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.

The Food You Eat Will Decide How You Breathe!

It’s very surprising for most people that the food they eat affects their breathing and health of their lungs. We know that our body uses food as fuel. Also, a single nutrient cannot help us to fulfil our body’s requirements and we need multiple nutrients from all food groups i.e. a healthy and balanced diet.

How food is related to breathing

The process of changing food into fuel is called metabolism. In this process oxygen and food are raw materials and carbon dioxide is waste material which we exhale. Carbohydrate food when catabolised releases maximum amounts of carbon dioxide as compared to fat. So, in case of COPD patients, it sometimes becomes beneficial to eat food with less carbohydrates as it can help to breathe easier.

Our lungs work tirelessly to keep our system going so it is necessary to give importance to proper care of the lungs for proper functioning. Inflammation of lungs makes breathing difficult and leads to congestion. In today’s polluted environment it becomes even more important to focus on one’s nutrition.

Nutrition Recommendations

Diet plays an important role for healthy lungs. Choose complex carbohydrates such as whole grains, fresh fruits, vegetables. If you are obese or overweight, try to lose weight and achieve an healthy BMI. Obesity causes substantial changes to the mechanics of lungs and chest wall which can lead to difficulty in breathing, exercise intolerance and worsening of asthma and  asthma like symptoms. Being Underweight is not directly related to poor lungs health but it leads to weakened immune system which makes you more prone to infectious and communicable diseases. Limit intake of simple carbs like sugars, cakes, soft drinks, candies etc.

Increase the intake of fibres to approximately 20 to 30 g each day. Take a good amount of proteins each day from natural sources, e.g. eggs, milk, meat, fish, nuts, etc. A good intake of protein will help you to make your respiratory muscles strong. Try to take healthy fats like canola oil, rice bran oil, olive oil etc. instead of saturated fats like margarine, butter, ghee, cookies, pastries, hydrogenated fats (like vanaspati ghee) etc.

Avoid foods that cause gas or bloating as they can further lead to difficulty in breathing and uneasiness.

Try to add more fruits and vegetables to your diet as these are rich source of vitamins and mineral which will help you to enhance your immune system and help you fight off chest infections.

Increase the intake of dairy products as these are rich in proteins and calcium. During COPD treatment there are chances of deficiency of calcium.

Try to limit the use of salt as excessive salt intake can cause edema (or swelling of the body) and lead to high blood pressure.

Drink plenty of water to keep yourself hydrated – at least 8 – 10 glasses per day. But in case of pulmonary hypertension consult your physician first on how much fluids you can take.

Consider adding a nutritional supplement at night-time to avoid feeling full during the day.

So adding healthy foods to your diet will give longer life to your organs. Before starting any diet consult your dietician and physician as diet should be tailored to you as per your body’s requirements call us: 0172-4911000, 9779030507.

                                 Eat right with every bite..

   

 

Lung Transplantation for End-stage Lung

An end-stage lung condition is defined as lung destruction leading to extensive respiratory disability and a state of crippling. Such a patient is completely bed-ridden and continuous oxygen dependent. The patients get severely malnourished, lose muscle mass and weight. In recent times, there is a significant increase in prevalence of end-stage lung problems and oxygen dependence especially after the COVID pandemic. Such a condition frequently results from some of the following common conditions:

1.      Extensive post-COVID lung fibrosis

2.      Progressive fibrosing illnesses of the lungs due to interstitial lung diseases

3.      Chronic obstructive pulmonary disease

4.      Vascular Lung Disease,  Primary pulmonary hypertension

5.      Other chronic diseases: Suppurative Lung Disease, Cystic fibrosis,  Bronchiectasis

Patients with end-stage lungs can be helped with several modalities besides the routine drug treatment such as the Respiratory Rehabilitation; Yoga and pranayama therapy; Breathing exercises; Nutrition support and muscle building; Psychological supports

Lung transplantation: Lung transplantation is offered as a last hope for some of such patients available at a few select centres, mostly in South India. Lung transplantation requires a large infra-structure and plan for availability of the organs besides the expertise and the costs.

