Natural Solution for Asthma

Asthma Free Forever Ebook

Jerry Ericson is a researcher and alternative medical practitioner. Jerry created this asthma treatment book basing on over 20 years of his personal experience in helping asthma sufferers relieve their symptoms within minutes, and get rid of asthma permanently without 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. More here...

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TABLE 644 Asthma Mimickers

Directed physical examination reveals hyperresonance to percussion, decreased intensity of breath sounds, and prolongation of the expiratory phase, usually with wheezing. Although wheezing results from the movement of air through narrowed airways, the intensity of the wheeze may not correlate with the severity of airflow obstruction. The silent chest reflects very severe airflow obstruction, with air movement insufficient to promote a wheeze. A pulsus paradoxus above 20 mmHg is also indicative of severe asthma. Although tachycardia and tachypnea are usually seen with acute asthma, vital signs normalize very quickly as airflow obstruction is relieved. Therefore, a normal heart rate, respiratory rate, and the absence of a pulsus paradoxus do not indicate complete relief of airway obstruction.

Aminophylline and Theophylline second line therapy

-Aminophylline loading dose, 5.6 mg kg total body weight over 20 min (if not already on theophylline) then 0.5-0.6 mg kg ideal body weight hr (500 mg in 250 mL of D5W) reduce if elderly, or heart or liver disease (0.2-0.4 mg kg hr). Reduce loading to 50-75 if already taking theophylline (1 mg kg of aminophylline will raise levels by 2 mcg mL) OR -Theophylline IV solution loading dose, 4.5 mg kg total body weight, then 0.40.5 mg kg ideal body weight hr. -Theophylline long acting (Theo-Dur) 100-400 mg PO bid-tid (3 mg kg q8h) 80 of daily IV aminophylline in 2-3 doses.

Care for Asthma via Mobile Phone CAMP

The primary goal of the Care for Asthma via Mobile Phone (CAMP) service is to provide an effective method by which Taiwan's asthma patients can easily monitor their asthma symptoms using a common mobile phone. With the CAMP service, the patient uses his own cellular phone to submit his daily peak expiratory flow rate (PEFR) and answer a simple questionnaire regarding to daily activities. The CAMP service participant then receives an asthma symptom assessment and care suggestion message immediately after imputing his information. This assessment, which is in accordance with the World Health Organization's (WHO) Global Initiative for Asthma (GINA) standard, includes weather conditions that might adversely affect the asthma patient (e.g. temperature, pollen count, etc.). This information is, in turn, used to advise the asthma patient how to avoid a severe asthmatic attack. Keywords. Long-distance care, long-term care, asthma care, chronic disease care, wireless-care system,...

TABLE 1201 Asthma Triggers

AIRWAY INFLAMMATION Bronchial smooth muscle cells are regulated by the autonomic nervous system. Sympathetic b2 receptors cause bronchodilation, whereas parasympathetics govern bronchoconstriction. While the exact neurogenic mechanism for hyperreactivity is unknown, IgE-mediated inflammation is well characterized as a contributor in the pathogenesis of an asthma attack. Mast cells release histamine, leading to the formation of arachidonic acid metabolites and the inflammatory cytokine cascade. Asthma is a two-stage process (1) bronchoconstriction due to histamine and leukotriene release (early stage) and (2) airway mucosal edema with mucous plugging (late phase). Since resolution depends largely on the degree of mucosal inflammation, an asthma attack may persist from days to weeks. AIR TRAPPING, V Q MISMATCH, AND HYPOXEMIA Bronchospasm, mucosal edema, and mucous plugging cause variable and reversible airflow obstruction with subsequent air-trapping and impaired oxygen exchange. While...

TABLE 1206 Differential Diagnosis of Asthma

INFECTION Fever and focal wheezing implicate infectious etiologies such as pneumonia or bronchiolitis. Nocturnal wheezing, nocturnal cough, and poor exercise tolerance may be clues of more chronic illness. Sinusitis can exacerbate asthma symptoms a history of nasal congestion and nocturnal cough or snoring should be treated with at least a 2-week course of antibiotics and nasal steroids. Recurrent attacks, failure to thrive, and a history of sinusitis and chronic ear infections should raise suspicion of cystic fibrosis as an etiology. CARDIAC LESIONS CONGENITAL AND ACQUIRED Infants with history of BPD may present with mild illness with rapid deterioration. Prolonged mechanical ventilation in the neonatal period causes smooth muscle hypertrophy and pulmonary hypertension, leading to cardiac disease. It may be necessary to distinguish pulmonary edema as a cause of wheezing usually a history of diuretic use will aid in diagnosis. Congenital heart lesions causing congestive heart failure...

Aminophylline and theophylline

Concomitant drugs (e.g. erythromycin or carbamazepine) may increase serum theophylline levels by decreasing drug metabolism. -Aminophylline loading dose 5-6 mg kg total body weight IV over 20-30 min 1 mg kg of aminophylline will raise serum level by 2 mcg mL . -Aminophylline maintenance as continuous IV infusion (based on ideal body weight) 1-6 mth 0.5 mg kg hr 6-12 mth 0.6-0.75 mg kg hr 1-10 yr 1.0 mg kg hr 10-16 yr 0.75-0.9 mg kg hr 16 yr 0.7 mg kg hr OR -Theophylline PO maintenance 80 of total daily maintenance IV aminophylline dose in 2-4 doses day OR 1-6 mth 9.6 mg kg day. 6-12 mth 11.5-14.4 mg kg day. 1-10 yr 19.2 mg kg day. 10-16 yr 14.4-17.3 mg kg day. 16 yr 10 mg kg day. -Give theophylline as sustained release theophylline preparation 100, 125, 200, 300 mg caps q8-12h -Theophylline oral liquid 80 mg 15 mL, 10 mg mL q6-8h. -Theo-Dur 100, 200, 300, 450 mg tabs scored, may cut in half, but do not crush q8-12h. -Theophylline Products Cap 100, 200...

Theophylline Overdose

Diagnosis Theophylline overdose -Activated charcoal 50 gm PO round-the-clock, with sorbitol cathartic, until theophylline level 60 mcg mL or if signs of neurotoxicity, seizure, coma are present. 11. Labs CBC, SMA 7&12, theophylline level now and in q6-8h INR PTT, liver panel. UA.

TABLE 1203 Classifying Severity of Asthma Exacerbations

Theo Dur 450

MEASUREMENT DEVICES FOR PEAK EXPIRATORY FLOW RATE (PEFR) The 1997 EPR-2 advocates use of the PEFR (or peak flow) meters in the ongoing assessment and management of asthma. The newer hand-held spirometers are designed for personal use and portability and are readily available in the ED. Forced expiratory volume in 1 s (FEV1) is estimated by measuring PEFR and correlates with the degree of airway obstruction PEFR is already decreased by 25 percent once wheezing is detected by stethoscope (see T,ab e.,.,1,2.0,-,4). PEFR values in liters per minute are based on the child's height. A PEFR of less than 50 percent indicates severe obstruction, less than 25 percent indicates possible hypercarbia. In the ED, PEFR is an excellent tool to evaluate mild asthma or for reevaluating patients after treatment, especially those who know their personal best score. Pre- and posttreatment values should be obtained when possible.

Chemokine Receptors and Allergic Asthma

Allergic asthma is often characterized by airway inflammation of different cell types, airway hyper-responsiveness (AHR), mucus production, and a variable airflow (Busse, 2001 O'Byrne and Parameswaran, 2001). The initiating phase is characterized by IgE and mast cells. In the propagation phase, Th2-polarized T-lymphocytes and eosinophils are guided to a chronic inflammatory state by infiltrating the airways. The effector phase is characterized by the production of spasmogenic substances, AHR, and mucus hypersecretion. Anti-cytokine therapy has been explored as a potential therapeutic approach in the treatment of allergic asthma, as the cytokines IL-4, IL-5, and IL-13 are of fundamental importance in its pathophysiology. The initial study using monoclonal antibodies (MAbs) against IL-5 (Leckie et al., 2000) in human asthmatics demonstrated a decrease in the number of eosinophils, though no major change in the AHR was observed. More recent studies showed the importance of CCR3 for the...

Complications of Moderate and Severe Asthma Exacerbation

Respiratory failure may occur even if treatment is in progress, mainly from muscle fatigue. Atelectasis is common and may be responsible for the overdiagnosis of pneumonia in pediatric asthmatic patients. While pneumomediastinum is rare, children may present with vague chest pains for which a radiograph can reveal the diagnosis. Most can be managed on an outpatient basis provided that there is good follow-up. Generally, mediastinal air will resorb over 2 to 3 days. A large pneumomediastinum and or pneumothorax requiring chest tube thoracostomy will require admission for close monitoring and observation.

