Elderly with asthma

Except for some precautions, goal of asthma treatment in elderly is same as that in other age group. The main points to remember and consider in elderly people suffering with asthma are discussed below. 1. Elderly asthmatics are usually suffering from few other medical conditions that may interfere with asthma treatment. This includes hypertension, IHD, diabetes mellitus and other related diseases. 2. Elderly do not respond as well to drug treatment as young people, so drugs must not be overused as they may aggravate other medical conditions like cardiac disease, arthritis etc. 3. Patient should tell his doctor which medicines he/she is taking for which disease. Medicines that may aggravate asthma like aspirin (commonly used in cardiac conditions and arthritis) and betablockers (atenolol) are to be avoided. 4. It is important not to misdiagnose asthma as COPD because asthma has a different natural history and a better prognosis with treatment. COPD is mainly a disease of smokers. Read more about COPD. 5. Dyspnea (breathlessness) in elderly occurs due to many causes that include congestive heart failure and other forms of chronic heart and lung diseases. 6. Smoking or exposure to tobacco smoke should be avoided. 7. When doing spirometry in elderly, a consistent pattern of decreasing FEV1 in tests repeated during the session is suggestive of asthma. 8. Depression is very common in elderly and can decrease their compliance to the treatment of asthma. Depression is also one of the most treatable problems in the elderly so should not be ignored. 9. Indoor allergens or triggers (dust mite, molds etc.) may be more important to evaluate than outdoor allergens since most elderly people spend more time in their homes than outside. The specific allergen will vary by geographic region. Allergy testing can identify the offending allergen. 10. Diseases that mimic asthma in elderly are: a. Chronic Obstructive Pulmonary Disease. b. Interstitial Lung Disease. c. Bronchiectasis. d. Cardiac Disease (Angina, IHD and Congestive Heart Failure). e. Upper Airflow Obstruction (Encroaching tumors, vocal cord paralysis, and thyroid enlargement). f. Pulmonary Embolism. g. Bronchogenic carcinoma. h. Aspiration. i. Gastroesophageal Reflux. back to top

11. Elderly patients with asthma can also have chronic, persistent airflow obstruction with poor bronchodilator responsiveness; a trial of therapy with corticosteroids for 15 days or more may be necessary to establish that there is reversible airflow obstruction. 12. Coexisting conditions (e.g., respiratory infections, gastroesophageal reflux) may exacerbate asthma, hinder effective therapy, and reduce asthma control. 13. Some asthma medications (e.g., theophylline, beta-adrenergic bronchodilators) can elicit adverse responses (e.g., cardiac ischemia or arrhythmia, drug toxicity, gastroesophageal reflux) in susceptible patients with coexisting disorders (e.g., ischemic heart disease, congestive heart failure, acute myocardial infarction, gastroesophageal reflux). 14. Nonselective beta-adrenergic blocking agents (like Timolol, atenolol), even in minute quantities as present in ophthalmic solutions, should not be prescribed for patients with asthma, because they can produce severe bronchospasm and perhaps anaphylaxis. 15. System corticosteroids, thiazide diuretics and beta2-agonists may contribute to hypokalemia (decreased potassium in blood) therefore routine monitoring of serum potassium and magnesium for early detection of electrolyte imbalance should be done. 16. Many elderly patients with asthma have concurrent rhinitis or sinusitis for which they take antihistamines (terfenadine and astemizole) which have the potential to produce prolongation of the QTc interval that could lead to ventricular arrhythmias such as Torsade de Pointes 17. Angiotensin-Converting-Enzyme (ACE) Inhibitors. can produce chronic cough in some patients. 18. Review of patient technique in taking medications is also important; not infrequently, a failure to respond adequately to therapy is a result of improper medication/inhaler technique. 19. Peak flow meter: The effectiveness of home peak flow monitoring among the elderly has not been clearly established. 20. Allergy Tests: Allergy skin tests or studies of specific IgE need not be routinely performed because allergens seem to play a less important role for elderly patients than younger patients. 21. Respiratory infections and medications for other diseases are the most common asthma triggers in elderly patients. 22. Measures to avoid or control asthma triggers should be specific to the patients asthma and allergy history. 23. Avoidance of exposure to allergens and tobacco smoke, both active and passive, is important as with asthma patients of any age.

What is asthma Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role: in particular, mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli. Reversibility of airflow limitation may be incomplete in some patients with asthma. "Guidelines for the Diagnosis and Management of AsthmaFull Report, 2007 Asthma is often linked to allergies, heredity and environment. In a normal individual, various airborne allergens (triggers) stimulate the production of antibodies and other chemicals in controlled quantity, which destroy the allergen but dont harm the body. But in allergic individual who have asthma there is over production of antibodies and other chemicals which cause inflammation of the airways, which is hallmark of asthma. Prevalence of asthma Asthma is considered as a major public health problem in many countries. It is one of the most common chronic disease affecting both adults and children. According to world health organization there are at least 300 million people suffer from asthma worldwide and more than 180,000 people die from it each year. Despite the availability increasing treatment, asthma-related morbidity and mortality continues to rise. The prevalence of asthma is increasing in developed as well developing countries through the world. The current prevalence of asthma is estimated to be 5 to more than 10%. Defining features and symptoms of asthma - Cough - Wheezing - Dyspnea or breathlessness.

moulds, cold air

and allergic disease like eczema, allergic rhinitis, allergic conjunctivitis.

Symptoms of asthma are due to intermittent reversible obstruction of airways caused by airway inflammation, airway hyper responsiveness and muscle spasm. Clinical hallmark of asthma include following symptoms: 1. Episodic wheezing, 2. Breathlessness or shortness of breath, 3. Cough specially at night and sputum production. 4. Chest tightness, pain or pressure. Between the episodes of asthma symptoms improve or may disappear completely. Asthma symptoms can vary from mild to severe. Before the attack of asthma occur, there are some early warning signs or symptoms that can tell the person that the asthma attack is about to occur.

Early warning signs of asthma attack: Full-blown asthma attack is usually preceded by certain signs and symptoms. They are as follows: 1. Loosing you breath easily or shortness of breath. 2. Feeling tired or weak. 3. Wheezing or coughing after exercise. 4. Decrease in PEFR reading in Peak flow meter or lung functions measured by spirometer. 5. Signs of cold or allergies like itchy throat, running or stuffy nose, headache. 6. Trouble sleeping. 7. Chest tightness. 8. Change in amount, color and thickness of mucus.

According to the American College of Emergency Physicians, recognizing and responding to the following warning asthma signs and symptoms can help people avoid an asthma emergency:

-relief inhaler more than twice a week;

activity;

Go to your doctor immediately if you have any of these symptoms because there is a need for urgent or emergency care.

Asthma symptoms during asthma attack: Full blown attack of asthma usually has following symptoms which are usually episodic: 1. Wheezing. A high pitched whistling sounds produced when breathing out especially in children. Lack of wheezing and a normal chest examination do not exclude asthma. 2. Coughing (specially in night). 3. Recurrent breathlessness or Shortness of breath. 4. Tightness of the chest, pain or pressure. Asthma symptoms vary from person to person. Some may have all the above asthma symptoms and some may have few of them. Severity of asthma symptoms may vary in each attack.

Asthma symptoms getting worse: In asthma attack airways become narrow, thus making difficult for the patient to breath air in and out of the lungs. The main cause of airway narrowing are: 1. The muscles surrounding the airways tighten. This narrowing of airway due to muscle spasm is called bronchospasm. 2. Inflammation of airways causing further narrowing. 3. Excessive mucous production, which fill the airways with mucous. All of these factors bronchospasm, inflammation, and mucus productioncause asthma symptoms such as difficulty breathing, wheezing, coughing, shortness of breath, and difficulty performing normal daily activities. Other symptoms of an asthma episode include some or all of the below: 1. Severe wheezing when breathing both in and out. 2. Coughing that won't stop. 3. Very rapid breathing and nasal flaring (the nostril size increases with each breath, a sign that person is working harder to take each breath. 4. Chest pain or pressure. 5

5. Tightened neck and chest muscles, called retractions. 6. Trouble focusing and talking. 7. Feelings of anxiety or panic. 8. Pale, sweaty face. 9. Cyanosis causing blue lips or finger nails.

The symptoms of status asthmaticus (Acute severe asthma) may include: 1. Persistent shortness of breath, 2. Inability to speak in full sentences, 3. Patient may be breathlessness even while resting, 4. Patient chest may feel closed, 5. Lips and/or finger nails may have a bluish tint, 6. In acute severe asthma patient may feel agitated, confused, or an inability to concentrate. 7. Patient may hunch his shoulders, sit or stand up to breathe more easily, and strain the abdominal and neck muscles. 8. These are signs of an impending respiratory system failure. 9. Silent chest i.e. no wheezing and coughing is ominous sign of asthma. Very severe asthma attacks such as status asthmaticus may constrict the airways so much that there is very less flow of air in and out of the lungs. Thus there may be no wheezing sound or coughing (silent chest).

Unusual symptoms of asthma: Being easily fatigued, and unable to exercise properly may be a sign orsymptom of asthma. Other unusual symptoms of asthma are:

-variant asthma),

rating,

Symptoms of asthma occur or become worsen in the presence of:

-dust mites (in mattresses, pillows, upholstered furniture, carpets),

, Symptoms of asthma may occur or become worsen at night, making the patient to awake.

Symptoms of asthma are due to intermittent reversible obstruction of airways caused by airway inflammation, airway hyper responsiveness and muscle spasm. Clinical hallmark of asthma include following symptoms: 1. Episodic wheezing, 2. Breathlessness or shortness of breath, 7

3. Cough specially at night and sputum production. 4. Chest tightness, pain or pressure. Between the episodes of asthma symptoms improve or may disappear completely. Asthma symptoms can vary from mild to severe. Before the attack of asthma occur, there are some early warning signs or symptoms that can tell the person that the asthma attack is about to occur. ________________________________________ Early warning signs of asthma attack: Full-blown asthma attack is usually preceded by certain signs and symptoms. They are as follows: 1. Loosing you breath easily or shortness of breath. 2. Feeling tired or weak. 3. Wheezing or coughing after exercise. 4. Decrease in PEFR reading in Peak flow meter or lung functions measured by spirometer. 5. Signs of cold or allergies like itchy throat, running or stuffy nose, headache. 6. Trouble sleeping. 7. Chest tightness. 8. Change in amount, color and thickness of mucus. ________________________________________ According to the American College of Emergency Physicians, recognizing and responding to the following warning asthma signs and symptoms can help people avoid an asthma emergency: Wheezing and/or coughing that disturbs sleep at night; Having to use a quick-relief inhaler more than twice a week; Taking time off from work or school due to breathing problems; Consistently having trouble breathing during physical activity; Inability to take part in normal, everyday activities; Go to your doctor immediately if you have any of these symptoms because there is a need for urgent or emergency care.

