Asthma

Diagnostic summary : recurrent attacks of dyspnoea, cough, and expectoration of tenacious mucoid sputum; prolonged expiration phase with generalised wheezing and musical rales; eosinophilia, increased serum IgE, positive food and/or inhalant allergy tests.

General Considerations

Bronchial asthma is a hypersensitivity disorder characterised by bronchospasm, mucosal oedema, and excessive excretion of a viscous mucus that can lead to ventilatory insufficiency; its prevalence is approximately 3% of the population, and although it occurs at all ages, it is most common in children under 10; there is a 2:1 male:female ratio in children, which equalizes by the age of 30.

• Major factors: hypersensitivity of airways; beta-adrenergic blockade; cyclic nucleotide imbalance in airway smooth muscle; release of inflammatory mediators from mast cells.

• Rate is rising rapidly, especially in children; reasons for this: increased stress on immune system (greater chemical pollution in air, water, and food; earlier weaning and introduction of solid foods to infants; food additives; genetic manipulation of plants – food components with greater allergenic tendencies.

• Pertussis vaccine: children breast-fed from first day of life, fed exclusively breast milk for first 6 months and weaned 1 year – relative risk of developing asthma = 1% in children receiving no immunizations, 3% in those receiving vaccinations other than pertussis, and 11% for those receiving pertussis; in group of 203 not immunized to pertussis, 16 developed whooping cough vs. only 1 of 243 in the immunized group.

• Major categories:
- extrinsic or atopic: immunologically mediated with increased serum IgE

- intrinsic: bronchial reaction due, not to antigen-antibody stimulation, but rather to such factors as chemicals, cold air, exercise, infection, agents that activate alternative complement pathway, and emotional upset.

• Mediators: mast cell-derived chemical mediators responsible for signs and symptoms: preformed: histamine (H), chemotactic peptides (eosinophilotactic factor [ECF] and high-molecular-weight neutrophil chemotactic factor [NCF], proteases, glycosidases and heparin proteoglycan; membrane-derived; lipoxygenase products (leukotrienes [LTs] and so-called slow reacting substance of anaphylaxis [SRS-A]), prostaglandins (PGs), thromboxanes (TXs) and platelet-activating factor (PAF); actions =  bronchoconstriction (H, LTC4, LTD4, LTE4, PGF2?, PGD2, PAF), mucosal oedema from increased permeability (H, LTC4, LTD4, PAF), vasodilation (PGD2, PGE2), mucosal plugging (H, HETEs, LTC4), inflammatory cell infiltrate (NCF, ECF-A, HETEs, LTB4, PAF), and desquamation of epithelium (proteases, glycosidases, lysosomal enzymes, basic proteins from neurtophils and eosinophils).

• Mild episodic asthma vs. moderate to severe sustained asthma: latter has a subacute/chronic bronchial inflammation with infiltration of eosinophils, neutrophils and mononuclear cells; episodic – due to bronchial smooth muscle contraction.

• Lipoxygenase products: leukotrienes = most potent chemical mediators in asthma; SRS-A (LTC4, LTD4, LTE4) 1,000 times more potent bronchoconstrictor than H; asthmatics have imbalance in arachidonic acid metabolism relative increase in lipoxygenase products; platelets from asthmatics – 40% decrease in cyclooxygenase metabolites and 70% increase in lipoxygenase products, aggravated in ‘aspirin-induced asthma’ – aspirin and NSAIDs inhibit cyclooxygenase while promoting lipoxygenase – shunt arachidonic acid to lipoxygenase pathway and excessive leukotrienes; tartrazine (ubiquitous yellow dye #5) = cyclooxygenase inhibitor and induces asthma, especially in children; tartrazine = anti-metabolite of vitamin B6.

• Autonomic nervous system: parasympathetic vs. sympathetic innervation; beta-2-adrenergic receptors (localized in lung tissue and react to catecholamines); parasympathetic vagus nerve stimulation releases acetylcholine (Ach) which binds to receptors on smooth muscle, forming cGMP; increased cGMP and/or relative deficiency in cAMP causes bronchoconstriction and degranulation of mast cells and basophils; decreased sympathetic activity or diminished beta-2 receptor numbers or sensitivity also promote the cyclic nucleotide imbalance; some mediators block beta-2 receptors and elevate cGMP. 

