Asthma Blog from the view of an asthma researcher, doctor, and mom

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Generalizability versus Singularity

One of the purposes of this blog is to communicate the results of research to non-researchers.  But just because one study suggests Pulmicort is more effective than Flovent doesn’t mean Pulmicort is better than Flovent for every patient.  In this blog, I also try to share patient stories because patients have distinct experiences.  There are plenty of patients who find that Flovent is more effective. And some patients can’t even take Pulmicort because of allergy or other reasons.

My goal to convey the results of research is to report on generalizations that might fit many, but not all people who have asthma.

An editorial in the current issue of the American Journal of Critical Care Medicine by Martin Tobin MD describes the balance between generalizability and singularity so well.

The main points are:

  • The practice of medicine is centered on two opposing yet complementary systems of knowledge (think Yin-Yang):  generalizability and singularity.
  • Individualized care is the crux of the practice of medicine, while scientific knowledge is based on generalizations.


  • The foundation of scientific knowledge is to develop generalizations in order to develop broad understandings.
  • Generalizability in randomized controlled trials is prized so that the results are more generalizable to diverse patient groups, although there are some exceptions.


  • The job of the physician is to focus on one particular patient at a given time and to determine which general principles are relevant and applicable.
  • The task is to take broad principles gained through research and to customize them to the individual patient.
  • No two individuals are exactly the same.  Even twins are different.
  • Personalized medicine is introducing a new twist to the traditional emphasis on individual care as genomics, proteomics, and biomarkers offer the potential to tailor therapy according to characteristics of an individual patient. (But even personalized medicine will be based on generalizations derived from research.)

So what’s the take home point? Take the research I report on in this blog with a grain of salt.

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Video games are getting more jobs than ever

When I got my first Atari, I’m not sure I learned much except how to move the joystick quickly without breaking it.  Now, video games are being used as an important tool to make people do things they don’t want to do.  And making people do things without realizing it. For example, video games are being used in the workplace to motivate sales people to increase sales.  Video games are being used in marketing to generate business.

Video games are everywhere now.  That Atari station I had was the first in the neighborhood because my father was an early adopter of technology.  Now, every child seems to be playing video games while waiting to be seen in clinic, sitting in the car or grocery cart.  On any given day, 60% of young people play video games, and almost half play on a handheld or cell phone.  I’m always surprised by the number of people I know in their 50’s or 60’s who play Candy Crush.

So, I’ve been thinking a lot about using video games to improve health in children.  And this means I’ve been looking at a lot of video games. 

This made me realize that I don’t enjoy playing video games. 

I made myself play Angry Birds a couple of years ago for 10 minutes because I wanted to understand what the hype was about.  When my 10 minutes were over, I had no urge to play more.

This made me ask my family why they think I don’t like video games.

My husband responded that I value efficiency too much.  He thinks I don’t want to get addicted to any game. So I don’t allow myself to play any video games and I force myself to not like them. Could this be true? Possibly. I did actively cut out TV several years ago in order to be more productive in all other aspects of my life. This has worked, except I sometimes struggle during dinner conversations because the only TV shows I watched in the past 15 years were Friends and Lost.

My daughter says that I think video games are just bad. She says that I always limit the kids to no more than 1 hour per day, so video games must be bad for some reason.

My son thinks I’m just not good at video games.  If I had the skills at getting high scores, maybe I’d enjoy playing them.

In any case, I’m fascinated by this whole area of gamification that I believe could incentivize people to do things they wouldn’t normally want to do.   As more video games come on the market to help motivate people to be healthier, I might just start playing video games again.

Filed under gamification

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Anonymous asked: Hi Ann. My insurance company has decided to discontinue coverage of Flovent and will only cover Asmanex, Pulmicort Flexhaler and Qvar. Which of those 3 do you think works best. thank you, Tom Egan

Dear Tom,

Many people like you have found that Flovent is no longer covered by their insurance. For example, Express Scripts stopped covering Flovent as of January 1, 2014.

