Essentials of Asthma Management

Asthma is a common chronic illness seen in almost all age-groups. It is an important cause of debility in both children and adults – frequently responsible for absence from work and school. Management of asthma is a major cause of concern both because of the disease morbidity and associated health-care burden. It is important to realize that currently there is no permanent cure of asthma. But the natural course of asthma may vary from person to person. Long periods of remissions are seen in some patients while others may continue to suffer, sometimes with severe asthma which may occasionally prove to be life-threatening.

Remedies for asthma have varied from the folklore practices to the modern drugs.There are innumerable faith healing and miracle treatments advertised and offered in different societies. In current clinical practice, asthma management comprises of a comprehensive plan which includes the following essential components:

·        Drugs (i.e. Pharmacotherapy) for symptomatic and control therapy

·        Avoidance of trigger factors which aggravate asthma

·        Patient education about the disease and overall management plan.

I.                  Drug – treatment (Pharmacotherapy)

 Asthma is generally managed with two kinds of drugs:

1. Relievers:  drugs which relieve the acute symptoms of Asthma. These drugs are used on “as and when needed” basis, whenever asthma symptoms are present.
2. Controllers or preventers:  These drugs are essential for long-term maintenance treatment on a regular basis. Appropriate and regular use of controllers is essential to avoid the need for the reliever medications. An increasing use of relievers indicates a poor control of asthma.

It is therefore important to remember the message: 

Use Controllers (Preventers) regularly and avoid asthma from worsening. Use of maintenance inhaler medication is very important in the overall prevention strategy. 

 It is also important to remember that most of drugs for asthma treatment are available for the inhalation route. Patients are generally reluctant to use inhalers routinely for treatment. This is more so in case of children and also the female patients who find the treatment as rather stigmatic. It is therefore important to spend time with them, listen to and patiently discuss their doubts and other misgivings. It should be repeatedly stressed that:

1. Inhalation is the most effective route for administration of anti-asthma drugs – direct approach to the respiratory system.
2. Inhalers contain minute quantities of drugs and are therefore safe for asthma patients.
3. There is no addicting potential of inhalers; they do not contain any such drug.
4. Use of inhalers is somewhat difficult – requires practice and active cooperation of patient.

 II.               Avoidance of triggers of asthma

All attempts should be made to recognize and avoid the situations which trigger the asthma attacks - it is as important as the use of drugs. Incidentally, it is generally difficult to practice and beyond the means of an individual patient. Alterations in living conditions are required to minimize the exposure to dust, smoke and other allergens in the house.  Particular attention must be paid to the bedroom where contact with dust mites and other allergens is highly likely..

 Some of the exposures are easy to avoid while others may require major changes.

1. Patient should preferably stay away from dusty conditions such as during sweeping, cleaning, white washing or when similar activities are being carried out.
2. Replace sweeping of floors and dusting of walls with vacuum cleaning, or at least with wet cleaning (or mopping).
3. Give sufficient exposure of sun and air to the clothes taken out from the closets after storage.
4. Keep the bedroom and possibly other places in the house as simple as possible.  Furnishing items that are likely to collect dust such as the stuffed toys, curtains, carpets, mattresses (etc.) should be either removed or replaced and covered with easily washable/plastic materials. It is important to keep them as dust-free as possible.
5. Avoid exposure to cigarette smoking.
6. Avoid exposure to smoke from domestic cooking in the kitchen.
7. Strong odors of seasoning, condiments, hot and spicy foods should be avoided.

 III.           Patient education

It is important for the patients and his/ her care-giver to understand asthma and overall management plan for and efficient control, especially in the state of an emergency. Although the doctor prescribes the drugs for asthma, asthmatics and their relatives play an important role.  Asthma Particular attention need to be paid to the importance of inhalation therapy, avoidance of triggers and how to correctly use the inhalers. Contact your best chest clinic to educate yourself as well as learn the correct inhalation technique.         

One should keep in mind the possibility of asthma getting out of hand and pose an acute threat. Appropriate and timely use of emergency drugs, especially the relievers, at home can prevent deterioration of disease as well as subsequent hospitalization. Similarly, well-informed asthmatics can regulate the controller drugs at home, either by themselves or with the help of the caregivers. Time to prevent an acute emergency is to maintain an adequate disease control with a comprehensive management plan.

