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...

Asthma Free Forever Overview

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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...

Theophylline Overdose

Diagnosis Theophylline overdose -Activated charcoal 50 gm PO round-the-clock, with sorbitol cathartic, until theophylline level < 20 mcg mL. Maintain head-of-bed at 30-45 degrees to prevent aspiration of charcoal. -Charcoal hemoperfusion should be considered if the serum level is > 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.

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...

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.

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

TABLE 1203 Classifying Severity of Asthma Exacerbations

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.

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.

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.

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...

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...

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...

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.

Asthma

Asthma is a disease of the lungs affecting both children and adults and characterized by 1) airway obstruction that is partially or completely reversible, 2) airway inflammation, and 3) airway hyperres-ponsiveness. A persistent rise in disease prevalence, hospitalizations due to disease exacerbation, and disease mortality over the last two decades underscores the importance of an increased understanding of disease pathogenesis and the development of improved therapeutic agents. This entry summarizes our current understanding of this disease entity.

Theophylline

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.

Bronchodilators

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....

Rural Emergency Medical Services

The key component of any EMS system is its personnel. Rural EMS systems face particular challenges in maintaining a cadre of EMS personnel. The volume of EMS responses in most rural communities is too low to allow for the employment of full-time EMS providers thus, rural EMS services often use volunteers or on-call part-time personnel who are paid only when called out. Volunteer and part-time personnel have limited time for initial training and continuing education and limited experience necessary for skill maintenance. Most, but not all, rural EMS services are provided at the EMT-B level. The recent revision of the model DOT EMT curriculum allows for an increased level of service by EMT-Bs that would be useful in rural areas. They can now assist patients with self-administration of some medications (e.g., nitroglycerin for angina or bronchodilators for asthma), use AEDs for cardiac arrest, and, with the optional 10-h training module, utilize advanced airway techniques. These...

Pharmaceutical Equipment

Another area where practice is becoming blurred between BLS and ALS is in the realm of medications. The new basic EMT model curriculum has a module on certain classes of pharmaceuticals to prepare basic EMTs for helping the patient administer his or her medication in a limited fashion. This module includes nitroglycerin for chest pain, inhaled beta-adrenergic agonists for bronchospasm, glucagon for hypoglycemia, and epinephrine preloaded injections for anaphylaxis. The curriculum assumes that the patient already has the medication and the EMT is simply assisting the drugs are not carried on the ambulance. Some states have gone beyond that and allowed limited carrying of medications on BLS ambulances. Drugs carried by ALS services are more extensive, but it must be emphasized that out-of-hospital pharmaceutical interventions are limited to a few that will make a real difference before the patient gets to the hospital. The drugs that can make a real difference when administered by a...

Commercial Airline InFlight Emergencies

The medical problems encountered on airlines occur with a frequency and in an organ system category type resembling those of populations at ground-level mass gatherings. For the calendar year 1996, an average of three in-flight medical emergencies per day occurred on one major US airline. An average of one life-threatening (i.e., asthma, choking, cardiac arrest, heart attack, loss of consciousness, or stroke) emergency occurred every 2.5 days. Nationally, data covering nine major US air carriers from 1991 to 1993 revealed that the most frequent (in decreasing order) complaints were neurologic, syncopal, cardiac, psychiatric, and respiratory. Intentional injury of crews by unruly passengers increased each year from 1993 to 1995, when 174 incidents were reported. The emergency rate (incidents per million enplanements) has increased each year from 1990 to 1993. The uneven training of flight attendants leads to requests for emergency assistance from educated bystanders. National survey...

History and Physical Examination

Past Medical History (PMH) Past diseases, surgeries, hospitalizations medical problems history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction, cancer. In children include birth history, prenatal history, immunizations, and type of feedings.

The role of respiratory system afferents

While the sense of effort is certainly a prominent component of the sensations of breathlessness, there are clearly other distinct and separable sensations that contribute to breathlessness. 'Chest tightness' associated with bronchocon-striction is the most studied example of this. In investigations of patients with cardiopulmonary disease, the description of chest tightness was significantly associated with asthma,4 which is thought to arise from the stimulation of receptors in the lung parenchyma.12 The sensation of chest tightness associated with bronchoconstriction has also been differentiated from the increased work of breathing and sense of effort.13 The origin of chest tightness may lie with mechanical receptors (rapidly adapting stretch receptors) in the lungs and or with chemical receptors (C-fibers). Pulmonary receptors may also play a role in the breathlessness associated with pulmonary vascular disease, congestive heart failure, atelectasis (as may occur in association...

Diabetes And Endocrine Disorders

Adequate hydration is extremely important in patients who present with car-cinoid syndrome resulting from vasoactive substances released by the tumor. Increased levels of serotonin cause diarrhea, abdominal cramping, respiratory distress due to bronchospasm, and hypertension. In patients with longstanding carcinoid, an echocardiogram should be obtained to test for right heart failure. Antihistamines can be used to counteract the effect of histamines and octreotide can be used to block the release of hormonal substances.

Perioperative Cardiac Complications

Of myocardial infarction by 56 (p 0.04), and the surrogate risk of cardiac death and nonfatal myocardial infarction by 67 (p 0.002). Administration of beta-blockers should be commenced prior to surgery, a dose-titration has to be carried out up to the induction of anesthesia, and a lifelong continuation of beta-blocker therapy is recommended in high-risk patients. The optimum time interval to start treatment with beta-blockers before surgery has not yet been defined by studies. The choice of the beta-blocker is of minor importance, since no specific beta-blocker demonstrated a superior effect in the perioperative setting. The side effects of perioperative administration of beta-blockers are a 4.3-fold increased risk of bradycardia (p 0.006), but hypotension, atrioventricular block, pulmonary edema, and bronchospasm are not significantly associated with perioperative beta-blocker therapy. The following contraindications should be kept in mind prior to commencement of beta-blocker...

Association of Anaesthetists of Great Britain and Ireland 1995

Irrespective of the mode of triggering, all the clinical manifestations of an allergic reaction occur as a result of the liberation of vasoactive substances. The typical clinical features of anaphylaxis are hypotension, bronchospasm, oedema and the development of a rash (Figure I.4). Cardiovascular collapse is one of the most common early signs (Figure I.5). This is usually the result of vasodilatation and may be compounded by arrhythmias (usually supraventricular tachycardia), hypovolaemia and a reduction in venous return, which will be exacerbated if high inflation pressures are necessary to facilitate ventilation of the lungs. Bronchospasm is variable in its severity from a transient degree of difficulty with ventilation to the situation where gas exchange is impossible despite the use of high airway pressures and slow inspiratory and expiratory times. The presence of wheals and erythema near the point of venous access is usually a sign of localised histamine release which usually...

