Scott Webb (Host): Asthma is a common condition. And despite the many triggers and limitations that it can cause, my guest is here to explain how he and the team at Prisma Health are helping patients to breathe easier. I'm joined today by Dr. Adam Schertz. He's a pulmonologist, ICU Medical Director, and Oconee Memorial Hospital Clinical Assistant Professor, University of South Carolina School of Medicine, Greenville.

 This is Flourish, the podcast brought to you by Prisma Health. I'm Scott Webb. Doctor, it's nice to have you here today. We're going to rely on you. We're going to lean on you so that we can all breathe a little easier, right? And you're going to give us this just sort of complete guide to asthma. What is it and how do you diagnose and how do you treat and all that good stuff. So, thank you for being here.

Dr. Adam Schertz: Thanks for having me, Scott.

Host: Yeah. It's a pleasure to have you here. I love to have experts on and pick their brains. And I might be suffering a little bit of asthma or allergies or whatever it is. So, good for me, good for listeners. Let's start there, Doctor. What exactly is asthma and what happens in the lungs during an asthma attack?

Dr. Adam Schertz: So, this is a complicated question. And I think what I'll try to do is break it down into a metaphor that hopefully helps people understand.

Host: Yeah, sure.

Dr. Adam Schertz: So, the respiratory system is kind of like this large tree that lives inside of us. The tree trunk is the trachea or the windpipe, and that trunk is firm, it's ringed with cartilage, and it's hollow. So, these are all just big air tubes. And so, that trunk, that air tube, splits into the main two air tubes that feed our right and left lungs, and those are called bronchi. And then, those bronchi continue to split into more branch points, all the way down 27 branch points. Those bronchi are just about the size of the thinness of a hair. And then, we're at the leaves, which are called the alveoli, and that is where the oxygen that we're breathing in from the atmosphere is exchanged into our body, and where the carbon dioxide that we're exhaling out first gets from our body into our lungs.

And so, asthma is an abnormal inflammation in those air tubes, those branches of our lungs. It's not in the leaves, it's not where the oxygen and carbon dioxide diffusion happens, it's in the air tubes themselves. And so, this inflammation is an overexaggerated response to something in the environment. Our respiratory system is always exposed to the environment, and some people have some predisposition to over-reactivity.

And during an asthma attack, there's three separate but related things that happen. The lining of those air tubes becomes inflamed or swollen, and then they start to produce this thick and sticky mucus in the walls that then, if you think about, you know, what I'm talking about on the microscopic level, start to fill in some of those really small airways. And then, there's rings of smooth muscle that surround those air tubes. And those become constricted, and that's what you get with an asthma exacerbation. You get inflamed airway walls, mucus production, and muscle constriction in the airways.

Host: Right. Yeah, you did a great job explaining that without any diagrams. You know, we're in audio form only today. So, I appreciate that. And you mentioned lungs there. So, let's talk about that. Like, how does asthma affect daily lung function, and maybe what are some of the most common and maybe even overlooked symptoms that folks might attribute to, like me, allergies, perhaps?

Dr. Adam Schertz: So, it's really variable how much asthma affects any individual person on a daily basis. It ranges from what we'll call mild intermittent asthma, and that's occasional symptoms. This is basically less than twice a month, and this is usually provoked by some kind of identifiable trigger, which I think we'll get into more. So, that's that mild to intermittent category that can move all the way along the spectrum to what's called severe persistent asthma, which is basically daily symptoms that aren't controlled, despite being on, you know, multiple inhalers.

I think as part of this portion of the discussion, it's really important to know that fatal asthma exacerbations don't only occur in people with the severe asthma. About one in five asthma deaths are actually seen in people with mild asthma. And so, it's not that people have daily symptoms are necessarily going to then, you know, die from this. But it is to say that this is a condition that can lead to death and that even people with mild asthma can have a trigger so severe that they can end up hospitalized.

