Nasal Congestion is More Complicated Than You Think.

Donald Trump wants to repeal the ACA again. The Supreme Court heard oral arguments in a case that will decide the fate of the Sackler family's culpability in the opioid epidemic. The Biden administration announces a new prescription drug patent reform.

Last week, we sat down with your local epidemiologist, Caitlyn Gentolina, and we talked about all the ways we could tackle the cold and flu season. As we discussed the challenges of getting people to do the very basic things they need to do to protect themselves, we stumbled upon what I think is a pretty important insight. When it comes to trying to get people to get vaccinated or test before they sit down for meals, we tend to focus on the extremes. We talk about how many people die of the flu every year, or what the Covid hospitalization rate is, but that misses a vital point.

You literally can't experience a death rate. The vast majority of people have never been hospitalized with an infectious disease. And when it comes right down to it, convincing someone to do something is about appealing to their experiences. And that's because we're just not that good at juggling numbers in our minds. What does it mean to have 53 times the risk of COVID-19 mortality when the overall risk of dying of Covid is less than 1%?

It may just be that, rather than reaching for the extremes, we'd be better off if we just spoke to the mundane. This is literally the second episode in a row we're doing on cold and flu season. Because, well, everyone knows what cold and flu season is like. No matter who you are, you've had one of these. That constellation of sore throats, runny noses, body aches and pains, itchy eyes and nasal congestion. See congestion. Probably never killed a single person, but it still sucks.

And because all of us have had it, literally, all of us can put ourselves in the experience of it. And when we tell folks what they can do to prevent it, it just may be that. Giving folks advice about how to avoid congestion is just more tangible and therefore more effective than giving folks advice about how to avoid hospitalization or death. Look, I'm probably wrong about this, so don't at me. But because, for the most part, congestion sits so low on the radar of the medical establishment, most folks don't even know how it works. I mean, I sat through years of medical lectures and I don't remember a single lecture about it.

That may also be because there are lots of lectures I've long since pushed out of my brain, but it also might be because nobody lectured on it. Because nobody's died of it, and at the same time, because so many of us have suffered it, and so many of us would rather not. I was intrigued when I came upon an article in the Atlantic by Sarah Zhang. See. It taught me a lot about what congestion really is, how it works and why it's so hard to do anything about. I wanted to have her on the show to share what she learned in reporting the piece and the implications it has for getting some relief during the impending season we're all facing.

Here's my conversation with Sarah Zhang.

It's actually just a decongestant that doesn't work, and that's the reason the F.D.A. was having the meeting. Funny enough, they were making a decision to pull this drug from the shelf. And in the course of reporting that story, I got in touch with an old professor based in the UK who happens to be the world's expert in nasal cycles. And then my first question is, what is a nasal cycle?

And that's when I got started about how I enjoy about the nose.

And some things that do things don't do them very well, just because of the nature of evolution and how we came to be. I mean, a knee is like a really, really poorly designed joint, as anyone who's ever tried to cut really hard on their knee and snapped an ACL will tell you.

And as one sort of one nose doctor I talked to described it to me, he says. You know, imagine the air you're breathing in, it's maybe 70 degrees, it's maybe, oh, 30 humidity. By the time it reaches the end of your nose, which is three or four inches, that air is 100 humidity, and, you know, 95 degrees. Just imagine how much work that nose had to do in the space of three or four inches.

So the point of a nose is to, basically, it readies air, it cleanses air, it warms air, it humidifies air, so it's ready for your lungs. If you were breathing dry, cold, dirty air directly into your lungs, your lung cells would not be very happy. You would also have a lot of gunk in your lungs. So the point of the nose is to keep your lungs happy, not just to bring in the air, but to prepare it for your lungs.

But each nostril actually kind of is really its own separate organ. They are not directly connected to each other. That's why you can be congested in one side of your nose, but not the other. It's because they're basically functioning independently and they actually work in tandem and kind of work in sync.

So the nasal cycle is this cycle that is always present in most people. Basically, one side of your nose is working harder than the other at the other time. What that means is that one side of your nose is always a little bit congested and the other side is fully open. And that's because the inside of your nose is blind with this. Like erectile tissue, which, as one nose doctor described, is similar to the erectile tissue in the penis. So it fills with blood and it swells, and that's why you feel congested.

I always thought when I got congested, it's because my nose was filled with mucus, and it's true, the mucus does make it worse. But maybe you've experienced this as well. Sometimes you can blow your nose and blow your nose, and there's like nothing coming out and you still feel congested. That's because that one side of your nose is really, really swollen.

It's the blood vessels that's filled with blood, and that's why it's, you know, literally stuffed up. There's nothing you can do that, you can't blow it open.

That's what you're saying.