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Asthma symptoms during asthma attack: Full blown attack of asthma usually has following symptoms which are usually episodic: 1. Wheezing. A high pitched whistling sounds produced when breathing out especially in children. Lack of wheezing and a normal chest examination do not exclude asthma. 2. Coughing (specially in night). 3. Recurrent breathlessness or Shortness of breath. 4. Tightness of the chest, pain or pressure. Asthma symptoms vary from person to person. Some may have all the above asthma symptoms and some may have few of them. Severity of asthma symptoms may vary in each attack. ________________________________________ Asthma symptoms getting worse: In asthma attack airways become narrow, thus making difficult for the patient to breath air in and out of the lungs. The main cause of airway narrowing are: 1. The muscles surrounding the airways tighten. This narrowing of airway due to muscle spasm is called bronchospasm. 2. Inflammation of airways causing further narrowing. 3. Excessive mucous production, which fill the airways with mucous. All of these factors bronchospasm, inflammation, and mucus productioncause asthma symptoms such as difficulty breathing, wheezing, coughing, shortness of breath, and difficulty performing normal daily activities. Other symptoms of an asthma episode include some or all of the below: 1. Severe wheezing when breathing both in and out. 2. Coughing that won't stop. 3. Very rapid breathing and nasal flaring (the nostril size increases with each breath, a sign that person is working harder to take each breath. 4. Chest pain or pressure. 5. Tightened neck and chest muscles, called retractions. 6. Trouble focusing and talking. 7. Feelings of anxiety or panic. 8. Pale, sweaty face.

9. Cyanosis causing blue lips or finger nails. ________________________________________ The symptoms of status asthmaticus (Acute severe asthma) may include: 1. Persistent shortness of breath, 2. Inability to speak in full sentences, 3. Patient may be breathlessness even while resting, 4. Patient chest may feel closed, 5. Lips and/or finger nails may have a bluish tint, 6. In acute severe asthma patient may feel agitated, confused, or an inability to concentrate. 7. Patient may hunch his shoulders, sit or stand up to breathe more easily, and strain the abdominal and neck muscles. 8. These are signs of an impending respiratory system failure. 9. Silent chest i.e. no wheezing and coughing is ominous sign of asthma. Very severe asthma attacks such as status asthmaticus may constrict the airways so much that there is very less flow of air in and out of the lungs. Thus there may be no wheezing sound or coughing (silent chest). ________________________________________ Unusual symptoms of asthma: Being easily fatigued, and unable to exercise properly may be a sign orsymptom of asthma. Other unusual symptoms of asthma are: Chest tightness and difficulty breathing in the early morning hours, Dry hacking cough (cough-variant asthma), Constant sighing, Rapid breathing, Difficulty sleeping, Anxiety; difficulty concentrating, Asthma symptoms can present as vomiting after bout of coughing in a child.

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Symptoms of asthma occur or become worsen in the presence of: Exercise, Viral infection, Animals with fur or hair, House-dust mites (in mattresses, pillows, upholstered furniture, carpets), Mold, Smoke (tobacco, wood), Pollen, Changes in weather, Strong emotional expression (laughing or crying hard), Airborne chemicals or dusts, Menstrual cycles , Symptoms of asthma may occur or become worsen at night, making the patient to awake.

Causes or triggers of asthma There are various mechanisms that cause asthma and vary among population groups and even individuals. It is seen that many asthma sufferers also have allergies. Not all people with allergies have asthma; however, not all cases of asthma can be explained by allergic response. Asthma is most likely a result of genetic susceptibility, which probably involves several genes and various environmental factors. An asthma attack can be induced by direct irritants (allergens or triggers) to the lungs such as: House dust mite , specifically mite faces. Pollen. Molds and fungi. Animal dander. Cockroach. Pollution.
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Cigarette smoking can cause both asthma and COPD. Food allergies. Occupational triggers. Exercise. Infections. Hormones. Cold air. Extreme emotions. Drugs. Gastro esophageal reflux disease (GERD).

Types of Asthma Asthma of any cause is a chronic inflammatory disease of the airways. Asthma can be classified in following categories: Extrinsic asthma: It is the most common form of asthma in all age group. It usually affect young age group. When any foreign particle either an allergen or an antigen enters into the body, the immune system of the body overreacts and forms antibodies and other chemicals to defend the body. This is a natural process of the body. The production of antibodies and the other chemicals bring specific changes in the airways which leads asthma. Various inhaled allergens like pollens, animal dander and dust mites are most common causes to develop extrinsic asthma. Extrinsic asthma is also known as atopic asthma or allergic asthma. People with allergic asthma and their family members frequently have other allergy related problems such as fever, skin rashes, hives, eczema, and rhinitis.

Intrinsic asthma: The intrinsic asthma is not related with the allergies. In fact it is caused by inhalation of
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certain chemical such as cigarette smoke, fumes of motor vehicles and factories, strong odors, intake of certain medicines like aspirin; chest infections, stress, laughter, exercise, cold air, food preservatives like azinomoto or a myriad of other factors. Antibodies are not produced by the body and the cause of developing intrinsic asthma may be the irritation of the nerves or muscle in the airway. Back to top

Mixed asthma: It is mixture of allergic asthma and intrinsic asthma. These people react to some allergies but their asthma is also triggered by other things also. For example symptoms are aggravated in an asthmatic while facing the chest infection. Apart from above classification of asthma you can further categorize asthma. Your condition may have been given one of the following labels.

Cough variant asthma: Cough may be the sole manifestation of asthma or a distressing symptom. Although chronic cough can be a sign of many health problems, it may be the principalor only manifestation of asthma, especially in young children. This has led to the term cough variant asthma. Monitoring of PEF or methacholine inhalation challenge, to clarify whether there is bronchial hyperresponsiveness consistent with asthma, may be helpful in diagnosis. The diagnosis of cough variant asthma is confirmed by a positive response to asthma medication. Treatment should follow the stepwise approach to long-term management of asthma. (Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma Full Report 2007) Back to top

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Nocturnal asthma: The patients presents themselves with the symptoms like wheezing, cough, breathlessness in the night in between 2.00am to 4.00am. Such night time symptoms disturb sleep and impair the quality of life. Nocturnal asthma is defined as an overnight fall of more than 20% in the FEV1 or PEFR. Sometimes this may be the sole manifestation of asthma or an important indicator of poorly controlled day time asthma. This night time propensity is due to a number of reasons: e to dust mite, animal dander. -esophageal reflux.

off.

Back to top

Gastro-esophageal asthma: Asthma may be caused or worsened by to gastro-esophageal reflux. The symptoms of GERD are common in both children and adults who have asthma. Reflux during sleep can contribute to nocturnal asthma. Treatment with a proton pump inhibitor was reported to reduce nocturnal symptoms, reduce asthma exacerbations, and improve quality of life related to asthma. Surgical treatment has been reported to reduce the symptoms of asthma
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and the requirement for medication. For patients who have poorly controlled asthma, particularly with a nocturnal component, investigation for GERD may be warranted even in the absence of suggestive asthma symptoms. medical management of GERD be instituted for patients who have asthma and complain of frequent heartburn or pyrosis, particularly those who have frequent episodes of nocturnal asthma. Medical management of GERD includes:

- to 8-inch blocks.

For patients who have persistent reflux symptoms following optimal therapy, further evaluation is indicated and surgical treatment may be advised.

Exercise Induced Asthma: Exercise induced asthma only refers to asthma that occurs only with exercise. Before exercise pulmonary functions tends to be normal, but within 5 to 10 minutes of exercise they tend to fall. Pulmonary functions comes back to normal after rest but some times tend to remain low for a longer time. The mechanism is not clear; increased blood flow and mediator release due to change in osmotic pressure have been proposed as probable causes.

How is asthma diagnosed? The diagnosis of asthma is based on the patient's medical history, physical examination, and laboratory test results. To establish a diagnosis of asthma, the clinician should determine that:

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e.

Recommended methods to establish the diagnosis of asthma are:

Physical examination. Physical examination focusing on the upper respiratory tract, chest, and skin. triggers the asthma symptoms or when the asthma symptoms get worse .

Investigations like Spirometry to demonstrate obstruction and assess reversibility, including in children 5 years of age or older. Significant reversibility is indicated by an increase of > 12 percent and 200 mL in FEV1 after inhaling a short-acting bronchodilator (American Thoracic Society 1991). A 2 to 3 week trial of oral corticosteroid therapy may be required to demonstrate reversibility. Spirometry is necessary for diagnosis of asthma.

Differential diagnosis of asthma: INFANT AND CHILDREN: Upper airway diseases

Allergic rhinitis and sinusitis

. Obstructions involving large airways

Foreign body in trachea or bronchus. Vocal cord dysfunction. Vascular rings or laryngeal webs. Laryngotracheomalacia, tracheal stenosis, or bronchostenosis.

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Enlarged lymph nodes or tumor

. Obstructions involving small airways

Viral bronchiolitis or obliterative bronchiolitis. Cystic fibrosis. Bronchopulmonary dysplasia. Heart disease

. Other causes

Recurrent cough not due to asthma. Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux

. ADULT:

COPD (e.g., chronic bronchitis or emphysema). Congestive heart failure. Pulmonary embolism. Mechanical obstruction of the airways (benign and malignant tumors). Pulmonary infiltration with eosinophilia. Cough secondary to drugs (e.g., angiotensin-converting enzyme (ACE) inhibitors). Vocal cord dysfunction.

Medical history for asthma diagnosis:

Doctors ask about the family history of asthma, allergies including allergic rhinitis, eczema. Children who have family history of allergies, asthma have greater chances of having asthma. History of recurrent and persistent cough and cold following exposure to cold air, changing seasons.
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Exercise limited by breathing problem and wheezing Occupational history for exposure to gases, fumes, chemicals etc. Any history of emergency room visits or hospitalization following breathing problem. In the children diagnosis is mainly clinical. Doctor determines when the parents first noticed child developing breathing problem, itchy eyes, nasal stiffness, eczema.

Asthma diagnosis is suspected in all adult and children whose have following sign and symptoms:

Recurrent Wheeze which is a high-pitched whistling sounds when breathing out especially in children. (Lack of wheezing and a normal chest examination do not exclude asthma.) Cough, worse particularly at night Recurrent breathlessness or difficulty in breathing Recurrent chest tightness Recurrent lower respiratory tract infections (LRTI) Exercise induced cough/wheeze

Physical examination for diagnosis of asthma: Physical examination includes listening to breath sounds over the chest for possible ronchi or wheeze or rales, examination of nasal passage for evidence of allergic rhinitis like nasal polyps and deviated nasal septum. Peak flow meter: Peak flow meter is a small portable hand held instrument used to measure peak flow rates, or how well the airways are open. Asthma is suspected when there is more than 20% diurnal variation on 3 days or more in a week or for 2 weeks in a PEF diary. For more information click Peak Flow Meter. Lung function testing (Spirometry): If symptoms and the patients history points towards the diagnosis of asthma, the physician will perform spirometry to confirm the diagnosis of asthma. Spirometer is used to access the airflow obstruction. For asthma diagnosis airflow obstruction should be at least partially reversible.

