Curing Asthma Forever

Asthma Free Forever Ebook

With Asthma Free Forever, asthma sufferers all over the world will discover the best way to cure asthma easily, naturally, and permanently. This guide was written by Jerry Ericson, an alternative medical specialist as well as former asthma sufferer. Inside this guidebook, users will discover the techniques that helped the author cure his asthma without useless and harmful medications. Inside this guide, users will discover the methods that helped the author cure his asthma without useless and harmful medications. The e-book contains a guided program that walks asthma sufferers through the process step by step, without the need for doctors. The program does not involve medication, drug therapies, or over the counter solutions. Asthma Free Forever is based on finding a natural solution to the problem, therefore it does not have any side effects. The natural treatments that are suggested are suitable for all asthma sufferers regardless of their gender or age. Asthma Free Forever has helped hundreds of people with asthma reduce their symptoms quickly and get rid of this disease easily and forever. The main e-book is itself a good value, but the additional bonuses that teach people to adopt a healthy lifestyle are just another weapon against asthma. With this productArticle Search, asthma sufferers can take their first steps toward a healthy life. Read more here...

Asthma Free Forever Overview


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Exercise Induced Asthma

The prevalence of exercise-induced asthma ranges from 9 to 50 , depending on the sport cited.21 The acute release of bron-choconstricting agents and the chronic inflammatory airway changes, both of which are complexly intertwined, suggest two pathways to target for prevention of exercise-induced asthma attacks. A recent Cochrane review confirms that albuterol, a short-acting beta agonist, is the number one treatment for exercise-induced asthma episodes. The bronchodilating effects of albuterol are superior in the acute setting to the anti-inflammatory effects of cromolyn (a mast cell stabilizer) or the anticholinergic effects of ipratropium.22 Appropriate use of albuterol must consider tolerance, timing of use, and ergogenic effects. Inhaled corticosteroids are standard therapy for patients with persistent asthma. While not well studied in exercise, the pulmonary delivery of inhaled corticosteroids has not shown any evidence of ergogenic or anabolic effects, and they are approved by...

Airway Inflammation and Hyperresponsiveness

Although the symptoms of asthma are intermittent, airway inflammation is chronic. Considerable variations in the pattern of inflammation may exist, resulting in pheno-typic differences.1 T-lymphocytes release cytokines that coordinate eosinophilic infiltration and IgE production by B-lymphocytes.9 Mast cells, eosinophils, macrophages, neutrophils, fibroblasts, and airway smooth muscle cells are also activated in asthma. Mast cells infiltrate airway smooth muscle and bronchial epithelium and may cause mucous gland hyperplasia. Proinflammatory mediators generated during mast cell AHR is the exaggerated ability of the airways to narrow in response to a variety of stimuli. AHR is a characteristic feature of asthma and is related to airway inflammation and structural changes in the airways.1 Treatment of airway inflammation with inhaled corticosteroids (ICS) attenuates AHR in asthma but does not eliminate it.1 Clinically, AHR manifests as increased variability of airway function. Although...

Factors Affecting Asthma Severity

Major factors that may contribute to the severity of asthma include allergens, environmental chemical exposures or pollution, and exposure to tobacco smoke. Up to 80 of asthmatics have symptoms of rhinitis, and treatment of rhinitis with intranasal cor- ticosteroids may relieve the symptoms. Gastroesophageal reflux has been associated with increased asthma symptoms, especially nighttime symptoms. Obesity has been associated with asthma persistence and severity. Nonselective P-blockers, including those in ophthalmic preparations, may cause asthma symptoms, and these agents should be avoided in asthmatics unless the bene fits of therapy outweigh the risks.1 In asthmatic patients requiring P-blocker therapy, a Pi-selective agent should be chosen. Because selectivity is dose related, the lowest effective dose should be used. P-blockers may inhibit P-agonist reversal of bronchos-pasm, and a larger dose of P-agonist or the use of an anticholinergic agent may be necessary to reverse...

Patient Care and Monitoring Chronic Asthma

Obtain a thorough medical history focusing on disease states that may worsen asthma severity. 2. Ask the patient about the frequency and severity of symptoms, when symptoms occur, and whether or not symptoms are associated with exposure to known allergens. Ask about previous emergency department visits and hospitalizations due to asthma. 5. Develop a patient education plan that fits the patient's needs. Educate about the differences between the asthmatic and normal lung and what happens to the lung during an asthma attack. Counsel the patient on how their medications work and differentiate between long-term control and quick relief medications. 8. Prepare a patient-specific self-monitoring plan and review it with the patient. Educate the patient on the signs and symptoms of asthma deterioration and when and how to take rescue actions. 11. Evaluate therapy on a regular basis. Assess the patient's control of asthma by evaluating the patient's impairment due to asthma and their risk for...

Acute Severe Asthma

Perform a brief medical history to determine the time of symptom onset, symptom severity, symptom severity in relation to previous exacerbations, current medications, previous emergency department visits or hospitalizations due to asthma, previous history of respiratory failure, and psychiatric or psychological disorders. 9. Restart the patient on maintenance therapy. Instruct the patient on what to do if asthma worsens and to follow-up with his her health care provider in 1 to 4 weeks.

Management of Asthma in Children

More than half of children with asthma develop symptoms before their fifth birthday. However, diagnosis can be difficult because there are no reliable tests for children at this age, and diagnosis must rely solely on clinical presentation. Among children younger than 5 years, the most common cause of asthma symptoms is a viral upper respiratory tract infection. Based on expert opinion, daily long-term control therapy should be initiated in young children who consistently require symptomatic treatment more than twice per week and those who experience severe exacerbations that occur less than 6 weeks apart. Therapy is recommended for children who had more than four episodes of wheezing in the past year that lasted more than 1 day and affected sleep and who have a positive asthma predictive index. A positive asthma predictive index is either one of two major risk factors (parental history of asthma or physician diagnosis of atopic dermatitis) or two of three minor risk factors (wheezing...

Management of Asthma Exacerbation

Asthma exacerbations consist of episodes of progressively worsening shortness of breath, cough, wheezing, or chest tightness. These exacerbations are characterized by decreases in FVC and PEVj that can be measured by peak-flow meters. Peak-flow monitoring can help grade the severity of an exacerbation. Early treatment is the best strategy for effective treatment of asthma exacerbations. Patients should receive a written action plan to guide self-management of exacerbation, especially patients with persistent asthma or any history of a severe exacerbation. Patients should be able to recognize the early indicators of an exacerbation, such as a decline in PEFR. There should be prompt communication between the clinician and patient during any abrupt worsening of asthma, as well as availability of a short course of systemic corticoste-roids even before this communication takes place. The goals of treating an exacerbation are correction of any significant hypoxemia, rapid reversal of...

Asthma Ease the Wheeze

Asthma affects more than 10 million Americans (3 million children and 7 million adults). Children under 16 and adults over 65 are more likely to have asthma. Hospitalizations due to this condition have increased 500 percent in the last 29 years, while the death rate in the U.S. from asthma has increased 45 percent in the past 10 years. Asthma is a condition that blocks the flow of air into your lungs. During an asthma attack, spasms in the muscles surrounding the bronchi (small airways in the lungs) make the air passages smaller. This makes you feel like you have to fight for every breath, and most people experience symptoms such as coughing, wheezing (the raspy, sucking sound as you breathe), and a feeling of tightness in the chest. These spasms of the airways are commonly triggered by hypersensitivity to environmental factors. Common Asthma Triggers There are several known causes of asthma, including the following > Early-onset asthma (extrinsic) Begins in childhood, hereditary,...

Oriental Medicines Answer to Asthma

Your child's individual symptoms of asthma determine the oriental diagnosis and treatment plan used. One of the most common pediatric asthma conditions that I see in my office translates into deficient spleen asthma. Weak digestion and excessive mucus characterize this. The cough produces a lot of phlegm, poor appetite, bloated upper abdomen, pale complexion, fatigue, loose or incomplete stools, and pale tongue.

Bronchial asthma Definition

Asthma, which is derived from the Greek ao0 ia, meaning short-drawn breath or panting, has until recently been defined as a disease characterized by an increased responsiveness of the trachea and bronchi to various stimuli and manifested by a widespread narrowing of the airways that changes in severity either spontaneously or as a result of therapy 1 . Although first highlighted in clinicopathologic studies of fatal asthma at the turn of the 20th century, it is only as a result of studies of bronchoalveolar lavage fluid, endobronchial biopsies and induced sputum over the past four decades that our appreciation and understanding of the inflammatory nature of the disease has increased 2,3 . This has resulted in a shift of emphasis away from airway smooth muscle dysfunction to a T-lymphocyte-modulated chronic desquamative eosinophilic bronchitis as the primary abnormality in asthma 4-6 . In the 1992 international consensus statement, asthma is now defined as 'a chronic inflammatory...

