As publisher of Slowtwitch.com I regularly receive emails asking one or another technical question on cycling- or triathlon-related matters. Not long ago I received this email on a matter of a different nature:

"I am looking for an allergist or doctor who works with endurance athletes for asthma. I have done 3 IMs this past year and am heading to Canada. I had trouble breathing in IM California. I'm outta time and kinda desperate. Do you have a name of a doc that is familiar with this?"

I’ll repeat what I told this gentleman—that I am not a doctor, nor do I play one on TV. But I have my own experience to relate, and that of my wife, which I suspect he found enlightening, as may you.

Our family represents both ends of the asthma continuum. My wife, JulieAnne, is a classic, textbook asthmatic, which is to say she has been afflicted her whole life and made the half-dozen or so obligatory trips to the emergency room via ambulance—with blue complexion—as a child. She suffered asthma attacks: bronchial spasms that constrict breathing and kill several thousand a year in the United States, and many times that amount in underdeveloped and developing countries. JulieAnne also has finished in second place at the Hawaiian Ironman in the pro women’s division (9:21), first at IM New Zealand, and won IM Canada twice (9:08). So while she has not conquered asthma, she has learned to manage it.

I am not an asthmatic in the classic sense. I do not suffer bronchial spasms. But if you accept the fact that asthma is not one disease but a catch-all word that describes any of a hundred maladies of differing severity—with differing triggers, symptoms and mechanisms—then I fit in there somewhere, too.

I am an armchair expert on asthma. I know just enough to make a nuisance of myself. Which I did at every turn. My wife got sufficiently bad advice from enough lazy doctors early in her racing career that I began making an ass out of myself (strike that, I made MORE of an ass out of myself than I already was). After enough whining and pushing we finally found a livable regimen that kept JulieAnne from gasping for air, both in the middle of the night and in the middle of the race.

In getting myself up to speed on asthma I spoke to officers and MDs at virtually every company in the world making asthma drugs, including Glaxo Wellcome, Schering Plough, Astra, Boehringer Ingelheim, Dura, Ciba, Rhone Poulenc Rorer, and 3M. If the U.S. division did not have suitably informed personnel, I contacted the office in the country in which their best doctors worked. In some cases I showed up in person, as was the case at Ciba’s world headquarters in Basel, Switzerland. I badgered the FDA, IOC and USOC as to which drugs were approved for use in competition, which were available for use in the U.S., and why certain drugs were not approved. I kept a database of every asthma drug, including those still undergoing clinical study and not yet on the market.

We waded through medical ambivalence. Once we found eager, competent medical personnel with whom we could deal, we still had to go through a long process of trial and error. We finally found the right combination of pharmaceutical regimen and proper environmental conditions. JulieAnne now enjoys the happily-ever-after.

I am not writing here about my wife’s experience with asthma, though, but my own. Anybody reading this who has grown up with asthma, as has my wife, will have gone through the processes she has gone through and, hopefully, will have a pharmaceutical regimen with both a prophylactic and rescue component. In layman’s terms, this means one or two drugs to keep you from getting an attack, and another in case you do get an attack. Obviously, I am not a doctor, and even if I were I cannot know anybody’s particular circumstance. I am just quoting what the National Institutes of Health, among others, says is the preferred way of treating asthma (in broad strokes).

Me, I don’t get attacks. But quietly, subliminally, I occasionally suffered the entire time I was trying to find a solution for my wife. As most readers know, I am the founder and former owner of Quintana Roo, inventors and manufacturers of triathlon-specific bikes and wetsuits. Our offices have always been within a few miles of the Pacific Ocean. Occasionally a certain kind of hazy weather pattern would envelop Southern California, and as it rolled in, it was my nudge to get out of town and up in altitude. If I didn’t, I became physically and emotionally depressed, my breathing became labored, and sometimes this degraded into a full-blown bronchial infection. But if I got up to the mountains early enough, a day and a half of bike riding above 4,000 feet put my lungs right.

This has not always been the case. I grew up in SoCal for the first 15 years of my life, and breathing had never been a problem for me. Then I moved to the higher, drier air of the Sierra Nevada range for a decade. Upon my return to the coast, I slowly started to experience these symptoms.

My occasional escape to high ground was good enough for me. Until two years ago. I experienced my worst winter. I was sick from November through March, nonstop. First my chest, then my head, my inner ears, lymph nodes, and afterward back to my chest for another round. But I would not admit I suffered from anything approximating asthma.

My doctor and I thought all this was just a bad patch of luck. But after several months—chest X-rays and everything else negative—it occurred to me that I ought to investigate more deeply. It became clear that I must recognize asthma as a possibility. My own conclusion was that I, over the years, had developed a sensitivity to something that occasionally inhabits the air where I live.