Common symptoms of asthma, just taking on that second part of the question there, chest tightness, wheezing, shortness of breath, cough, those are the big ones that we see. Basically, everybody I see who has asthma, I ask them, what, if any, usually all those symptoms they're experiencing.

And then, things that are overlooked. Typically, recurrent bronchitis, right? So, some people are like, "God, I just get sick and get bronchitis a couple times a year. Predictably every year around this time, I get this bronchitis and this cough that doesn't go away." And that can be asthma. Exercise intolerance, I think particularly in younger people, tightening of the airways, difficulty breathing with, you know, any kind of moderate exercise. And then, chronic cough is another thing we see even without the other typical asthma symptoms. Chronic cough can be caused by asthma.

Host: Sure. Yeah. Let's stay with the triggers. I feel like there's probably some surprising or unusual triggers that people need to be aware of. I know you mentioned one before we got rolling, but give us a sense, like, what usually triggers asthma in folks?

Dr. Adam Schertz: So, we'll start with the common ones. And then, I'll kind of deepen into the unusual ones. Commonly, upper and lower respiratory infections. So, viral infections, common cold, anything like that will be a major trigger for anybody who has asthma. Other things to think of, these are really common triggers. So, smoke, cigarette smoke. But also, you know, think of smoke from a fire pit, any smoke that's getting out there. Environmental allergens, so, like, pollen, dust, pets, molds, those sorts of things can be triggers for people; strong scents, cleaning supplies, perfumes, season changes, weather changes, hot air, cold air.

Host: So, pretty much everything

Dr. Adam Schertz: Yeah. So, I'm running down the list of all things that can do this.

Host: Just so pretty much everything everywhere. Got it. All right, good.

Dr. Adam Schertz: Yeah, exercise, occupational exposures, chemicals, cotton fibers, metal dust, all sorts of particulate matter, too, right? So, like I said, our airways are continuously exposed to the environment. And so, we have this really incredible immune system in the airway specifically that helps to deal and filter with these things. But for some people, we have an overactive immune reaction. And so, basically, everything in the atmosphere and the environment can trigger asthma.

Host: Yeah, sounds like it. Yeah.

Dr. Adam Schertz: So, we were talking about some surprising or unusual triggers. And I think there's a few fun ones out there. I shouldn't say fun. There's a few interesting ones out there that people wouldn't think about. So, a common one is aspirin or any non-steroidal anti-inflammatories. So, aspirin, ibuprofen, naproxen, any of those can be associated with asthma.

Host: Something that's supposed to help us, right?

Dr. Adam Schertz: Exactly, exactly. And so, some people can have this negative reaction to those. Thunderstorm asthma, this is a really interesting one. This is when there's pollen and grass. So, think now this time of year, in the springtime, pollen and grass can get sucked up into clouds, and you can get this pollen rain. And this is something that I think there was a well-documented case in Australia, some probably 20 years ago where there was just an enormous amount of hospitalizations because there was such bad air quality that got sucked into rain clouds and got dropped over people, and this causes, you know, pretty negative respiratory symptoms.

There's perimenstrual asthma. So, some women get worsening of respiratory symptoms around the time of menstruation. And then, another one, red wine, I think pretty well-documented that there's sulfites in wine, mostly red wine. And so, some people have, you know, allergies or sensitivities to these sulfite additives. And those can also provoke some respiratory symptoms.

Host: Yeah. I feel like, Doctor, that, you know, in the hands of a qualified and expert pulmonologist, diagnosing asthma is probably pretty straightforward. They come in and you start checking all the boxes. But give us a sense of how do you diagnose asthma and when should someone consider seeing a pulmonologist?

Dr. Adam Schertz: So, I mean, it's basically a clinical diagnosis. There's not objective criteria that necessarily makes somebody have a diagnosis of asthma. But those symptoms that we talked about, shortness of breath, wheezing, chest tightness, cough, any or all of those are typical symptoms of asthma.