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To establish airflow obstruction physician uses spirometer to measure (FEV1, FVC, FEV1/FVC) before and after the patient inhales a short-acting bronchodilator. For Obstruction to be present: 1. FEV1 should be less than 80 percent predicted. 2. FEV1/FVC should be 70 percent or below the lower limit of normal. Establish reversibility: FEV1 increases 12 percent or more and at least 200 ml after using a short-acting inhaled beta2-agonist (e.g., albuterol, terbutaline). NOTE: Older adults may need to take oral steroids for 2 to 3 weeks and then take the spirometry test to measure the degree of reversibility achieved. Spirometry is generally valuable in children over age 4; however, some children cannot conduct the maneuver adequately until after age 7. Challenge tests: If there are no signs of airflow obstruction and asthma is still suspected, the doctor may perform a challenge test by administrating histamine or methacholine (a substance which causes airways to contract in asthmatic individual), or may perform exercise challenge test. These tests are used mainly in clinical laboratories to evaluate airway hyper responsiveness. A trial use of asthma medication: If asthma mediications are taken and there is improvement in the symptoms, this further supports the diagnosis of asthma. Skin allergy tests: Skin tests are main tool in diagnosing allergies all over the world. It is out patient procedure and patient can go to school or office after the test. Each and every patient has different allergy profile which can be known by the skin allergy tests. Identification of allergen triggers can assist in formulating an avoidance strategy. A trial of allergen avoidance may be diagnostic and therapeutic. Mechanism of skin allergy testing: Cells and antibodies which are responsible for allergies are present under the skin as well as other parts of the body. If an allergen to which patient is allergic is applied to the skin a reaction occur and a wheal is formed. The size of the wheal is measured to grade the severity of allergy. There are number of ways to perform skin tests:

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Patch test ( used mainly for diagnosing contact dermatitis) Scratch test Skin prick test Intradermal test Skin end point titration Parasite- kustner test ( Passive transfer test)

RAST (Radio allegrosorbent technique): This test detects allergen specific IgE in the serum of the patients. The results of the tests correlate well with the skin allergy tests. One sample of the serum can be used to test many allergens. This test has many benefits over the conventional skin allergy tests. It can be used where the skin allergy tests cannot be performed like young children, severe atopic dermatitis, dermatographism, history of extreme sensitivity, patients afraid of multiple injections. The result of RAST is not influenced by drugs while skin tests are suppressed by anti allergic drugs and steroids. There is no risk of anaphylaxis with RAST. Back to top Complete Blood Count (CBC): CBC is done to rule out tropical pulmonary eosinophilia and other infections. Chest X-Ray: Chest X-ray is done if there is suspicion of presence of some other disease like infection, large airway lesions, obstruction by foreign object or heart disease. It is also done if a patient is not improving after taking asthma medication. Echocardiogram (ECG): This test is used if congestive heart failure is suggested based on history and physical examination findings. Gastroesophageal reflux assessment: A barium swallow and 24-hour pH probe is done to diagnose gastroesophageal reflux disease (GERD), especially if a patient is not responding to asthma therapy. If a patient has prominent symptoms of GERD, medical therapy is often tried without performing these tests.
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Nasal examination: Nasal examination is also done if they are suspected of contributing to the asthma severity. Procedures: 1. Direct and indirect laryngoscope is indicated if any laryngeal abnormality is suggested. 2. Cardiopulmonary exercise testing is indicated if the cause of dyspnea (breathlessness) cannot be determined.

Newer tests for the diagnosis of asthma Impulse osillometery (IOS) Impulse Osillometery is a newer technology that uses small amplitude pressure oscillations to determine the resistance of the airway. It is largely independent of effort does not require coordination, but does requires cooperation of the child. To perform IOS child holds a mouth piece in place over a 30 second period of time while breathing normally. Sound impulses of various frequencies from 5 to 35 Hz are applied to the airway through the mouth piece with total respiratory system resistance (Rrs) and reactance (Xrs) determined at various frequencies. Change in Rrs and Xrs is noted after inhalation of a beta-agonist. Young children with asthma show significant change in Rrs following beta-agonist inhalation. Till now IOS is mainly used as a research tool. Exhaled Nitric Oxide test NO is produced in discrete concentrations in the healthy human airway where it is important in physiological functions such as maintaining airway patency. NO is over produced in asthmatic individuals. It is responsible for airway inflammation (swelling) and is also the product of airway inflammation. Nitric oxide analyzers are used to measure exhaled nitric oxide (FENO). In 2003 Aerocrine exhaled nitric oxide monitoring system NIOX was granted clinical approval by USFDA for age of 4 to 65 years. The analyzer measures Nitric oxide by a chemiluminescent reaction with ozone. NO is drawn into the chamber and is combined with ozone. The reaction yields NO2, O2 and a photon, which is captured by the photomultiplier tube that analyzes and reports a proportional value of Nitric oxide. FENO is measured as part per billion (ppb) in asthmatic patient. Normal values vary with the patient, but it is considered that 20 to 30 ppb in the steroid naive patient is indicative of inflammation.

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Potential of FENO to predict exacerbations of asthma was recently examined and levels were found to be elevated before the fall in lung functions or the development of clinical symptoms of asthma exacerbations. There are two methods of collecting exhaled nitric oxide. An offline technique, where Nitric oxide is collected in special reservoir, that allows storage and subsequent analysis of nitric oxide content. An online nitric oxide techniques use continuous sampling and quantification during exhalation for dynamic measurement and flow analysis. Ingestion of foods containing nitrates, smoking status, ambient nitric oxide level, nasopharyngeal contamination, airway infections and drugs such as leukotrienes modifiers may effect the actual collection and quantification of exhaled nitric oxide. Patients are asked to take nothing by mouth for one hour before sample collection.

Childhood Asthma

Childhood Asthma is number one chronic diseases of childhood, and is the most common cause of emergency room visit and hospitalization for the children under the age of 18 years. The cost of asthma related illness accounts to about $ 10 billion worldwide. Asthma is the most common cause of school absenteeism due to chronic disease and also causes parents to miss days at work. Asthma often goes unrecognized in the children. Many children have more subtle symptoms including a night time cough, a cough that worsens with exercise or activity, or only a chronic cough that won't go away. In these children especially for infants and toddlers asthma can be hard to diagnose. Asthma cannot he cured, it can almost always be controlled. A child can live an active life if asthma is controlled properly.

THE RESPIRATORY SYSTEM The Respiratory system is basically concerned with the exchange of gases between the air we inspire and the blood. Lungs provide surface for transfer of gases through which blood gets rid of carbon dioxide and absorb oxygen which is vital for living. Lung is a cone shaped
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structure situated in the thorax; it is where the exchange of gases takes place. As the air passes through the nose and mouth, it is rapidly warmed and moistened. The nose and airways trap large particles (dust, pollen, molds bacteria) and chemicals (smoke. sprays, odors) which could cause serious injury to the lungs. The air is then transported through smaller airways. These airways branch like a tree forming millions of small airways that carry oxygen to the tiny air sacs called alveoli. The alveoli have network of capillaries around them. The gas exchange takes place here. The airways have a delicate cellular lining (mucosa), which is coated with a thin layer of mucous. Foreign particles are trapped by the sticky mucus and are removed by the normal cleansing process present in the airways. The process is assisted by the movement of millions of tiny whip like structures called cilia. Cilia are present on the inner lining cells of the airways. Cilia move the mucus and trapped foreign particles up toward the mouth and nose where they, are coughed and sneezed out or swallowed. Bundles of muscles surround the airways and the contraction of these muscles allows airways to selectively direct the flow of air. Back to top WHAT IS ASTHMA? Asthma is a chronic inflammatory condition of the bronchial (lung) airways. This inflammation causes the airways to become over-reactive to various stimuli, thus producing increased mucus, muscle swelling and muscle contraction These changes produce airway obstruction, chest tightness, coughing and wheezing. If severe this can cause severe shortness of breath and low oxygen levels in the blood. This obstruction is partially or completely reversible with or without treatment. Each child suffers a different level of severity. All children with asthma enjoy a reversal of symptoms until something triggers the next episode. WHAT IS THE CAUSE OF ASTHMA? Childhood asthma is a disorder with genetic predisposition and is caused by complex interaction between genetic and environmental factors. Approximately 75 to 80 percent of children with asthma have significant allergic problem. As stated earlier asthma is a chronic inflammatory disease of the airways. Every asthmatic patient has some degree of inflammation of airways of the lungs. This inflammation is produced by many factors mainly allergy, viral respiratory infections and airborne irritants. Studies indicate that allergic reactions produce both immediate and late phase (delayed) reactions. Research indicates that approximate half of the immediate allergic reactions to inhaled allergens are followed by a late phase reaction. This late phase reaction produces more serious injury and airway inflammation. This airway
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inflammation leads to Irritability or hyper responsiveness of the airways. In addition, prolonged airways, inflammation can cause scarring. Back to top WHAT ARE THE SIGNS AND SYMPTOMS? The common asthma symptoms are wheezing, coughing, chest tightness, shortness of breath, faster or noisy breathing. Wheezing though characteristic of asthma, is not its most common symptom. Coughing is noted with even "hidden" asthma when wheezing may not be apparent to childs family members or the physician. Any child who has frequent coughing or respiratory, infections (pneumonia or bronchitis) should be evaluated for asthma. The child who coughs after running or crying may have asthma. Coughing from asthma is often worse at night or early in the morning, making it hard to sleep. Infants who have asthma often have a ratty cough, rapid breathing and an excessive number of respiratory infections, episodes of bronchitis or chest colds. Obvious wheezing episodes might not be noted until after 18 to 24 months of age. Chest tightness and shortness of breath are other symptoms of asthma that may occur alone or in combination with any of the above symptoms. Since these symptoms call occur for reasons other than asthma, other respiratory diseases must always be considered. In a young child the discomfort or chest tightness may lead to unexplained irritability. Note: If your child has frequent coughing or respiratory infections (pneumonia or bronchitis) he or she should be evaluated for asthma. During an acute episode, symptoms vary according to the severity. Mild episode: Child may be breathless after physical activity such as walking. They can talk in sentences and lie down, and they may be agitated. Moderate severe episode: Child is breathless while talking. Infants have feeding difficulties and a softer, shorter cry. Severe episode: Child is breathless during rest, are not interested in feeding, sit upright, talk in words (not sentences), and are usually agitated. Symptoms with imminent respiratory arrest (In addition to the above symptoms), the child is drowsy and confused. However, adolescents may not have these symptoms until they are in frank respiratory failure. Absence of wheezing in severe asthma is associated with most severe airway obstruction and is a serious emergency situation.

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What IS hidden ASTHMA? Many times diagnosis of asthma is missed due to absence of classical signs of asthma i.e. wheezing, rapid breathing and coughing become obvious. The condition of many children with asthma will go undetected if careful examination is not done. These children with asthma usually suffer some degree of airway obstruction: and unless it is brought under control, the children may suffer respiratory illness more frequently. Hidden asthma however can produce so few recognizable symptoms that even the physician might not be able to distinguish abnormal breath sounds with his or her stethoscope. Pulmonary function testing usually reveals these cases of airway obstruction. Children with family history of atopy and allergy and who are also having recurrent cough and respiratory infections must be suspected for having asthma. Parent's input can be vital for diagnosing asthma. What usually triggers ASTHMA? Episodes of asthma often are triggered by some condition or stimulus. Some common triggering factors are:

Air pollution.