Asthma Etiology An Epigenetic Framework

In a genetics review, Wills-Karp and Ewart (2004) reported evidence of asthma susceptibility genes, which call to the fore the importance of identifying developmentally relevant environmental factors that through gene-environment interaction may promote gene expression and perhaps influence the course of asthma (Mrazek 2003). Onset of asthma in a genetically vulnerable child is likely determined by some complex interaction of genetic vulnerability (Wills-Karp and Ewart 2004) environmental exposure to respiratory infections, allergens, irritants, or environmental smoke (Busse and Lemanske 2001 Environmental Protection Agency 1992) and psychological influences such as maternal distress (Kozyrskyj et al. 2008) and stress (Wright et al. 2005). Problematic parenting appears to increase risk of asthma onset in children at genetic risk (Klinnert et al. 1994, 2001). Developmentally relevant stressful events and or the quality of caregiving may alter the emotional and physiological regulation...

Problems in Asthma Knowledge and Adherence

Compliance with medical regimens and asthma management play an important role in the course of illness (Bender 2006 Bender and Zhang 2008 Bender et al. 1998 McQuaid et al. 2003). Various factors, including emotional compromise in the child patient or the parent, may compromise adherence (Bender and Zhang 2008). Current asthma practice guidelines emphasize the importance of daily and regular monitoring of asthma symptoms and detailed action plans in the event of an attack (National Heart, Lung, and Blood Institute and National Asthma Education and Prevention Program 2007). Many of the recommendations include daily or weekly family routines, such as vacuuming the house once per week, monthly cleaning of duct systems, and monitoring airway peak flows. Families that are more capable of the organization of family routines have more effective management strategies (Fiese et al. 2005). Thus, families compromised by parental emotional disorder or marital distress are less likely to provide...

Bronchospasm Aetiology

General anaesthesia can alter airway resistance by influencing bronchomotor tone, lung volumes and bronchial secretions. Patients with increased airway reactivity from recent respiratory infection, asthma, atopy or smoking are more susceptible to bronchospasm during anaesthesia. Bronchospasm may be precipitated by insertion of an artificial airway during light anaesthesia, by stimulation of the carina or bronchi by a tracheal tube or by drugs causing p-blockade or release of histamine. Drug hypersensitivity, pulmonary aspiration and foreign bodies in the lower airway can also present as bronchospasm.

Anaesthesia for asthmatic patients

Elective surgery should proceed only if symptoms are optimally controlled. Premedication with the patient's usual bronchodilator therapy or an inhaled -agonist is recommended and the use of an anxiolytic should be considered. If regional anaesthesia is con-traindicated, use a general anaesthetic technique with minimal airway stimulation. If possible, avoid using drugs which release histamine and give all drugs slowly and after dilution. If tracheal intubation is necessary, ensure an adequate depth of anaesthesia. The provision of postoperative oxygen and maintenance bronchodilator therapy is essential.

Exerciseinduced bronchospasm EIB

It is well recognized that physical exercise has adverse effects in asthmatic subjects. In the 2nd century ad, Aretaeus of Cappadocia wrote 'If from running, gymnastic exercise, or any other work the breathing becomes difficult, it is called asthma' 8 , and the observation was repeated in the 17th century by the asthmatic physician, Sir John Floyer 'All exercise makes the asthmatic to breathe short and if the Exercise be continued it occasions a Fit' 9 . This phenomenon is described by the synonymous terms exercise-induced asthma (EIA) and exercise-induced bronchoconstriction (EIB). The breathing difficulties are due to bronchospasm, which can be detected by changes in the forced expiratory volume in 1 s (FEVj) on spirometry or in peak expiratory flow (PEF) using a peak flow meter. After a standardized bicycle ergometer or treadmill exercise protocol in the laboratory, the normal response in the postexercise period is a maximum fall in FEVl of less than 10 10 . When exercise testing...

Exercise Induced Bronchospasm

Exercise-induced asthma or, more accurately, exercise-induced bronchospasm (EIB) is a transient narrowing of the airways following vigorous exercise. Ninety percent of known asthmatics and 40 of patients with allergic rhinitis have bronchoconstriction caused or worsened by exercise (Feinstein et al., 1996). In some patients, the only manifestation of airway hyperresponsiveness is EIB, with up to 50 of athletes having EIB in some high-risk sports (Langdeau and Boulet, 2001). the addition of a leukotriene modifier (e.g., montelukast, 10 mg) taken at least 1 hour before exercise can provide additional relief (Coreno et al., 2000). Another treatment alternative is an inhaled mast cell stabilizer (e.g., cromolyn) before exercise. Inhaled corticosteroids are not as useful for acute prophylaxis because of their delayed onset of action, but can be very useful in patients with chronic persistent asthma and EIB. Any underlying chronic asthma or allergic rhinitis should also be optimally...

Treatment of Acute Severe Asthma

The optimal treatment of acute severe asthma depends on the severity of the exacerbation. The patient's condition usually deteriorates over several hours, days, or weeks. Gradual deterioration may indicate failure of long-term controller therapy. However, rapid deterioration can occur in some patients these patients usually respond well to bronchodilator therapy.41 Severity at the time of the evaluation can be estimated by signs and symptoms or presenting PEF or FEV1 but patient response 30 minutes after inhalation of a bronchodilator is the best predictor of outcome. 4 O In acute severe asthma, early and appropriate intensification of therapy is important to resolve the exacerbation, prevent relapse, and prevent severe airflow obstruction in the future. Starting therapy at home allows for rapid initiation and early assessment of response (see Fig. 14-3). Patients should follow their written action plan as symptoms intensify or lung function deteriorates. Based on the initial response...

The Complex Roles of Anaphylatoxins in Allergic Asthma and Autoimmune Diseases

Abstract Complement has a long-recognized role as a lytic effector system that protects against microbial pathogens as well as a mediator of acute and chronic inflammatory responses. Many of the inflammatory properties related to complement activation can be related to the complement cleavage fragments C3a and C5a, the so-called anaphylatoxins. Cloning and subsequent gene targeting of their corresponding receptors, as well as generation of specific C3a and CSa inhibitors, have fueled new interest in studies aimed at defining the roles of the anaphylatoxins in inflammatory diseases. Traditionally, the anaphylatoxins have been considered mediators of end-stage effector mechanisms. However, recent data from animal models of allergic asthma suggest that C3a and C5a provide a critical link between innate and adaptive immunity. Further, the anaphylatoxins appear to form a sophisticated regulatory network together with immunoglobulin G Fc receptors that links regulatory events with effector...

Effects of Stress and Depression on Asthma

The effect of emotional distress on asthma has been controversial over the years. Although emotional compromise has an effect on adherence to appropriate medical management, robust evidence also indicates that direct psychobiological pathways and mechanisms link stress and emotions with disease activity (Chen and Miller 2007 B.D. Miller and Wood 2003 G.E. Miller and Chen 2006 Wright et al. 1998). Evidence links negative family emotional climate to child depression, emotional triggering of asthma episodes (Wood et al. 2007), and worse disease activity (Wood et al. 2006). Mounting evidence indicates that chronic and acute extreme stress contributes to the worsening of pediatric asthma (Chen and Miller 2007 Sandberg et al. 2000, 2004). The most significant stressors are family-related circumstances and relational pro cesses. A series of multimethod (self-report, clinician report, family observation) studies has demonstrated that the chronic stress of negative family emotional climate,...

Chronic Asthma

Therapy for chronic asthma is directed at maintaining long-term control of asthma using the least amount of medications and minimizing adverse effects.1 Treatment goals are to (a) prevent chronic and troublesome symptoms (b) require infrequent use (2 or fewer days week) of SABA for quick relief of symptoms (c) maintain normal or near-normal pulmonary function (d) maintain normal activity levels (e) meet patients' and families' expectations of satisfaction with asthma care (f) prevent exacerbations of asthma and the need for emergency department visits or hospitalizations (g) prevent progressive loss of lung function and (h) provide optimal pharmacotherapy with minimal or no adverse effects.


