Tag Archives: Asthma

DR. C’S JOURNAL: COPD -CHRONIC OBSTRUCTIVE PULMONARY DISEASE

COPD is the brother of asthma. Both can cause shortness of breath and wheezing. Asthma is the more Treatable of the two, and is due to muscle spasm around the airways which narrow those airways making it more difficult to breathe in and especially out.

COPD comes in 2 general forms,  Chronic bronchitis and emphysema.
Chronic bronchitis is an inflammation of the airways, which differs from the usual allergic asthmatic TH2 type of inflammation. The inflammation of chronic bronchitis is the more common TH1 inflammation that comes from the likes of bacteria and viruses.

The second type of COPD is usually caused by cigarette smoke or other fumes which lead to the destruction of the air sacs and associated elastic tissue, allowing a check valve type of obstruction to occur on breathing out.

COPD is rarely a pure type of chronic bronchitis or emphysema, and is usually an admixture of the two. In fact there can be an “asthmatic element” mixed into COPD, which allows for a better response to the myriads of medication that we now have for asthma.

The symptoms of COPD include shortness of breath, wheezing, chest tightness and chronic cough with production of sputum. Coughing up a significant volume of phlegm from your chest suggests chronic bronchitis rather than emphysema.

The symptoms of COPD come on rather slowly and are usually not noticed until the problem is severe. After all, the cigarette smoker is EXPECTED to cough isn’t he?

As COPD becomes very advanced, fatigue, lack of energy, and unintended weight loss may occur. Swelling of the legs may be a problem and could indicate involvement of a heart; with COPD the right side of the heart has a hard time moving blood through the diseased lungs.

We’ve all seen people pushing around a cart with an oxygen tank. These people most often are smokers who developed COPD. One particularly disgusting advertisement against cigarette smoking showed a person with a hole in the windpipe (tracheostomy) through which he was smoking his cigarette.

Pulmonary function testing it’s often helpful in diagnosing asthma and COPD. In pulmonary function testing, the amount of air in the lungs  and the rapidity with which it can be expelled from the Lungs is measured and graphed. it is the rate of flow on exhalation that is diminished in COPD and asthma, the slower the rate the worse the blockage.

In the case of asthma the test is repeated after a bronchodilating adrenaline type medication has been given. The REVERSIBILITY of the airway obstruction is shown by comparing the airway function before and after treatment  With no improvement, usually COPD is usually the culprit.

In both asthma and COPD, respiratory infection is a big problem. The compromised lung is usually very vulnerable to these inflammatory reactions. There are a score of medications  that are commonly used in asthma which also benefit COPD to a certain degree. Doctors have a large armamentarium for respiratory disease these days.
As mentioned, asthma is more treatable. However if it is poorly treated or neglected, a condition known as REMODELING can occur which will render treatment less effectual.

Please check with the Mayo clinic article on COPD for more information.

—Dr. C.

Mayo Clinic article

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

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

DR. C’S MEDICINE CABINET: Benefits & Risks Of ‘Aspirin’

Aspirin (acetylsalicylic acid) was one of the first medicines constructed, or synthesized, in a chemical laboratory. After 40 years ( medical progress wasn’t too fast in the 19th Century), Bayer investigated it as an alternative to Salicylates, which had been used since antiquity in the form of Willow bark for medical treatment, especially of FEVER and PAIN relief.

It is an understatement to say that it was successful. After almost another century, in 1982, a nobel prize was awarded for the discovery of its mode of action. Its multiplicity of effects, some of them bad, are only now becoming appreciated. My practice in medicine was in Allergic diseases, and I treated many people with nasal, sinus and asthmatic diseases.

It became apparent that, in certain people, aspirin could worsen all 3 conditions, and rhinitis (with Polyps), sinusitis and asthma became known as “Samter’s Triad”, or simply ASPIRIN DISEASE. Believe it or not, the condition can be helped by “aspirin desensitization”, where the Patient was started on tiny doses of aspirin by mouth, which over a period of hours was gradually increased to a normal dose.