House dust mites.

Molds indoor and outdoor.

Cockroaches.

Environmental factors (cold air, fog, ozone, sulfur dioxide, cigarette smoke, diesel fumes).

Changing weather and temperature.

Pollens from flowers of grass and trees.

Exercise

Irritant dust and fumes and strong odors from fresh paints and cooking.
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Food addictives and preservatives (monosodium glutamate, tartarzine, metabisulfite).

Warm blooded pets (like dogs, cats, birds, and small rodents).

Pharmacological agents (aspirin, other NSAIDs, beta blockers).

Viral infections.

Strong emotions such crying and laughing.

CLICK: How to control asthma triggers

Back to top Exercise Exercise induced asthma is a subset of asthma which is initiated by exercise. Running can trigger an episode in over 80 percent of children with asthma. Swimming is the most asthma friendly exercise. Exercise induced asthma can be prevented by the use of short acting beta2 agonist like Salbutamol (albuterol) inhaler 15 minutes before exercise. If child is engaged in almost daily exercise schedule, long acting beta-2 agonists are preferred. IRRITANTS Air pollution, cigarette smoke, strong odors, aerosol sprays and paint fumes, strong odors are same the substances which irritate the tissues of the lungs and upper airways. Cigarette smoke is highly irritating and can trigger asthma. Cigarette smoking certainly should be avoided in the home of any child with asthma. Parents must be persuaded to quit smoking. It has been shown that when the parents of a child with asthma stop smoking, the child's asthma often improves. Irritants must be recognized and avoided. Back to top Weather There are number of climatic conditions that trigger asthma in children. Cold air is a common
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trigger for asthma. Pulmonary function studies demonstrate that breathing cold air provoke asthma in most of asthmatic children. Precautions may be necessary to avoid inhalation of cold air. A heavy scarf, warn loosely over the nose and mouth will also help avoid cold air induced asthma. Wearing a special ski mask designed for this purpose also helps. The weather affects outdoor inhalant allergens (pollens and molds). On a windy day more allergens will be scattered in the air, while a heavy rainfall will wash the air clean of allergens. On the other hand, a light rain might wash (just pollen but actually increase mold concentration. Moving to a new area may not always help in reducing asthma severity. There may be short term improvement but in long term this benefit vanishes. There does not seem to be one best climate for all children with asthma. Back to top Emotions Emotional factors are not the cause of asthma as many believe but emotional stress can infrequently trigger asthma. A child's asthma might only, be noticeable after laughing, crying or yelling in response to an emotional situation. These emotional' responses involve rapid and deep breathing that cools and dry the airway which in turn can trigger asthma. Emotional stress itself (anger, anxiety, frustration) also can trigger asthma but only in allergic or a topic children who are already suffering from asthma. Emotions can aggravate asthma. Many children with asthma suffer from severe anxiety during an episode as a result of suffocation produced by asthma. The anxiety and panic can then produce rapid breathing or hyperventilation, which further triggers the asthma. For this reason, anxiety and panic should be controlled as much as possible during the episode. The parent should remain calm, encourage the child to relax and breathe easy and give appropriate medication. Treatment should be aimed at controlling the asthma. When asthma is controlled other emotional factors can then be dealt with more effectively. As with any other chronic illness asthma is also associated with secondary psychological problems. Severe psychological problems require a specialist to help the child and his or her family. Is my child suffering from asthma? Recurrent chest problems in your child may be due to childhood asthma. Go to the questioner and answer the questions in yes and no. If the answer is yes it may be asthma. Consult your family physician for further analysis.

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Diseases mimicking childhood asthma (differential diagnosis) Upper airway diseases.

laryngeal webs.

Obstructions involving small airways.

Recurrent cough not due to asthma.

Recent advances in diagnosis of childhood asthma:

Impulse osillometery (IOS) Impulse Osillometry is a newer technology that uses small amplitude pressure oscillations to determine the resistance of the airway. Read More

Exhaled Nitric Oxide test. NO is produced in discrete concentrations in the healthy human airway where it is important in physiological functions such as maintaining airway patency. NO is over produced in asthmatic individuals. It is responsible for airway inflammation (swelling) and is also the product of airway inflammation

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Elderly with asthmaExcept for some precautions, goal of asthma treatment in elderly is same as that in other age group. The main points to remember and consider in elderly people suffering with asthma are discussed below. 1. Elderly asthmatics are usually suffering from few other medical conditions that may interfere with asthma treatment. This includes hypertension, IHD, diabetes mellitus and other related diseases. 2. Elderly do not respond as well to drug treatment as young people, so drugs must not be overused as they may aggravate other medical conditions like cardiac disease, arthritis etc. 3. Patient should tell his doctor which medicines he/she is taking for which disease. Medicines that may aggravate asthma like aspirin (commonly used in cardiac conditions and arthritis) and beta-blockers (atenolol) are to be avoided. 4. It is important not to misdiagnose asthma as COPD because asthma has a different natural history and a better prognosis with treatment. COPD is mainly a disease of smokers. Read more about COPD. 5. Dyspnea (breathlessness) in elderly occurs due to many causes that include congestive heart failure and other forms of chronic heart and lung diseases. 6. Smoking or exposure to tobacco smoke should be avoided. 7. When doing spirometry in elderly, a consistent pattern of decreasing FEV1 in tests repeated during the session is suggestive of asthma. 8. Depression is very common in elderly and can decrease their compliance to the treatment of asthma. Depression is also one of the most treatable problems in the elderly so should not be ignored. 9. Indoor allergens or triggers (dust mite, molds etc.) may be more important to evaluate than outdoor allergens since most elderly people spend more time in their homes than outside. The specific allergen will vary by geographic region. Allergy testing can identify the offending allergen.

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10. Diseases that mimic asthma in elderly are: a. Chronic Obstructive Pulmonary Disease. b. Interstitial Lung Disease. c. Bronchiectasis. d. Cardiac Disease (Angina, IHD and Congestive Heart Failure). e. Upper Airflow Obstruction (Encroaching tumors, vocal cord paralysis, and thyroid enlargement). f. Pulmonary Embolism. g. Bronchogenic carcinoma. h. Aspiration. i. Gastroesophageal Reflux. 11. Elderly patients with asthma can also have chronic, persistent airflow obstruction with poor bronchodilator responsiveness; a trial of therapy with corticosteroids for 15 days or more may be necessary to establish that there is reversible airflow obstruction. 12. Coexisting conditions (e.g., respiratory infections, gastroesophageal reflux) may exacerbate asthma, hinder effective therapy, and reduce asthma control. 13. Some asthma medications (e.g., theophylline, beta-adrenergic bronchodilators) can elicit adverse responses (e.g., cardiac ischemia or arrhythmia, drug toxicity, gastroesophageal reflux) in susceptible patients with coexisting disorders (e.g., ischemic heart disease, congestive heart failure, acute myocardial infarction, gastroesophageal reflux). 14. Nonselective beta-adrenergic blocking agents (like Timolol, atenolol), even in minute quantities as present in ophthalmic solutions, should not be prescribed for patients with asthma, because they can produce severe bronchospasm and perhaps anaphylaxis. 15. System corticosteroids, thiazide diuretics and beta2-agonists may contribute to hypokalemia (decreased potassium in blood) therefore routine monitoring of serum potassium and magnesium for early detection of electrolyte imbalance should be done.

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16. Many elderly patients with asthma have concurrent rhinitis or sinusitis for which they take antihistamines (terfenadine and astemizole) which have the potential to produce prolongation of the QTc interval that could lead to ventricular arrhythmias such as Torsade de Pointes 17. Angiotensin-Converting-Enzyme (ACE) Inhibitors. can produce chronic cough in some patients. 18. Review of patient technique in taking medications is also important; not infrequently, a failure to respond adequately to therapy is a result of improper medication/inhaler technique. 19. Peak flow meter: The effectiveness of home peak flow monitoring among the elderly has not been clearly established. 20. Allergy Tests: Allergy skin tests or studies of specific IgE need not be routinely performed because allergens seem to play a less important role for elderly patients than younger patients. 21. Respiratory infections and medications for other diseases are the most common asthma triggers in elderly patients. 22. Measures to avoid or control asthma triggers should be specific to the patients asthma and allergy history. 23. Avoidance of exposure to allergens and tobacco smoke, both active and passive, is important as with asthma patients of any age.

Occupational Asthma Introduction of occupational asthma: Are you often getting sick at your job? Answer the following questions in yes and no. If the answer of any one is yes then you may be suffering from Occupational asthma:

Do you experience coughing, wheezing or shortness of breath at work? Do you have itchy red eyes or running nose at work?
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Does the problem goes when you are away from work and comes back when you return to work?

Occupational Asthma is the most common occupational lung disease in most part of the world. It is responsible for 2 % to 15 % of the asthma prevalence. The frequency varies widely between different occupations and within industry at different level of exposure. Occupational asthma is a respiratory disease caused by the exposure to a trigger at the work place (be it dust, gases, vapors, fumes or chemicals). When inhaled these triggers irritate the airways and may cause Coughing, sneezing, chest tightness, pain in chest, difficulty in breathing. It may be associated with skin, eye and other allergies. Types of Occupational asthma: Generally two types of asthma attack occur:

Occupational asthma without latency

Asthma attack brought on immediately by exposure to extremely high levels of irritant gases such as ammonia, sulfur dioxide, chlorine. This is also known as Reactive Airways Dysfunction Syndrome (RADS)

Occupational asthma with latency (Long term sensitization)

Body develops an allergy from continuous exposure to a specific substance, sometimes over the period of months and years. Symptoms of OA occur when body develops allergic response to the substance Due to exposure to the trigger asthma attack is precipitated. The walls of the airways become inflamed and swollen. Lot of mucous is secreted blocking the airways. This makes it difficult for the air to be exhaled or pushed out of the lungs. Substances causing Occupational Asthma: Substances which cause Occupational Asthma are commonly known as triggers. At least 240 substances are known to cause Occupational asthma when inhaled. They are classified in 5 categories.
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Respiratory irritants: Like smoke, sulfur dioxide, chlorine gas, ammonia. Grain flour and food allergens: Like Grain dust and flours (like wheat & rye), proteins of cereal grains, sea food, egg processing, green coffee beans, castor beans, ispaghula. Animal allergens & proteins: These are found in hairs, furs, dander, scales, saliva and other body wastes like excreta. Enzymes: Enzymes are used in pharmaceuticals, detergents, flour conditioners, etc. Chemicals: 1. Acid anhydrides, isocyanides, complex platinum salts, poly amines, 2. Reactive dyes, units manufacturing paints, varnishes, adhesives, 3. Laminates, soldering fluxes, resins used in soldering. Industries at risk for occupational asthma: Most of the triggers are found widely in almost all industries and work places. But not every one will develop asthma after exposure to them. Some people are more susceptible to asthma than others. OA is more common in susceptible individual working in following industries:

