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Kristen Watson

When a breath is hard to catch

Profile image for By Peggy Heinkel-Wolfe
By Peggy Heinkel-Wolfe
A haze hangs in the air over western Denton looking out over Jim Christal Road on Thursday.David Minton
A haze hangs in the air over western Denton looking out over Jim Christal Road on Thursday.
David Minton
Kaden Bush, 7, plays with his 5-year-old sister, Cassidy, on Friday at their home in Denton. Poor air quality keeps the children indoors much of the time.Photos by  Kristen Watson
Kaden Bush, 7, plays with his 5-year-old sister, Cassidy, on Friday at their home in Denton. Poor air quality keeps the children indoors much of the time.
Photos by Kristen Watson
Medication used for Kaden’s asthma sits on a table at his family’s home. His doctor’s goal: to have Kaden on as little medication as possible as he grows up.Kristen Watson
Medication used for Kaden’s asthma sits on a table at his family’s home. His doctor’s goal: to have Kaden on as little medication as possible as he grows up.
Kristen Watson
Kaden and Cassidy Bush play in their home on Friday. Poor air conditions in their neighborhood often keep the children indoors.Kristen Watson
Kaden and Cassidy Bush play in their home on Friday. Poor air conditions in their neighborhood often keep the children indoors.
Kristen Watson

Denton County's hazy air quality has implications for the young

Kaden Bush faces a long climb back.

With his eighth birthday coming up, Kaden’s odds of making it back to good health are shrinking.

He was 5 years old when he came down with respiratory syncytial virus, or RSV. For the many children who come down with the virus, the symptoms mimic a common cold. But some children, as well as adults, can have a more severe case. Some suffer lung damage.

That’s what happened to Kaden. A boy who collects Marvel Super Hero Legos, who will pick up a yard full of sticks for a nickel, who rewrites the rules of a board game on the fly and then helps his little sister win, Kaden recovered from the virus. But he kept coughing.

“He never stopped coughing,” says Maile Bush, his mother.

She took him to the doctor. They tested his lungs.

He couldn’t take in as much air as other boys his age could. He couldn’t blow out as much. He couldn’t move air quickly either.

Kaden has asthma.

According to Cook Children’s Health Care System, asthma rates for older children in Denton, Hood, Johnson, Parker, Tarrant and Wise counties far exceed both the state and national rates. Vehicular and industrial pollution are major triggers for asthma, according to medical experts.

“My lungs don’t like me,” Kaden says.

Asthma in North Texas

Kaden and other children ages 6 to 9 in those six counties are three times more likely to have asthma than their peers statewide.

With good care and medical intervention, asthma can be controlled. Kaden’s asthma has been well-controlled, Maile Bush says.

He hasn’t needed urgent care since winter. He’s never had to go to an emergency room for his asthma, she says.

But other kids aren’t so lucky. Something in the air bothers their lungs, and soon their airways are overwhelmed, making it difficult to breathe. Asthma attacks send thousands of North Texas children to hospitals every year. Children’s Medical Center Dallas saw 5,157 asthma-related emergency visits in 2013. It hospitalized 1,631 children for their asthma symptoms that year, and 48 children returned because their problems continued.

Asthma often is not a fatal disease, but it can kill. In Denton County, eight people died from asthma between 2011 and 2013, according to the Texas Department of State Health Services.

Growing lungs

Muscles around and below the lungs lift the rib cage up and out and let it back down for each breath we take. That “tidal air,” as doctors call it, moves in and out of our lungs without any thought on our part.

Air rushes in through the nose and mouth and travels down the airways. Much of what’s in that tide of “air” — nitrogen, oxygen, carbon dioxide, water, along with ozone, other gases and superfine dust — reaches the lungs. The tide fills tiny little sacs called alveoli.

The alveoli exchange oxygen for carbon dioxide, and we live to take another breath.

When we are born, our lungs are not fully developed. We have our windpipe and bronchial tubes, but our alveoli are still growing.