And although it's not a diagnostic, something that's diagnostic for asthma, we'll often do pulmonary function testing where we have a respiratory therapist instruct you on these breathing techniques where we can look at how much air you can blow out, whether or not there's obstruction in the air that you're blowing out, what's your overall amount of air in your body? Is there any limitation in airflow? And so, we can look at all those things with pulmonary function testing.

During that pulmonary function testing, we can give medicine to relax the muscles in those air tubes that we talked about, and see if there's a difference when we give that medicine, that's called a bronchodilator challenge. Once again, not diagnostic for asthma if there is a positive response, but just kind of pushing us in that direction. There's a separate test, a more advanced test that we can do where we give somebody an inhaled substance to provoke a response in the airway. It's called a methacoline challenge. There's also the mannitol challenge, same basic thing. We look to see if there's a decrease in airflow associated with that medicine.

And then, we can have people exercise and look to see if there's a difference in airflow before exercise and after exercise, that's to look for what's called exercise-induced asthma. But once again, usually, you can make a clinical diagnosis kind of based off of people's history just listening.

Host: Yeah, patient history. Sure.

Dr. Adam Schertz: The second part of that question there is, you know, when should somebody see a pulmonologist. You know, I think not all asthmatics need to see a pulmonologist, but I think if somebody's asthma's not well-controlled on an appropriate inhaled medicine or, you know, if we're needing steroids one or more times a year for asthma symptoms or, if anybody goes to the emergency department or the hospital because of asthma, those are times to, you know, make sure we see a pulmonologist. And then, the last one would be if there's kind of continued unexplained respiratory or breathing problems, that's always a good time to come see a lung doctor.

Host: Right. And this is anecdotal at best, Doctor, but it seems to me when I was a kid, I grew up in the '70s, so everything seems to have been different and maybe worse because we just weren't as far along with science and medicine and all that. But anecdotally, it just seemed like every other kid that I knew growing up had an asthma inhaler, right? And we talked about asthma and everybody seemingly had asthma. I'm exaggerating, of course. But it seems to me that, through my own kids, right, going through school and one's, you know, already out of college, the other ones going to college next year, I don't hear about it much anymore. I don't hear about everybody having asthma and having their inhalers and "where's my inhaler," and all that stuff. So, I just want to get a sense from you, like, can asthma be cured and maybe what are some of the main treatment options? Like, how far have we come?

Dr. Adam Schertz: It's a really good point. So, you know, I'm not sure that the prevalence of asthma has changed, but I'll tell you that the treatments have changed, dramatically over time where, you know, if you were a kid in the '70s, you know, there was not much out there. There were some older medicines that could be used depending on how severe. But nowadays, you know, there are much better treatments out there for kids and adults. I think taking the first part there kind of leads me to like the discussion of why asthma happens in the first place and what kind of things predispose people to having asthma. And a lot of it has to do with the way we grow up. There's a huge difference between the way people grow up now versus the way they did in the '70s. I think smoking indoors in particular, but parents smoking indoors has changed dramatically.

Host: Smoking indoors, smoking in cars, smoking everywhere. Yeah, of course. Yeah, right.

Dr. Adam Schertz: So, secondhand smoke is one of the major, major risk factors for development of childhood asthma. If you think about it, it's because our air quality, both indoors and also with the smoke, is causing that inflammation in the airways.

Similarly, you know, you'll see differences in asthma rates in, like, inner cities versus country air, right, where there's more pollution in inner cities and maybe, you know, decreased pollution over that span of time as well over that 50 years has also kind of changed development of asthma in kids. So, those are kind of two things that I think of.

And then, I think you mentioned something about, like, you know, curing asthma.

Host: Yeah. Is that possible?

Dr. Adam Schertz: Sort of. A lot of kids grow out of asthma anyways. So even kids that have asthma or bronchitis, you know, when they're younger will often grow out of it. And it's because those air tubes that we talked about get bigger as we get older. And so, that inflammation or that overexaggerated response becomes less problematic as those air tubes get larger, because small changes in the air tube caliber, and the size of those air tubes from inflammation or thickening don't cause as much of a problem with airflow as we get older.