• Adrenal gland: cortisol = activator of beta receptors; epinephrine (Epi) = the prime stimulator of beta receptors: asthmatic attacks may be induced by relative deficiency of cortisol and Epi (which stimulates beta-2 receptors to catalyze formation of cAMP from AMP) leading to decreased cAMP:cGMP ratio and bronchial constriction.

Therapeutic considerations

General
• Hypochlorhydria: 80% of tested asthmatic children had inadequate gastric acid secretion – hypochlorhydria and food allergies are predisposing factors.

• Increased intestinal permeability: ‘leaky gut’ – increased antigen load on immune system; overwhelms immune system, increasing risk of additional allergies and bronchoconstrictive compound.

• Candida albicans: GI overgrowth implicated as causative factor in allergic conditions including asthma; acid protease produced by C. albicans is the responsible allergen.

• Food additives: must be eliminated; colouring agents, azo dyes – tartrazine (orange), sunset yellow, amaranth and new coccine (both red) – and non-azo dye pate blue; most common preservatives are sodium benzoate, 4-hydroxybenzoate esters, and sulphur dioxide; sulphites used in prepared foods; molybdenum deficiency may cause sulphite sensitivity – sulphite oxidase is the enzyme that neutralizes sulphites, and is molybdenum-dependent.

• Salt: increased intake worsens bronchial reactivity and mortality from asthma; bronchial reactivity to H is positively correlated with 24-h urinary Na and rises with increased dietary Na.

• DHEA: decreased levels common in postmenopausal women with asthma compared with matched controls; therapeutic benefit in asthma undemonstrated; important to immune function – positive effects possible.

Diet
• Food Allergy: immediate onset sensitivities – due to (deceasing order of frequency) egg, fish, shellfish, nuts, peanuts; delayed onset – (decreasing order of frequency) milk, chocolate, wheat, citrus, food colourings; elimination diets identify allergens and treat asthma, especially in infants; elimination of common allergens during infancy (first 2 years) reduces allergic tendencies in high-risk children (strong familial history).

• Vegan diet: long-term trial (elimination of all animal products) significantly improved 92% of 25 patients who compared the study (nine dropped out) based on vital capacity, forced expiratory volume at 1 s (FEV1), physical working capacity, haptoglabin, IgM, IgE, cholesterol, and triglycerides; also reduces tendency to infectious disease; 71% of patients responded in 4 months, 1 year required for 92%; diet excludes all meat, fish, eggs, dairy products, chlorinated tap water (drink spring water only), coffee, ordinary tea, chocolate, sugar, and salt; herbal spices allowed; water and herbal teas allowed up to 1.5 L four times a day; vegetables used freely = lettuce, carrots, beets, onions, celery, cabbage, cauliflower, broccoli, nettles, cucumber, radishes, Jerusalem artichokes, all beans expect soya and green peas; potatoes allowed in restricted amounts; fruits used freely: blueberries, cloudberries, raspberries, strawberries, blackcurrants, gooseberries, plums, pears; apples and citrus fruits not allowed; grains restricted or eliminated; beneficial effects of vegan diet = elimination of food allergens, altered prostaglandin metabolism, increased intake of antioxidants and Magnesium.

Nutrition

• Omega-3 essential fatty acids (?-3 EFAs): children who eat fish> once a week have 1/3 asthma risk of those who do not; fish oil supplements with EPA and DHA improve airway responsiveness to allergens and respiratory function; benefits due to increasing ration of ?-3 to ?-6 EFAs in cell membranes, reducing arachidonic acid; ?-3 EFAs shift leukotriene synthesis from inflammatory 4-series to less inflammatory 5-series, improving asthma symptoms; benefits may take as long as 1 year before apparent – time to turn over cellular membranes in toward omega-3 fatty acids.

• Tryptophan (Try) metabolism and pyridoxine (vitamin B6) supplementation: asthmatic children have metabolic defect in Try metabolism and reduced platelet transport for serotonin; Try is converted to serotonin (bronchoconstrictor in asthmatics); serotonin high in blood and sputum of asthmatics – elevated urinary 5-HIAI correlates well with symptom severity; patients benefit from Try-restricted diet or B6 supplements; plasma and RBC pyridoxal phosphate (PLP) in asthmatics much lower than in controls: 50-100mg oral B6 greatly decreases frequency and severity of wheezing and attacks and dosages of bronchodilators and corticosteroids; B6 fails to demonstrate significant improvement in patients dependent upon steroids to control symptoms; theophylline (headaches, nausea, irritability, sleep disorders etc.); tryptophan load test may determine appropriateness and level of B6 supplementation needed; urinary excretion of kynurenic and xanthurenic acids increases in patients responding to B6.