I would not try this at home. I sent my patients to a specialized medical center for treatment, Other undesirable effects induce bleeding disorders, stomach ulcers, and, in children, a very serious disease called Reye’s syndrome. The latter is so serious that aspirin is not often given to children; except when it is needed, such as in a condition called Kawasaki’s Disease, where it is very helpful.

I mention these details to counteract the blase attitude created by long use. No longer does the doctor say “Take an aspirin and call me in the morning”. For a long while, low-dose Aspirin was used in most Patients with coronary artery disease, as a method of preventing sudden clot formation. I took 65 mg. Of aspirin for years, even though I had no narrowing of my arteries.

Now it is found that aspirin can cause an excess of Hemorrhagic stroke, and it is not recommended in my age group and risk profile. Aspirin is a powerful medication with a wide variety of effects. Most of its beneficial effects have safer alternatives. Acetaminophen- Tylenol- is now used in place of Aspirin for Pain and fever relief. I suggest not using aspirin unless prescribed by a Doctor.

–Dr. C

HEALTH: COFFEE & THE EFFECTS OF CAFFEINE

Coffee has a long and colorful history. Billions of cups are consumed daily, and with such a large and passionate audience, I offer you a taste of the aura which abound on the subject of this popular drink.

The African story of happy animals galloping around at night after eating some red berries from bushes more than a thousand years is probably a myth. It wasn’t until 15th C. Yemen that the documented history of coffee begins.

The substance that was initially ingested wasn’t even a beverage, but was more like an evil-tasting paste. The reason that it endured was undoubtedly it’s stimulating quality.

The Muslim world proscribed alcoholic beverages, but coffee enabled the faithful to pray all night, and was welcome. The Time taken to bring the berries to market often resulted in spoilage. The cargo had to travel from Ethiopia to the port of MOCHA in Yemen, and by a long Voyage to middle eastern destinations.

With the blessings of the Ottoman Empire, however, roasting of the coffee berry was developed, and the resulting coffee bean was more stable. The market heated up, and plantings of C. arabica spread to JAVA and beyond. Eventually, the pleasures of Coffee reached Vienna,and by 1652, the first House dedicated to coffee drinking opened in London.

Coffee Houses spread, and soon catered to special groups like writers, Philosophers and Merchants. Lloyds of London started as a discussion group of traders who were privy to Embarking ships’ Bills of Lading, and enjoyed an economic advantage. Soon the different coffee houses excluded the general public.

The Tastes of the British drinking public was malleable, however. Just as disputes with France caused a switch from wine to gin, the East India Companies plethora of TEA eventually resulted in substantial displacement of coffee drinking by the english tea ritual.

The reverse happened in Revolutionary America. Beginning with the Boston Tea Party, coffee drinking became more popular. By the time of the Civil war, it was unthinkable for Confederate soldiers not to have their ration of coffee.

America is presently the country with the largest coffee consumption. However, the per Capita coffee consumption is higher in a dozen other countries, especially in Scandinavia. Those long, dark winters, with associated increase in seasonal depression meshes well with the STIMULATING VIRTUES OF COFFEE.

Yes, Coffee is stimulating, and its effect can, and often does become ADDICTIVE, as I discovered when I started my Medical Practice. I was drinking three cups of coffee a day and still was tired all of the time, since I was often up at night taking care of my asthmatic patients; I finally decided to quit drinking coffee, and after a full three weeks, started feeling better.

For me, coffee was NOT A SUBSTITUTE FOR SLEEP. I know of at least one Red Bull accolite that disagrees with me, and the NEJM article on the benefits of coffee would seem to support drinking more than one cup of coffee a day.

I currently take about 50 mg. Of caffeine by tablet about every 3-4 days when I am tired in the early afternoon, before 2:30 PM, so as to clear the drug from my system by bedtime. If I use it more frequently, I do not enjoy the same pleasant alertness that less frequent use affords.

