Most of us know about asthma, maybe even have friends afflicted with asthma.
Asthma is a condition involving the system of tubes that carry air in and out of the lungs. The trachea, bronchi and bronchioles are like an upside-down hollow tree, with ever smaller branches extending out to the tiny air pockets (alveoli) where oxygen and carbon dioxide are exchanged. Air flows in and out with every breath. The patency of these air passages, as well as the flexibility of the lung tissue, are key factors that allow respiration to occur easily, quietly and effortlessly.
With asthma, the lining of these air passages becomes swollen. The swelling may be mild or severe. Classically, breathing becomes effortful, and the sufferer wheezes. Milder cases may involve only some sensation of chest tightness, but no audible wheezing. At the other extreme, if asthma is severe, the air passages may become practically obstructed, and both inspiration and expiration may become overwhelmingly difficult. This is a life-threatening emergency (status asthmaticus) that needs immediate life-saving treatment.
Fortunately, this is rare, so this column is really about milder cases of asthma, cases where there is some choice in management. For asthmatic singers, management is a key issue. Asthma is a chronic condition, and one that can affect the voice, stamina, and breath support.
Asthma has many possible causes. Reactive asthma is a response to some irritant, such as an allergy or infection. Allergies can affect the lower airway as well as the nose and throat, so with any severe upper respiratory allergy, asthma should be suspected. If an infection triggers the asthma, treating the infection should address the problem. Exercise or cold air also may induce asthma—the air passages are very sensitive in asthma patients, and respond by swelling (reactive airway disease).
In some patients with GERD (gastroesophageal reflux disease), refluxed stomach acid spills down the trachea and causes swelling, which in turn causes asthma-like wheezing. Of course, in a large number of patients, doctors never find the cause, and the asthma is considered “intrinsic.” One interesting subgroup is so-called cough asthma, which causes no wheezing, and no sensation of chest tightness; the only symptom is a chronic, annoying dry cough.
The two issues for singers are 1) suspecting the condition where it is not obvious, and 2) long-term management.
Diagnosis is not always obvious. In cases of atypical asthma, the singer may just complain of nonspecific chest tightness, difficulty sustaining the phrase, even some loss of power. The cough-asthma group is often missed—patients with cough are often ineffectively treated for postnasal drip, infection, or even reflux, without considering the possibility of underlying asthma. If your chest gets tight after jogging, certainly exercise-induced asthma is a possibility, but the triggering factor could also be inhaled allergens.
Correct treatment begins with trying to avoid the triggering factors. If asthma persists, you have the choice of two basic groups of medications: ones that relax and open the airways (bronchodilators), and various forms of inhaled and ingested cortisone (anti-inflammatory steroids). The choices are many, and your physician normally bases those decisions on the frequency and severity of your asthma attacks, as well as your response to treatment. Ease of use is a secondary but significant consideration.
For singers, I generally prefer to avoid inhaled steroids, if possible. Inhaling cortisone can have negative effects on the vocal folds. These include fungal infections, as well as possible weakness and atrophy of the vocal folds. While the latter two are rare, if the condition can be controlled by pills vs. sprays, there is less potential harm to the larynx.
Advair, a newer combination (steroid-bronchodilator) inhaler, is effective and convenient, but particularly bad for the voice. Even non-singers may develop significant hoarseness from this medication. Fortunately, the hoarseness usually resolves when the medication is stopped.
In mild cases, I have found Singulair to be useful. Its great advantage is that it can also help with upper airway allergies, but has none of the drying side effects of antihistamines. Of course, in some cases it doesn’t work, but when it does it is easy (one pill a day) and helpful.
Overall, as always, treatment should be tailored to the condition, and these choices need to be made by your own doctor, ideally with your informed input! Tell him you are singer, and remind him that, sitting on top of your reactive tracheobronchial tree, is your livelihood.
