A machine produced the unmistakable sound, as it methodically dispensed a medicated mist to help Shannon VanGorkom breathe.

KILLER ASTHMA: Stephen VanGorkom visits the graves of his wife, Betty, and daughter, Shannon, about once a month. They died of complications of asthma. VanGorkom says he could never persuade them to leave Kingsburg and move to the mountains for better air. (Mark Crosse / The Fresno Bee)

Shannon, 21, and her mother, Betty VanGorkom, 50, of Kingsburg, had lived with asthma for years. Many nights, mother or daughter awakened, choking, gasping – unable to breathe through swollen air passages.

What caused Shannon's asthma attack this night? A change in the weather, a cold virus? Or was it fine diesel particles from trucks traveling on nearby Highway 99, soot from fireplaces, dust from plowed fields? Any one of these irritants could have been the trigger.

Her source of relief: whiffs of medicine pumped by the machine, called a nebulizer, plugged into an electrical socket by her bed.

Once the medicine soothed her lungs, she could fall into a fitful sleep.

This night of Feb. 17, 2000, seemed no different than dozens of other restless bedtimes in the VanGorkom home.

First severe attack at age 6

As a toddler, barely out of diapers, Shannon developed a chronic cough that worried her parents. They suspected asthma, but doctors treated Shannon for bronchitis for more than a year before a physician diagnosed the lung disease.

"Man, this kid's had asthma for a long time," Stephen VanGorkom remembers the doctor saying.

The VanGorkoms began a merry-go-round of appointments with lung and asthma specialists. They would try anything to help their impish daughter, with her dark, curly hair and round face.

Betty VanGorkom had had three miscarriages before Shannon was born about seven weeks premature on Sept. 30, 1978. A son, Curtis, was born five years later.

Shannon had her first severe asthma attack at age 6. The emergency room doctor in Selma was blunt: "She's either going to make it through the night or she's not."

Stephen VanGorkom stayed all night at the hospital, keeping a vigil at Shannon's bedside. The next morning, Shannon's airways opened – but the attack left her lungs shell-shocked – only a hair trigger from the next asthma attack.

Advised to leave Valley

Over the years, doctors advised Shannon to leave the San Joaquin Valley. The reason: air pollution. The pollutants rubbed against the delicate tissue in her lungs like sandpaper.

A doctor told her in 1999 she should move. Shannon said she was staying. The doctor's reply: "Well, it's going to kill you."

Deaths from asthma attacks are rare, but each year about 60 Valley residents – 600 Californians and more than 5,000 people nationwide – die of the lung disease.

Stephen VanGorkom, 54, a rural postal route carrier, wanted to move his family to Oakhurst, above the layer of smog that smothers the Valley.

He and Betty had gone to a couple of church retreats in Oakhurst. She felt better there. She could traipse up a hill and not be out of breath. In Kingsburg, she couldn't walk a block without panting.

But he couldn't make her leave Kingsburg. Betty VanGorkom, a hospital secretary, refused to budge, no matter how many times he suggested they live in the mountains. "Stubborn 'ol her. This was home," he said.

Shannon, a teenage image of her mother – 5 feet tall and chubby – also dug her heels in, refusing to be uprooted.

Asthma became another bond between mother and daughter. Doctors don't know what causes asthma, but having a parent with the disease is known to increase a child's risk of developing it. Researchers also know that dirty air aggravates asthma, and the Valley has some of the highest asthma rates in the state.

VanGorkom gave up his campaign to move – but he suspected the dust thrown up from nearby agricultural fields and exhaust belched by trucks and cars barreling down Highway 99 were part of the reason for his wife's and daughter's asthmatic attacks.

"This is not a good area if you have bad lungs," he says. "You can see the air here. If you can see it – it can't be good to breathe it."

Teen's lungs collapsed

In her teens, Shannon's asthma attacks escalated in frequency and intensity. She learned to medicate herself and expertly use a hand-held inhaler filled with albuterol, a drug that opens the lungs' airways.

She passed out at home at age 14.