Comparing Cultural Knowledge Across Different Settings

A closer look at what can be learned through a comparative approach. Three different approaches are examined here. The most ambitious of these is a collaborative, multisite study using a shared methodology to study intra- and inter-cultural variation in beliefs (Weller, Pachter, Trotter, & Baer, 1993, p. 109) for four geographically separated and distinctive Latin American samples. The illnesses are considered to be either biomedical or folk conditions. Weller and Baer (2001) present findings for five of the eight illnesses studied (AIDS, diabetes, the common cold, empacho, and mal de ojo with asthma, nervios, and susto also included in the larger design) and some detailed studies, comparing beliefs for individual illness conditions have been published (Weller et al., 1993, 1999). Noting that it is usually impossible to know if reported differences between cultures are due to cultural differences or due to a difference in methods used to study the cultures, the researchers...

Chronic Obstructive Pulmonary Disease COPD

The generation of oxygen free radicals by activated inflammatory cells produces many of the pathophys-iological changes associated with COPD. Common examples of COPD are asthma and bronchitis, each of which affects large numbers of children and adults. Antioxidant nutrients have therefore been suggested to play a role in the prevention and treatment of these conditions. A number of studies have demonstrated a beneficial effect of fruit and vegetable intake on lung function. For example, regular consumption of fresh fruit rich in vitamin C (citrus fruits and kiwi) has been found to have a beneficial effect on reducing wheezing and coughs in children. Vitamin C is the major antioxidant present in extracellular fluid lining the lung, and intake in the general population has been inversely correlated with the incidence of asthma, bronchitis, and wheezing and with pulmonary problems. Although some trials have shown high-dose supplementation (1-2g day) to improve symptoms of asthma in...

False positive results

The oesphageal detector device consists of a 60 ml syringe that can be attached to an endotracheal tube connector. A negative pressure applied to the lumen of the oesophagus will cause it to collapse whereas the adult trachea contains cartilaginous rings and will not collapse under the same conditions. Aspiration of the plunger will therefore freely withdraw gas if the tube is in the trachea but will encounter resistance if the tube is located in the oesophagus. If the syringe is replaced by a self inflating bulb then the principle of use remains the same compression of the bulb is followed by immediate refill if the tracheal tube is correctly placed whereas if the tube is in the oesophagus the bulb will remain collapsed. Although these devices are simple and sensitive they may fail to confirm tracheal tube placement if the tube is partially obstructed or if the patient has bronchospasm or is morbidly obese.

Immunological Mechanism

Allergic asthma The main primary mediator, histamine, activates Hj and H2 receptors. Pruritus, rhinorrhea, tachycardia, and bronchospasm are caused by the Hj receptors, whereas both Hj and H2 receptors mediate headache, flushing, and hypotension. Gastrointestinal signs and symptoms are associated with histamine more so than with tryptase levels.

Laboratory evaluation

Lung function tests vary from simple spirometry that can be done with hand-held electronic devices, to more complicated tests that require sophisticated equipment in a lung function laboratory. Standardized pulmonary function tests (PFTs) can be helpful to diagnosis the underlying problem and determine its severity and response to treatment. Spirometry can demonstrate two basic patterns of disorder obstructive and restrictive. Stulbarg has suggested that the relationship of pulmonary dysfunction and the severity of dyspnea is strongest within specific diseases.4 Mahler and Wells10 showed that in patients with COPD measures of maximal expiratory pressure (PEmax) (r 0.35) and maximal inspiratory pressure (PImax) (r 0.34) showed the strongest correlations to the intensity of dyspnea as measured by the baseline dyspnea index (BDI) in patients with asthma, FVC (r 0.78) and FEV1 (r 0.77) were highly related to BDI and in interstitial lung disease (a restrictive disease) PImax (r 0.51) and...

Critical Incidents During Anaesthesia

Central cyanosis can usually be detected at an arterial oxygen saturation of about 80-85 , depending on whether the patient is anaemic. Note that Absence of cyanosis does not necessarily mean normal arterial oxygen levels' (Nunn, 1993). Even at an oxyhaemoglobin saturation of 93 the patient is very close to the steep part of the saturation curve. At 89 saturation the PaO2 is only 7.5 kPa so that by the time central cyanosis is detectable the patient can be severely compromised. Cyanosis may be the result of failure to pre-oxygenate, airway obstruction, tracheal aspiration, drug overdose, a fall in cardiac output (haemorrhage, septicaemia, other surgical causes), inadequate ventilation and oxygenation (intubation of the right main bronchus, bronchospasm, laryngospasm), gross dehydration, and cardiac arrhythmias. Treatment depends upon the diagnosis but the first act must be to cut off all volatile and intravenous anaesthetics and administer 100 oxygen.

Qualitative dimensions of dyspnea

In discussing the assessment of dyspnea, it is important to understand that it is not a single sensation. Studies have shown that patients chose different phrases to describe their discomfort with breathing and that there is an association of different descriptors and clusters with different pathophysiological conditions (i.e. 'chest tightness', 'exhalation', and 'deep' with asthma).18-20 O'Donnell et al., however, found that while descriptor choices were clearly different between health and disease states, there was too much overlap to help distinguish between COPD, restrictive lung disease and congestive heart failure.21-23 Wilcock and colleagues also did not find that there was sufficient robustness and construct validity to support the use of word descriptors and clusters to help in determining a diagnosis.20

The legal background labelling

This fish sauce may contain many ingredients which might include shellfish capable of causing an allergic reaction in susceptible people, yet the labelling meets the requirements of the law. Also, the stipulation for the labelling of functional additives may itself give rise to problems. A garlic puree used in garlic bread may have contained sulphur dioxide as a preservative, but because this preserving effect is no longer required in the finished product, possibly because it is frozen, there is no need to label its presence. This may present a hidden problem for asthmatics. Other exemptions may be realised through the provisions which permit the use of generic names for certain ingredients or because the ingredient is a food which itself is not required to be labelled with an ingredients list. Certain foods such as chocolate currently fall outside the requirements of food labelling law and are subject to the specific requirements of their own legislation. Typically, this may not...