Methylxantines theophylline

Theophylline is noted for its very narrow therapeutic index so that even with close monitoring and apparent therapeutic levels, people can experience significant toxicity. There are theoretical benefits for dyspnoea beyond any effect on airway constriction. These include the ability to improve the strength and efficiency of the muscles of respiration, especially the diaphragm, and to stimulate the respiratory centre.43 There are studies that focus on symptomatic benefit in people with irreversible disease while other studies include people with significant reversibility in airway response to bronchodilators.44 A clinical trial of 12 patients with moderate to severe COPD without a reversible component crossed between placebo and active arms for four weeks each with a two-week washout in between. With therapeutic blood levels maintained on the active arm, overall dyspnoea was reduced by theophylline. Functional impairment was also reduced together with the threshold at which dyspnoea...

TABLE 1202 Pertinent Questions to Ask about Asthma History

CLINICAL SCORING SYSTEMS IN ASTHMA The Wood-Downes-Lecks13 clinical scoring system had been used in the past but is now replaced by the Expert Panel Report of the NIH (Table 1.2.0-3). The authors feel that scoring systems are not helpful in predicting outcome, since asthma is a dynamic and not static illness they

Special considerations Occupational asthma

Approximately 2 of all asthma is related to occupational exposures. A large and growing list of agents may precipitate this syndrome, including vegetable materials, chemicals, animal materials, metals and pharmaceuticals. While the high molecular weight compounds are complete antigens that elicit IgE synthesis, many of the low molecular weight compounds are haptens, creating a complete antigen only when bound to carrier proteins. There is often a latency period between the onset of exposure and the development of clinical disease. Symptoms tend to be worse on work days and better on weekends and holidays. Bronchoprovocation testing with the specific agent may confirm the diagnosis. Subjects with long exposure histories may suffer chronic pulmonary dysfunction despite removal from the environment. Asthma during pregnancy Poorly controlled asthma poses significant risks to both mother and fetus. The primary goals of asthma therapy during pregnancy are stabilization of disease with...

Acute Asthma In Adults

Theophylline Magnesium Asthma is a chronic inflammatory disorder characterized by increased responsiveness of the airways to multiple stimuli. Many cells and cellular elements, such as mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells, play a role in the development of the inflammatory response. In susceptible individuals, the inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variable, airflow obstruction, that is often reversible either spontaneously or with treatment. Most acute attacks are reversible and improve spontaneously or within minutes to hours with treatment. Although patients appear to recover completely clinically, evidence suggests that asthmatic patients develop chronic airflow limitation.1 The recognition that asthma is a chronic inflammatory disorder of the airways has...


Diagnosis Exacerbation of asthma -Prednisone 20-60 mg PO qAM. Aminophylline and Theophylline (second-line therapy) -Aminophylline load dose 5.6 mg kg total body weight in 100 mL D5W IV over 20min. Maintenance of 0.5-0.6 mg kg ideal body weight h (500 mg in 250 mL D5W) reduce if elderly, heart liver failure (0.2-0.4 mg kg hr). Reduce load 50-75 if taking theophylline (1 mg kg of aminophylline will raise levels 2 mcg mL) OR -Theophylline IV solution loading dose 4.5 mg kg total body weight, then 0.40.5 mg kg ideal body weight hr. -Theophylline (Theo-Dur) PO loading dose of 6 mg kg, then maintenance of 100-400 mg PO bid-tid (3 mg kg q8h) 80 of total daily IV aminophylline in 2-3 doses. Inhaled Corticosteroids (adjunct therapy) bronchodilator, followed by gargling with water -Triamcinolone (Azmacort) MDI 2 puffs tid-qid or 4 puffs bid. -Flunisolide (AeroBid) MDI 2-4 puffs bid. -Salmeterol (Serevent) 2 puffs bid not effective for acute asthma because of -Bitolterol (Tornalate) MDI 2-3...


Bronchodilators are drugs that open the airways in the respiratory tract. They are widely prescribed as pills and aerosol inhalers to patients with asthma to relieve the wheezing and difficulty in breathing characteristic of that disease. Most of these drugs work by stimulating the sympathetic nervous system, which regulates the muscular walls of the bronchial tubes. As a result, in addition to their desired effect, they commonly cause stimulation, anxiety, jittenness, and insomnia. Patients often dislike these side effects but have no alternatives to the drugs if they want to breathe. Another problem with the stimulant bronchodilators is their strong tendency to cause dependence. When the effect of a dose wears off, bronchial constriction increases as a reaction to the drug, making further doses necessary. Asthmatics frequently m- hide bronchodilators throughout the day, in addition to taking them regularly by mouth. This frequency of use increases risks of addiction and mood change....


Theophylline is no longer considered a first-line treatment for acute asthma.17 Studies have shown that theophylline, in combination with inhaled b 2-adrenergic drugs, appears to increase the toxicity, but not the efficacy, of treatment.25 Theoretically, theophylline may be a useful adjunct by providing a more sustained bronchodilator effect, contributing to small airway bronchodilation, improving respiratory muscle endurance, and improving resistance to fatigue. Recent data suggest an anti-inflammatory mechanism of action.26 The mechanism of action of theophylline remains unknown 90 percent of theophylline metabolism is hepatic and the remainder is excreted unchanged through the kidneys. A serum theophylline level should be determined for patients who regularly use theophylline. The most common side effects of theophylline are nervousness, nausea, vomiting, anorexia, and headache. At plasma levels greater than 30 pg mL, there is a risk of seizures and cardiac arrhythmias.

Part B Asthma

Asthma is a chronic disease characterized by increased airway responsiveness to various stimuli. This causes widespread narrowing of the lower airways that reverses either spontaneously or with treatment. Although the exact pathophysiology of asthma is complex and poorly understood, inflammation is thought to play a central role. Pathologic changes that occur in asthma include smooth muscle hypertrophy, mucosal edema, and mucous plugging. Asthma affects 4-5 of adults and 10 of children. Onset usually occurs in children and young adults.

Chapter References

Cydulka RK, McFadden ER Jr, Emerman CL, et al Patterns of hospitalization in elderly patients with asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 156 1807, 1997. 11. Jeffrey PK Pathology of asthma and COPD A synopsis. Eur Respir Rev 7 111, 1997. 26. McKay SE, Howie CA, Thompson AH, et al Value of theophylline in the treatment of patients handicapped by chronic obstructive lung disease. Thorax 48 227, 1993.

Low flow devices nasal cannulae simple face masks and reservoir bag masks

Patients with otherwise normal physiology (vital signs), for example, postoperative, slightly low SaO2, long-term oxygen therapy Higher concentrations required and controlled O2 not necessary, for example, severe asthma, acute left ventricular failure, pneumonia, trauma, severe sepsis

TABLE 114 Drugs Used for Induction of Anesthesiax

PROPOFOL Since its release in the United States in 1989, this drug has enjoyed increasing popularity, particularly in elective settings. Its onset of action is similar to that of thiopental, and it produces comparable decreases in blood pressure and cardiac output. Unlike thiopental, there is no reflex increase in heart rate. Propofol appears to be superior to thiopental at suppressing pharyngeal and laryngeal reflexes and for this reason is usually chosen for insertion of an LMA without paralysis. Like thiopental, it lowers intracranial and intraocular pressures, and, while experience with propofol is less extensive, it is probably as good a choice as thiopental in similar settings. It does not cause histamine release or stimulate bronchospasm, and extravasation has not been reported to cause significant tissue injury. It is notorious for causing pain on injection, which may be markedly attenuated by preadministration of a small dose of lidocaine. It is significantly more expensive...

TABLE 791 Vomiting and Diarrhea The Gastroenteritis Mnemonic

Learning more about the patient is as important as defining the illness. What complicating medical conditions does the patient have Is the patient diabetic If so, could the vomiting be a manifestation of diabetic ketoacidosis In a patient with a history of peripheral vascular disease, vomiting may be a sign of mesenteric ischemia. Patients with a history of multiple abdominal surgeries are at risk for intestinal obstruction due to adhesions. Knowledge of the medications to which the patient has access is also critical, since intentional and unintentional poisonings often present first with emesis. Physicians should be suspicious of drug-induced toxicity in patients taking medicines known to have gastrointestinal toxicity (e.g., lithium, digoxin, or theophylline). The social history provides clues, too. Vomiting in a person who enjoys mushroom hunting may well represent Amanita poisoning.