I’m glad you are being proactive about thinking about alternatives to Flovent. This is an important conversation to have with your doctor.  The mechanism of delivery of Asmanex twisthaler and Pulmicort flexhaler are different from the Flovent inhaler as they are both dry powder inhalation devices and you may like the twisthaler or flexhaler more or less.  Qvar is delivered via an inhaler like Flovent because it is also an inhalation aerosol.  In a post this past summer, I reported on a study of Qvar versus Flovent.  Click [here] for post.

Thanks for your question, but I can’t provide any clinical advice over the internet.



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Anonymous asked: The new HFA inhalers do not seem to be nearly as effective as the old ones. They clog easily and do not appear to deliver the medication as well. Do you see/hear this too? I have used asthma inhalers for many years. As a young child, I didn't have much access to asthma medication and learned to deal with it by finding a quiet place and slowing breathing and everything down. Hot tea seemed to help some too.

Dear Anonymous,

Thank you for contacting my blog.  Yes, I have heard many others say they do not like the CFC-free (or HFA) inhalers as much as the previous ones that were not safe for the ozone (see previous post for more details on the effects of CFCs on ozone).  I received this comment from a physician and included it in this post.  I even had a patient admit that he stock piled the CFC inhalers because of the more forceful propellant. 

The new inhalers do clog, so I reached out to Beth Klements, Asthma Clinical Nurse Specialist at Boston Children’s Hospital.  She wrote the following:

It has long been know that the propellant CFC (Chlorofluorocarbon) is harmful to the ozone layer protecting our environment. As a result, all inhalers made since January 1st, 2009 have contained a more environmentally friendly propellant called HFA (hydrofluoroalkane.) How does this affect our asthma inhalers? They still look the same, and contain the same active ingredients. There are several differences:

  • They may be slightly different in smell and taste
  • The mist is less forceful and warmer
  • The mist is also stickier and may block the small opening in the plastic sleeve where the medicine comes out
  • The inhaler needs to be primed more often

Clean your inhaler cover once a week so it does not clog. Do not clean the metal canister or get it wet.

1.      Wash hands.

2.      Take the metal canister out of the plastic inhaler cover.

3.      Take the cap off the inhaler.

4.      Hold either end of the plastic inhaler cover under warm water for 30 seconds.

5.      Turn the plastic inhaler cover upside down and run warm water through the other end for 30 seconds.

6.      If there is any medicine build up that hasn’t been washed away, repeat steps 3 and 4, or use a toothpick to remove hardened medicine from the little hole.

7.      Shake off any water on inhaler cover and let air dry.



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Genetics of smoking

I’m just back from the NIH supported Pharmacogenetics Research Network (PGRN) meeting.  I’m always excited to hear about the most recent research in pharmacogenomics. Somehow research in pharmacogenomics of asthma (my area of interest) feels like it lags behind because of the complexity of the disease, but when I talk to other researchers, they also feel their diseases of interest should be further ahead. 

As a research field, pharmacogenomics has moved forward plenty, and it was nice to reflect on this at the meeting which occurs twice a year.

Today’s post will focus on one research area: the genetics of smoking cessation which was presented by Andy Zhu.

A few interesting background points first:

  • Over 1 billion people smoke globally.
  • Smoking is responsible for 6 million deaths per year.
  • Estimates suggest there will be 1 billion deaths related to smoking in the 21st century.
  • 70% of smokers would like to quit, but only 3% quit successfully a year.
  • Quitting smoking by age 50 years of age will gain on average 6 years of life.
  • Heritability of smoking cessation is 50%.
  • Nicotine is the main addictive compound in tobacco.  Nicotine is inactivated to cotinine, and this reaction is mediated by the enzyme CYP2A6.
  • Slow metabolizers of CYP2A6 smoke fewer cigarettes, are less likely to be a current smoker, have lower dependence scores, and reduced risk for lung cancer.

In the most recently published paper, this research group studied 32 African Americans who are light smokers and slow nicotine metabolizers.  The researchers sequenced the CYP2A6 gene of these individuals and found seven new genetic variants that influence CYP2A6.

Genotyping assays were developed and allelic frequencies were assessed in 534 African Americans who were light smokers (they smoke 10 or fewer cigarettes per day).  The researchers confirmed these variants in CYP2A6 were associated with slow metabolism.