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with animals

The development of occupational asthma depends on: 1. Family history of asthma & allergy 2. Amount of allergen exposure 3. Frequency of exposure to the trigger 4. Cigarette smoking (smoking doubles the chances of having occupational asthma) Cigarette smoking doubles the risk of occupational asthma, possibly by recruiting the inflammatory cells into the lungs where they are available to react with the irritants and sensitizers. Repeated exposure over several months causes steady deteoration of lung functions. Clinical features then become indistinguishable from chronic obstructive lung disease. Common irritants like cold air, smoking can precipitate asthma attack. Symptoms Of Occupational Asthma The most characteristic feature in the medical history is symptoms of asthma that worsen on week days and improve in holidays and rest days. The following are the most common symptoms of occupational asthma. Person may have few or all of them

Coughing
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Wheezing Chest tightness Breathlessness Chest pain Excessive fatigue

In addition to the above symptoms, many other allergic symptoms can also occur. They show presence of irritants (allergens) in the air Skin- itchy, red (urticaria) or irritated. Nose- Itchy, blocked or stuffy, sneezing Eyes- Red, itchy, burning or watery. In most people symptoms appear at work or within several hours after leaving work. The asthma symptoms improve on weekends, vacations, or when away from work or chemical causing symptoms. Usually improvement occurs immediately after the cessation of exposure but some times it takes more than 2 days to recover. Thus true relationship between occupation andasthma can only be ascertained after prolonged cessation of the exposure allowing sufficient time for the lungs to recover. Reappearance of the symptoms immediately after the patient returns to work almost confirms the diagnosis. When to see a doctor: If you get asthma or related symptoms at work, and the symptoms get better when you are away from work on leave or vacation, contact doctor for evaluation. Occupational asthma is totally controllable and preventable disease if person gets right medical attention at right time. Prolonged exposure can cause permanent lung damage, and some amount of pulmonary functions may be lost for ever. If you have occupational asthma you must have an emergency asthma action plan prepared by your doctor. Emergency medicines must be available at the factory or unit.

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If you have attack, ask a friend to take you to the nearest hospital emergency department or call for an emergency ambulance service. Diagnostic tests and evaluation for occupational asthma: During the evaluation for occupational asthma the doctor will inquire about your respiratory symptoms and type of work. He will then try to establish the relation between them. Clearly describe in detail all the symptoms and when and how frequently they occur. How they are relieved. Also describe your job and job conditions. Chemicals and other substances you are exposed to ( like gases, dust, fumes, vapors, animal products, chemicals and other irritants). Proper diagnosis is essential to ensure that most appropriate treatment is given. Gold standard for the diagnosis of OA in the pulmonary laboratory is a specific inhalation challenge using the suspected agent. Following breathing tests will be done to determine the condition of the lungs. Spirometry: All patients with suspected occupational bronchial asthma should have and assessment to the response to bronchodilators. Spirometer is a device which measures the air flow rates in different parts of the airways. Peak flow meters: Peak flow meter is a small portable device used to measure how forcefully a person can blow the air out of the lungs. This test can also be done at the workplace during the asthma attack. Blood examinations including blood gas analysis during attack. Skin test and serology: They may be used in identifying the suspected irritant. However selection and preparation of the agent for skin testing is difficult. The positive test indicates previous exposure to the agent, but cannot confirm that the same agent is responsible for the OA. X-Ray Chest-PAV: Chest radiograph is usually done to rule out causes other than OA. Treatment of occupational asthma The goals of treatment are same as with asthma of any other cause:

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According to NHLBI, asthma therapy has following components: 1.Patient education. 2.Control of factors contributing to severity. 3.Drug therapy. 4.Access the severity of disease and monitor the therapy. The keystone of effective treatment is cessation of further exposure to the offending agent. However this is not always possible. In mild OA, avoiding the exposure to the triggers relieves the symptoms. You may be advised to wear mask or respirator during work. In moderate disease avoiding triggers and medication are usually helpful. In severe OA people may be required to consider switching to different job where the particular allergen is not present. Patient education: Patient education is an integral part of the asthma therapy. It should begin as soon as asthma is diagnosed and should be integrated in every step of the asthma management plan. Patient should ask their treating doctor about the written asthma treatment (action) plan. Monitoring the asthma: Periodic assessment and monitoring asthma in patients is a important part of anyasthma management plan. There are two ways of monitoring asthma in patients, Periodic assessment by the treating doctor and self assessment by the patient himself. The patient should know when the asthma is controlled and when it is worsening. Monitoring asthma should include: A peak flow meter A peak flow meter is a device used to measure how well the air move out of
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the lungs. Airways narrow during the asthma episode causing decreased air flow. The peak flow meter can measure these changes and can warn about the imminent asthma attack days or even weeks before it actually happen. Peak flow readings can help patients recognize if asthma is properly controlled or not. A diary Patient should keep a diary to record his daily asthma symptoms and the environmental factors that bring on the asthma attack or make the symptoms worse. He should note what work he was doing when the attack was precipitated. The exposure of chemical agent before attack. DRUG TREATMENT: There are two types of drug therapies: 1.Oral therapy. 2.Inhaled therapy. Oral medication include tablets and capsules of bronchodilators like salbutamol, terbutaline, theophyllines, newer medicines like leukotriene pathway inhibitors (zafirlukast, montelukast, zileuton). Anti inflammatory medications include predisolone, methylprednesolone etc. Inhaled medication includes reliever and preventer medication. Reliever medications are those which are given for immediate relief and control of the asthma symptoms. They include short acting (salbutamol, terbutaline, bitolterol, pirbuterol) and long acting (formaterol, Salmeterol) bronchodilators. Preventer medicines are anti inflammatory agents given to reverse the pathological process causing asthma. They include triamcinolone, fluticasone, budesonide, beclomethasone.

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Exercise Induced Asthma (Exercise Induced Bronchospasm)

Exercise Induced Asthma (EIA) or Exercise Induced Bronchospasm(EIB) or exercise induced bronchoconstriction refers to asthma that occurs only with exercise. The reported incidence of EIA varies between 5% and 20% of the general population. During start of exercise pulmonary functions tends to be normal, but within 5 to 10 minutes symptoms of asthma such as wheezing, breathlessness, tightness of chest appear. Patient may also feel extreme fatigue. After a rest period, the symptoms subside. But sometimes symptoms may become worse for a longer time. Hyperventilation and airway cooling are the two most important triggers of EIA. People with exercise induced asthma have airways that are sensitive towards changes of temperature and humidity. Hyperventilation during exercise is the primary event which causes cascade of events leading to EIA. Hyperventilation causes drying of the airway surface epithelium where by causing dehydration of the airway cells and increased intracellular osmolarity. The increased osmolarity results in the release of mediators from mast cells and damage airway epithelial. The mediators released during EIA include histamine, leukotrienes, cytokines, etc. All these events are called inflammatory reaction which is the root cause of asthma. Other but less important cause of EIA is the airway cooling that is found with hyperventilation during exercise. During rest we breath through nose. Nose has a temperature and humidity control mechanism that makes air humid and at body temperature. When we exercise we breath through mouth, our respiration becomes rapid (hyperventilation). This forces cold and dry air into the airways. After the exercise is over, the small bronchiolar vessels around the tracheobronchial tree warm up, and this reactive hyperemia leads to exudation of serum into the interstitial fluid and release of mediators that subsequently causes airway muscles to contract and also walls of airways become inflamed resulting in narrowing of airways.

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How is exercise induced asthma diagnosed? Diagnosis of EIA can easily be made symptomatic. Person is usually normal before exercise. During exercise he experiences shortness of breath and/or chest tightness, wheezing, and cough. After a period of rest , the symptoms subside. Sometimes symptoms such as prolonged cough after exercise, chest pain and fatigue may last longer. The diagnosis of EIB can also be confirmed by a variety of tests, such as exercise challenge, methacholine challenge, or eucapnic voluntary hyperpnea. The International Olympic Medical Commission recommends any or all of these tests, but in most cases the Eucapnic Voluntary Hyperventilation (EVH) test is the easiest to perform. If exercise challenge is to be performed, then this should be done in the athlete's sport. "Pure" EIA and persistent asthma with an exercise exacerbation can be differentiated by spirometry. During rest if the forced expiratory volume in 1 second (FEV1) is not normal, patient is administered an inhaled beta-agonist and test is repeated after 15 minutes. If the FEV1 improves 12% or more, that is an indicator of mild persistent asthma, and the patient should be treated for the persistent asthma in addition to the EIA. A 15% drop in FEV1 after 6 minutes of running or other exercise can be diagnostic of exercise induced asthma. Back to top

What is the treatment of exercise induced asthma? Treatment of EIA is same as that of asthma. Short-acting beta-agonists, such as albuterol (salbutamol) are use full before exercise. Albuterol should be taken 15 minutes before exercise to reduce chances of EIA. Inhaled steroids are also very effective for EIA but must be given daily and take about 2 weeks for effectiveness. Cromolyn and nedocromil can be given just prior to exercise like albuterol and work quite well.
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Leukotriene modifiers, such as montelukast, are given as a daily pill and do help reduce EIA, but they are not as effective as the inhaled products. Some patients may benefit from anticholinergics, such as Ipratropium. Many patients may require two or three medicines to treat EIA successfully. High-intensity warm-up before the exercise is helpful for reducing the EIA. A low-salt diet and fish oil supplementation are other nonpharmacologic therapies that have been shown to reduce airway inflammation and reduce EIA.

What is the precaution I can take to prevent the attack? With proper control of asthma, most adults and children with asthma call participate fully in physical activities. If needed you should take 2 puffs of short acting reliever (one with blue cap) inhaler 15 minutes prior to exercise. This usually prevents the attack. Back to top

Is exercise beneficial for EIA patients as with rest of people? Exercise reduces the risk of cardiovascular disease, diabetes, obesity and other health related problems in asthmatic person as in any other person. Aerobic exercise programs have shown to reduce airway responsiveness in patients who do them regularly. Studies also suggests that asthma sufferers who exercise regularly have fewer exacerbations, use less medication, and miss less time from work and school.

What are the exercise goals for asthma patients? The exercise goal for people who have asthma, as for most people, should be 20 to 30 minutes of activity that raises heart rate to 60% to 85% of maximum, four or five times a week.
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Which sports/ games are more suitable for EIA patients? Aerobic exercises like swimming, running or biking or which exposes the exerciser to warm, humid and moist air that tempers the effect on the airways are more suitable for asthmatic patients. The sports that require short bursts of activity interspersed with breaks, are least likely to trigger asthma attack. Some of the sports that are least likely to induce EIA are:

-distance running and track/field events,

. Yoga may help manage asthma. Sahaja yoga is a type of meditation based on yoga principals that was found to be somewhat effective in managing moderate-to-severe asthma.