“You don’t get all of them until about age 8,” says Marianna Sockrider, a pediatric pulmonologist at Texas Children’s Hospital in Houston. “Of course, all that lung capacity gets bigger as you get bigger. Your lung capacity increases until you peak out when you are about 20 years old.”

Both Maile Bush and Kaden’s asthma doctor, Erin Clarke, have their eyes on his upcoming birthday. A boy’s eighth birthday isn’t a hard and fast deadline for growing lungs. But they are mindful that time is running out.

After a recent checkup, Clarke delivered news that was hard for Bush to take. Kaden’s lung function still wasn’t 100 percent.

And it may never be, Clarke said, adding “85 percent may be his normal.”

She reminded Maile that the goal was to have Kaden on as little medication as possible as he grows up.

Maile proffered her own reminder. When Kaden was at his sickest, battling RSV, his lung function was 88 percent.

“How does that make sense? How is that fair?” she says, not really expecting a reason for the deterioration.

Capacity to breathe

Doctors can measure the work our lungs do. After a normal exhale, we can push more air out. Or we can pull even more in after a normal inhale. Residual air remains in the lungs, even after we try to force it all out. That tidal air, plus the extra air we can move with additional effort, makes up our lung capacity.

Doctors know some of that capacity depends on sex, height and age. Our lungs have their best capacity, and their best function, when we are in our 20s.

“It declines a little bit each year after that. We are all declining,” says Sockrider, the pediatric pulmonologist.

People who smoke lose lung function more quickly. People with lung diseases, such as cystic fibrosis, lose lung function far more quickly. But most of us lose lung function so gradually that we don’t notice the decline, Sockrider says.

In key ways, the slow decline in our lungs resembles hearing loss.

“Once the damage has gone on long enough, you lose enough to figure it out,” she says.

And, as with hearing loss, once we’ve lost part of our lung capacity, we cannot recover it. Patients work with their doctors to make sure their lung diseases are well controlled to help prevent additional losses, too, Sockrider says.

People with asthma also need to avoid things that will irritate their lungs.

“You can use tools to be smarter [about exposure],” Sockrider says. “Fitness is important, but you can choose not to exercise on a high-ozone day.”

Parents can help their children avoid irritants, but it’s impossible to avoid everything.

“You can’t put your child in a bubble,” Sockrider says.

Maile Bush says she doesn’t know what such a bubble would look like for Kaden. Bush restricts the time he spends outside, saying she knows the air quality in the region and her neighborhood isn’t good for him. He bounces around the upstairs play room of the family’s southwestern Denton home a bit more than she’d like.

“He’s a boy,” Bush says.

Breathing bad air: ozone and dust

To comply with the Clean Air Act, state environmental officials focus on two air quality measurements: ozone and superfine dust, or particulates.

Doctors understand ozone’s effect on the lungs pretty well, according to Dr. Norman H. Edelman, the senior scientific adviser for the American Lung Association. He’s a teaching clinic supervisor and a professor at the State University of New York at Stony Brook.

Ground-level ozone gets made in sunlight when combustion sources (in North Texas, that comes from vehicle engines, natural gas compressors, coal and cement plants) mix with volatile organic compounds (gasses that come from trees and plants, as well as oil and gas facilities).

Because ozone has three oxygen atoms in it, instead of two, it’s a superoxidant.

“If you blow oxygen on a flame it increases, but if you blow ozone, the flame really jumps up,” Edelman said.

When ozone gets into the lining of our airways, it burns the lining similar to the way sunlight burns skin, except we cannot see our airways get raw and swell from the burn, he said.

Healthy people might not feel the burn until ozone levels get high, but people with asthma and lung diseases often do.

Researchers are only beginning to understand the effect of particulates, Edelman said. Particulates can have both short- and long-term effects on the heart and lungs.

Researchers have discovered that if the foreign particle is fine enough, then our airways don’t filter it and our alveoli don’t block it from entering the bloodstream.