Scene and Circumstances Accidental Choking Deaths The phases of acute fatal airway obstruction are

Witnesses of a sudden death may describe signs of acute upper airway (glottic) obstruction (stridor, respiratory distress, coughing, choking) and the inability of the victim to speak (334-337). A rapid, deep inhalation frequently follows, causing a foreign object to pass further down the airway (333,338). Laryngospasm occurs (338). At this point, vagal stimulation, leading to arrhythmia and apnea, is a possible mechanism of death (339). An allergic reaction, manifest as laryngeal mucosal edema, happens under some circumstances (e.g., aspiration of pepper 340 ). In some cases of foreign body obstruction in the esophagus and lower tracheobronchial tree, there is an asymptomatic period prior to the onset of respiratory symptoms (coughing, wheezing, dyspnea 334,336,341,342 ). When hot liquid is aspirated, the onset of symptoms (difficulty speaking, dyspnea) develops following a latent period, up to 8 h (343). Incomplete obstruction eventually becomes complete when respiratory tract...

External Findings Traumatic Asphyxia

The color is not altered by the administration of oxygen (441). Petechiae disappear within days, but subconjunctival ecchymoses can persist for weeks, eventually fading to yellow and disappearing (11,441,444). There is associated facial edema (11,441,444,445). Similar but less pronounced observations are seen as a result of difficult delivery, prolonged vomiting or coughing, seizures and asthmatic episodes (see Subheading 1.5. and refs. 441 and 444). External blunt trauma injuries can be seen on the head, neck, and torso (444-446).

Measurement Of Venous Pressure

Forensic Pathology Images Enapure

Note the higher absolute level but smaller amplitude of pulsations on expiration. With bronchospasm jugular pulsations with normal pressures may only be visible above the clavicle during expiration due to the effect of straining, which elevates intrathoracic pressure with each expiration.

TABLE 641 Physiologic Consequences of Airflow Obstruction

Current hypothesis states that airway inflammation may be acute, subacute, or chronic. The acute response is determined by early recruitment of cells to the airway. Antigens come in contact with mast cells in the submucosa and cause elaboration of mediators, such as histamine, leukotrienes (including leukotriene B 4), chemokines, tryptase, interleukin 5 (IL-5), IL-8, proinflammatory cytokines, and IL-4, which produce an intense inflammatory reaction, with bronchoconstriction, vascular congestion, edema formation, increased mucus production, and impaired mucociliary transport. Eosinophils, platelets, and polymorphonuclear leukocytes are recruited to the site, activated, and contribute further to the inflammatory cycle that has already been initiated. The immunoglobulin E (IgE) response is controlled by T and B lymphocytes and activated by the interaction of antigen with the mast cell-bound Ig-E molecules.9 In the subacute or late phase, recruited and resident cells are activated,...

The case of the partners in Leeds

The first of these was on a new product for the treatment of hypertension the second was a multicentre paediatric asthma trial and the third was also a multicentre trial on a product for the treatment of asthma.10 In the second trial, diary cards completed by patients were also used. Patients had to record the daily medication, and the times when it was taken, severity of asthma symptoms and daily morning and evening peak flow readings measured by three successive blows each time. According to the age of the patients involved, the recording on diary cards was either by the patient, a parent, guardian or friend. Later in 1990, the contract research organisation was contacted about another study by a different company and Dr Chandnani again agreed to participate. As with the paediatric asthma study, he recruited all his patients very quickly. One patient, however, was noted to be a protocol violator, as the monitor found that the initials of this one patient were...

Antigenspecific methods

A consistent finding from animal and human stud ies is that abrogating or redirecting established (memory) responses in vivo is much more difficult than directing the initial induction of naive cells to a desired response. Consequently, there has been discussion of the potential utility of prophylactic desen-sitization of children with a high (genetic) probability of developing asthma to common environmental allergens.

Acute Exacerbations of COPD

The primary goal of emergency therapy in decompensated chronic airflow obstruction is to correct tissue oxygenation. This requires the restoration of the lungs as gas-exchange organs, assurance of hemodynamic efficiency, repletion of red blood cell mass where deficient, and limitation of excessive oxygen demands and carbon dioxide production. Factors that influence drug therapy in the emergency department include (1) the degree of reversible bronchospasm, (2) prior therapy of the patient, (3) recent drug usage and evidence of potential toxicity, (4) the ability of the patient to cooperate in taking inhaled medications, (5) the presence of contraindications to any drug or class of drugs, and (6) specific causes or complications related to the exacerbation. more effective than albuterol alone in relieving bronchospasm during COPD exacerbation. 23 Repeat doses need not usually be given more often than every 4 to 8 h. Side effects are minimal and appear to be limited to dry mouth and an...

Clinical significance of IL3

In the long term, as is the case with many peptide regulatory factors, antagonists may have more clinical significance than the factors themselves or agonists. Animal studies are revealing a variety of disease states - ranging from allergic and infectious diseases to leukemia - where antagonists may have a role to play in therapeutic procedures. For example, anti bodies to IL-3 given together with antibodies to IL 4 block the mastocytosis seen in parasitized rats. Administration of IL-3 results in accelerated IgF responses and expulsion of TrichitielLi spiralis, and appears to promote the production of 11-10 and II -13, cytokines which promote Tn2 responses. Thus IL-3 antagonists may find a useful role in allergic diseases or asthma. Antibodies to IL-3 and GM-CSF

Indications For Treatment And Admission

Although theophylline toxicity can lead to life-threatening side effects, toxic theophylline levels are common, and most patients tolerate them with only minor toxic manifestations.11 Serum theophylline concentrations do not correlate well with severity of toxicity in chronic exposures. However, serum levels for acute exposures are more valuable in predicting toxicity and clinical course. No well-conducted studies have demonstrated that prophylactic use of antiarrhythmics or antiepileptics decreases morbidity or mortality rates. Similarly, while hemodialysis, hemoperfusion, and oral activated charcoal therapy enhance theophylline clearance, there is no compelling evidence that their use lowers morbidity or mortality rates for patients with only mild toxic symptoms or minimally elevated levels. On the other hand, ventricular dysrhythmias or seizures may occur in patients before the manifestation of other minor toxic effects, leading some authors to advocate aggressive therapy. Older...

The paired ttest is only applicable to naturally paired data

The whole logic of the paired t-test that we just performed was founded on the fact that we could calculate a change for each individual participant in the experiment and then use those changes to calculate the rest of the test. With the theophylline rifampicin experiment (Table 6.1), the data also consisted of two columns of data, but in that case there was no pairing. The first figure in the first column and that in the second column were derived from different individuals and it would have made no sense to start calculating the difference between these two figures and then move down to the second number in each column and so on.

Choice of experimental design

Many experiments could be carried out either as paired or unpaired studies. For example the rifampicin theophylline experiment (Table 6.1) was performed on an unpaired basis - 15 people received one treatment and a separate group of 15 received the other. This is referred to as a 'parallel groups' trial. We could have used a paired structure, with 15 subjects receiving one treatment on one occasion and the other treatment at some other time (a 'cross over' trial). The paired alternative would almost certainly have been a lot more powerful. However, it does not follow automatically that we should always be looking for a paired experimental design. The following points need to be born in mind

Role of IL13 in atopic diseases

Several lines of indirect evidence suggest that both IL-4 and IL-13 are required for optimal induction of human IgE synthesis. Both IL-4 and IL-13 are upreg-ulated in the lungs of asthmatic patients after allergen challenge, indicating that both cytokines play a role in the regulation of allergic inflammatory responses. Atopy has been linked to genes in chromosome 5q31.1 in the area where the genes encoding IL-4 and IL-13 are located, suggesting a genetic predisposition for enhanced IL-4 and IL-13 production in atopic individuals. However, neutralization of either IL-4 or IL-13 activities in supernatants of activated allergen-specific TM2 cells with anti-IL-4 or anti-IL-13 mAbs indicated that IL-4 is the dominant cytokine in inducing IgE synthesis. On the other hand, the fact that IL-13 is also produced by naive T cells and T cell subsets not producing IL-4 suggests that IL-13 may be the dominant cytokine inducing IgE synthesis in situations where IL-4 is absent or present at low...

Extending the complexity of experimental designs

A 'factor' is something that we manipulate as part of an experiment in order to see whether it alters the endpoint we are measuring. In the rifampicin theophylline experiment (Chapter 6), the factor was rifampicin. We then say that the factor has a number of'levels'. This is the number of different possibilities for that factor. There were two levels for rifampicin - it was either administered or withheld. In the weight-loss experiment in the previous chapter, there was again just one factor (drug) and it also had two levels (used or not used). In fact, for any experiment that can be analysed by a t-test there is always one experimental factor for which there are just two levels - the simplest of all experimental designs.