"Her lungs just collapsed," Stephen VanGorkom says, trying to recall details blurred by time. "I think we got her to the hospital ... she was real bad."

Four years later, Shannon blacked out again.

An ambulance took her to the emergency room. Her lungs had collapsed.

"She was barely alive when they got her there," her father remembers.

Shannon adapted to the unexpected and frightening asthma attacks, and to the limitations the disease placed on her. She didn't go to school much. One week in a classroom, two weeks out sick. She missed six months of sixth grade when she caught pneumonia.

By age 16 – too sick to regularly attend high school classes – she studied at home. A teacher visited a few hours a week. The rest of the time, Shannon cracked the books on her own. She passed the test for a General Equivalency Diploma or GED.

She got a job as a cashier at a Carl's Jr. in Selma.

Someday, she told her family, she wanted to be a history teacher. When she let her imagination run wild, she talked about moving to Chicago to work for the Cubs.

Her fascination with the Cubs mystified her father. Why the Cubs? She wasn't a baseball fan – just a Cubs fan. Shannon was mum about her reasons. VanGorkom finally settled on a theory: His daughter was enthralled by the ivy-covered Wrigley Field.

And Shannon worshipped former Cubs' first baseman, No. 17, Mark Grace. Shannon's "screen name" in Internet chat-rooms: "Grace17."

A sleepless night

KILLER ASTHMA: A family photo of mother and daughter. (Mark Crosse / The Fresno Bee)

Awakening occasionally on this February night, VanGorkom could hear the rhythmic purring of the nebulizer and Shannon inhaling wafts of medicine.

His daughter had had a sleepless night.

But getting ready for his rural postal route the next morning, Stephen VanGorkom showed little surprise when Shannon appeared in the kitchen, dressed and ready for her morning shift at Carl's Jr.

She had snapped back many times from an asthma attack. The medicine she had taken overnight to control swelling, ease constriction and loosen thick mucus in her lungs gave her relief – or so he thought.

Then, he heard Shannon wheeze.

Each breath hissed like air being squeezed out of a balloon.

"Stay home," VanGorkom told her, knowing she wouldn't take his advice.

Better to feel lousy at work, she argued. She wanted to make some money and be with her friends at work.

Shannon always showed up at work, says co-worker Teresa Fuentes.

"She would rather go in when she was sick than to stay home," Fuentes says.

At the fast-food restaurant, her co-workers were alarmed. Shannon's face was bright red. She slumped against the cash register, too exhausted by the effort of forcing air into her lungs to stand upright.

They insisted she leave early.

Betty VanGorkom drove Shannon home from the restaurant. Betty's asthma had disappeared in childhood and returned in her 40s. When it progressively got worse, she had to go on disability from her hospital job.

Shannon fell asleep but slept fitfully all afternoon, not waking when brother Curtis came home from high school and her father returned from his postal route about 3 p.m.

As the afternoon wore on, Shannon's breathing became more jagged. Less air escaped with each exhale. She inhaled in desperate gulps, but her lungs refused to let air in.

After two hours of watching Shannon struggle to breathe, Stephen VanGorkom knew it was time to call an ambulance.

Shannon staggered into the living room. VanGorkom caught her as she started to fall.

Shannon had stopped breathing. VanGorkom couldn't wait for the ambulance to arrive with oxygen. He yelled for a pillow to put beneath Shannon's head. He tilted her neck, pinched her nose and breathed into her mouth.

But with each breath of air he gave his daughter, hopes faded. Shannon didn't respond.

"I knew her lungs were gone," he says. "Her lungs were so dead you couldn't even get any air in. They were so collapsed."

By the time emergency room doctors at University Medical Center in Fresno saw Shannon, her lungs were in the clutches of a full-blown asthma attack or "statis asthmaticus."

Air passages blocked

Dr. Victor Fernandez got the call from emergency room workers that Shannon needed to be admitted to the hospital.

Fernandez cannot talk about Shannon because of patient confidentiality, but he explained what happens during asthma attacks.