The disease called orthopnoia, wrote Aretaeus, is also called asthma because those who have paroxysms pant for breath (asthmainousi). The Greek term asthma, used by Homer for a gasping, painful breathing, had acquired a distinct medical sense by the time of Hippocrates. The two terms asthma and orthopnoia are not uncommon in ancient literature, but on the basis of the adjectival form, asthmatikos, a nonmedical usage (e.g., the labored panting of an athlete) may be suspected. Like many diseases, the etiology of asthma was explained in humoralistic terms. The cause, Aretaeus states, is the coldness and moistness of the pneuma but the matter is moist, cold, and glutinous. Airborne pollen and dust do not seem to have been implicated in the sometimes sudden onset of an allergic reaction, the latter a concept not explicitly associated with asthma in classical texts. It may be significant, however, that Hippocrates notes that asthmatic attacks are frequent in the autumn. Aretaeus's account...

Work Related Asthma

At least 10 of asthma cases in adults can be attributed to occupational exposures, so an occupational history should be obtained in every patient with asthma. Diagnostic criteria are the same as for other causes of asthma or airway obstruction, including spirometry (FEVj FVC ratio < 0.7) and evidence of reversibility. Chemical and natural agents can cause asthma or aggravate preexisting asthma. These include chemicals used in cleaning or manufacturing processes. Occupational exposures causing work-related asthma include dust exposures (e.g., cotton

Asthma in sports

After the disqualification of an asthmatic gold medallist in the 1972 Olympic Games for the use of a banned drug 51 , there has been an increased focus on accurate diagnosis and treatment of asthma in Olympic team athletes, especially from the United States and Australia. This interest has since encompassed ath letes at other competitive levels, and was further intensified in the 1990s following the observation that 37 of cross-country skiers finishing in the top 15 places in short-distance competitive events in the 1991 World Championship used antiasthmatic medication (Videman Tapio, American College of Sports Medicine meeting, May 1992). The relationship between asthma and sports appears to be dual in nature. It has long been recognized that asthmatics participating in sporting activities experience EIB. However, recent studies have highlighted high prevalences of chest tightness, cough, wheezing or prolonged shortness of breath and asthma in highly trained athletes, especially...


This may result from stimulation of the airway by inhaled material. It is commoner in asthmatic or bronchitic patients and in smokers. It may result directly from intrinsic asthma or may be part of an anaphylactic reaction. Several drugs used in anaesthetic practice may precipitate bronchospasm either by a direct effect on bronchial muscle or by releasing histamine these include barbiturates, -tubocurarine, morphine, mivacurium and atracurium. Treatment comprises the removal of any predisposing factor and the administration of oxygen and bronchodilators.


These are agents that cause the smooth muscle of the terminal bronchioles to relax, thus counteracting broncho-constriction and narrowing of the airway diameter. Two main types of bronchodilator are used in veterinary medicine Methylxanthines - work on the smooth muscle cells by interfering with their chemical composition, discouraging bronchoconstriction. They are not selective, so can cause a range of stimulatory side effects as they affect many other cells in the body. Examples include theophylline. As methylxanthines are metabolized by the mixed function oxidase system, the dose may need to be increased in patients concurrently being treated with other drugs metabolized by the same system.

Patient Encounter Part

There may be similarities and differences in illnesses such as infections, asthma, allergic rhinitis, attention deficient hyperactivity disorder, diabetes, and seizure disorders between children and adults. These have been discussed throughout the textbook. The incidence of previously common childhood illness such as measles, mumps, and rubella has significantly decreased as a result of en masse vaccination of infants and children. The Advisory Committee on Immunization Practices (ACIP) within the CDC release and update child and adolescent immunization schedules every year. Patients' immunization records should be reviewed routinely for needed immunizations based on these schedules. , Most of the common illnesses in children leading to missed school and or need for clinician consultation are ambulatory in nature however, some complications may require hospitalization.

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) has a prolonged and variable course. Patients with COPD have a high number of physician visits and hospital admissions. Palliative care treatment is directed at reducing symptoms, reducing the rate of decline in lung function, preventing and treating exacerbations, and maintaining quality of life. In end-stage COPD, bronchodilators and anti-inflammatory agents become less

Recent Technological Developments and Future Directions

The aptamer domain does not have to be explicitly selected as an aptazyme in order to function properly in that context. Active aptazyme constructs can be designed through simple secondary structure modeling. For example aptazyme constructs made with a pre-existing theophylline aptamer (Jenison et al., 1994) showed regulated group I intron splicing in vivo (Thompson et al., 2002).

Journals and Publications

In Germany, practice guidelines are coordinated by an association of 153 scientific medical associations from all fields of medicine (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften 2008) that represents Germany in the Council for International Organizations of Medical Sciences. Included are guidelines on consultation in psychosomatic medicine. National guidelines on the management of asthma and diabetes include a section on children, but no specific recommendations are provided covering children's mental health issues.

Emergency Department Treatment and Disposition

Identification and elimination of exposure to the allergen is important. Topical mast cell stabilizers, such as olopatadine or cromolyn, are useful for symptomatic relief, as are topical and systemic antihistamines, and nonsteroidal anti-inflammatory drugs. Cool compresses may help provide relief. In severe cases, topical steroids may be useful, but these should be used only in close consultation with an ophthalmologist. Figure 2.8.

Synthetic catecholamines

Isoproterenol is a Pi- and P2-agonist, with virtually no activity at a-receptors. It acts via cardiac Pi - receptors, and P2-receptors in the smooth muscle of bronchi, vasculature of skeletal muscle and the gut. After intravenous infusion, heart rate increases and peripheral resistance is reduced.- Cardiac output is increased by a combination of increased venous return, heart rate and contractility. Systolic pressure may increase, but diastolic pressure decreases and coronary perfusion may be impaired. Myocardial oxygen consumption is increased and arrhythmias are common. Other P2-mediated effects include relaxation of bronchial smooth muscle and stabilization of mast cells. It has been widely used in the treatment of severe asthma, although newer specific P2-agonists with fewer cardiac effects are now preferred. Isoproterenol is usually administered by intravenous infusion or aerosol. Its most important current indication is in the treatment of bradyarrhythmias or atrioventricular...

Phosphodiesterase inhibitors

Phosphodiesterase inhibitors increase intracellular cAMP concentrations by inhibition of the enzyme responsible for cAMP breakdown (Fig. 7.8). Increased intracellular cAMP concentrations promote the activation of protein kinases, which lead to an increase in intracellular Ca +. In cardiac muscle cells, this causes a positive inotropic effect and also facilitates diastolic relaxation and cardiac tilling (termed 'positive lusitropy'). In vascular smooth muscle, increased cAMP decreases intracellular and causes marked vasodilatation. Several subtypes of phosphodiesterase (PDE) isoenzyme exist in different tissues. Theophylline is a nonspecific PDE inhibitor, but the newer drugs (e.g. amrinone, enox-imone and milrinone) are selective for the PDE type III isoenzyme which occurs in the myocardium, vascular smooth muscle and platelets. PDE III inhibitors are positive inotropes and potent arterial, coronary and venodilators. They decrease preload, afterload, pulmonary vascular resistance and...

Selective P 2agonists

Specific p2-receptor agonists relax bronchial, uterine and vascular smooth muscle whilst having much less effect on the heart than isoproterenol. They include salbutamol, terbutaline, fenoterol, rimiterol and salmeterol. These drugs are partial agonists, (their maximal effect at p2-receptors is less than that of isoproterenol) and are only partially selective for P2-receptors. They are used widely in the treatment of bronchospasm (see Ch. 10). Although less cardiotoxic than isoproterenol, in high doses, P2-mediated tremor, tachyarrhythmias, hyperglycaemia, hypokalemia and hypomagnesaemia may occur. P2-Agonists are resistant to metabolism by COMT and therefore have a prolonged duration of action (mostly 3-5 h). Salmeterol is highly lipophilic and has a strong affinity for the P2-adrenergic receptor it is longer acting than the other P2-agonists, permitting twice-daily dosage. P2-Agonists may be administered by several routes (inhaled, oral, i.v., intramuscular or subcutaneous)....

Reactions resulting from fi blockade

Induction of bronchospasm in patients with asthma or chronic bronchitis who rely on sympathetically (P2) mediated bronchodilatation. Theoretically, Pi-selective drugs are less likely to aggravate bronchospasm in asthmatics, but as their selectivity is only relative, they should not be considered completely safe.