Definition and Etiology

The word 'asthma' originates from an ancient Greek word meaning panting. It is a chronic obstructive disease characterized by tracheobronchial hyperreac-tivity leading to paroxysmal airway narrowing, which may reverse spontaneously or as a result of treatment. The smooth muscle surrounding the bronchi has an abnormally increased reaction to stimuli. Specific bronchial stimuli include inhaled allergens (e.g., house-dust mite, pollen, and moulds). Nonspecific bronchial stimuli include upper respiratory tract infections, cold air, exercise, cigarette smoke, excitement, emotional stress, and chemical irritants. Aspirin and other nonsteroidal antiinflam-matory medications provoke asthma in some patients.

TABLE 492 Common Symptoms and Physical Findings in Heart Failure

Physical findings of left-sided heart failure include dusky or pale skin, diaphoresis, and cool extremities due to poor perfusion and peripheral arterial vasoconstriction.18 Pulmonary congestion commonly results in tachypnea and bilateral inspiratory crackles on auscultation. Additional auscultatory findings include rhonchi and wheezing ( cardiac asthma ) due to airway edema. Pleural effusions may develop, detected by dullness to percussion at the lung bases. In advanced heart failure, Cheyne-Stokes respiration can occur and is a respiratory pattern characterized by periods of hyperventilation separated by periods of apnea. 1

TABLE 1674 Indications for Hemoperfusion

In addition to being treated with b blockade, cardiac dysrhythmias may be treated with other antiarrhythmics. Verapamil has been effective in animal studies. The use of digoxin, lidocaine, and phenytoin has been reported for treatment of venticular dysrhythmias. Adenosine may be considered for supraventricular dysrhythmias, but it may induce bronchospasm. The contributory effect of hypokalemia should be considered in treating patients with resistant ventricular dysrhythmias, and correction of serum electrolyte abnormalities may be effective in terminating recurrent dysrhythmias.

Poisoning and Drug Overdose

-Magnesium citrate 6 solution 150-300 mL PO -Magnesium sulfate 10 solution 150-300 mL PO. -Activated Charcoal 50 gm PO (first dose should be given using product containing sorbitol). Repeat q2-6h for large ingestions. -Hemodialysis should be for isopropanol, methanol, ethylene glycol, severe salicylate intoxication ( 100 mg dL), lithium, or theophylline (if neurotoxicity, seizures, or coma).

Predisposing factors for anaphylaxis

It is clearly established now that pre-existing asthma may exacerbate or predispose to anaphylaxis. This is clearly in keeping with the concept of the target organ of the reaction being important. Sampson's group of fatal and nonfatal reactors were clearly distinguished by the presence of a diagnosis of asthma, particularly if the asthma was poorly controlled. Our study in Southampton has supported this finding (Table 4.4).10,21

Ventilationperfusion Scans

Pioped Modified

Diagnosis of PE on V Q scan is based on documenting perfusion defects in an area of normal ventilation, a mismatched defect. Perfusion defects in areas of associated ventilation abnormalities are probably due to vasoconstriction secondary to hypoxia. Such matched defects may be due to pneumonia, asthma, or chronic obstructive pulmonary disease. Underlying pulmonary pathology causes abnormalities in both ventilation and perfusion, making interpretation difficult.

Lung volume reduction

Patients likely to benefit from lung volume reduction surgery have relatively pure emphysema of a heterogenous nature. This means that they have a minimum of sputum production and easily controlled bronchospasm not requiring systemic steroids and that a ventilation-perfusion scan shows areas of mismatch between the lung being perfused and ventilated. These areas are usually at the lung apices and can be safely resected without reducing pulmonary function yet reducing the overall size of the lungs. Well selected patients should get several years of functional improvement before they once again deteriorate as their underlying loss of elasticity degenerates with age.

Lacrimation Chemicals

Lacrimation chemicals commonly take the form of synthetic agents (ortho-chloro-benzylidene malonitrile CS , 1-chloracetophenone CN ) or naturally derived substances (oleoresin capsicum OC ). They are used in the form of liquid or aerosolized sprays delivered to the face and are designed to cause intense pain, blepharospasm, and lacrimation. They are extremely irritating to exposed mucous membranes, and the effects may last for up to 30 minutes. Because of the nature of delivery they are useful only for close-range deployment. According to one study, most were sprayed within 1.5 mm, and the maximal effective range is approximately 3 to 4 m.9 Concerns exist about their effectiveness in incapacitating people who are particularly violent and focused, although in some instances the ineffectiveness may be related to ineffective delivery (e.g., onto clothing instead of the face). There have been several reports concerning safety issues with these chemicals, with most concerns centered on the...

Disease Management

The management of MG includes the administration of acetlycholinesterase inhibitors, thymectomy, chronic immune suppression, and acute immune modulation (plasma exchange, IV immune globulin), when indicated. Muscle weakness usually does not return to normal with the use of these modalities, and there can be great temporal variability in the nature and amount of muscle weakness. Under- or overdosing can cause significant complications. Variability in the amount of muscle weakness can be seen in response to asthma exacerbations, infections, menstruation, pregnancy, emotional stress, hot weather, and other disorders that alter the response to medication, such as renal and gastrointestinal disease.

Emergency Management and Diagnosis

Several drugs are known to affect neuromuscular function, and caution must be exercised with their use in MG patients. Drugs that should be avoided are listed in Tab e226 1. If a drug is absolutely necessary, such as steroids for status asthmaticus, equipment for emergency endotracheal intubation should be immediately available because respiratory failure can develop rapidly.

Plateletactivating Factor

Platelet-activating factor (PAF) is a potent autocoid mediator implicated in a diverse range of human pathologies including shock, ischemia, asthma, cardiac and systemic anaphylaxis, CNS and renal disorders, and a variety of inflammatory conditions. Originally isolated from antigen-stimulated rabbit basophils and characterized structurally as the al-kyl phospholipid is now known to be produced by, and act on, a variety of cell types including neutrophils, eosinophils, monocytes, macrophages, platelets and endothelial cells. Platelet-activating factor (PAF) acetylhydrolase is a physiological inhibitor of PAF which is widely distributed in plasma and tissues and inactivates PAF by removing the acetyl group at the sn-2 position. Studies on the pathophysiological role of PAF have been facilitated by a variety of compounds which can specifically inhibit the binding of PAF to its receptors in various cells and tissues. Such PAF antagonists include the triazolothienodiazepine WEB 2086, the...

Radiocontrastinduced Nephrotoxicity

Radiocontrast-induced nephropathy is a leading cause of hospital-acquired acute renal failure (ARF) with an incidence ranging from 2 to 10 depending on the population's risk factors. Risk factors include preexistent volume depletion, age, underlying chronic renal insufficiency, diabetes mellitus, proteinuria, and the amount of the radiocontrast dye used. The pathogenesis of ARF in this setting is probably related to decreased renal blood flow and medullary ischemia resulting from an imbalance of vasodilative and vasoconstrictive factors 14 . Radiocontrast agents may also be directly toxic to the renal tubule epithelium. This form of ARF is somewhat unique because preexisting risk factors can be identified and the timing and dose of dye can be controlled. Measures which have been proposed to prevent or reduce the severity of contrast-induced nephrotoxicity include volume expansion and the administration of furose-mide, mannitol, calcium channel blockers, dopamine, atrial natriuretic...

Radiosensitivity of lymphoid tissues

Localized irradiation of human thymus, as shown by studies of individuals irradiated prophylactically in infancy for an enlarged thymus to prevent 'status thymolymphaticus', resulted not only in an increased frequency of tumors, but also increased frequency of asthma and other autoimmune disorders (including sarcoidosis, enteritis, thyroiditis and others). However, no impairment of delayed hypersensitivity reactions was noted, suggesting that T cells with regulatory functions are more radiosensitive than those with effector roles.

Plant Phenolics As Phytopharmaceuticals

The use of phenolics as cancer chemopreventive metabolites has been also established with curcumin from Curcuma longa (1), isoflavonoids from Glycine max (5), and galanigin from Origanum vulgare (6). Other medicinal uses of plant phenolics include lithospermic acid from Lith-ospermum sp. as antigonodotropic (7), salvianolic acid from Salvia miltiorrhiza as antiulcer (8), thymol from Thymus vulgaris as anticaries (9), anethole from Pimpinella an-isum as antifungal (10), and hellicoside from Plantago asiatica as antiasthmatic (8).