So, why do I find this work exciting? Is it because now we can test people before they start smoking and determine who is likely to become addicted and who is less likely to be able to quit?

Of course, not.

But identification of these novel genetic variants gives us a more complete picture of CYP2A6 variability, improving understanding of genetic variation in smoking behavior.  You decide whether you pick up that first cigarette, but genetics might determine the rest…whether you turn into a 5 pack a day smoker for the rest of your life, or 5 cigarette per day smoker who quits after 5 years.

I had a preview of the work to come from this group, and it’ll continue to be exciting.

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Have you ever received a $50 bill in the mail?

It’s not everyday that I receive a $50 Ulysses Grant bill in the mail. Yet I’ve now received two of these from Reshma Jagsi MD Dphil, who is conducting a study of investigators who have received career development awards. 

I rarely complete surveys unless I feel a strong connection to the survey.  We all have our ways of time management, and this is one of my tactics.  It doesn’t matter if I receive a check for $3 in the mail (I never deposit them), and it doesn’t matter if I have the opportunity to earn a $50 Amazon gift certificate.

But I filled out Dr. Jagsi’s survey.  Twice.  One was three years ago and one was last week.

I was impressed with Dr. Jagsi’s gutsiness in sending $50 via U.S. postal mail.

Not certified mail or FedEx.

Regular, U.S. postal mail.  Dr. Jagsi’s cover letter states that over 75% of subjects like me responded to the survey.  This is a very high response rate, but I have to admit that it’s a little scary that 25% of the $50 got lost in the mail or pocketed.

They surveyed 1,719 and had 1,227 respondents, meaning $24,600 in cash was technically wasted, although I’d say the overall study was a success as it takes this type of incentive to get the attention of busy, junior investigators.

The second survey was a follow up questionnaire.  This made me look up the results of the first survey.  It’s not often that I’m a subject in a research study.  I found two articles in PubMed.

The first article I found reports on gender differences in salary on our group of young investigators who received career development awards.  Baseline demographics suggested that women were more likely to be unmarried.  Men were less likely to have a full-time working spouse.  Men were also more likely to have a PhD.  I am married with a full-time working spouse and have an MD.

The mean salary for the women was $141,000 and the mean salary for men was $172,000.  This gender difference in salary was not fully explained by specialty, academic rank, work hours, or spousal employment.  The investigators suggest that salary disparities in academic medicine exist early on when researchers are hired.  Women negotiate salary less aggressively than men do.  (Not surprising, but still frustrating.)

The second article is about mentoring and career satisfaction of male and female academic faculty.  I fell into the majority in terms of having an MD (as opposed to MD/PhD or other degree), having a specialty of women/children/family, and being married with kids.

The researchers reported career dissatisfaction as generally low, but women were more likely than men to be dissatisfied with work-life balance. (Also not surprising, especially given women were less likely to have non-working or part-time working spouses.)

So, I completed my second survey quickly and put it in the mail.  I’m looking forward to reading about the results of the longitudinal study.

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These two children with asthma are raised in contrasting environments, yet significant challenges for both

In a post earlier this week, three Health for America fellows interviewed a child with asthma.  In today’s post, they interview two more children with contrasting environments.  Abena, Miki, and Glenn write…

Patient 2

The fellows interviewed a two-year-old Hispanic girl whose primary caregiver was her mother as her parents are separated. She was recently diagnosed after being in and out of the emergency room for her constant wheezing and cold. Her mother was frustrated that she wasn’t diagnosed until just recently because she believed that administering earlier medication would’ve been beneficial. The patient’s flare-ups usually happen after visiting her father and grandmother who smokes.

The government-assisted housing they live in is very poor. There are roaches and mice in the bedroom, along with mold and mildew from water damage in the bathroom. In the living room, the carpet is unsanitary and dirty, despite the fact that she vacuums every couple of days.

