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Breathing Easier: A Complete Guide to Asthma · Flourish- A Prisma Health Podcast

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Scott Webb: Asthma is a common condition, and despite the many
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triggers and limitations that it can cause, my guest is here to explain how
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he and the team at Prisma Health are helping patients to breathe easier.
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I'm joined today by Dr.
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Adam Shurtz.
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He's a pulmonologist, ICU medical director, and Oconee Memorial
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Hospital Clinical Assistant Professor, University of South Carolina
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School of Medicine, Greenville.
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Scott Webb (Host): This is Flourish, the podcast brought to you by Prisma Health.
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I'm Scott Webb.
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Scott Webb: Dot, it's nice to have you here today.
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We're gonna rely on you.
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We're gonna lean on you so that we can all breathe a little easier, right?
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And you're gonna give us this just sort of complete guide to asthma.
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What is it and how do you diagnose and how do you treat and all that good stuff.
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so thank you for being here.
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Dr. Adam Schertz:
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Thanks for having me, Scott.
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Scott Webb: Yeah, it's a pleasure to have you here.
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I love to have experts on and pick their brains and I might be
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suffering a little bit of asthma or allergies or whatever it is.
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So, good for me, good for listeners.
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Let's start there, Doctor.
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What exactly is asthma and what happens in the lungs during an asthma attack?
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Dr. Adam Schertz:
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So, this is a complicated question, and I think what I'll try to do
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is break it down into a metaphor that hopefully helps people
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Scott Webb: Yeah, sure.
1:06
Dr. Adam Schertz:
1:06
So, the respiratory system is kind of like this large tree that lives inside of us.
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The tree trunk is the trachea or the windpipe, and that trunk is firm, it's
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ringed with cartilage, and it's hollow, so, these are all just big air tubes.
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And so, that trunk, that air tube, splits into the main, two air tubes
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that feed our right and left lungs, and those are called bronchi.
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And then, those bronchi continue to split into more branch points, all
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the way down 27 branch points to the ... Those bronchi are just about
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the size of the thinness of a hair.
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And then, we're at the leaves, which are called the alveoli, and that is
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where the oxygen that we're breathing in from the atmosphere is exchanged
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into our body, and where the carbon dioxide that we're exhaling out first
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gets from our body into our lungs.
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And so, asthma is an abnormal inflammation in those air tubes,
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those branches of our lungs.
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It's not in the leaves, it's not where the oxygen and carbon dioxide diffusion
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happens, it's in the air tubes themselves.
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And so, this inflammation is an Overexaggerated response to
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something in the environment.
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Our respiratory system is always exposed to the environment, and some people have
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some predisposition to over-reactivity, and during an asthma attack, there's three
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separate but- related things that happen.
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The lining of those air tubes becomes inflamed or swollen, and then they start
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to produce this thick and sticky mucus in the walls that then, if you think
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about, you know, what I'm talking about on the microscopic level, start to fill
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in some of those really small airways.
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And then, there's rings of smooth muscle that surround those air tubes, and those
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become constricted, and that's what you get with an asthma exacerbation.
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You get inflamed airway walls, mucus production, and muscle
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constriction in the airways.
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Scott Webb: Right.
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Yeah, you did a great job explaining that without any diagrams.
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You know, we're in audio form only today, so I appreciate that.
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And you mentioned lungs there, so, let's talk about that.
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Like, how does asthma affect daily lung function, and maybe what are some of the
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most common and maybe even overlooked symptoms that folks might attribute
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to, like me, allergies, perhaps.
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Dr. Adam Schertz:
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So, it's really variable how much asthma affects any individual
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person on a daily basis.
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It ranges from what we'll call mild intermittent asthma, a-
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and that's occasional symptoms.
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This is basically less than twice a month, and this is usually provoked by some
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kind of identifiable trigger, which we'll
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I think we'll get into more, and that can ... So, that's that mild to
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intermittent category that can move all the way along the spectrum to
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what's called severe persistent asthma, which is basically daily symptoms
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that aren't controlled, despite being on, you know, multiple inhalers.