Clinical presentation

Asthma may present acutely or as a chronic pulmonary disease. Symptoms of acute asthma include shortness of breath, chest tightness, wheezing and cough, often productive of clear or slightly colored sputum. When present, chest pain is usually musculoskeletal in origin. Audible wheezing may not be present in mild asthma, but may be elicited by forced expiratory maneuvers. Increased diurnal variations in pulmonary function are often associated with nocturnal exacerbations. Triggers for worsening asthma include cold air exposure, exercise, viral respiratory infections, sinusitis, gastroesophageal reflux, exposure to seasonal or perennial inhalant allergens, and exposure to inhaled irritants such as cigarette smoke. Seasonal variations in asthma severity often correlate with seasonal allergen exposure. Finally, a number of medications, including P adrenergic blockers and nonsteroidal anti-inflammatory agents, as well as sulfite preservatives, may exacerbate asthma in susceptible subjects....

Measurement of the affective responses to dyspnea

Both normal subjects50 and patients with COPD who are exercising54 or completing daily self-reports43 can distinguish the intensity of their shortness of breath from the anxiety and or distress it causes them. After treatment, patients have stated that the intensity of shortness of breath with exercise may be at the same level, but because they feel more in control of the symptom, they are less anxious about the symptom, and therefore, the same intensity of shortness of breath is less distressing for them. In addition, there is also evidence that patients with chronic illness may not change their rating of the level of the intensity of shortness of breath over time despite worsening of lung function60 or advancing disease.61 However, their anxiety or distress with the dyspnea may decrease after treatments such as pulmonary rehabilitation or exercise training.62 Therefore, it is important that the anxiety or distress associated with dyspnea be measured in addition to the intensity. At...

Controversies in Disease Evolution Studies

Evolutionary medicine has proposed explanations for an array of modern ailments ranging from obesity to lower back pain, asthma, otitis media, depression, and addictions. Allergies, for example, are thought to be related to originally adaptive responses to parasitic infections (Nesse & Williams, 1994). Even more problematic are evolutionary explanations for current behavioral aberrations, such as homicidal assault, sexual abuse and incest, depression, and infanticide. Intellectually it may be satisfying to link contemporary ills to past conditions, but the extent of genetic determinism is problematic.

Pre Existing Lung Disease

Patients with chronic obstructive airways disease (COAD) are at increased risk of hypoventilation in the post operative period. They may not be able to further increase their work of breathing to maintain an adequate PaCO2, particularly if bronchospasm or excessive airway secretions are present. Bronchospasm may occur in asthma, COAD, smokers and in patients with acute respiratory infection. It is commonly precipitated by upper airway irritation either during airway manipulation or if secretions are present. Other causes of wheeze include aspiration, pulmonary oedema, and bronchospasm associated with anaphylaxis. Treatment of bronchospasm will depend on the underlying cause and the severity but should include supplemental oxygen and inhaled bronchodilator therapy.

Risk Versus Benefit Assessment

A good example of an application of mechanistic modeling in quantitative risk benefit assessments comes from the literature on inhaled corticosteroids (43,44). While inhaled corticosteroids present a viable therapeutic option for asthma, there have been questions on their long-term safety. Specifically, these concerns stem from their potential to suppress development of the adrenal function. Consequently, a clear delineation of the benefit (for asthma) and risk (clinical adrenal suppression) is necessary for development of newer inhaled cor-ticosteroids. Here the benefit is a conglomeration of all favorable attributes of a molecule, including optimal PK properties, drug delivery properties, and increased residence in the lung, which may likely contribute to a more favorable systemic side-effect profile. An assessment of a quantitative risk benefit value would entail the use of cortisol levels in plasma as a biomarker of the suppression in adrenal function. PK PD modeling can then be...

Non Steroidal Anti Inflammatory Drugs

NSAID have several advantages over opioid analgesics. Their use is not associated with respiratory depression or gastric stasis and, as they are not controlled drugs, they are readily available. However, their use is associated with potentially serious side effects that include gastro-intestinal haemorrhage, gastric ulceration, renal impairment and an increased risk of post operative bleeding due to impairment of platelet function. NSAID are contra-indicated in patients with a history of peptic ulcer disease, gastro-intestinal bleeding, renal impairment, previous hypersensitivity reactions to aspirin or NSAID, asthma and bleeding diathesis. They should be avoided in the dehydrated or hypovolaemic patient and care should be taken when using NSAID in the elderly.

The Paediatric Patient

Pre-operative assessment in children should be as rigorous as in adults and questions should be addressed to the child even though the parents may answer for them. Most children are healthy but chronic conditions such as asthma, multiple allergies, congenital heart disease and systemic conditions (such as muscular dystrophy) may also be encountered. The presence of one congenital abnormality should stimulate the search for others. Chromosomal abnormalities may be linked particularly with congenital heart disease. Except for true emergency surgery, children with colds or upper respiratory tract infections should have their surgery cancelled and rescheduled to a later date. The inflamed airway is exquisitely sensitive to any kind of manipulation, resulting in laryngeal spasm. Laryngeal spasm in children is particularly dangerous because of the rapid onset of severe desaturation, made more marked by their higher metabolic rate.

Choice of specimen and collection and handling variables

They concluded that platelet-depletion of plasma may be desirable to avoid platelet activation with release of proteins, especially if there is a 4C step in the preparation. BD explained that 4C was chosen for centrifugation and holding of the tubes prior to aliquoting to aid in stabilizing labile biomarkers. For investigators concerned about platelet contamination, options include filtration of the plasma through a 0.2 m low protein binding filter double centrifugation of the specimen and use of additives that minimize platelet activation, such as CTAD, a mixture of citrate, theophylline, adenosine, and dipyridamole. Samples should be aliquoted and stored frozen with minimization of thaw re-freeze cycles, preferably in liquid nitrogen, though 80 C seems to be very nearly as good. Protease inhibitors would be desirable, but present cocktails introduce complications due to peptide inhibitors that may interfere in the MS and small molecule inhibitors that form covalent bonds with...

Water Soluble Vitamins

Vitamin C is particularly important in childhood not only because of its functions as a vitamin but also because it improves the absorption of non-heme iron. Failure to consume foods rich in vitamin C at the same time as vegetable sources of iron plays a part in the etiology of iron deficiency in childhood. Levels of vitamin C in cow's milk are low and infantile scurvy has been reported in infants receiving unmodified cow's milk as a main drink. Infant formulas are fortified with vitamin C. Estimates of requirements are generally extrapolated from adult data. Intakes of vitamin C that were low (but that met current recommendations) have been associated with increased prevalence of asthma in childhood.

Genetic Characteristics of Founder Populations

Founder populations may have increased prevalence of certain genetic traits, including genetic disease. Disease alleles that happen to be present in the founders may be passed on to offspring, and, since the population is small, there may be a higher prevalence of the disease than in other, larger populations. Isolated founder populations, with little marriage outside of the populations, are especially likely to have a higher prevalence of recessive disorders, since parents are likely to share many genes, and there is an increased chance of inheriting two copies of a particular disease gene. Examples of rare genetic diseases that are prevalent in founder populations are Tay-Sachs disease in Ashkenazic Jewish populations and asthma in the Hutterian population.