Conceptualizations of Chronic Illness

One of the controversies within the medical coping literature focuses on the use of a categorical versus a noncategorical approach to conceptualizing the childhood illness experience (R.J. Thompson and Gustafson 1996). In categorical approaches, illnesses are grouped in terms of specific diseases, such as inflammatory bowel disease or asthma. These approaches consider the different rates and presentations of psychological problems in childhood within each category of illness (e.g., cancer, heart disease). This method has the advantage of being able to identify important differences between conditions and to identify specific targets for intervention. However, as pediatric psychosomatic medicine has evolved, an increasing focus has been placed on the characteristics that pediatric illnesses have in com

Yin and Yangthe Great Balancing

Your acu-pro may be treating your Stomach Qi for poor digestion or your Lung Qi when you have a cough or asthma. These are examples of the functional aspect of Qi for organs. Qi also circulates throughout your body helping to nourish it with necessary blood and fluids. Remember that Qi is the unseen energy that supports your body's known and visible functions. The strength of your Qi will manifest in your physical, mental, and emotional states. This is why your acu-pro will want to know about all of these areas.

Control Of Respiration

Respiration is modified by many other factors, particularly from higher centres in the brain, including the cortex. The pattern of respiration is modulated by speech and ingestion of food and drink. The anticipation of exercise as well as the activity itself increases respiration. The respiratory centre also balances the depth of respiration (tidal volume, Ft) against the rate, so that the least energy is spent on breathing (F02 resp)- Increases in the elastic work of breathing (e.g. pulmonary oedema or fibrosis) tend to increase the respiratory rate, whereas increases in the resistive work (e.g. asthma) tend to increase Ft.

The Psychosomatic Patient

There are many ways of dealing with psychosomatic patients. First, identify the disorder Do not miss the possible diagnosis of an affective or anxiety disorder. Treatment of somatization is directed toward teaching the patient to cope with the psychological problems. Be aware that somatization operates unconsciously the patient really is suffering. Above all, the patient should never be told that his or her problem is ''in your head.'' Anxiety, fear, and depression are the main psychological problems associated with psychosomatic illness. The list of associated common symptoms and illnesses is long and includes chest pain, headaches, peptic ulcer disease, ulcerative colitis, irritable bowel syndrome, nausea, vomiting, anorexia nervosa, urticaria, tachycardia, hypertension, asthma, migraine, muscle tension syndromes, obesity, rashes, and dizziness. Answers to an open-ended question such as ''What's been happening in your life '' often provide insight into the problems.

Standardized Assessment Measures in Health Related Quality of Life

Several approaches to HRQOL measurement are currently available. Several of these are classified as generic measures, in that they assess the construct in general terms applicable to many medical populations. Two popular generic measures for pediatric populations are the Pediatric Quality of Life Inventory (Varni et al. 2003) and the Child Health Questionnaire (Landgraf et al. 1996) (see Table 3-5). These have the advantages of painting a broad portrait of HRQOL and allowing researchers to compare HRQOL across different illnesses. However, generic measures may not provide the precision necessary to track change over time, which is of great importance in clinical settings. As a result, several illness-specific measures have been developed, such as the Pediatric Asthma Quality of Life Questionnaire (Juniper et al. 1996) and the Cystic Fibrosis Questionnaire (Modi and Quittner 2003). These provide more precise measurement of the health-related issues most relevant to a particular...

Dosage and administration

Used occasionally as a last resort when bronchospasm is so severe that a nebulizer or aerosol is unlikely to deliver the drug to the target cells. Intravenous administration is associated with more frequent side-effects and should be used only when the patient is monitored intensively.

What questions should be considered before ordering a CTmyelogram study of the spine

Does the patient have any history of adverse reaction to iodinated contrast media or any conditions that increase the risk of an adverse reaction to these agents Some factors considered to increase the risk of a reaction to iodinated contrast include renal insufficiency, diabetic nephropathy, significant cardiac or pulmonary disease, asthma, multiple allergies, and patients at the extremes of age.

What types of adverse reactions can occur during a CTmyelogram procedure

Initially patients may experience discomfort during intrathecal injection of the nonionic water soluble contrast agent. After injection, patients may experience an anaphylactoid (idiosyncratic) reaction (urticaria, facial and laryngeal edema, bronchospasm, hypotension) or a nonidiosyncratic reaction due to the adverse effect of contrast on a specific organ system (nephrotoxicity, cardiac arrhythmia, myocardial ischemia, vasovagal reaction). Specific treatment depends on the exact clinical circumstance.

Anticholinergic drugs

The use of anticholinergic agents for their bronchodilator properties dates back two centuries when datura plants were smoked for the relief of asthma. Atropine was used later but the side-effects, particularly dry secretions, made it unpopular. Less soluble ammonia compounds such as ipratropium were then introduced. Ipratropium is active topically and there is little systemic absorption from the respiratory or gastrointestinal tract. It has been suggested that the cholinergic mechanism (increased intracellular cGMP) may be responsible for hyperreactive airways. Thus ipratropium is effective in both prevention and treatment of reflex bronchoconstriction. Mast cell stabilization has also been proposed as a complementary mechanism of action. The maximum effect occurs 30-60 min after inhalation. The effect may persist for up to 8 h.

Antiinflammatory Agents Steroids

Steroids remain the most effective anti-inflammatory agents for lung disease. A variety of mechanisms may be involved in achieving the anti-inflammatory effects (Table 10.8). There is growing evidence that hyperreactive airways are the result of an inflammatory process. Steroids reduce hyperreactivity of airways but have no direct bronchodilator effect. The anti-asthma property of an inhaled steroid is proportional to its anti-inflammatory potency. In addition to their anti-inflammatory actions, steroids sensitize p2-adrenoceptors to the effects of agonists, increase the receptor population and prevent tachyphylaxis.

Upon completion of the chapter the reader will be able to

Discuss the economic and health burden caused by asthma. 2. Explain the pathophysiology of asthma. 3. Describe the clinical presentation of acute and chronic asthma. 4. Identify factors that affect asthma severity. 5. Identify the goals of asthma management. 6. Classify asthma severity based on impairment due to asthma and future risk for negative outcomes due to asthma. 8. Educate patients on the use of inhaled drug delivery devices, peak flow meters, and asthma education plans. 9. Develop a therapeutic plan for patients with chronic asthma that maximizes patient response while minimizing adverse drug events and other drug-related problems. 10. Evaluate current asthma control and make therapeutic changes when necessary. 11. Develop a therapeutic plan for treating patients with acute asthma.

Epidemiology And Etiology

Asthma is the most prevalent chronic disease of childhood, and it causes significant morbidity and mortality in both adults and children. Approximately 22.9 million people in the United States carry the diagnosis of asthma, and nearly 6.8 million of these are younger than 18 years of age. The highest prevalence is in children 5 to 17 Approximately 10.1 million workdays and 12.8 million school days are missed every year due to asthma.2 In 2005, there were 1.77 million emergency department visits and 488,594 hospital discharges related to asthma. Children have the highest rates of emergency department visits and hospitalizations. ' There were approximately 3,816 asthma-related deaths in 2004. The total number of asthma deaths have decreased every year since 1999. Asthma is also a significant economic burden in the United States, costing 19.7 billion in 2007. Prescription drugs are the single largest direct medical expenditure and account for 42 of direct medical costs. Costs increase...

Clinical Presentation And Diagnosis

The diagnosis of asthma is based on a detailed medical history, a physical examination of the upper respiratory tract and skin, and spirometry. The clinician should determine that episodic symptoms of airflow obstruction are present, airflow obstruction is at least partially reversible, and alternative diagnoses are excluded.1 Spirometry is required for diagnosing asthma because the medical history and physical examination are not reliable for characterizing the status of lung impairment or excluding other diagnoses.1

Pulmonary Function Tests

Given this additional information, what is your assessment of the patient's asthma severity Long-term control medications should be initiated in patients who have had (a) four or more episodes within the last year that have lasted for a day or longer and affected sleep and (b) have one major or two minor risk factors for developing persistent asthma. Major risk factors include a parental history of asthma, diagnosis of atopic dermatitis, and evidence of sensitization to aeroallergens. Minor risk factors include sensitization to food, 4 or more eosinophils in peripheral blood, and wheezing apart from colds. In addition, controller therapy should be considered if the patient requires asthma exacerbations requiring systemic corticosteroids within 6 months. ' Daily ICS are the preferred long-term control therapy in all steps, and nonpreferred alternatives are cromolyn or a leukotriene receptor antagonist. Patients not controlled on low doses of ICS should be increased to medium doses...

