DR. C’S JOURNAL: ASTHMA – DIAGNOSIS & TREATMENT

Asthma is a lung condition with narrowing of the airways, especially on exhalation, or breathing out. This narrowing leads to the musical sound on breathing the air out of the lungs that I heard so often with  my stethoscope and over the phone, when I was in active allergy practice. With an asthma attack, the blockage to airflow can become severe enough to dangerously raise the carbon dioxide concentration in the blood stream, and lower the oxygen content.

Many attacks occurred at night .Over the phone, I had older kids and adults take a deep breath, and count from 1 to 30 as rapidly as they could. If they could count out loud to 30 with one breath, at least the obstruction and attendant blood gas changes were not usually serious at that moment in time. That helped me decide whether or not I had to see them in the emergency room.

Asthma is an inflammatory condition of the lining of the airway that stimulates the smooth muscle surrounding the airway to constrict and obstruct flow of air, particularly on exhalation. Early on in my medical practice the main pathology was thought to be overactive airway muscles, and the main effort was to relax those muscles so that breathing could be easier. This was typically done with adrenaline injections, or the inhalation of adrenaline-like agents such as albuterol.

More sustained opening the airway was accomplished by oral theophylline. As time went on, it became  known that its effectiveness required a certain blood level. We had an HPLC machine in the office to measure this. 5 to 10 µg per milliliter was required for relief, and anything over 20 µg per milliliter was dangerous. Many cases of convulsions have been recorded in people with excessive blood levels.

We were always aware of the fact that cortisone medications would relieve asthma, but regular use of these drugs caused worrisome side effects such as interference with growth in children, osteoporosis, weight gain and loss of sleep or other problems. Most worrisome was the possibility of adrenal insufficiency and sudden death. We used Cortisone only as a last resort.

There was a group of young children especially 1 to 6 years of age that developed extreme asthma a few days after they developed a common cold. I found that giving prednisolone for two or three days at the start of a runny nose would block the advent of this asthma, without suppressing the adrenal gland. Three days of prednisone was also used to blunt severe attacks.

The excellence of Cortisone in the treatment of asthma should’ve told us that inflammation was a particularly important factor. It is now known that Asthma is not a disease of airway smooth muscle sensitivity per se, but rather a chronic inflammation of the airways that causes the muscles to be irritable.

Asthma is more common in allergic individuals, particularly when they are young. For this reason, the allergies are treated by avoidance of exposure to such things as cats, dogs, house dust and pollen.  Allergy injections to the skin test positive items is also useful.
Currently,  asthma is treated by inhaling special cortisone  preparations and long acting bronchodilators.

The chain of chemical reactions that cause asthmatic airway inflammation has become apparent over the years. Drugs to block these are available, and include special antibodies can be exceptionally expensive; but very effective.

The youngest of my former partners is still practicing Allergy, and almost never has to deal with acute severe asthma.
The beast has been tamed, if not conquered.

—Dr. C.

Mayo Clinic Article

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Endocrinology: Thyroid Nodule Treatment (Video)

The Endocrine Surgery Program at Massachusetts General Hospital provides multidisciplinary, specialized treatment for thyroid nodules, a lump that commonly occurs in the thyroid. If you think that you may have a thyroid nodule, you should be evaluated by a physician. In this video, Sareh Parangi, MD, endocrine surgeon at Mass General, shares more about what to expect for diagnosis and treatment of thyroid nodules.

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Dr. C’s Journal: Rib Fractures & Cracks

Broken ribs are fairly common, and if you’ve ever had one, you don’t want another. A rib fracture causes lots of pain, which is worse when you take a deep breath, press on the area, or twist your body.

The pain on taking a deep breath creates a catch 22, because taking a deep breath every few minutes is a good idea, if not essential to keep your lungs open and functioning, yet you don’t want to do it because it hurts a lot.

A rib fracture is usually caused buy a direct trauma to the chest from a fall, automobile accident, or sport.

Repetitive minor injury can also cause rib fractures. This can occur when you escalate your exercise to rapidly and stress a bone, like in the foot, or when you have a chronic cough that’s violent and continuous, which could cause a stress rib fracture.

Interestingly, children age 10-12 can stress their chests enough with a heavy backpack to cause a problem where are the ribs meet the breastbone, called the costochondral junction.

Any severe chest pain raises concern for heart disease, and the fact that it is worsened by pressure on a certain area, or by taking a deep breath can be reassuring. The doctor should be contacted depending on the severity of the pain and how certain you are it is related to trauma.

Of course, if the pain in the middle of the chest, feels like pressure or radiates, You would be foolish not to go to emergency room. The treatment for a rib fracture no longer includes taping the chest, but rather continuing to take occasional deep breaths and use medication if needed for pain.

Of course you need a doctor’s diagnosis in order to continue doing this. If the Fracture was due to a fall, you should definitely educate yourself on how to avoid falls in the future. In July 2020, I posted an article on falls that you could access by typing “falls” into the question box.

There are a variety of things you can do to prevent falling: remove clutter in the house, strengthen your muscles, check your eyesight, hearing, proprioception, and balance. There are even programs for teaching the elderly HOW to fall.

Please refer to the mayo clinic article on broken ribs for more detail.

—Dr. C.

Mayo Clinic Article

Fungal Infections In The Lungs: Aspergillus

The genius aspergillus is a Fungus extremely common throughout the world. It is in the air almost everywhere, and it’s estimated that most people breathe hundreds of Aspergillus spores into their lungs daily. It affects almost exclusively people with compromised immune systems or with underlying respiratory illness.

COMPROMISED IMMUNITY is often present in people with diabetes, obesity and malnutrition, The very young and very old, Viral infections, particularly AIDS and Covid, cancer, autoimmune diseases, organ transplants, and the list goes on. With the advances in medicine in the past few decades, people are being kept alive longer, often by suppressing their own immunity.

UNDERLYING REPIRATORY ILLNESS is disease such as asthma, cystic fibrosis, sarcoidosis, tuberculosis and COPD.

When I was in an allergy practice, we were always on the alert for allergic bronchopulmonary aspergillosis in asthmatics who were difficult to control. ABPA at that time was reported mainly in England, which is unsurprising due to the wet British climate: fungi grow especially well where is wet.

Another unusual phenomenon is the Aspergillus fungus ball in the lungs, which is sometimes discovered only by chest x-ray. That such a dense mass of fungi could be tolerated in the lungs without invading the body is a tribute to the immune system‘s efficacy.

Galactomannan is in the cell wall of aspergillus, and can be used as a diagnostic test. PCR can also be used, shades of COVID-19. Of course x-ray, or microscopic study of tissues are also often used.

It is  estimated that aspergillosis accounts for around 600,000 deaths annually. Africa, with its large number of AIDS patients, contributes heavily to this. It’s difficult to know how common it is in the United States, because aspergillus is not a reportable illness. Please check with the following mayo clinic article for more information.

–Dr. C

Mayo Clinic article