Doppler ultrasound studies

The sensitivity and specificity of the Doppler respiratory method may be as high as 85-90 in expert hands. However, the studies are difficult to carry out and to interpret. They should ideally incorporate a simultaneous graphic record of the phases of respiration. Irregular patterns of breathing, irregular cardiac rhythm, and short diastolic periods resulting from rapid heart rate cause difficulty in interpretation. Falsely positive results can be seen when intrathoracic pressure variations are exaggerated, as in asthma or chronic obstructive airway disease in such conditions the flow velocity in the superior vena cava should be recorded, because the superior vena cava has much larger respiratory variation in flow velocity with respiration in pulmonary disease than it does in either constrictive pericarditis or restrictive cardiomyopathy.

Changes in pulmonary function

The administration of a diuretic, even to healthy subjects, suggests that pulmonary function is influenced to a considerable degree by the water content of the lung.12 In patients with radiological evidence of pulmonary venous hypertension, the mechanical and gas exchanging properties of the lung are both limited. In a study of ten non-smoking patients with asymptomatic left ventricular dysfunction, volume loading with saline provoked airflow obstruction and a decrease in the alveolar capillary membrane conductance (DM),13 and a similar obstructive defect has been described in patients with decompensated heart failure.14 Diuretic treatment to reduce lung water improves spirometry and improves the FEV1 to FVC ratio although the effect on lung compliance has been more controversial.15 Frank airway obstruction is uncommon in heart failure, although the syndrome of cardiac asthma associated with an increase in lung water and pulmonary oedema is well recognized clinically.16-18

TABLE 583 Causes of Wheezing

The duration of wheezing, or, more precisely, that portion of the expiratory phase occupied by wheezing, has been used to quantify the severity of airflow obstruction in moderate-to-severe acute asthma. As noted above, patients with the most profound obstruction may not wheeze, but their condition can be detected by noting markedly decreased lung sounds. Most patients with bronchospastic disease (either asthma or COPD) relate a history of previous attacks and response to bronchodilators. The finding of wheezing in a A chest radiograph may be useful in assessing wheezing, particularly for patients without a history of asthma. 10 As noted elsewhere, patients with uncomplicated acute asthma do not require routine chest radiographs during their emergency department assessment and treatment. Conversely, patients with COPD and congestive heart failure who present with dyspnea and wheezing should have chest radiographs to evaluate for severity and complications. ABG analysis is useful if...

Clinical Features

Excluding environmental exposures, acute cough is most often due to URI, lower respiratory tract infection, and allergic reactions. Common URIs are associated with a combination of rhinorrhea, sinusitis, pharyngitis, and laryngitis, with the cough due to drainage from the nasopharynx onto cough receptors in the pharynx and larynx. A productive cough is the hallmark of acute bronchitis. While pneumonia generally produces a cough, pulmonary secretions may be scant thus, the cough is not productive and the presentation may be dominated by other symptoms (e.g., altered mental status, fever, and dyspnea). Mycobacterial and fungal pulmonary infections may produce cough, but the presentation is usually more subacute or chronic. Acute asthma is often associated with cough, but symptoms of wheezing and dyspnea usually dominate. Occasionally, a patient with asthma may present with coughing, as opposed to wheezing, as a manifestation of airflow obstruction. Chronic cough is due to a wide variety...

Ca2 Channel Antagonists and Other Direct Vasodilators

Drugs that lead to increases in cAMP or cGMP in vascular smooth muscle cells represent another class of agents that may elicit natriuresis primarily by enhancing renal blood flow and GFR. These include methylxanthines (theophylline and aminophylline), the vasodilatory amines (dopamine), natriuretic peptides, nitric oxide donors, and vasodilatory prostaglandins. The methylxan- thines include the older nonspecific drugs that block membrane bound adenosine receptors as well as inhibit intracellular phosphodiesterase activity which also increases intracellular cAMP levels 31 . Most of these agents also have tubular effects to inhibit sodium reabsorption rate at one or more segments of the tubule. Varied renal hemodynamic responses have been reported with some reports showing substantive increases in GFR and others failing to establish significant changes in filtered load. Nevertheless, for any given level of perfusion pressure, renal blood flow is slightly augmented by these agents. While...

Mechanical Ventilation

When in spite of the emergency physician's best effort to treat an acute asthma exacerbation, when the patient begins to exhibit signs of acute ventilatory failure, eliminates the work of breathing and enables the patient to rest while the airflow obstruction is resolved. Fortunately, fewer than 1 percent of asthmatics ever require mechanical ventilation. Direct oral intubation is preferred over the nasotracheal route. The potential complications of mechanical ventilation in asthmatic patients are numerous. Increased airway resistance may lead to extremely high peak airway pressures, barotrauma, and hemodynamic impairment. Mucous plugging is frequent, often leading to increased airway resistance, atelectasis, and pulmonary infection. Due to the severity of airflow obstruction during the early phases of treatment, the tidal volume may be larger than the returned volume, leading to air trapping and increased residual volume intrinsic positive end-expiratory pressure (intrinsic PEEP) ....

Chronic Obstructive Pulmonary Disease

Extras Portable CXR, ECG, pulmonary function tests before and after bronchodilators pulmonary rehabilitation impedence cardiography, echocardiogram. 12. Labs ABG, CBC with eosinophil count, SMA7. Theophylline level stat and after 24h of infusion. Sputum Gram stain, C& S.

Chapter References

Mannino DM, Homa DM, Pertowski CA, et al Surveillance for asthma United States, 1960-1995. MMWR 47 1, 1998. 3. Centers for Disease Control and Prevention Asthma mortality and hospitalization among children and young adults United States, 1980-1993. MMWR 45 350, 1966. 4. Cydulka RK, McFadden ER, 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, 5. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema. Lancet 351 1225, 1998. 6. Weiss KB, Green PJ, Hodgson TA An economic evaluation of asthma in the United States. N Engl J Med 326 862, 1992. 8. Kraft MR, Djukanovic S, Wilson ST, et al Alveolar tissue inflammation in asthma. Am J Respir Crit Care Med 154(suppl) 1505, 1996. 10. Roche WR Fibroblasts and asthma. Clin Exp Allergy 21 545, 1991. 11. Busse...