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I think as part of this portion of the discussion, it's really important to know
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that fatal asthma exacerbations don't only occur in people with the severe asthma.
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About one in five asthma deaths are actually seen in people with mild asthma.
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And so, it's not that people have daily symptoms are necessarily going to then,
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you know, die from this, but it is to say that this is a condition that can
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lead to death and that even people with mild asthma can have a trigger so severe
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that they can end up hospitalized.
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Common symptoms of asthma, just taking on that second part of the
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question there, chest tightness, wheezing, shortness of breath, cough,
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those are the big ones that we see.
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Basically everybody I see who has asthma ask them, what if any, and usually all
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those symptoms they're experiencing, and then things that are overlooked
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typically, recurrent bronchitis, right?
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So, some people are like, "God, I just get sick and get bronchitis a couple
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times a year, predictably every year around this time, I get this bronchitis
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and this cough that doesn't go away."
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And that can be asthma.
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Exercise intolerance, I think particularly in younger people, tightening of the
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airways, difficulty breathing with, you know, any kind of, ah, moderate
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exercise, and then chronic cough is another thing we see even without
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the other typical asthma symptoms.
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Chronic cough can be caused by asthma.
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Scott Webb: Sure.
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Yeah, let's stay with the triggers.
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I feel like there's probably some surprising or unusual triggers
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that people need to be aware of.
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I know you mentioned one before we got rolling, but give us a sense, like,
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what usually triggers asthma in folks?
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Dr. Adam Schertz:
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So, we'll start with the common ones and then I'll kind of deepen,
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deepen into the unusual ones.
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Commonly, upper and lower respiratory infections, so, typically viral
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infections, common cold, anything like that will be a major trigger
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for anybody who has asthma.
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Other things to think of, these are really common triggers.
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So, smoke, , this is cigarete smoke, but also, you know, think of smoke from a fire
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pit, any smoke that's getting out there.
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Environmental allergens, so, like, pollen, dust, pets, molds, those
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sorts of things, can be triggers for people, strong scents, cleaning
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supplies, perfumes, season changes, weather changes, hot air, cold air.
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Scott Webb: So pretty much everything
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Dr. Adam Schertz:
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Yeah, so I'm, I'm running down the list of all things that
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Scott Webb: I'm just so pret- pretty much everything everywhere.
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Got it.
6:32
All right, good.
6:33
Dr. Adam Schertz:
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Um, yeah, exercise, occupational exposures, chemicals, cotton
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fibers, metal dust, all sorts of particulate matter, too, right?
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So, like I said, our airways are continuously exposed to the environment,
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and so, we have this really, incredible immune system in the, in the airway
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specifically that helps to deal and filter with these things, but for some
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people, we have an overactive immune reaction, and so, basically, everything
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in the atmosphere and the environment can
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Scott Webb: Yeah.
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Yeah, it sounds like it.
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Yeah..
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Dr. Adam Schertz:
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So, some, we were talking about some surprising or unusual
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triggers, and I think this is wh- there's a few fun ones out there.
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I shouldn't say fun.
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There's a few interesting ones out there that, people wouldn't think about.
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So, a common one is aspirin or any non-steroidal anti-inflammatories.
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So, aspirin, ibuprofen, naproxen, any of those, can
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be associated with
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Scott Webb: something that's supposed to help us, righ
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Dr. Adam Schertz:
7:26
Exactly, exactly.
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And so, some people can have this negative reaction to those.
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thunderstorm asthma, this is a really interesting one.
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This is when there's pollen and grass.
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So, think now this time of year, in the springtime, pollen and grass
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can get sucked up into clouds, and you can get this pollen rain.
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And this is something that, that I think there was a well-documented case in
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Australia, , some probably 20 years ago where there was just an enormous amount
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of hospitalizations because there was such bad air quality that got sucked
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into rain clouds and got dropped over people, and this causes, you know,
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pre-negative respiratory symptoms.
