|Asthma and Vocal Problems by Rosalie Loeding|
Asthma and allergies are common disorders that affect a large number singers and professional voice users. It is imperative to find a doctor who specializes in performing arts medicine; one that understands the special needs of vocal thoroughbreds, because of the high price exacted - financially , professionally and emotionally. A football player or baseball player must be in peak performing shape at all times; a vocal athlete should expect no less. Treating symptoms as they occur without a total evaluation and treatment plan -- the usual symptomatic treatment -- leaves a professional voice user insecure, fearing that his/her instrument will not function reliably. A recent article indicates that untreated and symptomatic care may responsible for the rising asthma death rate.
Respiratory conditions often remain undiagnosed and untreated because singers and professional voice users with mild, "silent asthma" seldom wheeze, they appear to be in good health, and the speaking voice may sound relatively normal. They are still able to perform, though not at optimal levels. Their pulmonary function tests are usually evaluated "Good," because the pulmonary specialist is not aware that singers and actors normally have higher lung volumes than the average population, often 120% of normal values. In order to properly treat these patients, it is important to ascertain reversibility.
For example, if the lung volume is found to be 85% of predicted, the singer could be operating 30-35% below THEIR 100%. Even singers with 5-22% reversibility often experience dramatic improvement in their speaking and singing voices following treatment.
Airway constriction/obstruction results in poor distribution of gases to the alveoli (the little air sacs in the lungs) and impaired ventilation (the volume of air breathed in a specified length of time). In asthma, obstruction of airflow is most marked in expiration/exhalation -- that is the air you use to sing. As airflow resistance increases, active muscle contraction is required to force air from the lungs during expiration. Mucus clogging (plugs) the airways also increases resistance. Therefore, greater muscular effort -- nearly 16 times as much -- is required under normal conditions and the air pressure available is less than needed for professional singing and speaking. As more energy is expended breathing, the singer tires, making it difficult to maintain good posture. One of the causes of the fatigue is the impaired and uneven distribution of air throughout the lungs, limiting the lungs' ability to rid itself of carbon dioxide.
A series of small -- or large -- disasters are responsible for vocal problems. Let's talk about a hypothetical radio talk show host, Joe Smith, who uses his voice for extended periods. This Spring his allergies were really bothering him -- a little hoarseness, but he was surviving vocally until he came home one night to find a note from his wife telling him that she is divorcing him and marrying his best friend. The next day the boss calls him in and says, "Sorry, Joe but we are moving to a country music format and won't be renewing your contract." Within days Joe has severe laryngitis and chest constriction alerts him to asthma problems. Stress exacerbates allergy and asthma.
Sometimes vocal problems sneak up on you - your voice is hoarse one day and seems almost normal the next (day-to-day variability), so you assume it is only temporary. I call it "Denial Syndrome." Though most of my clients originally say their symptoms began a few months before, but eventually realize that they began much earlier.
A singer must be especially alert for signs of physical problems that can cause vocal problems. Even when it doesn't hurt, there can be significant damage because there are no nerves in the vocal folds to relay pain back to the brain. Your vocal folds can be permanently damaged and sometimes irreversibly. A stiff, fibrous vocal fold(s), caused by long term overuse and abuse, may never vibrate adequately to again sing professionally.
Most asthmatics have allergies, but not everyone with allergies has asthma. Constriction of the airways and chest tension are often go unnoticed because the asthmatic has become used to it -- it is there all the time. This does not allow correct breathing, so the person is more tired and short of breath. He/she blames it on being out of shape, staying up late and getting older, but it is caused by asthma.
Some medications used to treat asthma/allergies, often in combinations.
ALBUTEROL: Inhalers such as Proventil (and other trade names) are non-steroid bronchodilators. They are often called "rescue" inhalers. This means they should be taken on the onset of acute asthma. Most asthma sufferers assume that is the only time they are to be used. Asthma should always be kept under control. Most of the people who die of acute asthma attacks have only used medications on a symptomatic basis. In order to sing at their optimal level, singers and professional voice user must keep their symptoms under control -- their pulmonary function should be as close to 100% as possible. Otherwise it is like running a race with one leg in a cast. The
usual dosage is two puffs morning and evening. Another inhaler, Serevent, is a long lasting albuterol which helps sustain the Proventil. It lasts 12 hours and reaches its peak in about 2 hours. It is not meant to be used instead of Proventil in acute situations. . The usual doseage is two puffs morning and evening.
STEROID INHALERS: Topical steroids are not dangerous to the voice if properly used and monitored-- and not used in high doses.
NASAL INHALERS: Beconase and others are great for inhaled allergens.