Pharmacological management

Many patients with heart failure will also have lung disease (asthma or chronic obstructive disease) and may take an inhaled beta-2 agonist. It has been suggested that such therapy might benefit patients with heart failure in the absence of significant lung disease because of the demonstrable increased airways resistance. Witte et al. have shown some benefit in breathlessness in 12 patients treated with inhaled salbutamol and the anticholinergic ipratropium (compared with 10 controls).45 Breathlessness and airways resistance improved as did lung reactance and peak tidal volume during exercise although exercise capacity did not improve. The role of beta-2 agonists remains unclear the benefits of beta blockade are now well established and should always be used in the absence of contraindications.

Acute Exacerbations of COPD

Although pulse oximetry may identify hypoxemia, it cannot identify hypercapnia or acid-base disturbances. Spirometric criteria that have been used to eliminate the need for arterial blood gases in asthmatic patients cannot be safely applied to patients with COPD. The finding of an arterial pH below that consistent with renal compensation for chronic respiratory acidosis implies either acute exaggeration of hypercapnia or acute metabolic acidosis. Radiographic abnormalities are common in COPD exacerbation therefore, radiographs should be strongly considered. 14 ECGs may reveal concurrent disease processes such as ischemia acute myocardial infarction and signs of cor pulmonale, as well as arrhythmias such as multifocal atrial tachycardia. The theophylline level should be determined in patients whose regimen includes this mediation. Finally, other tests may be indicated to determine the etiology of the exacerbation.

Future Considerations New Therapies

Bronchodilators play an important role in the long-term management of patients with COPD, but they do not alter the progression of COPD. Major advances include the development of long-acting b2-adrenergic agents, such as salmeterol and formoterol, and anticholinergic agents, such as tiotropium bromide. Tiotropium bromide

What is the role of qualitative studies

Randomized clinical trials and observational studies rarely consider individual patients' perceptions or preferences. Qualitative studies fill this void. One must not forget that patients may regard risks and benefits very differently, and patients with the same medical condition may have very different symptoms, as well as completely different thresholds of tolerance for these symptoms. Some patients with asthma may suffer primarily from exertion dyspnea, while others have difficulty coping with dry cough or insomnia due to nocturnal attacks. Any trial evaluating asthma interventions for symptomatic relief ought to focus especially on what is most important to individual patients. Patient perspectives and expectations should be taken into account when designing trials to evaluate interventions.

Pulmonary Angiography

Pulmonary angiography remains the gold standard for accurately diagnosing PE. The disadvantages include patient discomfort, cost, and complications. Pulmonary angiography has excellent interobserver reliability the PIOPED study found that review of study angiograms by another radiologist reached the same diagnosis in 96 percent of cases.8 Complications of pulmonary angiography include (1) fatalities in 0.5 percent, (2) major nonfatal complications such as renal failure, significant hematoma, or respiratory distress in 17 percent, and (3) minor complications such as angina, urticaria, or bronchospasm in 5 percent. 8

Definition and diagnostic criteria

Atopic eczema is a chronic inflammatory skin condition characterised by an itchy red rash that favours the skin creases such as the folds of the elbows, behind the knees and around the neck. The morphology of the eczema lesions themselves varies in appearance from vesicles to gross lichenification on a background of poorly demarcated redness. Other features such as crusting, scaling, cracking and swelling of the skin can occur.1 Atopic eczema is associated with other atopic diseases such as hay fever and asthma. People with atopic eczema also have a tendency to dry skin, which makes them vulnerable to the drying effects of soaps.

Incidenceprevalence

13-14 years in the International Study of Asthma and Allergies in Childhood (ISAAC) suggest that atopic eczema is not just a problem confined to Western Europe, high prevalence being found in many developing cities undergoing rapid demographic change.8 There is reasonable evidence to suggest that the prevalence of atopic eczema has increased two to threefold over the last 30 years, although the reasons for this are unclear.9 No reliable estimates of incidence are available for atopic eczema.

Pathologic Features of Sepsis General Approach

As a consequence of DIC in sepsis, petechial or more extended hemorrhages can be seen on the skin, on mucocutaneous surfaces and serous membranes, or in parenchymal organs by gross examination. Despite the fact that cutaneous pete-chiae also can be found in a variety of forensic autopsy cases of death from various natural causes, such as acute right heart failure (e.g., asthma fatalities), and that these petechial bleedings are also a frequent finding in those who were subjected to cardiopulmonary resuscitation efforts prior to death, the presence of cutaneous

TABLE 712 Causes of Gastroesophageal Reflux Disease

Less obvious presentations of GERD are also well recognized. Pulmonary symptoms, especially asthma exacerbations, and multiple ear nose throat symptoms are well described. GERD is present in many asthmatics, and in some can contribute to exacerbation by aspiration of minute amounts of gastric contents, with subsequent inflammation and bronchospasm, and by esophageal activation of reflex vagal tone, with consequent bronchospasm. Unfortunately, a reliable means for identifying asthmatic patients with GERD who will show an improvement in pulmonary symptoms with anti-reflux therapy has not been demonstrated in the literature.1718 GERD has been implicated in the etiology of dental erosion, vocal cord ulcers and granulomas, laryngitis with hoarseness, chronic sinusitis, and chronic cough. 1920

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...

Why is a priori testing important

In a New Zealand study evaluating asthma treatment,6 regular and as needed administration of fenoterol were compared using a non-standardized combination of respiratory flow, symptomatic improvement and drug use. The investigators reported that a significantly greater number of patients deteriorated over 24 weeks when given regular inhaled beta-agonist treatment compared to on-demand treatment. Unfortunately, the home-made criteria for assessing drug effectiveness had not been specified in advance. Often it is impossible for readers to know when investigators play the postmaster's game, even if the study is reported in a highly reputable journal. Without access to the trial protocol or a design paper, one cannot know for certain whether the investigators clearly stated a limited number of a priori hypotheses or whether the hypotheses

What factors will influence whether or not we obtain a significant outcome

Figure 6.8 shows the effect of the width of the confidence interval. We know that the interval width depends upon the variability (SD) of the data being considered and the number of observations available. Therefore, if the theophylline clearances are fairly consistent and large numbers of subjects have been studied,

Factors associated with dyspnea

Few studies have examined the factors associated with dyspnea in patients with cancer.11'13'17'19-24 Some of these have found that dyspnea in cancer patients has diverse etiologies, commonly with more than one factor contributing to the breathlessness.17,20 In one study the prevalence of dyspnea was strongly related to the number of risk factors a patient had.11 Most studies have found that lung or pleural involvement with cancer is associated with the presence of dyspnea.11'13'17'19'20 Escalante and associates found that the most common cause of shortness of breath in a group of patients presenting to an emergency room in lung cancer patients was their underlying disease (64 per cent) in breast cancer patients, pleural effusions (31 per cent) and in other cancers, lung metastases (20 per cent).17 Dudgeon and colleagues found that shortness of breath was significantly more common among cancer patients with a history of smoking, asthma, or chronic obstructive pulmonary disease, lung...