And then, you know, there's some evidence to suggest that bronchial muscle sensitivity, you know, that smooth muscle contraction that we're talking about lessens a bit over time. Although I will say a lot of children who are asthmatics do have some persistent bronchial muscle overreactivity, even if they technically grow out of their asthma.

Host: Okay. Yeah, wondering, I assume that the gold standard, if you will, for either controllers or rescue inhalers, like it's still inhalers, in other words, right? Like, is that still the go-to? Are there some other things? Are there other options, pills? Like, what are the treatment options?

Dr. Adam Schertz: So, the mainstay is still inhaler therapy. The most recent guidelines that were released in 2025, these are global guidelines for asthma, have put out a new recommendation for primary asthma treatment. Beforehand, most of what we're saying is have your rescue inhaler albuterol available. What we've seen over the last seven, eight years has been a paradigm shift in thinking around that particular topic, to say that, yes, some kind of smooth muscle relaxer like albuterol is useful, but that needs to be paired with an inhaled steroid, either in the same inhaler, which then becomes a different kind of inhaler than albuterol, or as a separate, you know, extra inhaler and another inhaled steroid.

 This is because, if you think about what albuterol does, kind of what we talked about, albuterol works on that muscle contraction, but it doesn't work on the inflammation part. The steroids work on the inflammation part in the air tubes. So, when you combine those two things together, we get better asthma control and less flares that occur.

There are a few inhalers on the market that are available that currently meet this criteria based off these 2025 guidelines. So, Airsupra, that's a new one that's albuterol and budesonide. There's Symbicort, which is an older one, but that's formoterol and budesonide. Budesonide's a steroid. Fomoterol is basically another smooth muscle relaxer. It's just slightly longer-acting. And then, there's another one called Dulera, which is fomoterol and mometasone. So, mometasone is another steroid, but these all are combined smooth muscle relaxers that are fast-acting plus a steroid to be used as kind of primary asthma therapy, and they work really well when we're using these optimally.

Host: So as you say, it's not so much curing asthma, it's controlling it better through advances. And I wanted to stick with the medications, Doctor, how maybe controller medications differ from rescue inhalers and maybe what are some of the common mistakes despite their best efforts that patients make when they're trying to manage their asthma?

Dr. Adam Schertz: So, for some patients, they can do just fine with these on-demand inhalers. But it has to be the right class. So, we talked about it, you know, if we have a muscle relaxer plus a steroid, not every asthmatic is going to need to be using those every day. If their symptoms are well enough controlled using those as-needed, that's ideal.

Some people will have symptoms most days of the week or every day. And for those people, it's important to use a daily inhaler, just so they're staying ahead of that inflammation. Because the thing that is important with asthma is that you never know when you're going to be exposed to a trigger. You can plan on, you know, walking through Macy's and avoiding the perfume counter, but you can't always plan on, you know, walking into a building and there being a cleaning crew out there, and you get a heavy bleach smell or something that's going to trigger your asthma, right? There's some things that are just unavoidable when we live in this world. And so, for those people, that's important. It's really important to not only have an on-demand or rescue inhaler available, but also to be taking a daily inhaler.

And then, on that topic, there's a new class of medicines for asthma. So, for people who are symptomatic consistently and still have exacerbations that require treatment with steroids or require hospitalizations, there's injectable medicines that we have now called biologics. And these range from, you know, subcutaneous doses every other week to every six months. And these work to decrease those inflammatory factors that cause these asthma responses.

And so, this has been a huge game-changer in asthma control, because there's some people out there who have such an overreactive inflammatory, what we'll say, inflammatory milieu in their airways, right? So much inflammation triggered by environmental exposures that they basically have constant symptoms, and this really helps to dampen down those inflammatory responses, these biologic therapies.

And so, we've been starting these kind of earlier and earlier. But of course, you know, these are medicines that are injectable, these are medicines that most people wouldn't want to take unless their asthma control is in such a state that this is a much better option for them. And it really has made a huge difference in people who have just very difficult-to-manage asthma.