On which days I should skip exercise? If you are wheezing, when allergies are particularly troubling, or when peak flow testing suggests a decline in lung function. These are signs that you have higher chances of having exercise induced asthma on that particular day.
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Back to top

Is it risky to exercising when pollen counts are high in the environment? EIA is believed to be inflammatory in nature but another stimulus an allergic asthmatic reaction due to inhaled airborne allergens in the EIA patient with inhalant allergies may also be present. These two stimuli (exercise and inhaled allergens) may be additive or synergistic. Exercising when pollen counts are high may cause more severe EIA in EIA patients allergic to pollens. Also read <How to control asthma triggers>

Which is the most common condition mimicking EIA? Vocal cord dysfunction is a disease that mimics EIA. In vocal cord dysfunction the patient has inspiratory stridor because of partially closed vocal cords. Patients complain of throat tightness rather than a chest tightness. These patients also have the major symptom of dyspnea with little or no wheezing or cough. In these patients the usual medications for EIA are not helpful. The diagnosis is best made by rhinolaryngoscopy after exercise, showing closure of the cords on inspiration. But vocal cord dysfunction may coexist with EIA making diagnosis difficult.

Winners With Exercise Induced Asthma: What do Jackie Joyner-Kersey, Dominique Wilkins, Nancy Hogshead, , Bill Koch, Greg Louganis, Jim Ryun and marathon runner and world record holder Haile Gebrselassie have in common? They are world famous athlete who has asthma. They come from diverse fields: swimming, track and field, cross-country skiing, diving, basketball, and longdistance running. Studies have shown that up to 35% of students and 50% of
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elite cold weather athletes may have EIA. Properly following their Asthma Action Plan help them become winners.

Which sports are more likely to cause EIA: Sports and games that are played in cold weather or require continuous exercise or activity are most likely to trigger an asthma attack.

-distance running, Hockey (ice and field), -country skiing. Back to top

Examples of potentially harmful substances that are inhaled in different sports: Sports Biathlon Cross-country skiing Nordic combined Swimming Figure skating, Speed skating, Ice hockey Potentially harmful substances

Cold, dry air

Organic chloride chemicals (chloramine and trichloramine) Nitrogen oxide from freezing machinery Ultra particles from polishing machines.

Approval of asthma medication during sports:

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Most drugs can be used by athletes with documented asthma, except systemic steroid, systemic 2 -agonists and other adrenergic drugs. These drugs have strict rules that athletes must follow if they have to take them. If athlete declares that he is using inhaled steroids and/ or inhaled 2 -agonists like albuterol and salmeterol, approval is not required. For systemic steroids and 2 -agonists, athlete must show clinical sign of asthma and bronchial hyperresponsiveness (BHR), which must be confirmed by bronchial challenge test. Leukotriene antagonist (like monteleukast sodium) and/or ipratropium bromide are effective and can be used in mild exercise induced asthma, as these drugs have no restrictions. If you are a elite athlete competing in any big (national or international) event, you must ensure that your current treatment is permitted by authorities.

Treatment and goals of Asthma management Main aim of asthma treatment is help asthma patient leads a healthy and productive life. The goals of asthma treatment are to: 1. Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the night, in the early morning, or after exertion). 2. Maintain (near) normal pulmonary function. 3. Maintain normal activity levels (including exercise and other physical activity) 4. Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or hospitalizations 5. Provide optimal pharmacotherapy with least amount of adverse effects 6. Meet patients and families expectations of and satisfaction with asthma care The Four Components Of Asthma Treatment and Management: 1. Measures of assessment and monitoring asthma, 2. Patient Education for a partnership in asthma care,
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3. Pharmacologic therapy for asthma, 4. Allergy immunotherapy. The Expert Panel Reports presenting clinical practice guidelines for the diagnosis and management of asthma have organized recommendations for asthma care around four components considered essential to effective asthma management. Measures of assessment and monitoring asthma: This is essential part of asthma treatment and includes objective tests, physical examination, patient history and patient report. This is used to diagnose and assess the characteristics and severity of asthma. It also monitor whether asthma control is achieved and maintained. Patient Education for a partnership in asthma care: Patient education is an essential component of successful asthma treatment. It should begin at the time of diagnosis and be integrated into every step of asthma treatment. Asthma education programs have led to improved patient outcomes, including reduced hospitalizations and emergency room visits, fewer asthma symptoms and physician visits, and improvement in asthma management skills. However, the performance and adequacy of education is not easily assessed through medical record review. Therefore, the review and the indicators that follow will not focus on the patient-education component of care. Asthma treatment should also include control of environmental factors and co morbid conditions that affect asthma.

Pharmacologic therapy for asthma: Asthma treatment has several components: patient education, control of factors contributing to severity, and pharmacological therapy. Asthma treatment also include use of objective measures to assess the severity of disease and monitor the course of therapy.

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Corticosteroids Corticosteroids are the most potent and the most effective antiinflammatory medication currently available for treatment of asthma. Antiinflammatory medications are proven to improve lung function (i.e. FEV1, airway hyperresponsiveness) and to decrease symptoms, exacerbation frequency, and the need for rescue inhalers. Inhaled forms are used for long-term control of asthma, and are now the mainstay of asthma therapy, Oral or systemic corticosteroids are often used to obtain prompt control of the disease when beginning long-term asthma treatment. Inhaled corticosteroids, at currently approved doses, are safe and effective for the treatment of asthma and are being utilized more frequently as primary therapy. In any patient requiring chronic asthma treatment with oral corticosteroids (i.e., exceeding one month in duration), a trial of inhaled corticosteroids should be attempted in an effort to reduce or eliminate oral steroids. High doses of inhaled steroids are used if conventional doses fail to permit oral steroid tapering. Pulmonary functions (PEF or FEV1) are monitored during tapering. Prolonged daily use of oral corticosteroids is reserved for patients withsevere asthma despite use of high-dose inhaled corticosteroids. In patients on long-term oral corticosteroids, pulmonary function tests should be used to objectively assess efficacy.

Mast cell stabilizers Cromolyn sodium and nedocromil are mild-to-moderate non steroidal anti-inflammatory medications with a strong safety profile. Both compounds have been shown to reduce asthma symptoms, improve morning peak flow, and reduce the need for quick-relief beta2-agonists. The clinical response to cromolyn and nedocromil is less predictable than the

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response to inhaled corticosteroids. This agent is often tried inchildhood asthma, given its safety profile, but may take a month to work. Beta2-agonists Inhaled short-acting beta2-agonists are the medication of choice for the prevention of exercise-induced bronchospasm and for the immediate treatment of acute asthma exacerbations. There appears to be some consensus in the medical community that regular (i.e., four times daily) use of beta2-agonists should be discouraged in favor of anti-inflammatory treatment. Inhaled long-acting beta2-agonists are used as an adjunct to anti-inflammatory therapy for providing long-term control of symptoms, especially nocturnal symptoms, and to prevent exercise-induced bronchospasm. Long-acting beta2agonists are not to be used for exacerbations. The frequency of beta-agonist use can be a useful monitor of disease activity. Patient education regarding correct use is critical. Note:

prescribed by your doctor.

call your doctor or emergency room. -acting beta2-agonists are not to be used for exacerbations. Methylxanthines Theophylline, the methylxanthine principally used in treating asthma, provides mild-to-moderate bronchodilation. Monitoring serum theophylline concentrations is essential to ensure that therapeutic, but not toxic, doses are achieved. Recent evidence suggests that low serum concentrations of theophylline are mildly anti-inflammatory. Sustained-release theophylline is mainly used as adjuvant therapy, and is particularly useful for controlling symptoms of nocturnal asthma.
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When there are issues concerning cost or adherence to regimens using inhaled medication, sustained-release theophylline can be considered as an alternative long-term preventive therapy, but is not preferred. Note: Patients on chronic theophylline should have a serum theophylline determination at least once each year to decrease the risk of theophylline toxicity. Elderly asthmatics should also be monitored closely as they may be suffering from other illness like heart disease. Leukotriene Modifiers Leukotriene modifiers can be considered an alternative therapy to low doses of inhaled steroids or cromolyn or nedocromil for patients 12 years of age (childhood asthma) or older with mild persistent asthma. According to the 1998 Leukotriene Working Group, leukotriene pathway modifiers may be useful as first-line therapy for mild persistent asthma or as an add-on or glucocorticoid-sparing medication in others. These agents are less effective than glucocorticoid inhalers but tend to improve compliance because of once-a-day oral dosing. Anticholinergics Ipratropiium bromide may be an alternative bronchodilator for some patients who do not tolerate inhaled beta2-agonists. It may also provide some additive beneInfluenza vaccinations: NHLBI guidelines recommend annual influenza vaccinations for patients withpersistent asthma. Immunotherapy: Also known as Specific Immunotherapy or SIT, this therapy has many names like desensitization, hypo sensitization, allergy shots, allergy vaccines and allergy injection therapy. This was discovered in 1911 by Leonard Noon at the St. Marys Hospital, London. This therapy had its high and low times and is now accepted as the corner stone of treatment for allergic disorders.
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The allergies are selected by skin tests and a vaccine is prepared. Subcutaneous injections of the allergen extract are given to the patient. They injections are initially given in low concentration usually 1:5000 twice a week, then slowly increased to 1:50 concentration and once a month. The immunization is usually done for 5 years. Indications for immunotherapy: SIT is a well tested therapy for allergic disorders. This has been proven by many well controlled trials. SIT has potential for altering the course of the disease and can even prevent progression. Main indications are:

SIT has no place in treating skin allergies. In fact it is contraindicated in urticaria as it may aggravate the disease. Children below the age of 5 years should not be given immunotherapy as there are greater chance of adverse reaction and anaphylaxis. Results of immunotherapy are also not as effective beyond the age of 50 years. Immunotherapy can be safely given in pregnancy. No harm has ever been reported to mother or fetus. If a lady becomes pregnant during immunotherapy the therapy is continued as such. But SIT is usually not started during pregnancy. Patients on Beta blockers should tell the doctor about the drug.fit to inhaled beta2-agonists during severe exacerbations

Asthma FAQ of the day What are asthma symptoms during asthma attack:
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Full-blown attack of asthma attack is usually episodic and has following symptoms: 1. Wheezing A high-pitched whistling sounds when breathing outespecially in children. (Lack of wheezing and a normal chest examination do not exclude asthma). 2. Coughing. 3. Recurrent breathlessness or Shortness of breath. 4. Tightness of the chest, pain or pressure. Symptoms of asthma vary from person to person. Some may have all the above symptoms and some may have few of them. Severity may vary in each attack. Proper asthma diagnosis is necessary for treatment.

Things which every body must know about asthma: Asthma affects millions of people worldwide. It is one of the disease where the incidence of disease is increasing year by year and is most common chronic disease affecting children. Here are some important facts about asthma: 1. Asthma is not a communicable disease. You cannot get infected and get asthma by any asthmatic patient. Asthma is disease where genetic and environmental factors play role. 2. Asthma is caused by the chronic inflammation (swelling) of airways of lungs. 3. Airway inflammation contributes to airway hyper responsiveness, airflow limitation (obstruction), epithelial; damage and long term structural remodeling of the airways causing respiratory symptoms.