Causes of allergic rhinitis

There are many occupational allergic hazards which can give rise to allergic rhinitis and, more important, to the associated asthma. Workers dealing with castor beans (Ricin spp.), whether in the fields, during transport, at the dockside or in ships, are particularly at risk. They are such a strong sensitizers that they will cause allergic inhalent problems to the so-called 'normal' population when downwind from a castor bean factory or when actively working with the beans.

Treatment of rhinitis

III antigens, most information is available about Dei. p 1. The fecal pellets are relatively large, 10-30 jxm, and cause allergic conjunctivitis as well as allergic-rhinitis and asthma. Airborne levels of Der. p I give a more appropriate idea of allergen level than arc-obtained in dust, where the highest concentrations are in the mattress and bedding. The allergens arc-also present in soft furnishing and carpets and especially toys. Many methods used to control house-dust mite rhinitis have been amazingly disappointing.

High Altitude Pharyngitis and Bronchitis

Most unacclimatized persons exercising at altitudes over 2500 m develop a dry, hacking cough. With exposure to extreme altitudes for prolonged periods of time, a purulent bronchitis and a painful pharyngitis become nearly universal. These problems may not be of an infectious nature high volumes of dry, cold air through the lungs may induce respiratory heat loss and cause purulent secretions on that basis alone. Bronchospasm may also be triggered by respiratory heat loss. Severe coughing spasms can result in cough fracture of the ribs.

Bioethics Perspective I Health Disparities

Despite some improvement over the years, the health gaps persevere and in some instances have gotten worse as the twenty-first century began. In 1970 infant mortality in blacks was twice that of whites at the beginning of the twenty-first century, black infant mortality is still twice that of whites. In 1970 deaths due to asthma were about three times higher in blacks at the beginning of the twenty-first century, deaths due to asthma have increased They are now five times higher than in whites (Centers for Disease Control, 1996). Researchers Robert Levine and his colleagues report that the disparities have not improved since the end of World War II, despite decades of funding for health-related programs.

Serotonin and secretion of lymphocyte chemoattractant factors

IL-16) is produced after stimulation of CDS' T lymphocytes with serotonin or histamine. IL-16 is preformed and stored in biologically active form and release from CD8+ cells is essentially complete at 4 h after stimulation with serotonin. This release is mediated through 5-HT2 receptors. IL-16, identified as a protein with a molecular weight of 56 kDa, has selective chemoattractive activity for CD4* T lymphocytes and may play an important role in the recruitment of CD4+ T lymphocytes into sites of inflammation. Interestingly, it has been demonstrated that IL-16 is released in bronchoalveolar fluid following subsegmental allergen challenge of atopic asthmatics but not in normal individuals.

Diagnostic Tests Skin Prick Tests

Skin prick tests are mainly used in research studies. The results of skin tests cannot be taken alone, and standard textbooks on allergy acknowledge that ''the proper interpretation of results requires a thorough knowledge of the history and physical findings.'' The problems in clinical practice are, for example, whether or not a subject with atopic disease (eczema, asthma, or hay fever) or symptoms suggestive of food intolerance will benefit from attempts to avoid certain foods or food additives. However, skin prick test results are unreliable predictors of response to such measures.

Preanalytical Variables Anticoagulant

Accurate assessment of in vivo or in vitro cellular expression of molecules requires optimal preanalytical conditions to prevent in vitro artifactual activation. The choice of anticoagulant is one of the critical preanalytical conditions because anticoagulants exert different effects on the activation of cells ex vivo. Historically, sodium citrate has been the favored anticoagulant for use in the studies of platelet activation and function, including aggregation and adherence. However, recent studies have shown that the anticoagulant CTAD (a mixture of sodium citrate, theophylline, adenosine, and dipyridamole) is better for retaining the ex vivo status of platelets (80). But it should be noted that this anticoagulant is light-sensitive and, when exposed, stable for only up to 4 h (81). In addition, when CTAD is combined with EDTA (ethylenediaminetetraacetic acid) and the blood held at 4 C, platelet activation after venesection is inhibited for at least 6 h after venesection (82,83)....

Bronchial hyperreactivity

There have been no large-scale epidemiological studies, but a positive relationship between asthma mortality and regional purchases of table salt per person has been shown. In a randomized doubleblind crossover trial in subjects with moderately severe asthma, the airway response to histamine was related to urinary excretion of sodium in a dose-response way, but only in men. A low-salt diet is regarded as having a potentially positive effect in patients with asthma and may help to reduce the need for anti-asthma drugs.

Can Low Po2 Cause Brain Damage

Anesthetists have long known that short periods of hypoxia, unaccompanied by significant hypotension or cardiac arrest, are innocuous. But additional documentation that hypoxia does not cause brain damage comes from the arena of bronchopulmonary and ventilatory diseases, including asthma, anaphylaxis, occlusive bronchitis and bronchiolitis, pneumonia, croup, and epiglottidis.

Physicochemical Properties of Excipients in Dry Powder Inhalers

Increased drug deposition is generally observed with smaller carrier size (61-65). Manufacture method may have significant effects depending on carrier excipient particle size. For example, poor dispersion of nedocromil was obtained using coarse carrier systems, whereas the use of fine carrier particles and high shear mixing techniques physically disrupted the drug-drug contacts and promoted deaggregation (66). Nedocromil sodium powder performance is considered to be dominated by cohesive drug-drug interactions. By decreasing the particle size of the lactose carrier, deaggregation and fine-particle drug dispersion were significantly improved. The carrier's functional effects were achieved by intercalating within the drug self-agglomerates and disrupting the cohesive drug-drug interactions (66). A subset of ternary blends uses fine excipient particles (i.e., lactose, 5 mm) to enhance powder dispersibility from DPI formulations. In one study, fine lactose was either mixed with the...

Phosphodiesterase Inhibitors

Selective phosphodiesterase inhibitors are used for their inotropic and vasodilator properties. They selectively inhibit the phosphodiesterase III isoenzyme (PDE III) responsible for the breakdown of cAMP in myocardial muscle and vascular smooth muscle. This is in contrast with the methylxanthines such as theophylline (see page 712-713) that non specifically inhibit all five phosphodiesterase isoenzymes. There are two chemical types of PDE III inhibitors, bipyridines and imidazolines.

Section 313 Respiratory Pharmacology

Typically, only 10 of an inhalationally administered bronchodilator reaches the lungs. Most of this is deposited in the upper airways with little benefit with about 3 reaching the alveoli. Distribution is little affected by the presence of obstructive airways disease, or particle size.

Corticosteroid metered dose inhalers or nebulized solution

-Triamcinolone (Azmacort) MDI 1-4 puffs bid-qid 100 mcg puff Cromolyn nedocromil -Cromolyn sodium (Intal) MDI 2-4 puffs qid 800 mcg puff or nebulized 20 mg bid-qid 10 mg mL 2 mL unit dose ampules -Nedocromil (Tilade) MDI 2 puffs bid-qid 1.75 mg puff Oral beta-2 agonists -Albuterol (Proventil) 11. Labs CBC, CBG ABG. Urine antigen screen, UA, theophylline level.

Racemic Drugs And Therapeutic Drug Monitoring

Patient populations is an important requirement before considering the use of plasma drug concentrations to guide pharmacotherapy. This approach is considered less desirable than the use of clinical and or pharmacodynamic endpoints to establish drug dose and the presence of therapeutic effects or toxicity if these parameters are clinically obvious, predictable, or measurable by a simple laboratory test (e.g. plasma prothrombin time). However, to properly use drugs with a low therapeutic index, for example, digoxin, theophylline, phenytoin, ph nobarbital, aminoglycosides, and a number of antiarrhythmic drugs, plasma drug concentration monitoring is essential to properly treat patients. Fortunately for the clinician, the antiarrhythmic agents are the only major group of drugs administered in most instances as race mi c mixtures and for which plasma drug concentration monitoring is routinely used to guide therapy. As has been suggested by Reidenberg (37) and others for these selected few...

David Rueda and Nils G Walter

Biosensors are devices that amplify signals generated from the specific interaction between a receptor and an analyte of interest. RNA structural motifs called aptamers have recently been discovered as receptor components for biosensors owing to the ease with which they can be evolved in vitro to bind a variety of ligands with high specificity and affinity. By coupling an aptamer as allosteric control element to a catalytic RNA such as the hammerhead ribozyme, ligand binding is transduced into a catalytic event. We have made use of fluorescence resonance energy transfer (FRET) to further amplify ligand induced catalysis into an easily detectable fluorescence signal. This chapter reviews in detail the methods and protocols to prepare a theophylline specific aptazyme and to label its substrate with fluorophores. We also include detailed protocols to characterize by FRET the binding affinity of the target, theophylline, as well as the external substrate to the aptazyme. The chapter...