• Antioxidants: oxidizing agents can stimulate bronchoconstriction and increase hyperactivity to other agents.

• Vitamin C: the major antioxidant in extracellular fluid lining airways surfaces; children of smokers have a higher rate of asthma (smoke depletes respiratory  C and E) and symptoms in adults appear increased by exposure to environmental pro-oxidants and decreased by C supplements; nitrogen oxide = oxidants from endogenous and exogenous sources – vitamin C protects against nitrogen oxide lung damage in lab animals; asthmatic patients have much lower levels of serum and WBC ascorbate; clinically asthmatics have higher need for C; seven of 11 studies showed significant improvements in respiratory measures and symptoms using 1-2g vitamin four times a day; high-dose C therapy may lower H-H initially amplifies immune response, by increasing capillary permeability and smooth muscle contraction, and then suppress accumulated WBCs to contain inflammation; vitamin C prevents H secretion by WBCs and increases H detox; vitamin C will only lower blood H if taken over a period of time.

• Flavonoids: key antioxidants to treat asthma – inhibit H release from mast cells and basophils stimulated by antigens, phospholipase A2 in neutrophils, lipoxygenase, anaphylactic contraction of smooth muscle, phosphodiesterase in lung (increasing cAMP), biosynthesis of SRS-A, Ca influx; quercetin spares vitamin C and stabilises mast cell membranes; sources = quercetin, grape seed, pine bark, green tea, or Ginkgo  biloba; proanthocyanidins from grape seed or pine bark have affinity for lungs.

• Carotenes: powerful antioxidants which increase integrity of respiratory epithelium; act as substrates for lipoxygenase, possibly competing with arachidonic acid, decreasing leukotriene formation.

• Vitamin E: antioxidant, inhibitor of lipoxygenase and phospholipase.

• Selenium: reduced Se levels found in asthmatics; glutathione peroxidise (Se-dependent matalloenzyme) reduces hydroperoxy-eicosatetraenoic acid (HPETE) to hydroxyl-eicosatetraenoic acid (HETE), thereby reducing leukotriene formation; decreased glutathione peroxidise common in asthmatics.

• Vitamin B12: Jonathan Wright MD mainstay in childhood asthma; weekly injections improved symptoms – less SOB on exercise, improved appetite, sleep, and general condition; B12 is especially effective in sulphite-sensitive patients; offers best protection when given orally prior to challenge; forms sulphite-cobalamin complex, blacking sulphite effect.

• Magnesium: i.v. Magnesium well proven/clinically accepted to halt acute asthma attack as well as acute exacerbations of chronic obstructive pulmonary disease (COPD); i.v. Magnesium only necessary in emergency – acute MI or asthma; oral Magnesium effective to optimize body Magnesium stores – 6 weeks needed to elevate tissue Magnesium; supplementation warranted – dietary Magnesium is independently related to lung function and asthma severity.

Botanical medicines

Historical herbals = Ephedra sinica (Ma Hung) in combination with herbal expectorants, e.g. Glycyrrhiza glabra (licorice), Grindelia camporum (grindelia), Euphorbia hirta (euphorbia), Drosera rotundifolia (sundew), Polygala senega (senega); ephedra alkaloids are effective bronchodilators for mild to moderate asthma and hay fever; peak bronchodilation in 1 h and  lasts 5 h after administration.

• Glycyrrhiza glabra (licorice root): documented anti-inflammatory and anti-allergic; primary active constituent is glycyrrhetinic acid – inhibits phospholipase A2 which cleaves arachidonic acid from membrane phospholipid, initiating eicosanoid synthesis; licorice is also expectorant.

• Lobelia inflate (Indian tobacco): alkaloid lobeline is an efficient expectorant; long history of use in asthma, but promotes bronchoconstriction and is respiratory stimulant in vitro; binds to nicotine Ach receptors in ganglions, promoting release of Epi and NE = therapeutic effects, effective alone, but traditionally used in combination with other botanical agents (Capsicum frutescens and Symphlocarpus factida).

• Capsicum frutescens: capsaicin induces long-lasting desensitization of airway mucosa to mechanical and chemical irritants; capsaicin depletes substance P (that increases vascular permeability and flow) in respiratory nerves; substance P = undecapeptide linked to ‘neurogenic inflammation’ via direct effect  and synergy with H on peripheral nervous system; respiratory and GI tracts have many substance P-containing neurons – believed to contribute to atophy (asthma and atopic dermatitis).

