
<v Speaker 5>that people are going to need potentially lifelong treatment for,

1:28:44.960 --> 1:28:49.479
<v Speaker 5>and so it's especially important that the studies that are

1:28:49.560 --> 1:28:52.760
<v Speaker 5>done are being done in an as non biased a

1:28:52.760 --> 1:28:56.200
<v Speaker 5>way as possible so that our data is as good

1:28:56.200 --> 1:28:59.400
<v Speaker 5>as possible so that people can have the outcomes that

1:28:59.400 --> 1:29:01.080
<v Speaker 5>we want with out corruption.

1:29:01.800 --> 1:29:04.360
<v Speaker 4>Really, I mean, yeah, I think it's I think it's

1:29:04.360 --> 1:29:07.519
<v Speaker 4>difficult because it's like they're at every step of the way.

1:29:07.600 --> 1:29:10.920
<v Speaker 4>There should be a focus or like a check point

1:29:10.960 --> 1:29:15.040
<v Speaker 4>to be like, is there potentially bias introduced at this

1:29:15.080 --> 1:29:17.920
<v Speaker 4>step versus this step? Or how could that bias be introduced?

1:29:17.920 --> 1:29:21.800
<v Speaker 4>And how do we acknowledge it? Like not saying you know,

1:29:21.840 --> 1:29:23.800
<v Speaker 4>it's just like what you said, These studies should be

1:29:23.880 --> 1:29:29.320
<v Speaker 4>done and they are important, and these drugs do work, right,

1:29:29.680 --> 1:29:36.040
<v Speaker 4>But I think finding a better way to disallow the monopolization,

1:29:36.520 --> 1:29:37.880
<v Speaker 4>I guess I think what.

1:29:38.000 --> 1:29:39.880
<v Speaker 5>It comes down to is something we talk about a

1:29:39.920 --> 1:29:43.360
<v Speaker 5>lot on this podcast, and that is the need for funding,

1:29:43.880 --> 1:29:47.080
<v Speaker 5>for public health funding and for research funding that's coming

1:29:47.080 --> 1:29:49.439
<v Speaker 5>from places that are not trying to make a profit

1:29:49.640 --> 1:29:50.719
<v Speaker 5>off of that research.

1:29:50.880 --> 1:29:51.000
<v Speaker 1>Right.

1:29:51.080 --> 1:29:53.320
<v Speaker 5>Yeah, that's what it comes down to, and that's usually

1:29:53.720 --> 1:29:57.479
<v Speaker 5>governmental funding, so which is extremely limited.

1:29:59.040 --> 1:30:02.360
<v Speaker 4>Yeah, so that's our best let's make a case yet

1:30:02.400 --> 1:30:06.000
<v Speaker 4>again funding funding funding, yep.

1:30:06.640 --> 1:30:10.120
<v Speaker 5>But just I think an interesting part and an important

1:30:10.120 --> 1:30:14.759
<v Speaker 5>part of how we conduct research, not just the research

1:30:14.800 --> 1:30:17.200
<v Speaker 5>that needs to be done, but how it needs to

1:30:17.240 --> 1:30:22.720
<v Speaker 5>be done going forward, and that is asthma.

1:30:25.280 --> 1:30:33.640
<v Speaker 4>Was that fun, it was something sources sources. I have

1:30:33.680 --> 1:30:35.880
<v Speaker 4>a bunch, but I'm only going to shout out right

1:30:35.920 --> 1:30:39.479
<v Speaker 4>now a book that I read by Mark Jackson called

1:30:39.720 --> 1:30:43.120
<v Speaker 4>Asthma The Biography Oh Love.

1:30:42.920 --> 1:30:48.400
<v Speaker 5>That I mentioned already one of my favorite papers for deep, deep,

1:30:48.600 --> 1:30:52.519
<v Speaker 5>nitty gritty dive on asthma path of physiology, and that

1:30:52.680 --> 1:30:56.680
<v Speaker 5>is the paper from twenty twenty by Ganz and gaffree Leva.

1:30:57.200 --> 1:31:00.680
<v Speaker 5>I also have several other papers on the path of physiology,

1:31:00.880 --> 1:31:04.479
<v Speaker 5>and I will of course link to those twenty twenty

1:31:04.479 --> 1:31:07.559
<v Speaker 5>two GENA guidelines that I mentioned, as well as the

1:31:07.560 --> 1:31:12.479
<v Speaker 5>AFP article that brought to attention the potential conflicts of

1:31:12.520 --> 1:31:16.040
<v Speaker 5>interest in those guidelines. But we'll post all of our

1:31:16.040 --> 1:31:19.240
<v Speaker 5>sources from this episode and all of our episodes on

1:31:19.280 --> 1:31:22.120
<v Speaker 5>our website, This podcast will Kill You dot Com under

1:31:22.160 --> 1:31:24.400
<v Speaker 5>the episodes tab A.

1:31:24.640 --> 1:31:28.280
<v Speaker 4>Big thank you again to Lindsay for providing your first

1:31:28.280 --> 1:31:30.880
<v Speaker 4>hand account. We appreciate it so very.

1:31:30.880 --> 1:31:34.600
<v Speaker 5>Much, so much. Thank you to Bloodmobile for providing the

1:31:34.680 --> 1:31:36.479
<v Speaker 5>music for this episode at.

1:31:36.479 --> 1:31:40.080
<v Speaker 4>All of our episodes, and thank you to Leana Sculaci

1:31:40.120 --> 1:31:42.200
<v Speaker 4>for our amazing audio mixing.

1:31:42.560 --> 1:31:46.160
<v Speaker 5>We love it. Thank you to Exactly Right Network.

1:31:46.200 --> 1:31:50.559
<v Speaker 4>And thank you to you listeners. This was a long one.

1:31:51.439 --> 1:31:53.760
<v Speaker 4>Thanks for hanging in there with us and we hope

1:31:53.800 --> 1:31:54.599
<v Speaker 4>you learned something.

1:31:56.160 --> 1:31:59.680
<v Speaker 5>Yeah, I hope so. And a special shout out as

1:31:59.720 --> 1:32:03.479
<v Speaker 5>always to our patrons. Thank you so much. Your support

1:32:03.640 --> 1:32:04.719
<v Speaker 5>means the world to us.

1:32:04.760 --> 1:32:05.960
<v Speaker 4>It really does. Thank you.

1:32:06.040 --> 1:32:06.439
<v Speaker 5>Thank you.

1:32:08.240 --> 1:32:12.800
<v Speaker 4>Okay, Well, until next time, wash your hands you feel

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<v Speaker 4>the animals