Role of Pepper Spray in InCustody Deaths

Oleoresin capsicum (OC) is a crude extract of hot peppers (genus Capsicum) that, when in contact with respiratory mucous membranes, causes individuals to choke or cough. OC may be used during police apprehension of an individual (see Subheading 3.7. and ref. 361). Variable dyspnea caused by bronchoconstriction parallels the intensity of the coughing. Asthmatics and others with pulmonary disease are at risk (90). Some subjects are unable to speak. A case of laryngeal edema complicated by respiratory arrest has been described in an 11-yr-old boy (362). To assess the role of OC in the death of an

Obtaining the P value

Whatever package is used, the theophylline clearance data from the previous chapter should produce a P value of 0.001. This can be read as If rifampicin actually had no effect on theophylline clearance, there would be only a 0.1 per cent (1 in 1000) chance that our samples would suggest an effect as great as (or greater than) the difference we actually observed.

Weaning frominvasive ventilation

Mini-tutorial intubation in acute severe asthma Intubation can be a life-saving intervention. Therefore it is important that it is performed early if indicated, particularly in acute severe asthma. A few minutes preparation beforehand is time well spent, particularly in those who are most unstable, as cardiovascular collapse can occur from uncorrected volume depletion, the abolition of catecholamine responses, and vasodilatation when general anaesthesia is given. Patients are volume loaded prior to intubation and a vasopressor (for example, ephedrine) is kept ready to treat hypotension. Anaesthetic drugs are given cautiously to minimise any vasodilatory effect and drugs that cause histamine release are avoided if possible. In life-threatening asthma, maximum medical therapy includes less commonly used bronchodilators, such as nebulised or subcutaneous adrenaline, intravenous salbutamol, magnesium sulphate, ketamine, and volatile anaesthetic agents. Once intubated, the patient is...

Which symptoms are most relevant

A similar situation exists for trials of anti-asthmatic treatments. In an asthma attack, exertional dyspnea and nocturnal orthopnea are the most troublesome symptoms for the patient clinical trials of acute treatment should focus on those symptoms. In contrast, trials evaluating the effectiveness of long-term maintenance therapy need to assess the prevention of acute exacerbations and disease progression, so it is appropriate to measure complication rates, changes in pulmonary function and, in more advanced disease stages, survival.

Igemediated Food Allergies

IgE-mediated food allergies are sometimes called immediate hypersensitivity reactions because of the short onset time (a few minutes to a few hours) between the ingestion of the offending food and the onset of symptoms. Since the mediators released from the mast cells and basophils can interact with receptors in a number of different tissues in the body, a rather wide variety of symptoms can be associated with IgE-mediated food allergies (Table 1). The most common symptoms associated with food allergies are those involving the skin and the gastrointestinal tract. Respiratory symptoms are less frequently involved with food allergies than with various inhalant allergies such as pollen and animal dander allergies. However, asthma is a very serious, though uncommon, respiratory manifestation of food allergies. Fortunately, most food-allergic individuals suffer from only a few of the many possible symptoms. Most of the symptoms of IgE-mediated food allergies are not particularly...

Polymorphic Changes In Oral Liquid Dosage Forms

There is an ever-present risk that a polymorphic form that has low solubility may form in solution and precipitate out or have a significant impact on bioavailability. This may be especially true for drugs in suspensions, based on the undissolved crystalline form in the formulation. One example is a theophylline suspension in which the micronized anhydrous crystals were used to create the formulation, and a needlelike crystal formed with time, which was the hydrate form. Another example is rito-navir, which was formulated as an amorphous dispersion and removed from the market in 1998 when an insoluble crystal (new polymorph) was formed during long-term storage. This thermodynamically driven process may be observed if the formulation is studied under refrigerated and or cyclic temperatures. Excipients can play an important role in the rate of a polymorphic change. For example, a polymorphic transformation of succinylsulfathiazole suspensions was found to be caused by several...

Definitions and Clinical Aspects

The Mallory-Weiss syndrome is characterized by bleeding from a mucosal laceration in the distal esophagus. The cause is a sudden rise in intraabdominal pressure, which may occur with forceful vomiting (especially in alcoholics), vigorous coughing, asthma attacks, or during pregnancy.

Disorders associated with food allergens

Among the quick-onset reactions, swelling of the lips and tongue, often associated with urticaria and angioedema, are the most common however, respiratory manifestations also frequently occur, mainly in the form of asthma, cough and stuffy nose. A family history of atopy is often present in such infants and these types of clinical reaction usually correspond to IgE-mediated hypersensitivity, which can be analyzed by means of prick tests and the determination of specific antibodies. Among the slow-onset reactions, food-sensitive enteropathies are the most frequent and also the most difficult to diagnose, especially because of the late onset of the reactions after the ingestion of the incriminated food (sometimes 1-3 days) and the numerous other causes which show a similar clinical picture. Food allergy and intolerance are important triggering factors of asthma. The true frequency is difficult to establish because, in most cases, other allergen famil ies also play a role. Asthma due to...

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.

Specific immunity Antibody

Although it is difficult to draw definite conclusions, for most of the mycoses there is little evidence to suggest that specific antibodies are critical to host defense. In marked contrast to patients with impaired cell-mediated immunity, those with hypogammaglobulinemia are not particularly predisposed to the development of invasive fungal infections. The principal role of antibody may be to enhance binding of fungi to phagocytic cells via Fc receptors. In the case of crytococcosis, specific antibody enhances the activity of most effector cell populations in in vitro systems and passive administration of antibody has been shown to be beneficial in animal models of infection. Some evidence from mouse models also suggests a role for humor,al immunity in resistance to systemic candidiasis. Specific antibodies are also important in the pathogenesis of allergic responses to inhaled fungi. For example, IgE-mediated immediate hypersensitivity reactions to fungal allergens may play a part in...