• Zizyphi fructus (jujube plum): traditional Chinese herb for treatment of asthma and allergic rhinitis; contains 100-500 nmol cAMP/g of dry weight, a concentration 10 times > than that of any other plant or animal tissue reported; contains beta-adrenergic receptor stimulator that also raises cAMP.

• Thea sinensis (green tea): adjunctive in asthma – methylxanthine and antioxidant constituents.

• Allium family: onions and garlic inhibit lipoxygenase and cyclooxygenase which generate TxA2, PGD2 and PGE2; onion contains quercetin plus benzyl and other isothiocyanates (mustard oils); may inhibit biosynthesis of arachidonic acid metabolites.

• Tylophora asthmatica: Ayurvedic medicine for asthma and other respiratory disorders; mode of action unknown, thought to be due to alkaloids (tylophorine) – anti-H, antispasmodic activity and inhibits mast cells degranulation; good results.

• Ginkgo biloba: unique terpenes (ginkgolides) antagonize platelet-activating factor (PAF), key mediator in asthma, inflammation, and allergies; ginkgolides compete with PAF for binding sites and inhibit events induced by PAF; improves respiratory function and reduces bronchial reactivity.

• Aloe vera: may be effective for patients not dependent upon corticosteroids; extract produced from supernatant of fresh leaves stored in dark at 4 degrees C x 7 days in increase polysaccharide fraction; 1 g of this extract produces 400mg neutral polysaccharides vs. 30 mg produced from leaves not subject to cold or dark. Solution of Aloe vera extract in saline, 40% of patients without steroid dependence felt very much better; mechanism of action via restoring protective mechanisms, with augmentation of immune system.

• Coleus forskohlii: forskolin increases intracellular cAMP, relaxing bronchial muscles and relieving respiratory symptoms; studies utilized inhaled doses of pure forskolin; efficacy of oral C. forskohlii extract yet to be determined; historical use and additional mechanisms of action recommend its use.

Therapeutic Approach

Underlying defects and initiating factors must be determined and resolved;
(1) defect allowing sensitization,
(2) metabolic defect causing excessive inflammatory response,
(3) triggering allergens with lifestyle, diet, and environment changes to avoid them,
(4) modulating inflammatory process to limit severity,
(5) effective treatment for bronchoconstriction of acute attack.

• Environment: minimize exposure to air-borne allergens (pollen, dander, dust mites); avoid dogs, cats, carpets, rugs, upholstered furniture, surfaces where allergens can collect; ensure bedroom is allergen-proof; encase mattress pads weekly; consider Ventflex (hypoallergenic synthetic) bedding material; install air purifier, e.g. HEPA (High-efficiency particulate arresting) attachable to central heating/air conditioning.

• Diet: eliminate all food allergens and additives and bananas if they aggravate condition; patient with many food allergies may need 4-day rotation diet and/or allergy FACT test from ICIM Medics; use garlic and onions liberally unless patient reacts to them; if patient is willing, or asthma unresponsive, try vegan diet (for 4 + months), with possible exception of cold-water ocean fish.

• Supplements
- Vitamin B6
- Vitamin B12
- Vitamin C
- Vitamin E
- Magnesium
- Quercetin
- Grape seed extract
- Carotenes
- Selenium

• Botanicals
- Ephedra sinica
- Glycyrrhiza glabra
- Camellia sinensis
- Tylophora asthmatica
- Coleus forskohlii

• Counselling: important for patients who respond to emotional crisis with asthmatic attacks and children with moderate to severe asthma, who may develop behavioural problems.

ICIM Medics Approach

If you feel that this article relates to you then please make an appointment for Your Respiratory Assessment http://icimmedics.com/medical-assessments/respiratory-assessment/

As the results from the assessment are immediate we often advise patients to see one of our Natural Medical Practitioners who will help you with your individualised treatment plan. This may include dietary, nutritional and/or botanical advice.

This article is not meant to be used for treatment but for information purposes only. If you feel that this approach is appropriate for you please contact ICIM Medics on 045 844 819 or www.icim.ie   e-mail : info@icim.ie  Both appointments can be arranged for you.

Tags: Asthma, Chronic Obstructive Airways Disorder, Osteopathy