You know, like I've lived like about 30 something years of my life and I had no idea this is what was happening.

And so that's just not going to happen. You can always breathe through your mouth.

It's like a really frustrating thing.

Because, to your point, right, you started thinking about this because you were covering an F.D.A. meeting about.

Phenylephrine, which is a drug that works because it basically closes down these erectile tissues in the nose, right? And so when you spray phenylephrine in your nose, it's extremely effective. Like you actually feel it like, extremely quickly. Because it acts at the level of the of the of the venules to close those venules down, to stop them from being stuffed up so that you can breathe evenly. Here's the problem, though, is that we've been giving them to people orally for years, thinking that they're going to have some sort of effect.

And you know, I feel like this proved that he doesn't listen to me because he got me the Sudafed PE, the sudafed phenylephrine. I was like, No, I literally just told you this, I just wrote an article about this. I can't believe you got this wrong. So I think, you know, on one hand, it's just like, what are the drugs that actually work, right?

So don't get oral phenylephrine, get Sudafed, which is the one that you need to show your ID for. And the reason for that is because it has been used as an ingredient to make meth. Though the sort of the sidebar the way meth is produced now, it actually rarely uses this ingredient.

It's a drug that makes those blood vessels in your nose constrict, so it's no longer erect, so your nose becomes open. The other thing that I was really surprised to learn is that you can also control the swelling on one side of your nose at a time. Which made sense once I thought about it. So maybe you and maybe the listeners have had this experience. Where you are congested on one side of your nose at night and you're trying to sleep and one side is blocked.

And you turn around and that side clears up after a few minutes. So I had always thought that this was like mucus moving from one side of my nose to another because of gravity. But actually, what's happening is that this is a reflex we all have. If you push really hard under your left armpit, your right nose will open, and vice versa. If you push really hard under your right armpit, your left nose will open.

In yoga, people sometimes use a yoga crutch under their arms, on one side or the other, to control their breathing. I've also maybe people have come across this. There's this online hack where you're supposed to put a bottle under one side of your arm and press really hard on the bottle. And that's supposed to open up one side of the nose. So this is a real reflex. The hypothesis of why it exists is that what it does is if you're lying on your left side, it opens the right side of your nose.

So your right side of your nose is further away from the ground, it's less likely to be obstructed. Maybe this is helping you breathe when you're lying down. That's the hypothesis. We don't really exactly know why this exists.

But next time you're congested or you feel one side of your nose unable to breathe, try pressing really hard under your armpit on the other side. I will say I tried this and I was not wowed by the results. It's not like flipping a switch, right? It's not like immediately your nose will open, but if you wait five minutes, it will happen.

It definitely works when I'm lying in bed and going back and forth. But the problem is then, like, the other side gets congested, so you still have to turn back around.

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Modern, hypothesis driven, empirical evidence driven medicine has the best answers to things, or has elucidated this. It would be really interesting to understand, when is it that we first fully understood this neurodynamic connection between armpits and noses? But, like, you know, you're talking about a yoga tradition that is substantially older than our ability to collect, you know, any sort of systematic evidence that had had this sort of insight and understanding well before. And anybody who listens to the show knows that.

I sometimes look askance at some of the alternative healing that folks will monetize, in large part because it doesn't have substantiation in evidence. But this is one of those important moments where you're saying, well, look like. First of all, yoga is a long, long, long historical tradition. And then two, right? Like, there is a way to bring your scientific mind to these questions and to ask if someone's trying to make a dollar on you, right? So this is not the same thing as you name the, you know, the good product that Gwyneth Paltrow is trying to sell you to make money.

This is, you know, a long historical tradition. And I think there's a lot we can learn by trying to apply evidence driven approaches to asking, You know what the links are in some of these older than science traditions? As far as you know, has anyone made good use of sort of an approach to thinking about congestion? That involves manipulating the underarm. Like, is there a well tried and true approach to dealing with your cold and flu symptoms? That involves, you know, surreptitiously massaging your underarm in public?

And, you know, when I was writing this article, I was trying to look a little bit more to see. Like, whether there had been any sort of formalized descriptions of it. And there really haven't, and I wish there were. I think I would love to learn more about it as well.

I've seen all the cold medication commercials I've seen. But here's this, like, very simple principle of how our noses work that none of us really know about. What even causes congestion? Most of us probably don't have the right answer. At least I didn't.

Would sell, you know, wildly sure, it probably would, but that's only if it's something that you can sell and not something that you can sort of manipulate in your own body or engage with. And look, there are medications that deal with, you know, one sided nasal erections, and they do a pretty decent job of it.