When the mother was asked what her biggest setback in managing her child’s asthma was, she explained that her primary doctor did not provide adequate hours for a working parent. This is a trend that was seen in other health care facilities. Standard 9 to 5 hours each day makes it very difficult for families to come in for a check-up, especially if they have a low income. Despite the several oppositions, the child’s mother still gives her controller medication twice a day with a spacer. She has only had to use the reliever medication twice in the past month.

Patient 3

The third patient interviewed was a 6-year-old white male who regularly takes his asthma medication. He lives in a middle to high-income household with good housing conditions, and and his caregiver is a registered nurse in a pulmonary clinic.

When the patient was younger, he used a whistle device that made sounds to demonstrate the duration and quality of breath to learn how to breathe correctly into an inhaler. He also used a Nintendo DS that had an interactive breathing video game for asthma. He mentioned that he enjoys playing video games or bicycling with the Wii while using his nebulizer.

The patient takes his controller medication twice a day around the same time and has gotten better at remembering to take it and self-managing his condition as he has gotten older. He has never been admitted to the ER due to asthma because he and his caregiver carefully control and manage his asthma. Furthermore, his asthma does not hinder him from doing outdoor activities or playing sports.

The caregiver mentioned several challenges, such as the overwhelming expenses for asthma medication. In addition, insurance does not cover all of these medications anymore. In addition, providers cannot get reimbursed after purchasing a spacer, so it becomes an eating cost. As a healthcare provider, her experience as a caregiver was frustrating initially because she had to be firm about her child’s diagnosis.

It took some time for the patient’s pediatrician to catch on because the patient was active and seemed “normal”. He is also a silent wheezer, which made the diagnosis even more difficult. This highlights the common problems of misdiagnoses and backing patients off of medication when they seem “normal” when dealing with pediatric asthma. Children who have less severe asthma and are extremely active may go unnoticed. This is dangerous because they can crash hard after physical exertion and are susceptible to pneumonia or asthma flare-ups if left untreated.

The visit with the third patient showed us that it is possible for patients and caregivers to effectively manage and live with asthma. There are, however, still challenges that make it difficult even for people with higher incomes, including high costs and disagreements with providers about the diagnosis and treatment of one’s children.

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For this child with asthma, he has trouble taking his medicines on time, but has plenty of time for video games

I’ve had the opportunity to work with Health for America, a non-profit organization that is passionate about using young fellows to change the world of healthcare.  Last summer’s fellows spent eight weeks conducting research to identify sustainable community-based solutions to improve childhood asthma.  I was impressed with all the research the fellows did, and I managed to meet with them too.  I’ve continued to have regular communication with their founders, Kapil Parakh and Madhura Bhat, as they shape their vision for the future.

The fellows, Abena Dakwahene, Miki Lendenmann and Glenn Means, focused on childhood asthma in low-income communities in Washington, DC, and Louisville, Kentucky.  They kept a blog that can be read here. The fellows interviewed physicians, nurse practitioners, health educators, health technology startup companies, insurance company representatives, and venture capitalists, in order to gain an all-inclusive perspective of the health care system.

The fellows also prepared a paper on their research, and I received permission to post excerpts here. 

In order to better understand patient and caregiver perspectives, the fellows interviewed three patients from different parts of the country. Following a fundamental concept in design thinking, they met with patients who manage their asthma differently to develop a deep understanding of the human experience with the disease. Patients who they spoke with included those from low-income communities with poorly controlled asthma to those with a higher socioeconomic status to patients with well-controlled asthma whose caregivers were medical professionals.

The rest of today’s post will focus on one patient.

The first patient interviewed was an 11 year old African American male who had two siblings with asthma.   The patient scored a 6 out of 25 on his asthma prevention-screening test but when asked what his knowledge was of asthma care he was able to tell the physician exactly what he wanted to know.  The child understood how to administer his controller medication, but had difficulty adhering to the medication. He was recently in the emergency department for coughing and wheezing.

His father smokes at home, which aggravates the child’s asthma.  The child frequently overuses his rescue inhaler, which sometimes warrants him to run out of the prescription very quickly. One incident even caused a panic from the mother when the pharmacist wouldn’t give him another rescue inhaler because he ran through many prescriptions too quickly. Therefore, she was forced to use her other child’s prescription.