How does Obesity affect your lungs?

Obesity i.e overweight is a common condition the world over, including in India. It is not altogether wrong to say that there is almost an epidemic of obesity particularly noticeable in the developed countries. Even the developing countries are not spared of the menace of over-weight.

Obesity is common among adults as well as children. It is largely attributed to a sedentary life-style and excessive use of ‘junk foods’ rich in fats, carbohydrates and calories. Even though a good weight is surely a sign of a healthy body, overweight is considered as a ‘medical problem’ or a ‘disease’ in itself. Excessive weight is an unnecessary burden on the body which poses risks for almost all body systems. In particular, it is responsible for muscle and joint problems and diseases of the heart and the lungs.

Effects on the respiratory system

Obesity affects the respiratory system in multiple ways. The lung function is poorer in the overweight persons. To a large extent, the lung capacity is adversely affected by excess body weight. Thoracic and lung expansion is restricted due to the mechanical effects of fat on the chest wall and diaphragm in the obese people. Clinically significant restriction is generally present whenever there is massive obesity defined by the patient’s weight-to-height ratio of 0.9-1.0 kg/cm or greater. Obese people may complain of breathlessness due to poor lung function even in the absence of a definite lung disease. It is important to assess lung function with the help of breathing tests such as spirometry, Diffusion Capacity and exercise testing done at a good lung function laboratory.  Other tests may also be required as advised by your chest physician.

There is important association of asthma and chronic obstructive pulmonary disease (COPD) with obesity. Obese asthmatics have more significant symptoms of breathlessness, wheezing and cough. Moreover, asthma is difficult to control in obese patients. This is particularly worrisome in obese children who present with a severe form of asthma. COPD is a progressive form of airway obstructive disease which is more commonly seen in smokers. Obesity is usually not a problem with most patients of COPD who often complain of significant weight loss and muscle wasting. Obesity may however be present in patients with chronic bronchitis in whom it will add to the symptoms of breathlessness.

One of the most important problems seen in obese people is Obstructive sleep apnea (OSA) which is characterized by intermittent obstruction of the upper respiratory tract especially during sleep. The obstruction occurs due to loss of tone and inability of the pharyngeal muscles during sleep to keep the airways open and thus resulting in its partial closure. It causes momentary cessation of breathing and fall in oxygen saturation, snoring and other physiological effects. In due course of time, OSA is responsible for hypertension, diabetes, cardiovascular and cerebro-vascular diseases.

Obesity is an important risk-factor for OSA, a potential fatal disease. OSA can cause sudden death; some of the celebrities had in fact had succumbed to this problem recently. Patients with OSA tend to fall to sleep within minutes and even while driving resulting in frequent and sometimes fatal accidents. Undoubtedly, OSA is the most serious complication of obesity. Weight reduction is an important component of treatment of OSA. Mild OSA may even be reversed with treatment of obesity.

OHS is characterized by hypoventilation i.e. decreased (than normal) amount of air entering the lungs with each breath resulting in lower oxygen saturation and increased carbon dioxide pressure in the blood. In the long run, the condition leads to failures of the respiratory and cardiovascular systems. Weight reduction is the most important component of treatment.

Management

Weight reduction is the most significant component of all forms of problems associated with obesity. Dietary control and physical exercise are important but often difficult to achieve.  Frequently, one has to resort to other measures of weight reduction. The doctor can advise about the type of management required in a case. Standard treatment of the respiratory disease associated with obesity should be done as appropriate for the individual patient. People suspected to suffer from OSA must see the best chest doctor and also get a full sleep-study done.

When I Get Breathless!

Breathing difficulty – Breathlessness

Breathlessness, also termed as dyspnea is an unpleasant sensation of breathing difficulty or discomfort. In real terms, breathlessness means rapid or difficult breathing either on exertion and activity, or even while resting in the bed. Patients may describe the feeling in different symptoms such as feeling uncomfortable, unpleasant sensation or congestion in the chest, feeling puffed, short of breath or heaviness in the chest, tightening in the chest, air hunger, or a feeling of suffocation. Breathing is essential for survival. Any difficulty in breathing therefore causes anxiety and fear.