Patient Encounter Part 3

What further information do you need to assess this patient's asthma control Patients with incomplete responses should contact their health care provider immediately for instructions. Those with a poor response should proceed directly to the emergency department.1 In the emergency department, baseline PEF measurements and oxygen saturation should be monitored. PEF should be monitored before and 15 to 20 minutes after bronchodilator administration. Treatment should be initiated as soon as lung function is assessed (Fig. 14-4). Multiple doses of inhaled ipratropium should be added to SABA therapy in patients with severe airflow obstruction.1 Dosages for emergency department and hospital use of quick-relief medications are shown in Table 14-4. Routine antibiotic use is not warranted because the primary infectious agents associated with asthma exacerbations are viruses.1 Antibiotics should be reserved for situations when bacterial infection is strongly suspected (e.g., fever and purulent...

Patient Encounter Part 4 Emergency Department Visit

RB is brought to the emergency department short of breath and unable to speak in complete sentences. The symptoms started approximately 1 hours ago, and she has already used four puffs of albuterol every 20 minutes for three doses. She has never been hospitalized for asthma previously. On exam, she has inspiratory and expiratory wheezes and appears to be in distress. She is leaning forward to breathe, pursing her lips, and has intercostal and supraclavicular retractions. Her heart rate is 120 bpm and her respiratory rate is 26 breaths per minute. A PEF measurement is 35 of predicted value and her O2 saturation is 87 . Patients with aspirin-sensitive asthma are usually adults and often present with the triad of rhinitis, nasal polyps, and asthma. In these patients, acute asthma may occur within minutes of ingesting aspirin or another nonsteroidal anti-inflammatory drug (NSAID). These patients should be counseled against using NS AIDs.1 Although acetaminophen is generally safe in this...

National Hearu Lung and Blood Institute

The role of T lymphocytes in the pathogenesis of asthma. J Allergy Clin Immunol 2003 111 450-463. 8. Robinson DS. The role of mast cells in asthma Induction of airway hyper-responsiveness by interaction with smooth muscle J Allergy Clin Immunol 2004 114 58-65. 9. Cohn L, Elias JA, Chupp GL. Asthma Mechanisms of disease persistence and progression. Annu Rev Immunol 2004 22 789-815. 10. Bradding P, Walls AF, Holgate ST. The role of the mast cell in the pathophysiology of asthma. J Allergy Clin Immunol 2006 117 1277-1284. 11. Lemanske RF Jr, Busse WW. Asthma. J Allergy Clin Immunol 2003 111 S502-S519. 12. Beckett PA, Howarth PH. Pharmacotherapy and airway remodeling in asthma Thorax 2003 58 163-174. 13. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2) LEN and AllerGen). Allergy 2008 63(Suppl 86) 8-160. 14. Rodrigo GJ, Rodrigo C, Hall JB. Acute...

Nonpharmacologic Therapy

Avoidance of risk factors), especially through smoking cessation influenza vaccination Short-acting inhaled bronchodilator when needed (e.g ipratropium, albuterol, or combination inhaler) ADD Add substitute oral theophylline ADD LABD, long acting bronchodilator (tioiropium6. salmeterol, or

What Practitioners Say It Does

Another claim is that fasting enhances the immune system and reduces the demands placed on it. In addition to its role as part of health maintenance, some believe that fasting is an effective way to treat illnesses, including arthritis, ulcers, heart disease, asthma, and other problems.

Treatment Desired Outcomes

Maximizing nutritional status through pancreatic enzyme replacement and vitamin and nutritional supplements is necessary for normal growth and development and for maintaining long-term lung function. Reduction of airway inflammation and infection and aggressive preventive therapies minimize acute pulmonary exacerbations and delay pulmonary decline. In pulmonary exacerbations, therapy is directed toward reducing acute airway inflammation and obstruction. This is accomplished through more aggressive airway clearance regimens and antibiotic therapy with a goal of returning lung function to pre-exacerbation levels or greater.

Pharmacologic Therapy

Airway clearance therapy is usually accompanied by bronchodilator treatment (alb-uterol also known as salbut-amol outside the United States by nebulizer or metered-dose inhaler) to stimulate mucociliary clearance and prevent bronchospasm associated with other inhaled agents. Hypertonie saline for inhalation (Hyper-Sal) 7 or 3.5 is sometimes used as an add-on mucolytic agent or for sputum induction. It must be preceded by a bron-chodilator due to a greater incidence of bronchospasm and may not be tolerated by Many patients with CF also have reactive airways or concurrent asthma and benefit from long-acting P2-agonists.5 Patients with recurrent wheezing or dyspnea who have demonstrated improvement with albuterol (known as salbutamol outside the Un ited States) should be considered for maintenance therapy, as should patients with bronchodilator-responsive pulmonary function tests (PFTs). Inhaled corticosteroids may also attenuate reactive airways and reduce airway inflammation in some...

Patients With Atypical GERD

In patients presenting with extraesophageal GERD syndromes such as laryngitis or asthma, treatment with twice-daily PPI therapy for 2 months is probably warranted when there is a concomitant esophageal GERD syndrome. Patients with suspected reflux chest pain syndrome should receive twice-daily PPI therapy after cardiac causes have been excluded. Manometry and pH or impedance pH monitoring should be considered in patients who do not respond to PPI therapy.2

Depression and Health Care Behaviors

The impact of depression on treatment adherence has been an important area of investigation. For physically ill children and adolescents, treatment nonadherence is a serious problem, resulting in significant morbidity and mortality (DiMatteo et al. 2000). The relationship between depression and poor treatment adherence has been demonstrated in many pediatric illnesses, including asthma (Norrish et al. 1977), HIV disease (Murphy et al. 2001), renal disease (Brownbridge and Fielding 1994 Simoni et al. 1997), and diabetes mellitus (Ciechanowski et al. 2000). Depression has also been associated with higher rates of adverse health risk behaviors, including overeating, smoking, physical inactivity (Goodman and Whitaker 2002), increased sexual risk behaviors (Lehrer et al. 2006), and substance abuse (Bukstein et al. 1989).

Etiology And Epidemiology

Oral contraceptives, hormone therapy, oral hypoglycemic agents, anticonvulsants, and opioids are other common therapies that can cause nausea and vomiting.1,6 Some medications, such as digoxin and theophylline, cause nausea and vomiting in a dose-related fashion. Nausea and vomiting may indicate higher-than-desired drug concentrations. Ethanol and other toxins also cause nausea and vomiting.

Respiratory system

Ventilatory drive is decreased by thiopental as a result of reduced sensitivity of the respiratory centre to carbon dioxide. A short period of apnoea is common, frequently preceded by a few deep breaths. Respiratory depression is influenced by premedication and is more pronounced if opioids have been administered assisted or controlled ventilation may be required. When spontaneous ventilation is resumed, ventilatory rate and tidal volume are usually lower than normal, but they increase in response to surgical stimulation. There is an increase in bronchial muscle tone, although frank bronchospasm is uncommon.

Increased susceptibility in the elderly

The alteration in the structure of blood vessels, such as thickening of the walls of the arteries with age-related arteriosclerosis, will prevent compensatory increases in blood flow that may be necessary (due to loss of elasticity) to prevent ill-health following toxic exposures. Similarly, chest or respiratory diseases such as emphysema or chronic bronchial asthma may prevent compensatory respiratory mechanisms coming into effect if respiration is compromised by toxic exposures.

Air pollution episodes involving sulphur dioxide

According to the UK's Advisory Group on the Medical Aspects of Air Pollution Episodes in 1992 (Department of Health 1992), during episodes of elevated sulphur dioxide concentrations in the air, those suffering from pre-existing respiratory diseases (particularly asthma) may need to take steps to reduce their exposure. The evidence reviewed indicated that although individuals not suffering from respiratory disease should not be affected by the kind of air pollution episodes of elevated concentrations of sulphur dioxide typically found in the UK, asthmatic patients were found to be more sensitive to exposure to sulphur dioxide. Sulphur dioxide pollution is also considered more harmful when particulate and other pollution concentrations are high (UK Air Quality Archive 2007). In parts of the UK, levels of sulphur dioxide can regularly exceed those at which effects of clinical significance, including tightness of the chest, coughing, and wheezing, have been demonstrated in these...

Beta Adrenergic Receptor Blockers

Tive heart failure), these differences mainly affect side effects, contraindications, and frequency of dosing. For example, nonselective agents may increase bron-chospasm in asthmatic patients. Lipophilic agents may have more central nervous system effects, such as sedation and depression. The type of metabolism affects plasma half-life in patients with renal or hepatic insufficiency. P-Blockers with ISA slow the heart rate less than P-blockers without ISA P-blockers with ISA are less likely to decrease HDL or increase triglycerides.

