Richard R. MacMahon, Ph.D.
Asthma is a disease of the immune system. Asthmatics react to substances in the bronchioles of the lungs with what is termed "bronchial hyperreactivity". Two things happen in a reaction. First, there accumulate secretory cells at the site of the irritation , eosinophils that release eosinophil-cationic protein and eosinophil-derived neurotoxin, and lymphocytes that secrete interleukin-2 and interleukin-5. (See Boushey and Fahy, 1995, for a detailed discussion of this mechanism). Second there are severe contractions of the smooth muscles in the bronchioles, resulting in serious constriction and limiting of air flow. These constrictions of the smooth muscle are caused mostly by the proteins secreted from the eosinophils and lymphocytes. These proteins cause an immune reaction in the bronchioles. This leads to inflammation of the involved bronchiolar tissue.The result is the constrictions of the airways, swelling of the inflamed tissue and secretion of an abnormally large amount of mucus material which characteristically is thick and ropey.
Not only do the bronchioles become spasmodically constricted, but the inflammation of the bronchiolar tissue further constricts the air ways. And at the same time, subepithelial collagen is deposited which causes the basement membrane to appear thicker. This all leads to further constriction and permanent damage to the air ways. (Boushey and Fahy, 1995)
The combination of constricted bronchioles, inflammation and excessively thick mucus results in severe impairment of the air flow in these areas. This results in shortness of breath and usually a wheezing sound that is typically associated with an attack of asthma. It is particularly hard for asthmatics to exhale.
This results in a loss of capacity to exchange air - which may be measured by a peak flow meter (PFM). This meter is capable of showing constriction before the onset of obvious symptoms, and is thus an invaluable aid to those with asthma. It is now strongly urged that asthmatics carry a PFM at all times. They are small, the newer ones hardly bigger than a lipstick case.
Asthma and Intelligence: School performance & Psychological Patterns
Two studies give some insights as to the psychological effects of asthma. (McCowan
et al
, 1998; Yellowlees
et al
, 1987). McCowan studied a population of asthmatic Scottish children for four years. He reported slightly slower growth rates, but no apparent decrease in intelligence. Yellowlees examined a sample of fifty older people with chronic airflow obstruction. He found them twice as likely (when compared to a control group) to be anxious (general anxiety disorder) as well as showing depression, hysteria and cognitive deficits.
Yellowlees
et al
(1987) also reported that these patients were in an "emotional straight jacket" and could not effectively express rage, anger, agression, hostility and resentment because of the adverse effects these emotions have on breathing. In other words, asthmatics soon learn to suppress and internalize strong emotions to avoid triggering an asthma attack. How hard this situation must be for adolescents, who are just developing an adult personality (Adams
et al
, 1994)
In contrast, other papers report a long list of emotional symptoms for asthmatic children (Lehrer
et al
, 1993; Carr
et al
, 1992). These symptoms include:
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• Greater emotional facial expression
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• Greater expression of direct and indirect anger
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• More expression of helplessness and decreased competence
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• Greater agression, at least verbally
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• Marginally greater psychiatric disturbances
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• A higher prevalence of behavioral and school-related problems
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• A higher prevalence of social competence problems in asthmatic boys
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• A higher degree of low self-esteem in asthmatic girls
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• Greater maladjustment than in normal children
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• A tendency to hold anger in
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• Emotions expressed for a shorter duration
Some of these findings are contradictory and obviously not all symptoms occurred in all children. However, it is evident that there is a considerable emotional burden placed on young people with asthma.
One important aspect of the psychological side of asthma is the effect asthma medicines may have on the patients. I was able to find direct side-effects of bronchodialators and corticosteroids (see the forth page of this paper) but little other information. I consulted three manuals for asthma management written for physicians, (Glaxo Cont. Ed, 1994; Nat. Asthma Ed. Prog., 1991; 1992) but could find nothing on the side-effects of asthma medicines. The interplay of adolescent personality development, the asthmatic condition and side-effects of medicines for asthma should be a fascinating story. But I was not able to find references to such a study.
As far as asthma relates to school work, I can add nothing beyond what I have already said (See pages 2-4 of this paper). Students who are constantly absent because of asthma fall behind. Poor performance on tests and other types of assignments are usual simply because they have missed so much. These same students become frustrated and are often at odds with the school administration over rules and regulations. They are often in disciplinary trouble and may be suspended from school more often than other students. All of these factors contribute to poor academic performance. If you compare attendance records and grades, there is usually an inverse correlation between grades and rate of absenteeism.
Asthma Classification:
The severity of asthma varies enormously from an occasional mild attack to constant breathing difficulties which may only be controlled by daily medication. (JAMA, 1997a). Asthma may be classified into a number of categories as follows:
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• Intermittent - only when exposed to a specific trigger
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• Mild Persistent - symptoms more than twice a week but less than once a day. Nighttime exacerbation occurs more than two times per month. Lung function is 80% of normal
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• Moderate Persistent - daily symptoms and daily use of quick relief medication. Exacerbation occurs more than twice a week and may persist for days. Nighttime exacerbation occurs more than two times per week. Lung function is 60% to 80% of normal.
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• Severe Persistent - the patient has continuous symptoms, limited physical activity and frequent daily and nighttime exacerbations. Lung capacity is less than 60%.
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• Status Asthmaticus - a severe, life threatening attack that does not respond to medication. Emergency treatment at the doctor's office or hospital is needed. Hospitalization is usually required.
This classification provides a convenient way to talk about asthma. The classifications in themselves do not mean that much. Asthmatics may shift from one group to another and back. The main thing is that this classification provides a structured way with which to deal with asthma. (JAMA, 1997a).