When a person is having an asthma attack, the bronchiole tubes spasm or constrict, cutting off the air flow, he says. The lung is designed like an upside down tree. The leaves represent the tiny air sacs called alveoli, the main tree trunk is the larynx or throat and all the branches of the tree are the bronchi or air passages.

During an asthma attack, the air passages also swell and mucus spills into the airways.

Not only are the airways squeezed, Fernandez says, they're swelling: "When it swells, it constricts further and there's also secretions that are inside that constrict it more, and when secretions are thick, they form a plug."

The asthmatic can take in a breath easier than blowing one out. Each inhaled breath of air causes more pressure to build inside the lungs. Asthmatics feel like they aren't getting enough air, so they inhale faster.

But the lungs can't expel the bad air – carbon dioxide. It accumulates in the air sacs. The heart beats faster, trying to get the oxygen it needs. Things start to happen in the tissues and blood. The acid/base balance starts to become unbalanced. The heartbeat becomes irregular, as the heart works harder.

Doctors use drugs to relax the airways and high-dose steroids to stop the domino effect of constriction, swelling and mucus production. They can put a tube down the throat to force air into the lungs. But sometimes the cascade of biological reactions that block the flow of air can't be stopped.

Living on borrowed time

Shannon was dead.

"They just couldn't do anything," says Stephen VanGorkom. Doctors had tried to save Shannon for almost two days before she died on Feb. 19, 2000.

The official cause of death: cardiopulmonary arrest due to severe asthma.

Shannon had been living on borrowed time since her first serious asthma attack 15 years earlier, her father says. "Ever since that first time her lungs collapsed, I knew one of them could get her. It just destroys your heart and everything. I knew that."

And Shannon knew it, too.

She also knew the Valley's smog and particle pollution put her at greater risk of asthma attacks.

A few months before she died, Shannon told a friend she believed there was not much more doctors could do for her. Her father said she had accepted that.

Laboring to breathe

The hum from the nebulizer filled the bedroom.

Betty VanGorkom needed her husband's help to assemble the breathing machine on the sweltering night of Aug. 3, 2000.

Her health, fragile the last 10 years, had crumbled in the five months since her daughter was buried.

VanGorkom settled his wife into bed about 9 p.m.; she fell asleep. Her labored breathing sounded like a wind tunnel throughout the house.

VanGorkom slid into bed and dozed off about 11 p.m.

Betty's scream startled the "bejeebies out of me," he says.

VanGorkom yelled for his son to call the ambulance while he grabbed a syringe of epinephrine – a form of adrenaline that helps reduce the swelling of the airways to ease breathing – kept ready for such a severe asthma attack.

"I started getting medicine out for her. Just as I did, she was sitting on the bed ... and she fell. She passed out," he says.

The paramedics loaded her onto a gurney.

Her last words, spoken through a plastic oxygen mask as she was wheeled away in the emergency room: "I love you."

Within hours, Betty was dead.

The swelling, tightness and sticky fluid had formed an impenetrable dam inside her lungs.

'She wouldn't move ...'

VanGorkom and his son, Curtis, moved to a duplex in Kingsburg, where dirty dishes and uneaten food go unnoticed by father and son.

VanGorkom gets antsy sitting in the sparsely furnished apartment without his wife to talk to. Some nights he goes bowling after work.

Betty was the homebody, he says. He liked to travel and go bowling. He stayed home to be with her.

He misses Betty. "You get lucky in something in life sometimes," he says of their relationship.

But there also is a shadow of anger behind the warm memories.

"She wouldn't move out of here," VanGorkom says of Betty's steadfast refusal to relocate to a less-polluted environment. "I tried to get her to move, I don't know how many times.

"I told her we'd move up to Oakhurst. The air's just that much better, yet it's still in the area. I could have even kept my old job, I told her: 'I'll drive two hours to and from if you guys will feel better. It don't matter to me. I just want you guys to feel decent.' "

But he's not really mad at Betty or Shannon. They were two, stubborn strong-willed women, he confides, with a fondness and a tinge of admiration in his voice.

He visits the Kingsburg cemetery, where mother and daughter are buried, about once a month.

"I'm bent," he says, "but I'm hanging in there."