Patients who are fit for lung transplant need to be carefully selected and undergo preoperative pulmonary physiotherapy and RR so that they can get best results from the transplant

These patients also need a long term post operative physiotherapy and rehabilitation program so that the advantages of transplant can be maintained. They also require regular surveillance for early signs of rejection and other complications with help of blood investigations, radiology, bronchoscopy and biopsies.

Respiratory Problems due to Obesity

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 lifestyle 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 even 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. Some of the important effects are described as under:

•  Lung function:  Lung function is poorer in 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 obese people. The 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 definite lung disease.
• Asthma: There is some association of asthma 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.
• Chronic obstructive pulmonary disease (COPD): 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.
• Obstructive sleep apnea (OSA): OSA is an important problem 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 cerebrovascular diseases.
• Obesity is an important risk factor for OSA, a potentially fatal disease. 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 the treatment of OSA. Mild OSA may even be reversed with the treatment of obesity.
• Obesity hypoventilation syndrome (OHS): 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 which may include bariatric surgery. 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.

Diagnosis and management of Interstitial pulmonary fibrosis

The Shrunken Lungs

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Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP
(Emeritus-Professor, Postgrad Instt Med Edu & Research,Chandigarh, India)
Medical Director, Jindal Clinics,SCO 21, Sector 20 D, Chandigarh, India 160020
Email: dr.skjindal@gmail.com  Ph. 0172-4911000; 0172 4911100

Websites:  www.jindalchest.com, www.ivfchandigarh.com

Blog: medicalvignettes.blogspot.in

COPD

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Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP
(Emeritus-Professor, Postgrad Instt Med Edu & Research,Chandigarh, India)
Medical Director, Jindal Clinics,SCO 21, Sector 20 D, Chandigarh, India 160020
Email: dr.skjindal@gmail.com  Ph. 0172-4911000; 0172 4911100

Websites:  www.jindalchest.com, www.ivfchandigarh.com

Blog: medicalvignettes.blogspot.in

FENO - a new test for asthma

FeNO

FeNO or fraction of exhaled nitric oxide, has emerged in recent years as one of the new tests to diagnose and monitor asthma. Asthma is one of the most common diseases in humans, with children especially afflicted. The diagnosis of asthma is primarily a clinical one and the management too has been based more on the clinical sense of the treating physician. However, with increasing patient populations and more information about new subtypes of asthma, a test was needed to help support the clinician’s diagnosis and management strategy. FeNO has stepped up to meet the gap.

It may come as a surprise to many that the normal lungs produce some amounts of nitric oxide or NO. The amount produced is minuscule though, in parts per billion. In disease states - such as asthma – the amount of NO produced increases significantly. This finding cal be exploited in routine clinical practice to support the diagnosis of asthma and to monitor treatment.

Asthma is mainly of two types – eosinophil predominant and non-eosinophil predominant (eosinophils are a kind of blood cell). The eosinophil predominant type of asthma responds very well to inhaled steroids while the non-eosinophil type does not. Therefore, the differentiation of asthma into these two subtypes is of importance in the management of the disease. The only way to do this other than the use of FeNO is to do sputum (saliva) analysis, which besides being messy is also time consuming. The FeNO test can be very helpful in this situation. FeNo levels will be high in patients with eosinophil predominant asthma and will be normal in the non-eosinophil predominant subtype. So, by checking the FeNO levels one can decide whether or not to start inhaled steroids.

FeNO levels are very useful in monitoring the response to treatment. In patients who are compliant with treatment and are improving, the FeNo levels should fall. In patients in whom there is a partial improvement, checking serial FeNO levels will help in decision making, i.e. whether to stop, decrease or increase treatment. These levels can used in conjunction with standard spirometry for additional information.

Children are often unable to perform rigorous pulmonary function testing. They find it easier to perform FeNO testing, which is done by gently blowing into the mouthpiece of the measuring device for 10 – 12 seconds. The result is subsequently displayed on the screen in a few seconds.

In summary, FeNo is a non-invasive, easy to perform, quick and reliable test which is an useful adjunct in the management of asthma, especially in children and difficult cases.