Asthma versus The Beaver

Oscar was 28 years old, thin and muscular, with the look of the outdoors in his eyes. He was not from one of my villages, and I had never seen him as a patient before. His appointment was for “cough and runny nose x 2 days.” His chart was as thin as he was, which told me he had not been seen in the hospital very often. When I asked him why he had come to clinic that day, he said “it’s just a cold. I’m coughing a lot at night, and I wondered if I could get some cough syrup.”

We discussed his symptoms and their duration, and I noticed that his breathing was unlabored and his speech regular. His vital signs were normal, except that the oxygen saturation seemed a little low (96%) for a person of his age and apparent level of fitness. He denied any chronic meds, but when I asked him if he were taking any meds for his cold, he said “I have a puffer if I really need it.” I saw in his chart that he had been given an albuterol inhaler about a year earlier.

“When did you last use it?” I asked.

“About two weeks ago,” he said.

I asked whether he had ever been given a second inhaler or other medicines to help his breathing, but he said no. He denied a history of asthma, had never been told he had reactive airway disease. He did admit that he often didn’t sleep well, and woke up tired in the morning.

His physical exam was unremarkable except for the runny nose and the persistent expiratory wheezes in all lung fields. His best effort on a peak flow meter was 85% of predicted for his age and height. His chest x-ray was normal.

He admitted when I asked him that he could hear himself wheezing. “So why haven’t you been using your inhaler?” I wondered.

“Well, I’m still breathing good, even I’m wheezing, and I don’t want to get hooked on it,” was his reply. “I’ll use it if my breathing is really bum.”

“Oscar,” I said, “what you have is asthma. You need to have two inhalers, an inhaled steroid that you use all the time, and albuterol that you use whenever you are coughing and wheezing.”

“It works like this. Asthma causes the lining of your airways to be inflamed, you know, like red and warm and extra-sensitive. That makes the little muscles encircling the airways want to squeeze up, so instead of breathing through a nice big garden hose, you have to breathe through a tiny little straw. It is hard work and it makes you cough and wheeze. If you use the albuterol inhaler, it will help the squeezing to relax and let you breathe better. But it won’t take away the inflammation, so as soon as the albuterol wears off, your lungs will squeeze back up again. You need a second type of puffer, an inhaled steroid, to take away the inflammation so you don’t squeeze back up. The albuterol is your rescue medicine; when your breathing is bum, it will help you right now. The inhaled steroid is your maintenance medicine; it will work to keep your lungs cooled down so they don’t want to squeeze up, and your breathing will stay good.”

He was mostly getting it, but not quite. I could feel an analogy coming on.

Think of it this way. Your house is next to a stream, and you get your water from that stream. Up stream there lives a beaver. He is working night and day, chewing through saplings and dragging them across the stream to build a dam. When he does that, you don’t get enough water at your house. You can spend all your time with a saw, cutting through the saplings he has piled up, and you can keep the water flowing well enough to get what you need. Or you can get rid of the beaver.

“Ah,” he said. “I get it.” He smiled sideways at me. “I’ve got a beaver in my lungs.”