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There's perimenstrual asthma, so, some women get worsening of respiratory
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symptoms around the time of menstruation.
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And then another one, a red wine, I think pretty well-documented that, that there's
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sulfites in, in wine, mostly red wine.
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And so, some people have, you know, allergies or sensitivities to these
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sulfite additives, and those can also provoke some respiratory symptoms.
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Scott Webb: Yeah.
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I feel like, doctor, that, you know, in the hands of a qualified and expert
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pulmonologist diagnosing asthma is probably pretty straightforward.
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Y- they come in and they, you start checking all the boxes.
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But give us a sense of how do you diagnose asthma and when should someone
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consider seeing a pulmonologist?
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Dr. Adam Schertz:
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So, I mean, it's basically a clinical diagnosis.
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There's not objective criteria that necessarily makes somebody have a
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diagnosis of asthma, but those symptoms that we talked about, shortness of
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breath, wheezing, chest tightness, cough, any and, or all of those
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are typical symptoms of asthma.
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And, although it's not a diagnostic, something that's diagnostic for asthma,
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we'll often do pulmonary function testing where we have a respiratory
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therapist, instruct you on these breathing techniques where we can look
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at, , how much air you can blow out, whether or not there's obstruction in
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the air that you're blowing out, what's your overall amount of air in your body?
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Is there any limitation in airflow?
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And so, we can look at all those things with pulmonary function testing.
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During that pulmonary function testing, we can give medicine to relax the
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muscles in those air tubes that we talked about, and see if there's a
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difference when we give that medicine, that's called a bronchodilator challenge.
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Once again, not diagnostic for asthma if there is a positive response, but just
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kind of pushing us in that direction.
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There's a separate test, a more advanced test that we can do where we
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give somebody an inhaled substance to provoke a response in the airway, , but
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it's called a methicoline challenge.
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There's also some of the Manitol Challenge, same basic thing.
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We look to see that there's a decrease , in airflow associated with that medicine.
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Scott Webb: Yeah..
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Dr. Adam Schertz:
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And then, we can have people exercise and look to see if there's a difference
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in airflow before exercise and after exercise, that's to look for what's
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called exercise-induced asthma.
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But once again, I, I, usually, you can make a clinical diagnosis kind
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of based off of people's history,
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just listening
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Scott Webb: history.
10:19
Sure.
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Dr. Adam Schertz:
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The second part of that question there is, you know, when should
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somebody see a pulmonologist?
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You know, I think not all asthmatics need to see a pulmonologist, but I think if
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somebody's asthma's not well-controlled on an appropriate inhaled medicine or,
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you know, if we're needing steroids one or more times a year for asthma symptoms,
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or if anybody goes to the emergency department or the hospital because of
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asthma, those are times to, you know, make sure we see a pulmonologist, and
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then the last one would be if there's kind of continued unexplained respiratory
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or breathing problems, that's always a good time to come see a lung doctor.
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Scott Webb: Right.
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And this is anecdotal at best,Doctor, but it seems to me when I was a kid,
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I grew up in the '70s, so everything seems to have been different and maybe
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worse because we just weren't as far along with science and medicine and
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all that, but anecdotally, it just seemed like every other kid that I knew
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growing up had an asthma inhaler, right?
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And we talked about asthma and everybody seemingly had asthma.
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I'm exaggerating, of course.
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But it seems to me that through my own kids, right, going through school and
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ones, you know, already out of college, the other ones going to college next
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year, I don't hear about it much anymore.
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I don't hear about everybody having asthma and having their inhalers and
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where's my inhaler and all that stuff.
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So I just wanna get a sense from you, like, can asthma be cured and maybe what
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are some of the main treatment options?
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Like how far have we come?
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Dr. Adam Schertz:
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it's a really good point.
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So, I, you know, I'm not sure that the prevalence of asthma has changed, but
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I'll tell you that the treatments have changed, dramatically over time where, you
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know, if, if you were a kid in the '70s, you know, there was not much out there.