Occupational food allergy

A number of shellfish can cause occupational asthma and rhinoconjunctivitis primarily from inhalation of particles during food processing. The reactions have been demonstrated to occur with shrimp, crab and oyster handlers. Workers affected include those involved in seafood processing, cooks and fishermen (Malo and Cartier 1993). Up to 10-40 of workers exhibit respiratory symptoms, and in studies where skin testing has been done up to 60 are found to be positive, with a close correlation between skin test reactivity and clinical reactivity (Orford and Wilson 1985, Cartier et al. 1986). Baker's asthma is due to sensitisation to cereal proteins. The majority of cases are reported to wheat, rye and barley, and it has been one of the most common occupational diseases in the UK (Block et al. 1984). One study found 7-9 of bakers to be affected (Thiel and Ulmer 1980), and there may be a long latent period of up to 10-15 years before symptoms occur. Again, atopic individuals appear to be at...

Aptazyme Transcription and Purification

The aptazyme can be conveniently transcribed in vitro from a DNA template because it does not contain any site-specific chemical modification that would require incorporation by solid phase synthesis. The following protocols describe in detail how to transcribe and purify the theophylline specific aptazyme (Fig. 1) starting from the initial design of the DNA template. This procedure is schematically depicted in Fig. 3.

Macromolecular Composition

Infection is transmitted via respiratory secretions. After a variable incubation period of up to 4 weeks the disease begins with growing hoarseness and aching throat, mild cough, and fever and does later develop into an atypical pneumonia. 12,13 In rare cases infection may also present as sinusitis or otitis media or lead to the aggravation of asthma. 14 In immunocompetent individuals the infection is usually self-limiting, but may be complicated by superinfections. In immunocompromised persons infection may take a more severe course. Reinfections do occur but are generally milder than primary infections. 13

Systemic Pharmacologic Agents

Ketorolac is a pyrrolizine carboxylic acid derivative. It is an anti-inflammatory, antipyretic, and potent analgesic agent with similar actions and side effect profile to other NSAIDs, with slightly less GI irritation when given IV IM than for oral NSAIDs. Overall, ketorolac has a lower incidence of side effects and longer duration of action than morphine. It acts peripherally, does not affect opiate receptors, and does not cause respiratory depression. Ketorolac is the only IV NSAID approved by the FDA. It may be used in combination with opioids, but has an opioid-sparing effect. Thus, smaller opioid dosages may provide adequate pain relief. It should not be admixed in the same syringe as opiates or hydroxyzine due to incompatibilities. Ketorolac also has good oral bioavailability, but has not been shown to be more efficacious than less expensive NSAID oral preparations. There is limited data on the use in children less than 16 years of age. In addition to GI irritation and platelet...

Applying an Integrated Cultural Epidemiological Approach

Prevalence is partly influenced by disease duration. If a disease lasts a long time in an individual, such as diabetes or asthma, the prevalence of that disease in the population will usually be larger than its incidence because more people in the population have the disease at one point in

TABLE 1131 Causes of Acute Respiratory Deterioration in Infants with BPD

Sudden respiratory deterioration in a patient with BPD is usually due to aspiration, either from gastroesophageal reflux or to a poorly coordinated suck swallow reflex. Exposure to cigarette smoke or other environmental pollutants may precipitate acute bronchospasm. An increase in pulmonary edema is usually accompanied by the development of peripheral edema and excessive weight gain. Therapy should be directed toward the specific cause of deterioration, but oxygenation is the cornerstone of treatment. Although BPD infants often have chronic CO 2 retention, there is no evidence that respiratory drive is decreased with oxygen administration. Therefore, oxygen should be used liberally while definitive diagnosis and treatment are debated. Specific therapies for BPD have recently been extensively reviewed.11 Care in an emergency department often centers on the treatment of acute bronchospasm. The most commonly used medications for acute bronchospasm are aerosolized b2 agonists (e.g.,...

Collaboration with governments

However, all this began to change in late 1993 when five deaths triggered by allergic reactions to peanuts or nuts received widespread national publicity. Almost overnight, allergy became a serious issue. The death of my teenage daughter Sarah was reported by the Mail on Sunday in December 1993 - two days before an inquest was held - and subsequently by numerous other newspapers and television news programmes just before Christmas. Sarah's death caught the imagination of the media and the public generally. She was an attractive young hairdresser who had taken a rail trip to town one afternoon on her own and had treated herself to a slice of lemon meringue pie in her favourite restaurant. She had died a few hours later of anaphylactic shock, the most severe symptoms being severe bronchospasm and a dramatic fall in blood pressure. I am sure many people were deeply moved by the image of this innocent young girl being killed by something as innocuous as the peanut. Other deaths which...

Common Symptomatic Lung Sounds

Signal Lung Sound Vesicular

The high-pitched whistling music type of sounds heard over large airways as well as over the chest are called wheezes. Fig. 7.4 shows a typical wheezing sound in the time and time-frequency domain. Wheezes can be caused by airway narrowing and the increased secretions. Wheezes are usually heard in congestive heart failure, asthma, pneumonia, chronic bronchitis and emphysema, bronchiectasis.

Recognizing Causative Factors of Undernutrition

A wide variety of prescribed drugs can cause anorexia, nausea, and other symptoms of gastrointestinal distress in older persons, rendering medication review an important component of nutritional management. Digoxin, theophylline, and nonstero-idal anti-inflammatory agents are frequent culprits in this regard. Enquiry must also be made into the use and tolerance of self-prescribed medication. Offending drugs, once identified, must be discontinued. Iatrogenesis also contributes to undernutrition by way of therapeutic diets. Low-cholesterol and low-salt diets are often prescribed to older persons on the basis of data extrapolated from younger persons. There is currently little evidence to suggest that these diets are of any benefit to older persons when used as primary prevention strategies. Available data actually indicate increased mortality in older adults with low-cholesterol levels. Evidence suggests that hypocholesterolemia may reflect increased cytokine expression in acutely ill...

False food allergy or pseudoallergy

These types of reaction outnumber the true immunologically mediated ones. Various clinical syndromes are also known to be induced by such reactions, for example chronic urticaria, anaphylactic shock, intermittent diarrhea and irritable bowel syndrome, migraines, rhinitis and asthma. Table 3 lists some of the substances and mechanisms implicated in false food reactions.

Empirical Support For Biofeedback

Empirical studies of biofeedback with pediatric populations became more prevalent during the past decade. Similar to adults, empirical research with children and adolescents supports the use of biofeedback as part of a package of cognitive-behavioral treatment. Biofeedback-assisted relaxation training has been found to be efficacious in treating recurrent headache, particularly thermal biofeedback (Fentress, Masek, Mehegan, & Benson, 1986 Holden, Deichmann, & Levy, 1999). EMG biofeedback has also shown efficacy in treating emotion-induced asthma (McQuaid & Nassau, 1999). EMG biofeedback in combination with

Type I hypersensitivity

Reinjcction of fish antigen immediately triggered a wheal and a flare at the site of reinjection. This observation goes back to 1921. It is surprising that the term allergy or atopy (altered reactivity) has become synonymous with a type I hypersensitivity only in more recent times when the term 'allergen' was introduced for proteins and chemicals responsible for this reaction, and the term 'anaphylaxis' was established for the resulting generalized immune reaction. The localized form of anaphylaxis is exemplified by hay fever, asthma, eczema and urticaria (skin wheals). The systemic anaphylaxis characterized by sudden shock and dyspnea, frequently leading to death, occurs in extremely sensitive individuals.