The child has a pouch that he carries his inhaler in which attaches to the side of his belt loop. When at school, he isn’t allowed to carry his medicine on him and is forced to leave it with the school nurse. Because the school nurse isn’t always there, it makes it difficult for him to get his medication in a timely manner.

When asked if the child uses his spacer, he admitted that he doesn’t at all. He says that it’s too bulky and he doesn’t have anywhere to carry it on him like his inhaler. It seems as if this child understands all the education he is receiving. At times, the child seemed to know more than the asthma educator. This child doesn’t need more education but just needs some changes in adherence to help him in taking his medication on time and taking the right medication.

When asking the child what he likes to do for fun, he stated that he loves to play video games. The children have a Nook that they play applications on and they play lots of games where certain levels must be achieved before moving on to the next level. 

So, adherence to asthma medicines is tough for this child who loves video games. Could this be a hint at a possible solution?

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Is cuteness an important design issue for asthma and kids?

"Say ‘hi’ to my fishy mask," the 3 year old said as he waved a nebulizer mask in my face.

On Twitter, there had just been a conversation on whether cuteness on design of inhalers was important. I was a little late to the dance party and didn’t see the conversation until the next day.

Here’s the conversation:



So, this made me ask this 3 year old’s mother if having a fish on his mask made a difference.

“For sure,” she said.

In the past, they’ve used a plain, clear mask, and he cried when she tried to put it on his face.

But he loves the fish mask.

He calls it his fishy mask and loves watching the fish “blow” the bubbles.

The bubbles “grow” in the medicine chamber of the nebulizer when you turn it on.  The type of nebulizer this boy uses (and the most common type) is connected by tubing to a compressor which shoots compressed air at high speed through a liquid medicine (in this boy’s case the liquid was Pulmicort daily and albuterol as needed).  The liquid medicine turns to aerosol and can be directly inhaled from the mouthpiece into the lungs.

I had never understood why the masks in our clinic were fish. But this boy’s mom’s explanation made sense. And the nebulizer machine certainly makes lots of bubbles.

In fact, this was the reason this mother-son came in. The chief complaint, main reason for coming in, was “there are no more bubbles coming from the nebulizer.” Not only did this 3 year old want to see his bubbles, but his mother suspected this meant the nebulizer attachment wasn’t working.

So back to the question on the Twitter discussion. How important is cuteness in the design of inhalers for kids with asthma? Based on this parent, cuteness is very important.

Like others on Twitter, I believe function is also important.  I looked up the website for the fish nebulizer mask we carry in clinic.  It turns out the fish’s name is, in fact, Bubbles.

The mask is described on the website as follows:  The included child mask has a cute, Bubbles the Fish design that will help your child take a nebulizer treatment with less complaints. “Bubbles” has a unique front-loading design that minimizes aerosol loss, facial and ocular deposition while maximizing lung deposition.

So these designers thought cuteness AND function were important.

Here’s Bubbles:


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Wellapets, educational asthma video game, available today

In clinic this week, when I asked a 13 year old boy what helps his asthma most, his mother interrupted with the response of “swimming, Tai Chi.” 

He looked at his mother and said, “She’s asking me!”  Then he said,

“Video games help my asthma the most.”

While I would never encourage kids to play just any video game for asthma, this 13 year old will be happy to know that there is now a video game that could help kids develop better understanding of their asthma.  

Kids have the opportunity to take care of a pet who has asthma, helping the pet (who the child names) avoid triggers and remember to take her inhaler. Friends and siblings can also learn about asthma. This video game, Wellapets, is available in most app stores today.

Wellapets focuses on educational objectives for successful asthma management. These objectives include:

  • Proper inhaler technique
  • Using inhalers on time
  • Avoiding asthma triggers
  • Acting on asthma symptoms

If you decide to buy this game, I’d love to hear your input on the game.  My kids just downloaded the game for $2.99 and are playing the game as I am posting this.  They seem to like the new background music as I hear my son humming it.

A few screenshots…. (So glad there’s a spacer with the inhaler!)

This guy can blow fire!