Lipoxygenase and Atherosclerosis An Example of Nutrigenetics Nutrigenomics

Shown that genetic variants of the 5-LO promoter, already known to be associated with variable sensitivity to anti-asthmatic medications, also influence atherosclerosis. Variant genotypes of the 5-LO gene were found in 6 of a cohort of 470 healthy middle-aged men and women. Carotid intima-media thickness (IMT), taken as a marker of the atherosclerotic burden, was significantly increased, by 80 in the variant group compared to carriers of the common allele, suggesting increased 5-LO promoter activity associated with the mutant (variant) allele. Furthermore, dietary AA intake significantly enhanced the proatherogenic effect of 5-LO gene variants, while intake of EPA and DHA decreased (blunted) the effect of 5-LO and was associated with less IMT. EPA and DHA decrease the formation of leukotrienes of the 4-series by competing with AA (Figure 5) as substrates for 5-LO and generate weaker leukotrienes of the 5-series. The results of this study suggest that person with genetic variants are...

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...

Viral Infections with Congenital Heart Disease

Although few normal children have problems with common viral pathogens such as influenza virus, parainfluenza virus, or respiratory syncytial virus, children with congenital heart disease are at unique risk for major sequelae. Distinguishing minor early infections with these agents and differentiating them from the symptoms of congestive heart failure is a challenge, even for seasoned clinicians. Children with lesions that increase pulmonary blood flow are far more at risk because of pooling of alveolar secretions. The pooled secretions allow for stasis and secondary bacterial overgrowth. Dramatic increases in mortality and morbidity are evident among affected infants. No effective therapy is available for parainfluenza and influenza virus, and prophylaxis against influenza B with amantadine analogues is not approved for small children. Hospitalization and specific treatment of infants affected by respiratory syncytial virus has been difficult to justify due to conflicting studies...

Problems Of The Lungs

Cough Asthma Bronchitis Pleuritis Pneumonia Tuberculosis Cough Asthma Bronchitis Pleuritis Pneumonia Tuberculosis Asthma is an allergic disorder characterized by breathiessness (dyspnoea), which isthe resultof aspasmodic narrowing of the respiratory passage. (C) For relieving an acute attack of asthma, also stimulate the trigger areas for the adrenal glands (see page 89) and tie small rubber-bands on all toes for 10-12 minutes. During this time, if a toe starts paining or turns black, remove the concerned band for a while (till the normal colour returns) and then reapply it.

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).

Sources of further information and advice

The Ministry of Agriculture, Fisheries and Food has produced information packs for the catering industries on how to anticipate the problems that might arise from allergic individuals in their restaurants. The Anaphylaxis Campaign, the British Allergy Foundation and their American counterpart, the Food Allergy Network, are excellent sources of rationally prepared and non-hysterical advice for individuals affected by food allergy and intolerance. The American Academy of Allergy, Asthma and Immunology has a website that has free patient information available, links to other sites and access to American physicians who may treat individuals. The Anaphylaxis Campaign has recently gone online. The British Allergy Foundation website is rather rudimentary at present.

Agents for Adjunct Ambulatory Treatment

Cromolyn sodium has long been used to inhibit mast-cell degranulation and histamine release. It is not recommended in the acute attack. Nedocromil (Tilade) works similarly however, it may be effective only if strict compliance is maintained. A primary feature is that it reduces the cough component of asthma it is also considered to be steroid sparing. Leukotriene receptor inhibitors (LTRIs) are increasingly popular agents for use in the outpatient prophylactic management of asthma. These medications do not supersede steroid use in the acute attack. They are classified as 5-lipoxygenase inhibitors or 5-lipoxygenase-activating protein inhibitors, of which montelukast is approved for pediatric use zafirlukast may be used in children of age 12 and above. Currently only limited data are available, but the initial response is encouraging and suggests less need for medication and chronic steroid use. A trial comparison to inhaled steroids will provide more information. Although initial...

Reassessment and Disposition

Care unit (ICU) for continuous therapy. Children with oxygen requirements, refractory asthma, and or dyspnea on exertion may be admitted to the floor. If parents of children with newly diagnosed asthma do not feel comfortable taking care of their children even with adequate teaching, admission may be warranted (this also applies to patients with mild attacks requiring nebulization but with limited resources and inability to obtain nebulizers on weekends and at night).

TABLE 1213 Diagnostic Studies in Seizure Patients

Symptoms of a complex, yet treatable, underlying disease. Seizures have been reported in children after topical application of N, N-diethyl-m-toluamide (DEET) and lindane (Kwell). Ingestion of rare and common agents has been associated with new-onset seizures, including camphor, theophylline, isoniazid, tricyclic antidepressants, oral and parenteral meperedine, cyclosporine, stimulants such as methylphenidate, and lead and mercury exposure. These seizures may be brief and self-limiting or may progress to status epilepticus and result in permanent neurologic sequelae and epilepsy. Identification and specific treatment of the underlying problem are most important to achieve full recovery. Aseptic and bacterial meningitis, viral encephalitis, brain abscess, and more uncommon problems such as cat-scratch fever and mycoplasma-related encephalopathy may present with seizures. In a child with a ventriculoperitoneal shunt, seizures are more likely to arise from associated cerebral...

Clinical Note continued

Asthma is the other main obstructive pulmonary disease. Asthma causes severe bronchoconstriction leading to low Va Q regions in the lung but no shunt. A big advance in the treatment of asthma was the development of selective p2-adrenergic agents (e.g., albuterol) to stimulate bronchodilation. Older, non-selective -adrenergic agents (e.g., isoproterenol) stimulated receptors on the heart also, which increased blood flow to low Va Q regions of the lung and could actually decrease PaO2. The benefits of relieving bronchoconstriction and increasing ventilation generally outweighed the negative side effects of -adrenergic agents on gas exchange, but the selective 2-adrener-gic agents completely obviate these side effects.

Metabolism of Chemotherapeutic Agents

While most significant associations between GST genotypes and clinical phenotype have not been replicated, a minority have been independently confirmed. For example, GSTP1 Val105 Val105 has been associated with reduced risk of airway hyperresponsiveness (odds ra-tio 0.23-0.38) in three studies in asthmatic adults and children. 20 This genotype is also protective against childhood respiratory illness. 21 The advent of high-throughput genotyping, availability of new SNP, and ease of deriving haplotypes should place an emphasis on large studies incorporating some assessment of reproducibility. Furthermore, assessment of further allelic GST sites associated with binding of peptides involved with cell signaling warrants further investigation.

The History of Circumcision

The practice of routine neonatal circumcision has been debated within the U.S. medical profession for over a century. Circumcision was initially advocated in the Victorian era as a measure that would reduce masturbation. Medical benefits from the procedure were first widely proposed in 1891 by P. C. Remondino, who claimed that circumcision prevented or cured a host of diseases, including alcoholism, epilepsy, asthma, and renal disease (Wallerstein). More scientific studies of the potential medical benefits of circumcision began to appear in the professional literature in the 1930s. Urologists observed an association between penile cancer and an intact foreskin (Schoen, 1992). During World War II, American troops stationed in the Pacific and in desert climates had problems with irritation and infection of the penis because of sand and the inability to maintain adequate hygiene. The military response was to circumcise many of the affected soldiers. However, the Japanese did not use...