The inflammation cells gather around particulates and that adds to the burden, especially for people with asthma, Edelman said.

But it has implications for all of us, he added. On bad days for particulates, researchers have discovered more people have heart attacks.

“It’s harder to understand, but currently we think it’s related to the inflammatory process,” Edelman said.

Inflammation is our bodies’ defense against foreign invaders. Chemical mediators circulate throughout the body, calling for different kinds of cells to combat the invasion. Cells gather and engulf the foreign invaders.

“But sometimes that works against you,” Edelman said. “In artery diseases, it’s not a ball of dead wax coating the arteries. There are unstable plaques. When the inflammatory cells get underneath that plaque, it can rupture and leak. Or trigger a blood clot.

“This is the best theory we have to explain what’s happening,” Edelman said.

In North Texas, officials have only recently begun monitoring particulates. For ozone, the region’s levels are among the highest in the state and the nation. At the Denton monitor, ozone readings don’t appear to be getting better. This summer, the readings indicate they are getting worse.

Maile Bush says a new compressor on a neighborhood gas well adds insult to injury for people nearby. The compressors have special equipment to keep emissions low, but their function is to burn some of the gas at the well site to help keep production up.

Charles Grodzin, a pulmonologist who left his Denton practice to join the medical faculty at Emory University in Atlanta, says what triggers lung ailments, such as asthma, is complicated and can include genetics, disease and injury, including injury from environmental exposures. And what exacerbates ailing lungs also varies from person to person — indoor irritants, outdoor pollutants, heat, humidity and pollen, to name a few.

When the Denton City Council considered its repeal of the citizen-driven ban on hydraulic fracturing, Bush came to speak. She has been outspoken about her health concerns for the community and worked for the ban.

She told the City Council she wasn’t planning on speaking, but her daughter, Cassidy, got a nosebleed that morning. She brought a photo of Cassidy covering her nose with her hands and shared it with the public.

“We need to make this stop,” Bush said.

Models behaving badly?

The Texas Commission on Environmental Quality, a state regulatory agency, is in charge of coming up with plans to clean up the air. Part of the Clean Air Act calls for North Texas businesses and residents to help with strategies, if needed.

Scientists generally agree that ozone levels below 60 to 65 parts per billion are “safe enough” to breathe, but many critics of the Environmental Protection Agency, which enforces the Clean Air Act, say that standard is too costly for the benefit it brings. Denton’s coal plant operator says they are concerned about the cost of improvements needed to meet ever-stricter air quality regulations, which get passed on to utility bills.

TCEQ develops the models that predict whether the air will get better, stay the same or get worse. Recent models show North Texas air getting better.

People continue to buy new and cleaner cars, so state regulators didn’t add any big, new strategies for the region’s coal plants, cement plants or the continuing production of shale oil and gas.

TCEQ’s latest model showed North Texas air is getting better at an unprecedented pace, about 3 to 4 ppb less ozone each year. For the past 20 years, North Texas air improved at about 1.1 ppb less ozone each year.

This summer’s ozone levels don’t appear to be following the model’s predictions. Instead, ozone levels appear to be increasing. Denton’s long-term averages are the highest in Texas, with an average of 84 ppb for this year, according to TCEQ data.

TCEQ could be missing important new trends with its model, according to Jim Schermbeck, a leader of Downwinders at Risk, a North Texas clean-air advocacy group. For example, the model omits what Maile Bush noted in her neighborhood: Emissions from compressors are installed on aging gas wells to keep them in production longer.

The TCEQ model assumes oil- and gas-related emissions will drop as drilling and fracking moves out of the Barnett Shale region.

But TCEQ also has been looking at ethane emissions associated with oil and gas production. TCEQ scientists noted that ethane emissions have been going up the most at Denton’s monitor. At Denton’s monitor, ethane emissions are about five times higher than anywhere else in the region. They also are nearly three times higher than the next highest monitor, which is in Fort Worth.