There are a variety of ways to treat asthma, and the treatment depends on what the symptoms are and how severely one is afflicted. Generally, you can take everybody and broadly divide them into two categories: those who suffer from bronchial inflammation only and whose inflammation eventually leads to bronchial spasm. My wife is in the latter category and, for these people, a "rescue medication" is indicated. By far the most prevalent among such drugs is called, alternatively, albulterol and salbutamol. The two most popular brand names of this drug are Ventolin and Proventil. These drugs—called beta-2-agonists—are sometimes used as prophylactic (preventive) treatments but generally are what you’d use if you were having an attack and needed relief. An "attack" is when one’s bronchii go into spasm—sort of like a muscle cramp, but of the smooth muscle surrounding your breathing passages.

Best, though, is to keep an attack from occurring in the first place. So one might engage in a regular regimen of treatment—generally morning and night—to keep one’s bronchii in check. There is a new class of long-lasting beta-2-agonists—Serevent (salmeterol) is the most popular—in this category. Such drugs are not helpful for me because I do not go into bronchial spasm. There is another category of drugs, inhaled corticosteriods, which are probably the most popular prophylactic asthma drugs.

These differ from the steroids we often read about in sports in that they are catabolic—as opposed to anabolic—and break down tissue instead of building it up. Cortisone is a corticosteroid. If you were to get a rash on your skin, you might spread a thin layer of cortisone cream on it, and this would make the rash diminish. This is precisely the mechanism involved. It is my hypothesis—which my doctor believes is a reasonable, though not provable, one—that the months-long bronchial sicknesses I suffered were the result of almost constant bronchial inflammation—almost like a rash on my lung tissue—that allowed opportunistic infections to take hold. Inhaling a corticosteroid is a bit like putting the cortisone cream on a rash, but on your bronchial tissue.

So, positing this in my own mind, I experimented with my wife’s Azmacort inhaler for a couple of weeks (this corticosteroid is part of my wife’s anti-asthma regimen). Within a few days I was a new man. So I called my doctor, described everything, told him of my experience, got my lecture on how I’m not supposed to use other people’s medicine, and then got my own prescription.

I’ll mention one word about the side-effects of inhaled corticosteroids and other asthma drugs for those who might be concerned. One benefit of taking such drugs in an inhaled form is the very small degree to which such drugs enter the bloodstream. So one should not be concerned about one’s muscle tissue becoming degraded due to a regular regimen of inhaled steroids. Likewise, inhaling beta-2-agonists is not going to do the opposite. There has been an assumption that these drugs are anabolic, and some high-profile athlete bans several years ago resulted from positive tests for clenbuterol (a veterinary drug, as I recall). But the anabolic characteristics are based on the most spurious of studies. Data indicating the contrary appear to be more prevalent. But the IOC is slow to realize this, and even albuterol, while legal for competition, is restricted. (There was a case a few years involving a German triathlete that unfolded this way: Albuterol is legal if you have a letter from your doctor in your possession—but this pro raced in France and was disqualified because, though he had a letter, it was from a German doctor, not a French one. This indicates the extremity to which even science and sport sometimes stands in the way of one’s ability to receive effective treatment.)

Excuse me while I wax ecological for a moment. Just last week, the American Lung Association came out with its grading of American cities. Most of them flunked on air quality. But wait! Haven’t I been reading for a decade or more about how clean our air has been getting compared to historic norms? Carbon monoxide is down, they say, but ozone is as high as it has ever been. Is ozone my problem? I don’t know.

What is statistically a fact, around the world, is that asthma is down in almost no country. It is up in most. Perhaps the situation isn’t getting any worse. But if not, at least people are—as individuals—more likely to recognize its symptoms. This is the state of affairs in the world in general. What about athletes?

Specifically, our kind of athletes. It is one thing to breathe bad air. It is another altogether to breathe, perhaps, 60 liters of air per minute instead of 10 liters. What might be mildly irritating to one’s lungs at rest might be akin to sandblasting one’s lungs during hard endurance work. So would it be hard to imagine, if one’s bronchial system could talk, that it would finally say, after years of such work, "I’ve had enough?" (At which point it starts to shut down?)

Of course there are those otherwise healthy souls who might try to take unfair advantage of asthma drugs during competition. But I must relate some bad news for those so inclined, based on my own experience. Such drugs did not, in my case, improve my respiratory performance if symptoms were not present. Albuterol doesn’t do a thing for me because I do not have bronchial spasms.

But what if you are having symptoms? Some doctors will sometimes paint your problem with the "exercised-induced asthma" brush, like it's a thing that can easily be treated with rescue medication, if and when you get a "flare-up." This might be just the ticket for some people. But my wife and I, especially after our own experiences, find ourselves suspicious of such off-the-cuff remedies.

One other thing we must mention: We changed our living conditions. We pulled up the carpet in several rooms of our house and replaced it with either hardwood or tile. We replaced drapes with wooden blinds. We altered our diets. We are picky about how and where we travel, and where we stay, when going to out-of-town races.

There is one common thread to all this, though. Yes, we did finally find good medical help. But, that said, we, not doctors, became the asthma managers in our family.