Water Exercises And Water Running

Water exercises may be prescribed as rehabilitation and alternative training for most injuries, unless the person has wounds, eczema or other skin disorders. Usually, a surgical wound requires two weeks of healing and any stitches to be removed before starting water exercises, due to the risk of infections. Water exercising allows an athlete to maintain or improve aerobic and anaerobic capacity if suffering injuries that do not allow full impact on hard surfaces. Water running and work-out exercises can be used as alternative training for most types of injuries, as you can see from the frequent green light in the 'exercise on prescription' summaries in chapter 4. An athlete who is immobilised in one limb can have a plastic brace, which allows water training, instead of a plaster one. Water exercising can improve the endurance and flexibility of asthmatic athletes and people with different disabilities. It is a superb alternative training method for disabled or elderly patients, where...

Inhalational anaesthetic agents

Diethyl ether has been abandoned in the West because of its flammability, but it remains in widespread use in less developed countries. As it has a higher therapeutic ratio than more modern agents, it is relatively safe for administration in the hands of unskilled individuals. Its use is limited because it is highly irritant to the respiratory tract and can cause coughing, breath holding and profuse secretions. However, at deeper levels it was at one time a recommended treatment for bronchospasm.

Lung Disease in Primary Care

Breathing and heartbeat draw the line between life and death. Pulmonary disease, respiratory symptoms, and respiratory failure are common, high-impact conditions. For example, asthma is the most common chronic disease of childhood, respiratory failure causes many admissions to our nation's intensive care units (ICUs), and lung cancer is now the leading cause of cancer death for both men and women in America. Lung cancer accounts for 31 of cancer deaths in men and 25 of cancer deaths in women (American Cancer Society, 2002). In part because of the global spread of tobacco, the World Health Organization (WHO) estimates that chronic obstructive pulmonary disease will move from

Smoking and Other Risk Factors for Lung Disease

Smoking cessation is the most important factor in preventing lung and cardiovascular disease and all-cause mortality. Avoidance of secondary exposure to smoke, especially in the household, is also important in preventing childhood asthma and infections as well as adult cancers (DHHS, 2006).

Substance Induced Anxiety Disorder

Anxiety may be induced by a variety of substances or medications, either as a direct effect of a substance or as a withdrawal reaction (see Table 7-7). Corticosteroids, anticholinergic medications, beta-adrenergic agonists, and asthma medications are all potential causes of anxiety, particularly if the medication has recently been started or the dosage has changed (see Table 7-8). Table 7-9 serves as a reference for how anxiety disorders relate to the specific DSM-IV-TR specifiers of substance dependence, abuse, intoxication, withdrawal, and intoxication delirium for specific classes of substances.

Obstructive Lung Disease

The most common chronic lung diseases that have a major global impact on disability and health care costs are three obstructive lung diseases asthma, chronic obstructive pulmonary disease, and chronic bronchitis. Some patients have features of more than one of these conditions, such as the patient with asthma (acute episodes of reversible obstruction) who also has chronic bronchitis (cough productive of phlegm at least 3 months of the year for at least 2 years in a row), or the adult patient with asthma who is developing some level of irreversible decline in pulmonary function. COPD alone can ultimately result in pathologic signs of emphysema, a diagnosis previously made only with tissue pathology or large blebs on x-ray film but increasingly visible with various multislice HRCT techniques.

Epidemiology and Risk Factors

Asthma is the most common chronic disease of childhood and affects many adult patients as well. The prevalence of asthma is increasing rapidly worldwide. It now affects more than 300 million people and causes the loss of more than 15 million disability-adjusted life-years (DALY) each year (Global Initiative for Asthma, 2006). Asthma prevalence is increasing in many countries and is not decreasing globally, despite some indications of decreased emergency care utilization linked to improved care (Anandan et al., 2009). In the United States, National Health Interview Survey (NHIS) data (2002) suggest that 20 million Americans would report currently having asthma (72 per 1000 people). Asthma affects an estimated 6.1 million children nationally (83 per 1000). Across all age groups, asthma led to 1.9 million ED visits (National Hospital Ambulatory Medical Care Survey, 2002) and 4261 deaths in 2002, down from 4487 deaths in 2000 (National Vital Statistics System, 2002a). In 2003, asthma was...

Delayed effects following an acute exposure

A relatively recent report relating to accidental exposure to chlorine gas suggests that chronic sequelae following acute exposure may be more frequent than previously anticipated a follow-up study in July 1999 on 20 individuals (previously exposed in 1995) indicated that 75 had residual lung volumes below 80 of their predicted value and nearly half the subjects tested for airway reactivity to methacholine had a greater than 15 decline in FEV (Schwartz et al. 1990). There is some evidence to suggest that a single, acute exposure to chlorine gas may cause reactive airways dysfunction syndrome (RADS), also known as irritant-induced asthma (Ayres and Baxter 2004 Winder 2001).

Diagnosis and Staging

Asthma Onset early in life (often childhood) Symptoms vary from day to day Symptoms at night and early morning Allergy, rhinitis, and or eczema are also present Family history of asthma Largely reversible airflow limitation From Global Initiative for Chronic Obstructive Lung Disease Executive Summary Global Strategy for the Diagnosis, Management, and Prevention of COPD, Updated 2008, p 39. *These features tend to be characteristic of the respective diseases but do not occur in every case. For example, a person who has never smoked may develop COPD, especially in the developing world where other risk factors may be more important than cigarette smoking, and asthma may develop in adult and even elderly patients.

Physiologic responses to cold exposure

Many of the cold-induced physiologic responses attenuate physical performance. Low temperature of muscles causes poor efficiency and coordination, and risk of muscle and tendon tears. Shivering muscles make use of energy stores, and shivering may also cause clumsiness. Physiologic mechanisms activated by cold are presented in the box below. Cold-induced skin vasoconstriction leads to increased blood pressure, plasma extravasation (leakage of fluid from the plasma to the interstitium) and diuresis. Increased sympathetic activation and hemoconcentration reduce maximal physical performance. Finally bron-choconstriction in winter athletes is common and may lead to exercise-induced asthma (see Chapter 4.5). A recent study showed that 23 of the Olympic winter

Other Pulmonary Diseases of the Pulmonary Vasculature

Diffuse alveolar hemorrhage may result from autoimmune collagen vascular disease or vasculitis, Goodpasture's syndrome, and other vasculitides. Goodpasture's syndrome results from the formation of anti-glomerular basement membrane antibodies, which can also attack the lung capillary membranes. Primary pulmonary vasculitides affect mostly small vessels, but systemic conditions can affect vessels of all sizes. Churg-Strauss syndrome is a small-vessel vasculitis that often manifests first as asthma. Most patients also have maxillary sinusitis, allergic rhinitis, or nasal polyposis. Gastrointestinal, neurologic, and cardiac involvement often follows. The condition responds well to systemic steroids, but patients can require long-term low-dose prednisone as maintenance therapy (Guillevin et al., 2004).

Hypersensitivity Pneumonitis

Figure 18-9 Causes of work-related asthma, 1993-1999. (From National institute for Occupational Safety and Health. Distribution of agent categories most often associated with work-related asthma cases for all four SENSOR reporting States California, Massachusetts, Michigan, New Jersey , 1993-1999. Worker Health Chartbook 2004.

The Health and Occupational Reporting

The Health and Occupational Reporting (THOR) is an example of a UK system for occupational disease surveillance. THOR activity at the Centre of Occupational and Environmental Health, University of Manchester has a range of surveillance programmes. It includes surveillance of work-related and occupational respiratory disease (SWORD), particularly occupational asthma, benign and malignant pleural disease, mesothelioma, lung cancer, and pneumoconiosis surveillance. The most common cause of occupational asthma in the UK consists of the di-isocyanates (used in various industries such as in 'twin-pack' spray painting). Other important asthma hazards include colophony fume (from soldering flux). The SWORD scheme successfully picked up trends such as an increase in asthma associated with exposure to latex, and thus helped in raising awareness and reducing the risks.