Getting breathless following an exercise is normal and the breathing pattern returns to normal after resting. Exercise is a normal physiological cause of rapid breathing. Physiological breathless without the actual disease of heart or lungs can also occur during menstrual periods and pregnancy in women, presence of high fever (of any cause), depression, excessive anxiety and pain. Lack of exercise and increase in weight are also important causes of breathlessness.

Persistent, recurrent and progressive breathlessness may point to the presence of a disease involving most commonly the lungs or the heart. Diseases of blood or other organs can also cause breathlessness either directly or indirectly.

Some of the important diseases causing breathing difficulty include the following: 

A. Diseases of the lungs and the respiratory system

• Bronchial asthma – especially in the younger age-groups
• Chronic obstructive pulmonary disease (Chronic bronchitis and emphysema – most commonly in the middle and older age groups  especially amongst those who are smokers of cigarettes or bidis)
• Interstitial lung diseases such as hypersensitivity pbeumonias or those with pulmonary fibrosis/ scarring of any cause
• Lung infections such as pneumonias, tuberculosis and fungal infections
• Lung tumours especially cancers of the respiratory system
• Any other lung disease causing destruction of lung tissue
• Pleural diseases such as pleural effusion causing lung compression or pleural thickening causing lung entrapment

B. Diseases of the heart and cardiovascular system 

• Cardiac insufficiency of any cause –hypertension and ischemic heart disease heart attack.
• Heart arrhythmia (heart rhythm problems)
• Pulmonary arterial hypertension
• Valvular heart disease due to rheumatic heart disease
• Peri-cardial effusion and Cardiac tamponade (excess fluid around the heart)
• Congenital heart diseases – shunts and valvular stenoses
• Cardio myopathies
• Pulmonary thrombo-embolism

C. Miscellaneous diseases

• Anemia, especially when severe
• Blood cancers
• Any other systemic disease causing insufficiency/ failure of the liver, kidneys or other vital organ systems
• Sleep apnea syndrome
• Diseases of the brain and nervous system, muscles and nerves.

There are several other uncommon causes which can also be responsible for breathlessness. Diagnosis of these conditions can be made only after a detailed clinical work-up and appropriate tests.

Acute episode of breathlessness can occur due to anaphylaxis (a severe allergic reaction), acute asthma, carbon monoxide poisoning, or one of the other above-mentioned causes.

Correct diagnosis is important for an effective management. It is essential to follow an algorithmic approach and undertake investigations directed to look into the possible cause. Detailed clinical history is most essential to pinpoint the origin of the symptom. Routine blood examination and chest x-ray are almost always required. Specialized tests are done following the leads based on initial suspicion and baseline investigations.

Treatment of breathlessness essentially depends on the cause. 

Some of the group of drugs which may be temporarily used for management include the painkillers, sedatives (to relieve anxiety), sterile salt water (saline), diuretics and bronchodilator drugs. The use of all such drugs is limited to a short period before one arrives at a specific diagnosis. 

• To remove several misgivings, the following important points should always be kept in mind regarding breathlessness:
• Breathlessness is generally considered to be serious when it is accompanied by red-flag signs such as chest pain, fainting, bleeding in sputum, nausea, a bluish tinge to lips or nails, or a change in mental alertness. Some of these signs may point towards a heart attack or pulmonary embolism.
• Oxygen saturation has no direct relationship with breathlessness; Any person can have breathlessness even though when the actual levels of oxygen are within a normal range. Similarly, the pulse oximeter does not show shortness of breath. 
• Symptoms of shortness of breath, headache, and confusion or restlessness may occur when the blood oxygen falls below a certain level.
• Over exertion can cause breathlessness but breathlessness which comes on suddenly and unexpectedly may point towards a serious condition.
• Exercises and aerobic activities such as walking, running or jumping rope are good for shortness of breath but should be undertaken under medical advice and supervision in the presence of disease.

For more information visit: Jindal Chest Clinic.