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There were some older medicines that could be used depending on
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how severe, but nowadays, you know, there are much better treatments
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out there for kids and, and adults.
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I think taking the, first part there, kind of leads me to, like, the, A discussion
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of why asthma happens in the first place and what kind of things predispose
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people to having asthma, and a lot of it has to do with the way we grow up.
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a huge difference between the way people grow up now versus
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the way they did in the '70s.
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I think smoking indoors in particular, but parents smoking
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indoors has changed dramatically.
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Scott Webb: indoors, smoking in cars, smoking everywhere.
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Yeah, of course.
12:25
Yeah,
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Dr. Adam Schertz:
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So, secondhand smoke is one of the major, major risk factors for
12:31
development of childhood asthma.
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If you think about it, it's because our air quality, both indoors , and
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also with the smoke, is causing that inflammation in the airways.
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Similarly, you know, you'll see differences in, in asthma rates in, like,
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inner cities versus country air, right, where there's more pollution in inner
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cities and maybe, you know, decreased pollution over that span of time as
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well over that 50 years has also kind of changed development of asthma in kids.
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So, those are kind of two things that I think of.
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And then, I think you mentioned something about, like, you know, curing asthma.
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Um, sort of, a lot of kids grow out of asthma anyways, so even kids that have
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asthma or bronchitis is, you know, when they're younger, will often grow out
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of it, and it's because those air tubes that we talked about get bigger as we get
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older, and so, that, that inflammation or that overexaggerated response becomes
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a less problematic as those air tubes get larger, because small changes in
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the air tube caliber, at the size of those air tubes, from inflammation or
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thickening, don't cause as much of a problem with airflow as we get older.
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And then, you know, there's some evidence to suggest that bronchial muscle sensit,
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you know, that smooth muscle contraction that we're talking about lessens a
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bit over time, although I will say a lot of children who are asthmatics
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do have some persistent bronchial muscle overreactivity, even if they
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technically grow out of their asthma.
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Scott Webb: Okay.
13:59
Yeah, wondering, I assume that the gold standard, if you will,
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for either controllers or rescue inhalers, like, like it's still
14:05
inhalers, in other words, right?
14:07
Like, is that still the go- to?
14:08
Are there some other things?
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Are there other options, pills, like, what are the treatment options?
14:12
Dr. Adam Schertz:
14:12
So, the mainstay is still inhaler therapy.
14:14
The most recent guidelines that were released in 2025, these are
14:19
global guidelines for asthma, have put out a new recommendation
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for primary asthma treatment.
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Beforehand, most of what we're saying is, have your rescue
14:30
inhaler albuterol available.
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What we've seen over the last seven, eight years has been a paradigm shift
14:39
in thinking around that particular topic, to say that, yes, some kind of
14:46
sm- smooth muscle relaxer like albuterol is useful, but that needs to be paired
14:53
with an inhaled steroid, either in the same inhaler, which then becomes a
15:00
different kind of inhaler than albuterol, or as a separate, you know, extra
15:04
inhaler and another inhaled steroid.
15:07
this is because, if you think about what albuterol does, kind of what
15:10
we talked about, albuterol works on that muscle contraction, but it
15:13
doesn't work on the inflammation part.
15:15
The steroids work on the inflammation part in the
15:18
air tubes.
15:19
So, when you combine those two things together, we get better asthma
15:22
control and less flares that, occur.
15:25
There are a few inhalers on the market that are available that
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currently meet this criteria, right, based off these 2025 guidelines.
15:33
So, Airsupra, that's a new one that's albuterol and budesonide.
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There's Symbicort, which is an older one, but that's formoterol and budesonide.
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Budesonide's a steroid.
15:43
Fomoterol is basically another smooth muscle, a relaxer, it's
15:46
just slightly longer-acting.
15:48
And then there's another one called Dulera, which is fomoterol and momasone.