Clinical Presentation

Symptoms that bring patients to medical attention most often emanate from the lungs, skin, or the eyes (uveitis and lacrimal gland enlargement). Diagnosis of sarcoidosis may be delayed if symptoms are attributed to more common lung diseases such as asthma or chronic bronchitis (Judson et al., 2003). Pulmonary symptoms may result from bronchial obstruction, either external compression caused by adenopathy or granulomas within the airways. Progressive disease may cause damage to the lung parenchyma, with a restrictive pattern of pulmonary function and decreased diffusion capacity, consistent with progressive interstitial lung damage. Clinical features associated with a worse outcome include the presence of lupus pernio, chronic uveitis, hyper-calcemia or nephrocalcinosis, nasal mucosal involvement and bone cysts. Neurosarcoidosis and cardiac involvement can be especially challenging to diagnose.

Adrenergic Receptors in Pulmonary Medicine

All three subtypes of a1-adrenergic receptors (particularly the a1A-subtype) and all three subtypes of -adrenergic receptors are expressed in human lung at the mRNA level, but no major role in the regulation of human airway function has been described (49-53). Among the P-adrenergic receptors, P1- and P2-adrenergic receptors coexist in the human lung the P3-subtype appears to be absent (53). P2-Adrenergic receptors are more abundant than P1-adrenergic receptors in all pulmonary cell types (except in pulmonary blood vessels) and are apparently the only subtype on airway smooth muscle cells (53). Accordingly, relaxation of airway smooth muscle is a prototypical function of P2-adrenergic receptors, and P2-selective agonists have been used for many years as bronchodilator drugs in asthma, chronic obstructive pulmonary disease, and other pulmonary conditions. Short-acting P-adrenergic agonists, such as salbutamol or terbutaline, are well established as acute bronchodilators, whereas...

Epidemiological studies

Time-series studies examine the relationship between day-to-day changes in concentrations of pollutants and day-to-day changes in the counts of health (or ill-health)-related events such as deaths and admissions to hospital. These studies require very careful control of confounding factors that also vary on a day to day basis. The key confounding factor that varies in this way is ambient temperature. Associations between all the common pollutants (particles, ozone, nitrogen dioxide, sulphur dioxide, and carbon monoxide) and a range of effects, including deaths from cardiovascular and respiratory disease, hospital admissions for heart attacks, and worsening of chronic respiratory conditions and asthma attacks,

Diagnostic procedures in eczema herpeticum

In all EH cases, the patient's personal history and family history of concomitant atopic diseases, such as allergic rhinoconjunctivitis and bronchial asthma, as well as personal and environmental history of herpes labialis, should be well documented to allow further information about predisposing factors for EH. Serum IgE levels usually correlate with the severerity of AD.25

Clinical application

There are a number of medical indications for intravenous sedation, particularly if the patient has a condition that is aggravated by stress. This group includes those with asthma, epilepsy, hypertension and those with mild ischaemic heart disease. Intravenous sedation can also be useful in those with mental and physical special needs.

Organophosphorus compounds

These substances are considered to be irreversible inhibitors of acetylcholinesterase, as by phosphorylation of the enzyme they produce a very stable complex which is resistant to reactivation or hydrolysis. Synthesis of new enzyme must occur before recovery. These agents, which include di-isopropylfluorophosphonate (DFP) and tetraethylpyrophosphate (TEPP), are used as insecticides and chemical warfare agents. They are readily absorbed through the lungs and skin. Poisoning is not uncommon among farm workers. Muscarinic effects, such as salivation, sweating and bronchospasm, are combined with nicotinic effects, such as muscle weakness. Central nervous effects such as tremor and convulsions may occur, as may unconsciousness and respiratory failure. Reactivators of acetylcholinesterase are used to treat this form of poisoning they include pralidoxime and obidoxime. Atropine, anticonvulsants and artificial ventilation may be necessary. Chronic exposure may produce a polyneuritis....

Conclusions and Future Perspective

The interindividual variability in responsiveness to adrenergic agonists and antagonists presents not only a major challenge, but also an important opportunity for the future use of such drugs. Part of this variability has a genetic basis (i.e., polymorphisms and other variants in the genes encoding the adrenergic receptor subtypes) (42,43,96-98). Although variation in the genes for the adrenergic receptors (or their signaling machinery) have the potential to influence tissue responsiveness to adrenergic drugs, variants in the genes that encode drug-metabolizing enzymes also may influence adrenergic drug responses. Another type of interindividual variability derives from differences in the regulation of adrenergic receptor expression and responsiveness that result from physiological factors such as age, pregnancy, and pathophysiological conditions such as heart failure or asthma and from drug treatment (6). This has been best documented for the heart (18) and airways (56). These...

Pulmonary Complications

Despite a lack of data demonstrating clear benefits of regional over general anesthesia in patients with preexisting lung disease, many anesthesiologists will choose regional anesthesia for their patients with advanced lung disease for surgery on the lower body to avoid the need to instrument the airway. Airway devices, like the endotracheal tube, may significantly irritate the airways in the patient with severe lung disease and stir up a host of unwanted side effects like bronchospasm (wheezing), increased coughing, and straining. Regional anesthesia usually avoids these problems.

Treatment Nonspecific Measures

Removing known allergens is of prime importance because it can eliminate symptoms. When exposure is unavoidable, environmental control should reduce symptoms and prevent exacerbations. The patient or the family must assume responsibility for environmental control, so an understanding of allergens is helpful. Commonly inhaled allergens include pollens, which can produce symptoms of seasonal allergic rhinitis, conjunctivitis, and asthma. Allergenic pollens come from trees, grasses, and weeds. Pollens from flowering plants are insect-borne and are not important allergens. Pollen prevalence is usually determined by gravity slides, which sample pollen fallout without regard to wind direction, speed, and turbulence, so that daily reports of pollen prevalence often do not reflect the true concentration in the air or individual exposure.

Precipitating Factors

All patients suspected of having asthma should be questioned about early warning signs and precipitating factors. Early warning signs of an attack include symptoms such as cough, scratchy throat, and nasal stuffiness, especially if an attack follows an upper respiratory tract infection. Many other precipitating factors can provoke asthma symptoms or an acute attack (Box 20-3). Identification of these precipitating factors can help patients manage their asthma by learning their early warning signs and avoiding any exposure that triggers an exacerbation. These symptoms and identification of triggers are the first stages of diagnosis of asthma.

General Considerations

The magnitude of pulmonary disease is enormous. In 2007, there were 115,652 deaths from chronic obstructive pulmonary disease, more than 5 million people had some degree of pulmonary disability, and more than 20 million had pulmonary symptoms. In addition, there were 91,871 deaths from pneumonia and influenza. Asthma accounted for more than 5400 deaths. In 1967, the estimated cost of morbidity and mortality from lung disease was 1.8 billion. In 2007, this figure skyrocketed to more than 65 billion.

Treatment Classification

Asthma is classified into four categories based on subjective symptoms of frequency and severity and objective measurements of pulmonary function (Figs. 20-1 and 20-2). The goal of asthma therapy is to maintain control of asthma with the least amount of medication and the least risk for adverse side effects. Obtaining control of asthma can be difficult to define for the patient and the clinician. Several keys to the definition of controlled asthma are prevention of troublesome symptoms (cough or wheezing), maintenance of normal pulmonary function, maintenance of normal activity levels, prevention of recurrent exacerbations, and meeting patients' and families' expectations of asthma care. Figure 20-2 Classification of asthma severity. (From Busse WW, Boushey HA, Camargo CA, et ai. Guidelines for the Diagnosis and Management of Asthma. National Asthma Education and Prevention Program, Expert Panel Report 3. NIH Pub No 08-5846, October 2007.) Classification of Asthma Severity > 12...

Paradoxical Vocal Cord Motion

Paradoxical vocal cord motion is defined by an inappropriate adduction of the true vocal cords on inspiration and adduction on expiration. The functional airway obstruction results in marked inspiratory stridor and wheezing, and the symptoms are similar to asthma. Often misdiagnosed as refractory asthma, paradoxical vocal cord motion appears to be psychogenic and occurs most often in young women with a history of prior psychiatric illnesses (e.g., depression, personality disorder, posttraumatic stress disorder, sexual abuse, generalized anxiety). Diagnosis is made by direct laryngoscopy with visualization of the cords throughout the respiratory cycle. Treatment is difficult because there are no published studies on the efficacy of psychodynamic therapy or pharmacologic treatment.

Location Of Tonsils And Adenoids

A runny nose can cause a cough, particularly at night as fluid drips down the back of the throat and causes irritation. A cough at night, even if it is not accompanied by wheezing, can be a symptom of asthma, and you should consult your doctor if you are concerned.