STEROID INHALERS for the chest: Flonase, Vanceril, Asthmacort, Beclovent and others are excellent for breaking the allergic/asthma cycle and controlling symptoms. One must be properly instructed in their use and for singers it is even more important to use spacers such as Optihalers, Aerochambers to name a few, or the vocal folds can be adversely affected. With the spacers, you avoid a concentrated blast of steroid or propellant to the vocal cords. ORAL STEROIDS such as prednisone are also very effective in breaking allergic cycles and controlling asthma, but must be used with extreme caution by singers. Most arts medicine otolaryngologist advise 7-10 days maximum. Prednisone can cause vocal fold tremors and even loss of high notes if continued too long (and too often). Many singers like the dramatic improvement that can be gained by using steroids and may ask their doctor to prescribe it for them for rather mild conditions. (ASIDE: They also like the feeling of energy/euphoria it gives them after feeling tired and lethargic because of asthma.. But beware, some people become very hyper.) Not realizing the consequences, if their own doctor refuses to prescribe prednisone, they will often go to another doctor. Steroids can be your best friend or your worst enemy. It can make possible a performance. It can also has serious consequences. In case of an accident where the person goes into shock, the doctor needs to know that you are on steroids or discontinued recently, because steroids suppresses the secretion of natural adrenalin.
Some doctors may advise the use of these steroid inhalers to apply the steroid to the larynx when the vocal cords are swollen. Here you again use the spacer, but now you take shallow puffs to get medication only to the larynx and not to the chest.
CROMOLYN SODIUM: Nasalcrom and Intal takes 3 to 6 weeks to make a difference. For this reason many people do not think it is not working and quit taking it. It is a preventative. Often it is taken on an as needed basis. If you know when your pollen season is coming - check the pollen calender, you can start this 3 - 6 weeks before the start of the pollen season. Cromolyn is available without a prescription. When taken only on an as needed basis, it is relatively ineffective.
ANTIHISTAMINES: If you must take antihistamines, it should be
1). For a real emergency -- sudden exposure to an allergen (dogs, cats, bee, spider and insect bites or by contact with plants and other allergens) with symptoms of hives, itchy eyes, wheezing, sensation of not getting enough air. Immediately call 911 and go to the hospital. If this is a frequent problem, the doctor may advise carrying an Epipen - an epinephrine auto-injector- to use in case of a serious allergic reaction. For example a severe reaction to peanuts.
2). For short term allergies to pollen -- for instance, on a vacation. If these allergies are long term see an allergist who understand singers and follow his instructions.
Antihistamines are very drying to the mucous membrane linings of the nose, throat and lungs and cause thick mucus. Asthmatics should avoid them if at all possible because their mucus is already drier. When the mucus is very thick the cilia in the lungs cannot cough it up without great effort and lots of coughing. Coughing irritates the vocal folds. Generally coughing takes over when the cilia of the chest fail to move the mucus out of the chest. Enzymes such as Bromelain from pineapple or Papain from papaya may be useful. See http://www.sinus-relief.com/clearease.com
Other measures you can take to help yourself:
All asthmatics whether or not they are singers should have and use a Peak Flow Meter. It tells you the staus of your respiratory function. To translate: what you can expect from your breathing at that time. Take the reading before using an asthma inhaler (Proventil) and then about 15 minutes after the inhaler. If using Serevent, wait 2 hours before checking the results. The best times to monitor are 7 AM and 3 PM. It is a useful tool, but don't become paranoid about it. Buy an air cleaner with a hepa filter. I use Cloud Nine in my bedroom to filter dust and other allergens from the air while I sleep. After all, I am in that room for 7 straight hours. Reminder, do not open the windows between midnight and approximately 10 AM. This is when pollen is released. Treat yourself to a small steam inhaler -- only seven and one half inches -- to specifically moisten dry nose and throat membranes. Every singer should have one and use it often. The usual room humidifier is good, but does not get the moisture to the specific place. It is easily obtainable from pharmacies, discount stores and many catalogues. The heat control assures that the steam is not too hot. It has automatic dual voltage (110/220) -- wired for travel. For steam it is best to stick out your tongue. Beware of boiling water for direct steam use. Might inhale too much burning gas.
Another handy dandy old fashioned remedy for nasal allergies and dry nasal passages is Nasal Washing. Use a saline solution without preservatives. You can make it with one teaspoon of salt, 1/2 teaspoon of baking soda to a pint of water. Preservatives such as benzalkonium can make the condition worse. You can get Breathe.ease XL without preservatives - see
Nasal washing removes allergens from the nose and washes out thick proteins that the body creates to fight the enemy. The result is thick mucus we refer to as postnasal drip. It drips down the back of the nose into the throat and onto the folds, changing the vibratory patterns and irritating the vocal folds. I cannot state strongly enough the importance of keeping the nose and throat membranes moist. The voice resonates best and feels right when the membranes are moist.
Use Entertainer's Secret to keep the mouth and throat membranes moist.
To summarize, You must educate yourself about asthma and how it affects singers and professional voice users. Take a tape recorder to doctor visits so that you will be able to exactly follow his directions. Keep your respiratory function as close to 100% as possible. Co-operate with your physicians and be a partner in your care. With the asthma under control you can have a successful career.
Reprinted with Permission