Documenting a Diagnosis of Food Allergy

Another common problem is the misinterpretation of a sequence of events. For example, a child with an ear infection is given an antibiotic, and 3 days later gets diarrhea, so the parents come to believe the child is allergic to the antibiotic. In fact the cause of the diarrhea is far more likely to be either an underlying viral infection, or a disturbance of the gut flora. Another example is the report of a child who is believed to be allergic to sesame seeds because of reactions occurring after eating buns coated with sesame seeds many such children are in fact not allergic to sesame seeds but are reacting to the egg glaze that has been used as an adhesive for the seed coating. Another common example is the child with asthma who coughs and wheezes after drinking a diluted orange squash drink, with the result that it is believed that the child is reacting to the yellow-orange coloring agent tartrazine. If fact such reactions are more likely to be due to sulfite preservatives in the...

Drug Treatment in the Management of Food Allergy

Saving treatment is to restore the circulating volume with intravenous fluids and to give oxygen. The third mechanism is severe bronchoconstriction (asthma) here, the life-saving treatment is with bronchodilator drugs and artificial ventilation. If patients with life-threatening anaphylactic shock are to be saved, they must be given urgent (within minutes) medical attention. For individuals who have already experienced a life-threatening allergic reaction to a food, it is common practice to provide them with a syringe preloaded with adrenaline (epinephrine), with the aim that this should be administered while waiting for medical help. Unfortunately, self-administered adrenaline is not without its hazards (e.g., inadvertent intravenous administration causing fatal cardiac arrest), and there is no proof that it is life saving indeed, there are many cases in which the subject died despite the use of epinephrine. Nevertheless, it is the best one can do when faced with someone who is...

Prevention of allergy

There is general consensus that the prevalence of asthma and other atopic diseases, including food allergies, is increasing. A history of allergic disease in the immediate family (atopic heredity) is the most important risk factor. Recent studies indicate that exposure to allergens in utero and in the first few months of life is critical in the development of allergic disease in children with an atopic heredity. In children at high risk, reduction in exposure to allergen should lead to a decline in disease prevalence. Food proteins are important allergens in early childhood. A hypoallergenic diet has therefore been suggested as a means of preventing the development of allergy.

Metered Dose Inhalers

The popularity of pressurized MDIs (pMDIs) grew rapidly after their introduction in the late 1950s. They are currently used by over 25 million Americans for the management of a variety of diseases, such as asthma, COPD, and other lung diseases characterized by obstruction of airflow and shortness of breath. pMDIs contain active drug ingredients dissolved or suspended in a propellant, a mixture of propellants, or a mixture of solvents, propellants, and or other excipients in pressurized aerosol canisters fitted with metering valves (Fig. 1). The aerosolization of the formulation from the pressurized container is a transient and complex process. When the metering chamber is opened, the pressurized formulation is released and expands rapidly, undergoing preatomization and forming a mixture of gas and liquid before being discharged as a jet through the orifice of the actuator. Aerosolization involves complex fluid dynamic processes that include high shear stress on the formulation and...

Other symptomatic treatment

Ketotifen with antihistaminic and anti-inflammatory properties has been used in food allergic reactions such as urticaria and bronchospasm. It may be useful as an additional therapy in some patients. Beta-2 agonists such as salbutamol or terbutalin may be used when bronchospasm is a prominent feature in an allergic reaction. These drugs can be delivered by inhalation through a metered dose inhaler, in an aerosol form through a nebuliser, or by intravenous route. Food-related eczema and rhinitis should be treated along the standard line with topical steroids and antihistamine in addition to allergen avoidance.

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.

Assessing breathlessness in children

Ments of dyspnea have included having children with cystic fibrosis take a deep breath and then count out loud to 15 wherein the number of breaths taken to complete the count is the score11 For children who are able to verbalize how they feel, creating a scale that is simple for the child to use and that incorporates their own language is more likely to be clinically relevant in day to day practice. Children may describe the sensation of dyspnea breathlessness in many different ways. For example one study looked at the different terms 39 school age children with asthma used to describe their breathing on a 'bad breathing day'.12 These children most frequently described their breathing as 'It is hard to breathe'. Words chosen most often were 'wheezy', 'short of breath', and 'tight'. Importantly this group of children with chronic asthma coped with their dyspnea by the use of medications, change in position, decreased activity, and fluids in short, many of the same coping mechanisms...

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,...

Severe allergic reactions

Bronchospasm Mild to moderate bronchospasm commonly occurs as part of a generalised reaction but may be the most prominent symptom. This usually responds to inhaled or nebulised bronchodilator in addition to corticosteroids. Short-acting beta-2 agonists such as salbutamol or terbutalin may be given through a metered dose inhaler attached to a spacer device when outside the hospital. If the response is not adequate, the patient should be transferred to the hospital where nebulised or intravenous bronchodilator may be administered. Corticosteroids

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...

Immunotherapy Of Allergic Diseases

Allergen immunotherapy represents the dominant immunologic, as opposed to environmental or pharmacologic, approach to management of allergic diseases such as allergic rhinitis, conjunctivitis and asthma. It was developed empirically, coincident with the modern-day discovery of allergy by Portier, Richer and von Pirquet. In essence, it involves identification of the allergen(s) to which a patient exhibits immunoglobulin E (IgE)-dependent sensitivity followed by subcutaneous administration of minute amounts of natural extracts containing these allergens. The goal is lasting modification of immune processes responsible for the maintenance of atopic symptoms. Other, infrequently used, forms of desensitization (i.e. IgE-mediated drug reactions)

The question of efficacy

In insect venom immunotherapy, protection is achieved in well over 90 of subjects following a short (usually several day) course of injections. Efficacy is commonly tested by deliberate administration of an insect sting challenge in the presence of a physician, yielding clear-cut evidence of success or failure. In contrast, the efficacy of immunotherapy for inhalant allergens, used in therapy of allergic rhinitis or allergic asthma, remains controversial. Proponents argue that allergen immunotherapy is highly effective and that the equivocal results are attributable to use of insufficient or poorly prepared allergen extracts, use of inappropriate or insufficiently rigorous criteria for patient selection or unwillingness of patients to complete a sufficiently long course of treatment. They draw support from statistically significant differences that have been observed in a number of parameters measured in randomized, double-blind, placebo-controlled studies. On this basis, the formal...

Coping with Asthma

Coping with Asthma

If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.

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