Problem is, we've been selling to folks the other stuff for a very long time. And so the hard part is, we don't do much work on things that are not deadly, but are broadly annoying for a lot of people. And then we don't do a lot of work really making sure that we get information out about these things. And it's a big reason why I wanted to talk to you about your reporting on this piece. Because it was just so astounding to me. That this thing that so many of us experience, so few of us actually have any knowledge about, including many of us who had medical training. And this was a really important and insightful perspective on how to understand this human condition that so many of us face.

I too have kids that are really young, I too deal with nasal congestion for most of the year. And I too, at times would sit there, blow my nose and wonder why it is that this is not working if I'm getting all this stuff out of my nose. And here we are, you know, with a better understanding of the basic anatomy and physiology of the nose, with a better understanding of, like, what to do about it. I want to ask you.

So as someone who sort of covers the space, are there other questions like this that you feel like we're really missing? Things that you've come across? That are just like, we should know a lot more about this than we actually do.

Like, you know, I appreciate the eyebrows look a certain way, but like, I never thought about eyebrows as a as, like, literally a like, a like a windowpane, almost for your eyes, right? They just they keep, they keep the sweat right out. So, you know, there's a lot of parts of this that that we sometimes don't appreciate. Simply because they don't tend to be universal or ubiquitous experiences of losing them.

And also that that they tend to be like small annoyances, right? Getting getting sweat in your eyes when you're working out is one of those things that's not going to kill you, right? But it'd be pretty annoying if it was your experience.

So I fortunately did not lose my nails, but my my daughter did so. She had a couple of toenails that fell out. And that made me think, like, what is the point of nails? And I was like, Well, yeah, I guess I didn't have a nail and my finger probably get injured all the time.

And you know, they're not using them for hunting. But you're right, like you can imagine. Also, especially on your toenails like that, can you imagine how bad stubbing your toe would be if you didn't have toenails? Yeah, that's a really right.

Like, this notion of like protection is a really interesting one.

I had to have my appendix taken out a couple of years ago, and I remember a lecture of med school on this is like, we don't really know why we have appendices. We think it had to do with, you know, in the past. When we ate relatively undigested food, we would eat rocks, the rocks would go into the appendix, and then those rocks would help digest much more fibrous foods.

But, like, clearly we don't do that anymore. Because, you know, many, many, many centuries ago, we realized that if you cook your food, you have to spend way less time chewing it or digesting it. So here we are. But so that's the other part of it is like things that used to have that may have had obvious uses for our distant, distant, distant ancestors. Our modern way of life have now abrogated the need for, and we're only now trying to make sense of them. And we really appreciate your reporting, Sarah, and for you taking the time to join us to teach us a bit more about the large organ in the middle of our face. Literally, that we only really pay attention to, despite its Yeoman's work for us when it gets stuffed up, because apparently it's having erections. And appreciate you writing.

Our guest today was Sarah Zhang. she is a staff writer at The Atlantic and wrote a fantastic piece about congestion. Sarah, thank you for taking the time to join us today.

There is absolutely no plan to replace it. See, the ACA was the Republican plan developed by the Conservative Heritage Foundation in 1989. I share this to remind us just how much is at stake in the elections in 2024. Last week, the Supreme Court heard arguments in a case regarding the opioid settlement with Purdue Pharmaceuticals and their owners, the Sackler family. While the settlement requires the Sacklers to invest $6 billion of their personal fortune into a fund for survivors. It does so in exchange for immunity from future litigation, meaning they get to keep many billions of dollars they made off their opioid business.

The suit brought by the Department of Justice's trustee program, which adjudicates the bankruptcy process, argues that the settlement is a misuse of that process. It wasn't intended to protect folks who aren't in bankruptcy, which is, of course, what the Sacklers would explicitly be protected from. But the settlement is supported by 97 of affected folks. And if the Supreme Court were to upend it? Both stakeholders and Purdue Pharma argue that it could result in a far less equitable distribution of relief dollars. In essence, it would result in what attorneys call a race to the courthouse, where folks who sue first get way more than folks who come after them.

The case highlights a broader set of uncomfortable tensions at play. How do you hold the folks who profiteered off the opioid epidemic accountable? While also making sure that the billions they made actually go to the people who suffered the?

Giving the government march-in rights over high-cost prescription drugs will have two big implications for those prices. The first is the obvious one that for medications that are too expensive. The federal government could march in and hand over the manufacturer's patent. Second is the knock-on effect. The fact that the order is now in place will force manufacturers to think twice about how high they set prices in the first place. The order did some other important things, too.

It launched a government-wide inquiry into quote corporate greed in health care. That inquiry will specifically focus on the impact of private equity and consolidation. Two hobby horses on this show. Though these kinds of executive orders tend to be a bit more for show than for substance, they're still an important start.

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