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So, momedicine is another steroid, but these all are combined smooth muscle
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relaxers that are fast-acting plus a steroid to be used as kind of primary
16:01
asthma therapy, and they work really well when we're using these optimally.
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Scott Webb: So as you say, it's not so much, curing asthma, it's controlling
16:10
it better, , through advances.
16:12
And, and I wanted to stick with the, the medications, Doctor, the, how maybe
16:16
controller medications differ from rescue inhalers and maybe what are some
16:20
of the common mistakes despite their best efforts that patients make when
16:23
they're trying to manage their asthma?
16:24
Dr. Adam Schertz:
16:24
So, for some patients, they can do just fine with these on- demand inhalers,
16:31
Scott Webb: Okay..
16:31
Dr. Adam Schertz:
16:31
but it has to be the right class.
16:33
So, we talked about it, you know, if we have a muscle relaxer plus a
16:37
steroid, not every asthmatic is gonna need to be using those every day.
16:41
If their symptoms are well enough controlled using those
16:44
as-needed, that's ideal.
16:46
Some people will have symptoms most days of the week or every day, and
16:51
for those people, it's important to use a daily inhaler, just so they're
16:56
staying ahead of that inflammation, because the thing that is important
17:00
with asthma is that you never know when you're gonna be exposed to a trigger.
17:04
You can plan on, you know, walking through Macy's and avoiding the perfume
17:09
counter, but you can't always plan on, you know, walking into a building and there
17:15
being a cleaning crew out there, and you get a heavy bleach smell or something
17:18
that's gonna trigger your asthma, right?
17:20
There's some things that are just unavoidable when we live in this world.
17:23
And so, for those people, that's important.
17:25
It's really important to not only have a on- demand or rescue inhaler available,
17:29
but also to be taking, a daily inhaler.
17:33
And then, on that topic, there's a new class of medicines for asthma.
17:37
So, for people who are symptomatic consistently and still have exacerbations
17:42
that require treatment with steroids or require hospitalizations, there's
17:47
injectable medicines that we have now called biologics, and these range from,
17:52
you know, subcutaneous doses every other week to every six months, and these work
17:58
to decrease those inflammatory factors that cause these asthma responses.
18:05
And so, this has been a huge game-changer in asthma control, because there's
18:08
some people out there who have such an overreactive inflammatory, what we'll say,
18:15
inflammatory milieu in their airways, rig?
18:17
So much inflammation triggered by environmental exposures that
18:20
they basically have constant symptoms, and this really helps
18:23
to dampen down those inflammatory responses, these biologic therapies.
18:27
And so, we've been starting these kind of earlier and earlier, but of course,
18:31
you know, the- these are medicines that are injectable, these are medicines
18:34
that most people wouldn't want to take unless their asthma control is such
18:37
a state that this is a much better option for them, and it really has made
18:42
a huge difference in people who have just very difficult to manage asthma.
18:46
Scott Webb: I'm sure, yeah.
18:47
And there's such a range, and it's, you know, patient by patient, and it's
18:51
great that we have experts, of course.
18:53
Let's just finish up here today, doctor, and good stuff.
18:55
How does asthma compare to other lung conditions, let's say like COPD or
18:59
chronic bronchitis, and what may be practical steps can you recommend to
19:03
help folks to protect their lungs, to have better lung health, if you will?
19:08
Dr. Adam Schertz:
19:08
this is a really complicated and nuanced question.
19:10
I'm gonna try to keep it as simple as I can.
19:13
So, bronchitis is kind of a catch-all term.
19:15
, This just means inflammation in those air tubes, and we usually think of
19:18
it as, related to an infection, you know, like a viral infection, right?
19:21
It causes inflammation and bronchitis.
19:24
COPD, chronic obstructive pulmonary disease, and chronic
19:27
bronchitis are related conditions.
19:29
So, COPD is, almost entirely, in the United States, a
19:32
smoking-related condition.