Principal Mechanisms and Pathophysiology of Food Intolerance

The term 'allergy' implies a definite immunological mechanism. This could be antibody mediated, cell mediated, or due to circulating immune complexes. The clinical features of an allergic reaction include urticaria (nettle rash), angioedema, rhinitis (sneezing, nasal discharge, blocked nose), worsening of pre-existing atopic eczema, asthma (wheezing, coughing, tightness of the chest, shortness of

TABLE 1772 Treatment of Anticholinergic Toxicity

The most controversial topic surrounding anticholinergic toxicity is the use of physostigmine. Physostigmine is a tertiary ammonium compound that is a reversible acetylcholinesterase inhibitor that crosses the blood-brain barrier and reverses both central and peripheral anticholinergic effects. 2 Physostigmine may aggravate dysrhythmias and seizures and must be used with extreme caution.7 The indications for its use include the presence of peripheral anticholinergic signs and seizures unresponsive to conventional therapy, uncontrollable agitation, hemodynamically unstable dysrhythmias unresponsive to conventional therapy, coma with respiratory depression, malignant hypertension, or refractory hypotension. Physostigmine should be avoided in cyclic antidepressant overdose because it may potentiate toxicity and increase mortality.Z The initial dose of physostigmine is 0.5 to 2.0 mg IV over 5 min. Improvement of central signs usually occurs within 5 to 15 min. The minimal effective dose...

Acupuncture and acupressure

Maa and colleagues added an acupressure treatment to a pulmonary rehabilitation program to determine if there was additional improvement in dyspnea.73 Thirty-one COPD patients were taught to apply pressure to seven accupoints that are believed to give relief to patients with dyspnea. Patients applied pressure daily at home for six weeks alternating with a sham acupressure. Dyspnea on a Visual Analogue Scale (VAS) was significantly less during the acupressure than the 'sham', however, there were no significant differences between the treatments in dyspnea measured by the Borg Scale or after the six MW. These same investigators later compared the effect of'standard care' plus acupressure or acupuncture to 'standard care' in asthma patients with 'chronic obstruction'.74 The acupuncture group received 20 treatments using five points previously hypothesized to provide relief for dyspnea75 and the other group self-administered their acupressure daily for eight weeks. Although slightly...

Clinical Features

The symptoms of asthma consist of a triad of dyspnea, wheezing, and cough. Many patients will relay the history of asthma upon presentation, but some will not. Early in the attack, patients will complain of a sensation of chest constriction and cough. As the exacerbation progresses, wheezing becomes apparent, expiration becomes prolonged, and accessory muscle use may become evident. Key historical points should be obtained on asthmatics presenting with exacerbation to emergency departments (EDs) (T,a ble 6.1-2.). Acute asthma exacerbation can be categorized based on clinical features (Table. . , 64-3). TABLE 64-2 Key Historical Elements When Obtaining a History from Patients with Acute Asthma Exacerbation Physical examination findings are variable. Patients presenting with a severe asthma attack may be in obvious respiratory distress, with rapid breathing and loud wheezing, whereas patients with mild exacerbation may present with cough and end-expiratory wheezing. At times, wheezing...

Chronic Obstructive Pulmonary Disease

The treatment of chronic obstructive pulmonary disease is mostly symptomatic once the patient has stopped smoking. Bronchodilators are useful if there is an element of reversible airways obstruction. Patients may be prescribed inhaled beta2-agonists, ipratropium bromide and theophylline. Diuretic therapy may be used to control right sided heart failure. Patients who are hypoxic with pulmonary hypertension may be on domiciliary oxygen therapy, a bad prognostic indicator. Peak expiratory flow rate (PEFR) is the rate of flow of exhaled air at the start of a forced expiration and is measured using a simple flow meter. Reduced values compared to predicted values for age, height and sex indicate airflow obstruction. Serial measurements are useful for monitoring disease progress and for demonstrating a response to bronchodilator therapy. Spirometric tests of lung function are easy to perform. If a subject exhales as hard and as long as possible from a maximal inspiration, the volume expired...

Muscle antigens Smooth muscle

Sera from patients with chronic active hepatitis contain antibodies to smooth muscle antigens that are detectable by IIF and bind smooth muscle of all organs. The major antigen of the smooth muscle is actin. The antibodies belong mainly to the IgG class, but they can also be found in the IgM class. The test is performed on unfixed cryostat sections of rodent stomach as substrate. Smooth muscle antibodies arc found in 40-70 of patients with active chronic hepatitis, with lower titers found in 50 of patients with primary biliary cirrhosis, and 28 of patients with cryptogenic cirrhosis. These antibodies are also found at low titer in patients with acute viral hepatitis, infectious mononucleosis, asthma, yellow fever and malignant tumors (carcinomas of the ovary, malignant melanoma). They have been found in less than 2 of the normal population.

Ophthalmic Surgery Cataract Surgery

Cataracts may be congenital, traumatic, steroid- or radiation-induced, or degenerative. In degenerative cataracts there will also be other medical conditions of the ageing population. While diabetics have no more cataracts than the general population, they tend to present earlier and so there seems to be a preponderance of diabetic patients presenting for cataract surgery. Steroid induced cataracts present in patients taking long term steroids for other conditions, particularly eczema or asthma which should be taken into account. Cataract surgery demands a still eye with low intra-ocular pressure. This can usually be achieved by smooth anaesthesia with muscle relaxation and IPPV to achieve mild hypocapnia, whether via a tracheal tube or laryngeal mask, though the latter is preferable because of the lack of intubation pressor response or laryngeal spasm and coughing on extubation. There is a fashion for local anaesthesia for cataract surgery despite this having a higher failure rate,...

Treating the immediate symptoms 551 Acute allergic reactions to foods

The severity of reaction depends on sensitivity of the patients to food allergen and the amount ingested. Patients with life-threatening symptoms such as respiratory difficulty due to laryngeal oedema or severe bronchospasm and or hypotension should be regarded as having a severe reaction or anaphylaxis.13 Troublesome, but not immediately life-threatening, reactions such as generalised urticaria angioedema and bronchospasm of moderate severity may be termed severe allergic reactions. Sometimes the reaction is mild and confined to an organ or system, for instance oral or gastrointestinal symptoms or localised urticaria.

Dosage Form Decisions

The other key item in selecting the product profile is defining how the product will be used. A product intended for surgical anesthesia would be most amenable to an injectable dosage form that can be easily titrated to achieve the desired level of anesthesia. A product intended to treat heartburn would likely need to be self-administered as an oral dosage form. A product intended to be given predominantly to smaller children would be easier to administer as a solution or a suspension. Product use and the resulting product profile also may be dependent on the disease being treated. Diseases producing significant nausea such as cancer may need non-oral alternatives to ensure proper dosing. Asthma can be treated with inhalation products, depending on the mechanism of action, given the pulmonary site of disease and the accessibility of lung tissue to direct product administration. Diseases that harbor in specific tissues may benefit from special direct extravascular administration, such...

Increasing consumption what is being done

In several programmes, emphasis is placed on the education and involvement of children, because many of the processes linked to the development of chronic disease begin in childhood. Evidence from the Bogalusa Heart Study, tracking early risk of heart disease among American children, suggests that eating habits in childhood have a potential lifelong effect on cholesterol levels and on adult coronary heart disease.32 A study of British schoolchildren found that children who ate fruit more than once per day had better lung function compared with those who did not. The difference was evident even after controlling for possible confounding factors such as social class and passive smoking.33 A further study in Italy found that even low intakes of fruit can reduce wheezing and asthma with effects being most noticeable in children with a history of respiratory problems.34 Continued attention to increasing fruit and vegetable consumption in children is viewed as a practical and important way...

Neuromuscular Blockade

Paralytic Agent Ventilator Management

In the ED, neuromuscular blockade can facilitate tracheal intubation, improve mechanical ventilation, and help control intracranial hypertension. Paralysis improves oxygenation and decreases peak airway pressures in a variety of disorders, including refractory pulmonary edema and the respiratory distress syndrome. Patients with refractory status asthmaticus, status epilepticus, or tetanic spasms resulting from clostridial infections or a variety of toxins, including strychnine, may improve with blockade. Atracurium also offers advantages when continuous infusion is essential to maintain a precise, required level of neuromuscular blockade. A disadvantage is that histamine release can cause bronchospasm and hypotension. The risk with prolonged infusion is accumulation of laudanosine, a neuroexcitatory metabolic by-product.

Cardiac Evaluation Of The Posttransplant Patient

Electrocardiograms (ECGs) obtained on transplant recipients should demonstrate normal sinus rhythm. The donor heart is implanted with its sinus node intact to preserve normal atrioventricular conduction. The technique of cardiac transplantation also results in the preservation of the recipient's sinus node at the superior cavoatrial junction. The atrial suture line renders the two sinus nodes electrically isolated from each other. Thus, ECGs will frequently have two distinct P waves ( Fig. 56-1). The sinus node of the donor heart is easily identified by its constant 1 1 relationship to the QRS complex, while the native P wave marches through the donor heart rhythm independently. The presence of the two separate P waves may lead to confusion about the patient's rhythm. The ECGs may be interpreted erroneously as showing atrial fibrillation, atrial flutter, or frequent premature atrial complexes. The use of calipers aids in the definition of the two distinct P waves. Sinus node...