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4. Atopy, the genetic predisposition for the development of an IgE-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma. Go to diagnosis >>>. 5. Viral respiratory infections are one of the most important causes of asthma symptoms and exacerbation and may also contribute to the development of asthma. 6. The main symptoms of asthma are wheezing, coughing, recurrent breathlessness or shortness of breath, tightness of the chest, and pain or pressure on the chest. 7. Diagnosis of asthma is made by detailed medical history, physical examination focusing on the upper respiratory tract, chest and a test called spirometry. Diagnosis is also made by Peak flow meter. 8. Asthma is not a contraindication for doing exercise. Many great athletes suffer from asthma symptoms and attack. Read Exercise Induced Asthma. Proper diagnosis and treatment is necessary in Exercise induced asthma. 9. Two main categories of asthma medication and treatment are Reliever (used to treat symptoms and exacerbations or acute attacks) and Preventer medication. 10. Inhaled route is the most preferred way to provide asthma treatment as it delivers drugs directly to lung airways. This makes the action of the drug faster with lower or negligible side effects. 11. Asthma is one of the most common potentially life-threatening condition complicating pregnancy. Read pregnancy and asthma. Proper diagnosis and symptoms control is necessary. 13. Remember that asthma is a treatable disease and you can live a healthy and productive life like any body else with proper treatment. Any query go to asthma FAQs.

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How to control asthma triggers

If you have asthma, then many of the things present normally near you can trigger asthma attack. Each person has different trigger. A trigger is anything that irritates the airways and set of the symptoms of asthma. Here are common triggers and action you can take to control them. By controlling the triggers, your asthma is controlled better, as there are fewer attacks and exacerbations. You must know what makes your asthma worse for better asthma control. Bed room is a place where you spend a lot of time, controlling triggers present in bedroom is very important part of "trigger control." This article contains things you can do throughout your home and outside to minimize your exposure to substances that trigger asthma attack.

HOUSE DUST MITE: House dust mites are the important cause of asthma attacks. They may be found in soft toys, curtains, clothing, bedding, mattresses, box springs carpets, and upholstered furniture. They feed on dead skin which we shed. The excreta of house dust mite are the cause of allergy. Actions to take:

Put your mattresses, pillows and box springs in an airtight allergy free covers. Wash pillow once a week, every week in hot water (54.4oC or 130 oF) if no covers are used.
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Dry cleaning is also effective in killing house dust mites.

Carpets which are placed on concrete should be removed. Bed covers and cloths should be washed in hot water (130 oF) once a week. Sleeping or lying on upholstered furniture should be avoided. Reduce indoor humidity to less than 50%. Use a dehumidifier if possible. Carpets must be removed from the bedroom. If you cannot remove the carpets use short pile carpets instead of long pile carpets. Use vacuuming frequently with HEPA air filter equipped vacuum cleaner. Avoid been present in the room during cleaning process.

If you have to vacuum then take following precautions: 1. Use a dust mask 2. Use a central vacuum cleaner with collection bag outside the home. 3. Use a powerful vacuum cleaner with HEPA filter. Shampoo, steam clean or beat non-washable carpets once a year. This removes large particles missed by the vacuum cleaner. Use chemical agents to kill mites. Tannic acid, a protein denaturing agent commonly found in tea, has been shown to reduce allergen levels in house dust, but it does not eliminate mites
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UST (including house dust) People who are allergic to dust must take measures to avoid build up of dust. Vacuum cleaner should be used as advised earlier. Some of the dusts catching items in the room are windows, curtains, frames, tabletop ornaments, piles of books and magazines, cabinet top, childs toys and plastic bins used for storage of toys. The quantity of such items must be eliminated or reduced in the room. Closed storage must be used as much as possible. Curtains and window coverings must be of washable material and less dust catching type. Blinds must be used instead of curtains as they can be cleaned easily with wet cloth or vacuuming. Vertical blinds are better than horizontal blinds as later can catch lot of dust.

Back to top INDOOR MOULDS: Molds are fungi that grow best in warm humid areas. Molds can be found outside, in shady, damp areas and on decaying leaves. Molds can also be found in the home in areas of high humidity such as bathrooms, kitchen and basements.

Bathrooms, kitchen and basement must be well aired. There should be no damp wall in the room. Pipe fittings must be checked for leakage and anti dampness treatment for walls must be done. Bathroom, kitchen and basement must be cleaned regularly. Dehumidifiers must be used for damp areas of the basement. Humidity levels must be set in between 25 % to 50 %. Dehumidifier water tray must be empty and cleaned regularly. Do not use humidifiers.
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Enamel paint inhibits mold growth more effectively than latex paint. An antifungal substance can be added to paints to inhibit growth even more. Foam pillows and mattresses can be sites for mold growth. Replace foam pillows with washable polyester ones, and cover foam mattresses with a nonporous covering (for example, plastic).

Back to top WOOD SMOKE: Use of kerosene heaters or wood burning stoves at home must be avoided. Chimneys should be used if it's unavoidable. Place should be cross ventilated so that smoke doesn't accumulate there.

STRONG ODORS AND SPRAYS:

Avoid perfume and perfumed cosmetics like hair sprays, talcum powder, deodorants. Do not use perfumed washing powders and other household cleaning products. Room deodorants and sprays must not be used. Perfumed mosquito repellants (e.g. goodnight) and mosquito repellent candles must not be used. Kitchen must be well aerated and must have exhaust fan and electronic chimney. Patients should not stay when their house is being painted and until the paint has dried.

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TOBACCO SMOKE:

Smoking in any form be it cigarette, cigar, bidi etc. should be strictly prohibited in the house. Person with asthma must stop smoking at all cost. Even passive smoking is harmful. It has been well documented that child of smoking mothers suffer from more asthma than of non smoking mothers. Asthmatic children who live with smoking parents suffer from more severe asthma and have more frequent emergency room visit due to acute asthma attacks.

Click > COPD < to go to COPD Questioner and know if you are suffering from COPD.

COCKROACH AND MICE: Cockroaches are one of important allergens. Both male and female Cockroaches produce different allergens. Both cockroach fecal extracts and whole body extracts are associated with positive skin tests, and it has been concluded that fecal matter may be the most medically significant allergen.

Use cockroach traps. Use baits and traps, gels, and boric acid powder in places where cockroaches live and hide, out of reach of children. If volatile chemical agents (e.g. sprays) are used, the home should be well ventilated, and the person who has asthma should not return to the home until the odor has dissipated. Boric acid indoors can reduce cockroach numbers. Tannic acid works to denature cockroach antigens, but does not kill the roaches themselves. Food should not lie open in the house, use airtight containers for storing food items.
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Seal hiding places like holes and cracks in walls, along baseboards, pipes, windows, and doors with caulk or putty. Remove source of water repair leaks, wipe up spills and keep surfaces dry. Clean up soon after eating, and clean the pets dish too if you have one. Empty trash cans regularly. If nothing works then you should call a professional exterminator. Mouse allergen exposure can be reduced by a combination of blocking access, low-toxicity pesticides, traps, and vacuuming and cleaning.

Back to top ANIMAL ALLERGY: Warm blooded animals like cats, dogs, rodents and birds all can make asthma worse. The proteins present in the scales, flakes, hairs, urine and dried saliva are the main cause of allergy.

Best remedy is to remove the pet from the house. But if this cannot be done due to emotional reasons the following measures must be taken to reduce exposure. Pets must be kept out of bed room; they should not sleep with you in the bedroom. Wash the pet once a week every week. Visit to friends and relatives who have pets with furs and feathers must be avoided. If there is forced air heating in the room, then close the air vents of your bedroom. Products made of furs and feathers, kapok cotton, must be avoided. These include fur cotes, pillows, beddings and furniture.
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If you want to have a pet chose pet without fur and feathers like fish. When you visit a place where animals or birds with furs and feathers are present, take reliever medication at least 15 minutes before visit. Cat allergens persist for months after the cat has been removed from the home.

Back to top POLLENS AND OUTDOOR MOULDS: Pollens are small particles produced from flowers of grass, ragweed, or trees that can cause seasonal problems.

Use air conditioners at home and in office especially in the season when pollen and moulds are higher. Keep windows closed during pollen season Avoid going outdoor during afternoon and mid day when amount of pollens in air are highest. Wash hairs in the night before sleep if you have gone outdoors in pollen season to wash away the pollens. Avoid freshly cut grass. A person with pollen allergy should not mow the lawn. Special Nasal filters can be used to reduce pollen inhalation. Avoid contact with decomposing organic material like wet, dead leaves. Stay away from standing water, gardens, if you have mould allergy.

Back to top EXERCISE:

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Exercise can make the asthma worse in many asthmatics. But exercise must not be avoided. Swimming is the most asthma friendly exercise. Work with your doctor to formulate a plan. Take short acting beta adrenergic inhaled medication at least 15 minutes before exercise. If you exercise daily and for long hours, then long acting beta adrenergic agents are preferred. Leukotriene inhibitors can also be taken. Warm up before exercising and cool down afterwards. Avoid exercise in very cold or hot weather. Take with you short acting beta adrenergic inhaler when you exercise outdoor. Click on > Exercise induced asthma < to read more.

Back to top WEATHER:

Avoid exposure to cold air. Wear scarf over your nose and mouth in cold weather. Avoid sudden changes in temperature, like going outside from a airconditioned room in summers.

AIR POLLUTION: While many asthma attacks suffered by children are caused by viral infections, they are more serious if the child has been exposed to traffic pollution. Exposure to nitrogen dioxide (NO2) from vehicles exacerbates the attacks. It drops the lung function and increases the symptoms after a virus infection up to 200%.

Stay indoors if air pollution is high or it's "ozone alert day.

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Drive car with windows closed.

Back to top GASTRO ESOPHAGEAL REFLUX DISEASE (GERD) Gastroesophageal reflux disorder diseases is a disorder in which the acid contents of the stomach enter the lower part of food pipe (esophagus). This may cause the asthma to worsen. Acidity and heart burn also worsen asthma. Tell your doctor about the problem for which he will prescribe corrective medication.

ADDITIONAL PRECAUTIONS:

Take influenza vaccination (flu shots) if you have not taken yet. Take nutritious food. Dont be afraid to exercise. Yoga like pranayam can also help. If you have sinusitis, have it treated promptly. Avoid close contact with people having cold and flu. Wash your hands after shaking hands with these people. Dont over exert yourself, take proper rest and sleep.

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When to call Asthma Specialist

A person should contact a pulmonologist, allergy specialist or immunologist if any of the following problems are present: Specialist must be consulted if the asthma symptoms are not controlled even after 3- 6 months of therapy; i.e. more than one rescue inhaler use per month, oral steroids used more than 2 times per year, step 4 therapy required ( step 2 or higher if patient aged less than 3 years) For immunotherapy. Refractory cough. Abnormal chest radiograph finding. Life threatening asthma exacerbations. Intensive Asthma patient education. Poor quality of life. Persistent chest pain or atypical features. Persistent shortness of breath. Persistent or fixed wheezing. Spirometry or PEFs don't fit the clinical picture. Suspected occupational asthma. Stridor. Weight loss.

If significant social, psychological, or family problem is present additional referral to the psychologist or family counselor may be needed.