19:34
There's a small percentage of COPD that's related to occupational dust
19:38
and fume exposure, biomass, fuel combustion, like wood-burning stoves,
19:41
but a much smaller proportion of COPD.
19:44
So, with COPD, there's prolonged exposure to smoke and toxins and cigarette smoke
19:50
that leads to chronic inflammation in the ear tubes, but unlike asthma, COPD
19:54
also affects those air sacs, righ?
19:56
Those leaves in the tree.
19:58
And so, over time, this chronic inflammation can cause destruction in
20:01
the air tubes or air sacs, and it can cause chronic bronchitis, and that's,
20:06
you know, a person who coughs every day for three months of the year and
20:09
produces phlegm with that cough, and then also causes emphysema where those air
20:14
sacs themselves are getting destroyed, and now, that air is going to these
20:18
dead-end spaces in, in our lungs where it's not getting into our body, right
20:22
oxygen's not getting into our body.
20:24
The air is just siting in these dead sacks, these defects in the lung where
20:29
there's, there's nothing going on there.
20:30
The air's just sitting behind, and that's emphysema.
20:33
Bronchitis and emphysema will often coexist in long-term smokers, and
20:37
there's genetic factors that, you know, are a- at play as to how
20:40
much emphysema somebody develops.
20:43
Long-term asthma, uncontrolled asthma.
20:45
So, if we have poorly controlled asthma long-term, it can lead to
20:48
similar chronic changes in the airway, like the chronic bronchitis, right?
20:52
Those air tubes can become inflamed, and, there could be obstructed
20:55
airflow over time, but honestly, with modern treatment methods, asthma
20:59
doesn't tend to lead to obstruction.
21:02
And so, that, that's the big distinction, is that asthma is really a disease of
21:06
those air tubes from a overreactive immune response, whereas COPD is
21:09
this chronic prolonged inflammation that affects both the air tubes and
21:13
the air sacs and is irreversible.
21:15
And then, I think Just taking the last question, what
21:17
practical steps can people take?
21:19
So, what, what things can we do to protect our lungs?,
21:22
This is the most important thing we're gonna talk about.
21:24
Number one is don't smoke.
21:25
Number two, on the same basic, front is get your partners,
21:28
parents, family, friends, everybody you know to stop smoking.
21:31
Number three, regular exercise.
21:34
Number four is gonna be, if you're sensitive to air quality, invest in air
21:38
purifiers, good air filters for your HVAC units, this is like MERV 13 or higher
21:44
is usually what I recommend to folks.
21:46
If you're looking at your app on your phone and you're seeing what the air
21:49
quality numbers, the AQI or the air quality index looks like, if there's
21:52
a bad air-quality day, you know, maybe think about staying indoors.
21:56
If you work around hazardous chemicals or fumes or if you weld,
22:00
you're gonna be exposed to things, you know, wear a respirator mask.
22:03
And then the last one, and this is not necessarily an asma thing, but just
22:06
important for everybody to know, is that, consider checking your house for radon,
22:10
um, because although it doesn' affect your lungs on a day-to-day basis, it is
22:13
a known cause of lung cancer, and it's something that we would not be a- aware
22:17
of unless we were testing, our basements or a homes to make sure that we don't have
22:22
kind of continued chronic radon exposure.
22:25
Scott Webb: Yeah.
22:26
Yeah, that might an entirely separate podcast.
22:27
Another thing from the 70s seems like folks always were talking about radon
22:31
back in the day and we don't talk about that much, but, really good stuff
22:34
today, good suggestions from an expert.
22:36
I appreciate your time, your expertise, all of that.
22:38
Thank you so much.
22:39
Dr. Adam Schertz:
22:39
Thank you for having me, Scot.
22:40
Scott Webb: And for more information, go to prisma.health/asma.
22:44
Host: For more information and other podcasts just like this one, head
22:47
on over to prismahealth.org/podcast.
22:50
This has been Flourish, a podcast brought to you by Prisma Health.
22:53
I'm Scott Webb.
22:54
Stay well.