Pagonist Lean Efficiency Enhancing Agents

The compounds most commonly studied include cima-terol, clenbuterol, L-644-969, ractopamine, salbutamol, and zilpaterol (Fig. 1). They are orally active and administered as feed ingredients. They belong to a class of compounds called phenethanolamines. This class of compounds has been used safely and effectively in human medicine for more than 30 years as bronchodilators for asthma treatment, uterine relaxants to treat pregnant women to arrest premature labor, and cardiostimulants to treat cardiac irregularities. 8 The compounds that have been studied for their effects on lean efficiency (Fig. 1) have demonstrated effects on the metabolism of fat and muscle in livestock species. They have no antibiotic

Types of Contrast Reactions

Signs Hyponatremia

Contrast reactions can be divided into three categories anaphylactoid, chemotoxic, and vasovagal ( Table.294-2). Anaphylactoid reactions occur idiosyncratically, and they mimic allergic or anaphylactic reactions and shock. Anaphylactoid contrast reactions are not true anaphylactic reactions because they have no known consistent pathophysiologic mechanism. They may involve one or more of the following mechanisms histamine release, complement activation, hapten formation, contact sensitivity, endovascular reactions, and central nervous system factors. However, unlike true immunoallergic or anaphylactic reactions, they do not involve IgE mediation. An increased risk of anaphylactoid contrast reaction is associated with a history of asthma, food or drug allergy, or a previous contrast reaction. Low-osmolality agents are associated with a lower risk of anaphylactoid contrast reaction.

Causes of dyspnea in advanced disease in children

There are myriad causes of dyspnea in a child which involve many of the branches of general paediatric medicine and paediatric respiratory medicine in particular. It is not within the scope of this chapter to address the aetiology and management of all causes of dyspnea with which a child with advanced disease might present. For example a child may have asthma in addition to the diagnosis of a brain tumour. At the end of life for this child it is possible that his asthma may be a significant cause of dyspnea and its treatment, based on current asthma guidelines, is well described in standard paediatric textbooks. In addition, given the paucity of data on dyspnea in paediatric palliative care there is little data correlating specific disease entities with dyspnea in paedi-atric palliative care. Classification systems for dyspnea may be based on the time course acute, subacute, chronic, or recurrent. Alternatively dyspnea can be classified according to the type of sign or symptom it...

Equipotent Enantiomers

There are not many known racemic drugs with equipotent enantiomers (4). Examples include the antiasthmatic drug proxyphylline, the antineoplastic cyclophosphamide, the antimalarial agent primaquine, and the antiarrhythmic agents propafenone, flecairtide, and disopyramide. For these drugs there seems to be little rationale for separating the two enantiomers, as the known target receptors do not distinguish between the two chemical entities. However, although the enantiomers may be qualitatively and quantitatively similar with respect to the main therapeutic properties for which they are indicated, they may have subtle and sometimes unknown differences. For example, although enantiomers of propranolol have equal potencies in reducing sperm motility, the adrenoceptor property of the drug is attributed mainly to its S enantiomer (4). Hence, as a spermicide, -propranolol may be a safer drug as it reduces sperm motility without much of an effect on the cardiovascular system. A similar...

Regulation of eosinophil function

There is substantial evidence for the presence of eosinophil hematopoietins and other regulatory molecules in plasma or tissue samples from human subjects with eosinophilia. One study found that three patients with the idiopathic hypereosinophilia syndrome had very high levels of circulating IL-5. Multiple studies have shown high accumulations of these three hematopoietins in the airways of asthma patients. This information suggests that elevated levels of these regulatory mediators are an underlying cause of eosinophilia-associated diseases. It also suggests that therapy directed at the production of certain immunologic mediators may benefit the patient.

Food Intolerance and Allergy

Many people eat a variety of foods and show no ill effects however, a few people exhibit adverse reactions to certain foods. Food sensitivities refer to the broad concept of individual adverse reactions to foods. Food sensitivities are reproducible, unpleasant reactions to specific food or food ingredients. There are many types of adverse reactions to foods, e.g., hives, headaches, asthma, and gastrointestinal complaints. Food sensitivities can be divided into primary and secondary sensitivities (Table 10.1). in the blood stream are called basophils. Basophils and mast cells contain granules filled with active chemicals (mediators) thatcanbereleasedduringanallergicor inflammatory response. The mechanism hypersensitivity (Type I Figure 10.1), is composed of two major events. The first event or sensitization is when an allergen(antigen)isconsumed.Otherroutes of exposure can be portals for Serum concentration of IgE is low comparedwiththatofotherimmunoglobulins, and its serum half-life...

Cannabis and the cannabinoids

There are two features of the cannabinoids which may ultimately be of therapeutic importance. THC lowers intraocular pressure, which may be of benefit in the treatment of glaucoma. There is also evidence that THC is a moderately effective antiemetic agent. Such a discovery has led to the development of nabilone, a synthetic cannabinoid, as an antiemetic agent, but its use is limited because of the dysphoria, depersonalization, memory disturbance and other effects which are associated with the cannabinoids. Whether the bronchodilator action of THC will ever find therapeutic application in the treatment of asthma remains an open question.

Vitamins and Nutritional Supplements

U-series contained 48 different substances and included bronchodilators like theophylline and thyroid hormone stimulators. Some companies supply a standardized formula to all, whereas others require the performance of metabolic blood tests to customize or target the formula to each individual ( targeted nutritional intervention or TNI ).

Effects on Particular Organs or Organ Systems

Occupational exposure to a variety of substances is known to be capable of causing asthma. This is an allergic reaction in which exposure causes histamine to be released. Histamine stimulates the bronchi to contract, greatly increasing breathing resistance. This is known to affect bakers exposed to flour and workers exposed to wood dust, as well as butchers exposed to fumes caused by heat-sealing PVC films for wrapping meat. Some people become sensitized to toluene diisocyanate, which is used in polyurethane products. Subsequent exposures to very small amounts can cause a severe asthma attack. Immunostimulants usually cause their reaction within 15 minutes of exposure. A first exposure does not cause a reaction since the immune system must generate immunoglo-bulin antibodies. Second and later exposures cause the release of histamine, heparin, serotonin, prostaglandins, and other compounds. These result in symptoms such as asthma and rhinitis. Examples of immunostimulant toxins include...

Biological functions of IgE

On the whole, allergy is a concern in the more highly industrialized parts of the world, where immunology is mainly practised and where intensive efforts are being made to understand the 'pathogenesis' of allergy. Allergic conditions include hayfever or rhinitis (the most common), asthma, atopic dermatitis, food allergy and allergic uveitis (affecting the eyes). Anaphylactic shock is the only manifestation of the response that is systemic in nature, and thus differs from the others, which predominantly affect single organs. There has been an alarming increase, corresponding to a 10-year doubling rate, in the incidence of allergic disease in the industrialized parts of the world over the last few decades. Now one in five adults suffers from some form of allergy and a similar proportion of children suffer from asthma. IgE is implicated in the pathogenesis of allergy, as a key component in both the afferent (by way of dendritic cells and B cells) and the efferent (by way of mast cells...

Immediate and Nonimmediate Reactions to Contrast Media

Serious reactions to CM are comparable to type 1 hypersensitivity reactions (anaphylaxis), which begin within minutes after antigen exposure and are mediated by a variety of chemotactic, vasoactive, and spasmogenic compounds. Histamine seems to be the primary mediator of anaphylaxis anaphylactoid reaction and is responsible for the intense immediate manifestations. Preformed histamine is present in basophils and mast cells and is released rapidly by degranulation of these cells in a response to a variety of stimuli. There are several other biological mediators produced by mast cells and basophils, including leukotrienes, prostaglandins, enzymes, and a variety of cytokines. These substances act in an autocrine, paracrine, and endocrine fashion, triggering a cascade of inflammatory mediators. They induce vasodilatation, an increase in vascular permeability leading to edema, contraction of smooth muscle cells precipitating bronchospasm, and an increase in airway mucous secretion. The...

TABLE 2261 Drugs That Should Be Used With Caution in Myasthenia Gravis

Acute respiratory failure can result from either acute myasthenic or acute cholinergic crisis. Cholinergic crisis patients who fail the Tensilon test may require immediate intubation and management of excessive secretions and acute bronchospasm. Other complications of muscle weakness, such as impaired swallowing, aspiration pneumonia, dehydration, and decubitus ulcers, also must be considered.

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