Medical Disorders in Pregnancy

Many medical disorders can be seen in the pregnant woman few are incompatible with pregnancy. In the management and care of the pregnant woman with a medical illness, it is important to understand the normal physiology of pregnancy and the effect of the disorder on the pregnancy, and vice versa. Common medical problems in pregnancy include anemia, asthma, hypertension, diabetes, and pyelonephritis. Women with moderate to severe preexisting medical illness should be referred for evaluation to a physician experienced in managing the disorder in pregnancy.

Impact of Lung Disease on the Patient

Since ancient times, clinicians have recognized that emotional factors play a role in the onset and maintenance of symptoms in bronchial asthma. Attacks of asthma can be provoked by a range of emotions fear, anger, anxiety, depression, guilt, frustration, and joy. It is the patient's attempt to suppress the emotion, rather than the emotion itself, that precipitates the asthmatic attack. A patient having an asthmatic attack becomes anxious and fearful, which tends to perpetuate the attack. Hyperventilation may contribute to the breathlessness of the frightened patient. Despite being given adequate medical therapy, these patients remain dyspneic. In such patients, it is the anxiety and its causes that require attention. They need continuing medical and psychologic support after an acute attack. As early as the 12th century, Maimonides recognized that ''mere diet and medical treatment cannot fully cure this disorder.'' Asthma in children presents a special problem. Anxiety,...

Respiration A Breath of Fresh

V Oriental medicine helps asthma sufferers breathe with confidence In this chapter, we give you hope of treating your awful allergies and asthma. Oriental Medicine once more comes to the rescue in the case of bronchitis. We'll take a look at the issues of allergies, their treatment, and prevention. Asthma and bronchitis sufferers will get tips on self-care techniques using acu-points and medical massage. Life can be challenging enough without struggling for each breath. Now it's time to begin your journey to better breathing.

Clinical Manifestations Diagnosis Treatment and Control

As is often true for helminthic infections, low worm loads may cause few or no symptoms. Large numbers of larvae in the lungs may produce ascaris pneumonitis, with symptoms resembling pneumonia. Allergic reactions can cause asthma attacks. Larvae can reach atypical (ectopic) sites such as the brain, eye, or kidney, where they may produce grave, life-threatening conditions, but such events are fortunately rare. Adult worms in the intestine can cause fever, abdominal discomfort, diarrhea, and allergic reactions to their proteins. Fever may induce worms to wander to the larynx, where they can cause suffocation, or to exit the mouth or nostrils. Heavy infections rob the host of nutrients, and tangled masses of worms can result in fatal intestinal obstruction if not treated promptly. Intestinal ascariasis is especially serious in young children. A study in Kenya showed that ascariasis produced signs of protein-energy malnutrition in many children and...

Hypersensitivity Reactions

Immediate hypersensitivity reactions occur within 8 h of secondary allergen exposure and are not cell-mediated, but humoral in nature, resulting in generation of antibody-secreting plasma cells and memory cells. The hypersensitivity reactions may be classified into type I (IgE-dependent), type II (antibody-mediated cytotoxicity), type III (immune complex-mediated hypersensitivity) and type IV (delayed type hypersensitivity) and are shown in Table 24.1. Type I reactions are mediated by IgE antibodies which bind to receptors on mast cells or basophils, leading to degranulation and release of mediators. The principal effects are smooth muscle contraction and vasodilatation, and these may result in serious life-threatening systemic anaphylaxis, asthma, hay fever and eczema. Table 24.2 shows common antigens associated with type I reactions.

Question 1 Was the reference standard an acceptable one

While many single tests (such as histopathologic examinations) are considered classic examples of reference standards, such tests do not always work for complex conditions. Sometimes, researchers resort to establishing disease presence using multiple criteria (e.g. the Jones criteria to diagnose rheumatic fever) 1 or even response to therapy (e.g. reversible airway obstruction to diagnose bronchial asthma) 2 . Whatever they choose, they must ensure that their reference standard defines disease in a way that is acceptable to medical practitioners.

Simulated Moving Bed Chromatography

Large-scale separation of chiral drugs (a priority in the pharmaceutical industry) can be achieved with this method. In simulated moving bed chromatography (SMBC) 6-12 columns containing a CSP are joined in a ring and the fluid is circulated using 4-5 pumps. As the racemate travels through the columns a zone of one enantiomer leads the rest of the injected sample while a zone of the opposite enantiomer lags behind. Using a computer-controlled system, some of the leading enantiomer, and, independently, some of the trailing enantiomer are withdrawn at intervals. As polysaccharide-based columns have a high loading capacity they have been widely used for chiral SMBC separations of up to 1.5 kg of racemate per kilogram of CSP per day. SMBC has been applied for the separation of a number of chiral drugs and intermediates such as propranolol, analgesic tramadol, antiasthmatic agent formoterol, antidepressant citalopram, and antitussive agent guaifenesine.

Infancy through Adolescence

Although malnutrition is still a problem in the United States, inappropriate nutrition, especially calorie-nutrient imbalance leading to overweight and obesity, has become commonplace. Recent NHANES studies demonstrate that the prevalence of overweight (BMI > 95 ) in girls 2 to 19 years old increased from 13.8 in 1999-2000 to 16 in 2003-2004, and the prevalence of overweight in boys 2 to 19 years old increased from 14 to 18.2 (Ogden et al., 2006). Increased pediatric BMI is associated with high blood pressure, sleep apnea, asthma, polycystic ovarian syndrome, type 2 diabetes, gastroesophageal reflux, and orthopedic problems (Benson et al., 2009). A nationwide survey of more than 6000 children and adolescents found that at least 30 consumed fast food on a typical day. These children consumed more total fat, total carbohydrate, more added sugars and sugar-sweetened beverages, less milk, and fewer fruits and nonstarchy vegetables than children who did not eat fast food (Bowman, 2004)....

Rule Out Cardiac Tamponade

The technique for assessing the magnitude of a paradoxical pulse is as follows Have the patient breathe as normally as possible. Inflate the blood pressure cuff until no sounds are heard. Gradually deflate the cuff until sounds are heard in expiration only. Note this pressure. Continue to deflate the cuff slowly until sounds are heard during inspiration. Note this pressure. If the difference in these two pressures exceeds 10 mm Hg, a marked (abnormal) pulsus paradoxus is present cardiac tamponade may be the cause. Cardiac tamponade results when there is an increase in intrapericardial pressure that interferes with normal diastolic filling. A marked paradoxical pulse is not a specific phenomenon for tamponade because it is also seen in large pericardial effusions, in constrictive pericarditis, and in conditions associated with increased ventilatory effort, such as asthma and emphysema.

Reduction of Medication Errors Due To the Availability of Electronic Decision Support Tools At the Point of Prescribing

In the study by Nebeker,7 documenting 937 hospital admissions, it was found that 483 admissions had significant ADEs associated with them and that 27 of these were associated with medication. Of the medication-related ADEs, 61 were associated with prescribing errors and 25 with monitoring errors and the authors concluded that EP with decision support (DS) features would have a major impact on these error rates, by reducing inappropriate prescribing at the outset and by providing suitable monitoring tools when certain drugs are prescribed (e.g. digoxin, lithium, theophylline). Indeed, the consensus among electronic prescribing specialists is that decision support tools should be an integral part of EP systems, as they have the potential to add value to the system as a clinical tool. The above data suggest that DS functions are particularly valuable in reducing selection errors and inappro

Colic Massage Rub a Dub

Pediatric Asthma Silence Is Golden Asthma now affects 4.8 million American children under the age of 17. I've heard parents say to me, It seems like a lot more kids have asthma. You know what They're right The rate of asthma among children has increased by about 72 percent between 1982 and 1994. Most experts are attributing this to a dramatic increase in environmental toxins in our cities and towns. Asthma can begin at any age, but most children experience their first attack before age four or five. In the early years, 10-15 percent of boys and 7-10 percent of girls develop asthma. By adolescence, the girls' rate catches up to the boys' until adulthood. Half of children are free from asthma by the time they are 20 years old, but can relapse into attacks with stress, poor diet, and a decline in overall health. The proper management and prevention for your child is essential in order to avoid a lifetime of breathing problems. The cost of pediatric asthma is stunning, on a personal and...

Dealing With Asthma Naturally

Dealing With Asthma Naturally

Do You Suffer From ASTHMA Chronic asthma is a paralyzing, suffocating and socially isolating condition that can cause anxiety that can trigger even more attacks. Before you know it you are caught in a vicious cycle Put an end to the dependence on inhalers, buying expensive prescription drugs and avoidance of allergenic situations and animals. Get control of your life again and Deal With Asthma Naturally

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