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How to use a Peak Flow Meter A peak flow meter for asthma is like a sphygmomanometer (blood pressure instrument) for hypertension or thermometer for a fever. Peak flow meter is a small hand held device that measures the fastest rate of air that a person can blow out of his lungs. It shows how well the airways are open. It measures peak expiratory flow rate (PEFR). What are the uses of peak flow meter? Peak flow meter is a valuable tool in the arsenal of patients to monitor asthmaand to know before hand is there are any chances of impending asthma attack. The main indications are:

Determine the severity of asthma. Check the response to treatment of asthma medication. Monitor progress in treatment of asthma. Provide objective information for any possible adjustments in therapy. Detect worsening in lung function before hand and thereby avoid a possible serious flare-up in asthma with early intervention

One of the most important functions of the peak flow meter is to help you and your physician evaluate asthma severity. You will see a drop in peak flow readings even before the symptoms of asthma (like coughing or wheezing) get worse. Decreases in peak flow may indicate that you need to increase your medication. The earlier a warning sign is detected, the sooner the problem can be addressed. back to top

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How to use a Peak Flow Meter? A peak flow meter helps you check how well your asthma is controlled. Peak flow meters are most helpful for people with moderate or severe asthma. This article below will tell you: (1) How to take your peak flow reading. (2) How to find your personal best peak flow number, (3) How to use your personal best number to set your peak flow zones, and (4) When to take your peak flow to check your asthma each day. back to top

How to take your peak flow reading? A peak flow meter measures air flow, or peak expiratory flow rate (PEFR). To take a peak flow reading you should:

First set the pointer at zero. Should stand or sit in a comfortable, upright position. Then hold the peak flow meter level (horizontally) and keep the fingers away from the pointer. Now take a deep breath and close the lips firmly around the mouthpiece. Do not put your tongue inside the hole. Then blow as hard and fast as you can. Look at the pointer and check the reading. But if you cough by mistake then do the test again. Reset the pointer back to zero. The whole procedure is to be done three times and highest reading is to be recorded.
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back to top

How to find your personal best Peak Flow number: The personal best peak flow (PEFR) is the highest peak flow value a patient can achieve over a 2-3 week period when his or her asthma is under good control. To find your personal best peak flow number, take your peak flow each day for 2 to 3 weeks. Your asthma should be under good control during this time. Take your peak flow (PEFR) as close to between noon and 2:00 p.m. each day. The highest peak flow number you had during the 2 to 3 weeks is your personal best. Personal best can change over time as disease is controlled or when child grows up. Your physician will periodically readjust your personal best. Ask your doctor when to check for a new personal best. Note: This time is only for taking the reading only for finding your personal best peak flow. To check your asthma each day, you will take your peak flow in the morning back to top

How to use your personal best number to set your peak flow zones? Knowing your personal best peak flow number can be very helpful in the management of asthma. Your should keep a daily record of your peak flow readings. If your medicine is working you should see an improvement in your peak flow reading. back to top

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Traffic light system Once you and your pulmonologist have established your personal best peak flow, you should make every effort to maintain values within 80% of this number so you feel your best. The following traffic light system can serve as an easy guide: Green Zone: Peak expiratory flow rate (PEFR) 80-100% of personal best. All systems "go." You are relatively symptom-free and can maintain your current asthma management program. If you are on continuous medication and your peak flow is constantly in the green zone with minimal variation, your physician may consider gradually decreasing your daily medication. Personal best PEFR *80 / 100 is lower limit of Green zone. Yellow Zone: PEFR 50-80% of personal best. "Caution," as asthma is worsening. A temporary increase in asthma medication is indicated. If you are on chronic medications, maintenance therapy will probably need to be increased. Contact your physician to fine-tune your therapy. Personal best PEFR * 50/100 is the lower limit of yellow zone. Red Zone: PEFR below 50% of personal best. "Danger," your asthma management and treatment program is failing to control your symptoms. Use your inhaled bronchodilator. If peak flow readings do not return to at least the yellow zone, contact your allergist/immunologist, who will help you employ aggressive therapy. Maintenance therapy will have to be increased. Personal best PEFR * 50/100 is the highest limit of red zone. These traffic light zones are broad guidelines designed to simplify asthma management. Successful control of asthma depends upon a partnership between the patient and the physician. This open communication and exchange of information can be improved with peak flow monitoring and

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reporting. Your physician can use this data to design and adjust your asthma medication to achieve the best asthma control possible for you.

Allergy Shots (Allergy Immunotherapy) Allergy shots also called immunotherapy were once considered as the last resort and were lesser preferred treatment for allergic disorders like allergic rhinitis and asthma. But the result of the latest study by Imperial College School of Medicine in London show that Allergy shots may offer long term and sustained benefit. "They may never relapse into symptoms as severe as what they had originally," Samantha Walker, one of the study's authors told The Associated Press. "In carefully selected patients, this form of treatment is extremely effective." The researchers said their findings and other studies suggest that starting immunotherapy sooner after an allergy appears, particularly in children, could prevent the allergy from becoming severe and prevent development of additional allergies. Here are answers of the questions which you may ask about Immunotherapy. back to top

What is Allergen Immunotherapy? Allergen immunotherapy is a form of asthma treatment aimed at decreasing your sensitivity to substances that cause allergic attack. These substances are called allergens. Allergy testing is done to identify the offending allergens. Vaccine is prepared against these allergens. Shots of vaccine are given subcutaneously twice weekly for few months, slowly the duration is increased to one month. This is continued for 4 to 5 years. back to top

How does Immunotherapy work?

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Allergen immunotherapy desensitize your to specific allergens. Vaccine is given subcutaneously in gradually increasing doses. Body responds by developing an immunity or tolerance to the allergens. As a result of these immune changes, immunotherapy can lead to decreased, minimal or no allergy symptoms when you are exposed to the allergens included in the allergy vaccine.

What are the concentration of allergens used? After knowing your allergy profile, a diluted solution is made of allergens for which you are most susceptible. This is known as vaccine. Usual starting concentration is 1:5000 (one part allergens and 5000 part diluents). The concentration is later increased to 1:500 and then 1:50 as vaccination progresses. back to top

What is the dose schedule of the allergens used? Initially about 09 doses of 1:5000 vaccine are given twice a week in increasing volume. Starting dose is usually 0.1 ml increased by 0.1 ml each time to 0.9 ml. Then 1:500 dose is started with the same dose schedule. After completion 1:50 conc. is started. Total of 9 doses are given at weekly interval. Next 9 doses are given at 15 days interval. Then maintenance dose is started at 0.9 ml to 1.0 ml once a month for 3 to 5 years. back to top

How Should I Prepare for Allergy Shots? For two hours before and after you are given allergy shot, do not exercise or do vigorous activity. Exercise stimulate increased blood flow to the tissues and may promote faster release of antigens into the bloodstream. This can cause allergic reaction or even anaphylaxis.
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Is Immunotherapy really effective? If the selection of the allergens are correct, the therapy schedule is followed the therapy is usually effective. The allergens (specially pollen/ plants) which are selected must be those that are found where you live. back to top

Is immunotherapy effective for all allergens? The effectiveness of immunotherapy varies depending on the severity of a person's allergies and the number of substances to which the person is allergic. Immunotherapy is usually effective for allergies to stinging insects, pollens and dust mites, fungus and moulds. It is also effective for pet dander. Immunotherapy is not recommended for hives or food allergies, as it's efficacy is not proved. back to top

What should one expect after allergy shots? Redness, swelling and irritation at and near the site of the injection is normal. These symptoms usually go away within 4 to 8 hours after receiving the allergy shot. Usually, the patient is monitored for about 30 minutes after receiving an allergy shot to make sure that they don't develop side effects such as itchy eyes, shortness of breath, runny nose, or tight throat. If they develop these symptoms after leaving the doctor's office, they should take an antihistamine and go back to doctor's office or to the nearest hospital or emergency center. back to top

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In how much time I will get relief after starting allergy shots? Relief usually starts during first year of treatment. But best results only come in 2nd year. By the end of third year people are usually desensitized to the allergens present in the vaccine. back to top

Is Immunotherapy safe for children? It has been found that a child of five year can take allergy shots. This is the youngest recommended age to start immunotherapy in the United States Immunotherapy in young age can prevent allergies from worsen during later life. They also prevent development of new allergies. back to top

I am pregnant, can I have immunotherapy? A number of reports have appeared describing immunotherapy without apparent adverse effects on human pregnancy. Though anaphylaxis during pregnancy is a potential risk for mother and fetus. Patients already receiving immunotherapy may be maintained at their current level or at somewhat reduced doses. However it is generally advised not to begin immunotherapy during pregnancy. back to top

How long should I continue taking allergy shots? Usual span of allergy shots is five years. But this may be increased if patient lives in highly allergic environment. Allergy shots many times cause significant reduction in the symptoms of asthma or allergic rhinitis, causing reduction in requirement of medicines. Patients who are benefited may continue vaccination for longer periods.
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How can I know about my allergy profile? Allergy testing is done to know to which substances person is allergic to. back to top

I am afraid of injections. Is there any other way? Oral immunotherapy is now available. Oral immunotherapy works in the same way as allergy shots by giving increasing doses of allergen to gradually build up a person's tolerance. The allergen extract is taken as drops, usually placed under the tongue for about 2 minutes and then swallowed. These drops can be taken at home. back to top

Are there any recent advances in Immunotherapy? In addition to the traditional allergy shots, several new immunotherapy procedures have been proposed, many are still in experimental stage: Rush immunotherapy: This approach involves a more rapid, or rushed, buildup to the maintenance dose of extract. During the initial phase of treatment, increasing doses of allergen are given every few hours rather than every few days or weeks. There is a greater risk of a side effects with this approach. That is why rush immunotherapy is usually done in a hospital under close medical supervision. In some cases, pre-treatment with medications can reduce the risk of an allergic reaction during rush immunotherapy. Enzyme potentiated desensitization (EPD): Enzyme potentiated desensitization, also called low-dose immunotherapy. Very small doses of allergen are used along with an enzyme called beta-glucuronidase. EPD is can be used to treat a broad range of allergens without the need for weekly shots.
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This includes allergies to foods, which generally are not successfully treated with traditional allergy shots. back to top

What is the cost of allergy shots? Before you go for allergy shots one must have allergy testing to know about the allergens he or she is allergic to. The initial skin test costs around $1000 in USA. Most insurance companies cover 60% to 100% of the cost. It also depends on what type of allergens you are being tested for (house dust mite, foods, grasses, pollens etc). In India allergy testing costs $ 30 for Intradermal test to $ 100 - 250 for blood test called a radioallergosorbent test (RAST). A series of allergy shots in USA will cost approximate $1,480 to $2500 after six years. Researcher Timothy J. Sullivan III, MD, of Emory University, calculated that the patient would pay $800 for the first year of allergy shots (the most expensive year). In following years, when allergy shots are done monthly or even less frequently, those costs drop to between $290 and $170. Over six years patient can save $1,300 to $2,900 with allergy shots then with drugs for the same period, that study shows.

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