The Environmental Protection Agency sent TCEQ an 11-page letter in May questioning TCEQ’s model, too. The letter said ozone levels are improving on the east side of the 10-county North Texas region. But monitors in Denton and other western parts of the region affected by oil and gas production “seem to be countering the normal reduction” in ozone.

The EPA says it’s unreasonable to expect North Texas air to improve at the pace the TCEQ model predicts.

According to TCEQ spokesman Terry Clawson, the agency is revising the plan to show North Texas air will meet federal clean-air standards by 2017. The commissioners are expected to consider and adopt the plan in June.

All air is local, too

TCEQ started another program to better respond to local air quality complaints in 2009. In Denton County alone, agency inspectors have collected nearly 400 air samples, prompted by residents’ complaints about an odor or a health symptom near oil or gas production facilities.

These local complaints occasionally have led to orders for corrective action, and, in some rare cases, fines.

TCEQ publishes the air sampling data online, along with a comparison to values set by the toxicology division. The rest of the investigation information — for example, the nature of the odor complaint or the health symptoms reported — is filed away.

Clawson said TCEQ keeps information on file to look for trends in compliance by regulated companies. TCEQ scientists recently published a paper in the Journal of Unconventional Oil and Gas Resources showing air quality problems tend to be hyper-local and sporadic — the kind of readings that don’t require big changes in how polluting companies do business.

“With millions of data points collected and analyzed from these [air] monitors, the TCEQ has not seen ambient pollutant concentrations at levels of health concern,” Clawson wrote in an email.

Medical anthropologist Janice Harper, who wrote an important theoretical paper in 2004, titled “Breathless in Houston,” calls for a different kind of research to understand what poor air quality does to people.

Techniques that would combine air-quality data with anecdotal information about sick patients and their lung ailments are often used in other countries, but are rarely used in the U.S., Harper says.

Lisa Henry, a medical anthropologist at the University of North Texas, says people can and do make good observations about impacts in their communities. Researchers and policymakers could better understand the effects of ozone levels if they went into communities and asked people what is happening, she said.

As Kaden and Maile Bush sign in at Dr. Clarke’s office, they walk past a signboard displaying the day’s pollen count, which gets taken at the medical park on Scripture Street and Interstate 35 in Denton.

Bush isn’t quite sure what triggers Kaden’s asthma setbacks, but she doesn’t write it off to “allergies.”

The last time Kaden required urgent care for a coughing episode came in February. Bush talks about all her concerns with the doctor, and Clarke listens. Clarke tells Bush that ozone and dust in late summer can make it a tough time of year for kids.

Clarke intervenes when Bush says her own sinus infection continues even though she had sinus surgery months ago. Clarke urges her to make her own appointment, telling her that’s too long for an infection to last.

Clarke tells Bush to bring Kaden back for another checkup in six weeks. They talk briefly about changes to the special asthma action plan developed specifically for Kaden and his still-growing, still-recovering lungs.

Bush talks about another item that isn’t on the doctor’s plan for Kaden but is on her action plan for her family: moving away from Denton to the northeastern part of the county in search of better air for all of them to breathe.






Number of Texas children with asthma



Number of asthma-related hospitalizations


$172.9 million

Cost of pediatric hospitalizations statewide


$53.9 million

Cost of pediatric hospitalizations in North Texas



Percent of those hospitalizations for children age 0-4




Denton 2013 average



Denton 2014 average



Denton 2015 average (to date)



Denton three-year average



Houston/Galveston area three-year average

SOURCES: Children’s Medical Center of Dallas, Texas and North Texas Asthma Statistics and Facts, 2013. (Statewide data as of 2011.) Texas Commission on Environmental Quality, unofficial 8-hour ozone attainment as of 12:13 p.m. Friday.


PEGGY HEINKEL-WOLFE can be reached at 940-566-6881 and via Twitter at @phwolfeDRC.