Host: I'm sure, yeah. And there's such a range, and it's, you know, patient by patient. It's great that we have experts, of course. Let's just finish up here today, Doctor, and good stuff. How does asthma compare to other lung conditions, let's say like COPD or chronic bronchitis, and what may be practical steps can you recommend to help folks to protect their lungs, to have better lung health, if you will?

Dr. Adam Schertz: This is a really complicated and nuanced question. I'm going to keep it as simple as I can. So, bronchitis is kind of a catch-all term. This just means inflammation in those air tubes. And we usually think of it as related to an infection, you know, like a viral infection, right? It causes inflammation and bronchitis.

COPD, chronic obstructive pulmonary disease and chronic bronchitis are related conditions. So, COPD is almost entirely in the United States a smoking-related condition. There's a small percentage of COPD that's related to occupational dust and fume exposure, biomass, fuel combustion, like wood-burning stoves, but a much smaller proportion of COPD.

So, with COPD, there's prolonged exposure to smoke and toxins and cigarette smoke that leads to chronic inflammation in the ear tubes. But unlike asthma, COPD also affects those air sacs, right? Those leaves in the tree. And so, over time, this chronic inflammation can cause destruction in the air tubes or air sacs, and it can cause chronic bronchitis, and that's, you know, a person who coughs every day for three months of the year and produces phlegm with that cough, and then also causes emphysema where those air sacs themselves are getting destroyed. And now, that air is going to these dead-end spaces in our lungs where it's not getting into our body, right? That oxygen's not getting into our body. The air is just siting in these dead sacs, these defects in the lung where there's nothing going on there. The air's just sitting behind, and that's emphysema. Bronchitis and emphysema will often coexist in long-term smokers. And there's genetic factors that, you know, are at play as to how much emphysema somebody develops.

Long-term asthma, uncontrolled asthma. So, if we have poorly controlled asthma long-term, it can lead to similar chronic changes in the airway, like the chronic bronchitis, right? Those air tubes can become inflamed, and there could be obstructed airflow over time. But honestly, with modern treatment methods, asthma doesn't tend to lead to obstruction. And so, that's the big distinction, is that asthma is really a disease of those air tubes from an overreactive immune response, whereas COPD is this chronic prolonged inflammation that affects both the air tubes and the air sacs and is irreversible.

And then, I think just taking the last question, what practical steps can people take? So, what things can we do to protect our lungs. This is the most important thing we're going to talk about. Number one is don't smoke. Number two, on the same basic, front is get your partners, parents, family, friends, everybody you know to stop smoking. Number three, regular exercise. Number four is going to be, if you're sensitive to air quality, invest in air purifiers, good air filters for your HVAC units. This is like MERV 13 or higher is usually what I recommend to folks. If you're looking at your app on your phone and you're seeing what the air quality numbers, the AQI or the air quality index looks like, if there's a bad air-quality day, you know, maybe think about staying indoors. If you work around hazardous chemicals or fumes or if you weld, you're going to be exposed to things, you know, wear a respirator mask.

And then, the last one, and this is not necessarily an asthma thing, but just important for everybody to know, is that consider checking your house for radon. Because although it doesn't affect your lungs on a day-to-day basis, it is a known cause of lung cancer. And it's something that we would not be aware of unless we were testing our basements or our homes to make sure that we don't have kind of continued chronic radon exposure.

Host: Yeah. Yeah, that might an entirely separate podcast. Another thing from the '70s, it seems like folks always were talking about radon back in the day and we don't talk about that much. But really good stuff today, good suggestions from an expert. I appreciate your time, your expertise, all of that. Thank you so much.

Dr. Adam Schertz: Thank you for having me, Scott.

Host: And for more information, go to prisma.health/asthma. For more information and other podcasts just like this one, head on over to prismahealth.org/podcast. This has been Flourish, a podcast brought to you by Prisma Health. I'm Scott Webb. Stay well.