I currently drink a cup of green tea in the morning, which I believe delivers about 20 mg. Of caffeine and some other health benefits as well. Caffeine makes you more alert by competitively blocking the sedative action of Adenosine, which gradually accumulates in parallel with ATP depletion during the course of energy expenditure in the activities of the waking day.

Chemically, caffeine is trimethylxanthine, and is a cousin to the drug theophylline, which was the mainstay of asthma therapy for the first decade or so of my allergy practice. Before theophylline therapy was standardized, a strong jolt of coffee was often used for severe asthma.

Coffee apparently shares with Theophylline the inhibition of Phosphodiesterase, causing the heart to speed up, and lung airways to open. So enjoy your coffee, especially after reading about its health benefits in the recently posted NEJM article.

But be careful about drinking too much. There is rarely such a thing as a ’free lunch” in the worlds of economics and drugs. YES, CAFFEINE IS A DRUG, and the intoxicating aroma notwithstanding, please respect it as such.

–Dr. C

TELEMEDICINE: A REVIEW OF 9 CONDITIONS THAT CAN BE TREATED ONLINE (VIDEO)

TELEMEDICINE is here to stay! With all its’ advantages Patients will demand It!

This video is one of the few to highlight WOMENS’ HEALTH as an appropriate field for Telehealth. A remote visit first may at least let the Doctor order some tests that will accelerate your care.

Urinary problems can also be appropriate for telemedicine; the MEDICAL HISTORY is such a VALUABLE DIAGNOSTIC TOOL!

Psychological and Psychiatric care could be completely remote, by telemedicine. The Doctor could save on expenses, and deliver care less expensively.

Distance disappears as a barrier to Consultations and second opinions. A University medical center or prestigious multi specialty Clinic are on your doorstep.

Of course, barriers remain in the form of regulations, litigation, bureaucracy, and Insurance, but these can be overcome, if the Will is there.

—Dr. C

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #1 – THE “CHRONIC COUGH”

In my 88 years, I have had at least a dozen medical problems. Some have gone away on their own, some have been removed surgically, and a few have become CHRONIC, lasting for years, ultimately becoming a part of my life.

I have compiled a list of these and other SYMPTOMS & CONDITIONS I have seen as a physician. Over the next year, I will discuss them one by one, appending these vetted articles for further reading.

The ‘CHRONIC COUGH’ will be the first discussed.

As an Allergist, I was involved with coughing all of my adult life. If my patients did NOT have asthma, they usually coughed from mucus pouring down the back of their throat (post-nasal drip), from their allergic nasal condition (allergic rhinitis), or sometimes from the associated SINUSITIS drainage.

Asthma was a much more common cause of Chronic Cough for my Patients, sometimes theIr main problem. All asthmatic have a chronic inflammation of their breathing tubes(bronchi), and the resulting BRONCHITIS irritates the airway nerve endings, causing Cough.

Without enough narrowing of the airways to cause wheezing, this is called “cough equivalent asthma”. With the addition of airway narrowing (constriction) to the above situation, ASTHMA results.

There is added shortness of breath (dyspnea), and the cough becomes the “tight” wheezy cough of full-blown Asthma.

COPD (chronic obstructive pulmonary disease) may be a residue of long-term asthma, but commonly results from cigarette  smoking. Where loss of alveolae (air sacs) predominates, dyspnea (shortness of breath) is more common.

Where bronchial tube inflammation is more prominent, mucus and cough result. This cough is useful in clearing the mucus; a USEFUL COUGH (although my Patients did not always appreciate their friend, which could be bad enough to cause hernias or incontinence). 

Gastro-esophageal reflux is a chronic condition where stomach contents are not retained in the stomach by the G-E Sphincter ( a type of “purse-string” Gate), but spill(reflux) up, when not restrained by gravity, at NIGHT. The ACIDIC STOMACH CONTENTS burn the esophagus on the way up(heart burn), and are often aspirated into the airways during sleep, causing inflammation and COUGH.

There are many other less common CHRONIC LUNG ( pulmonary) DISEASES (conditions) such as sarcoidosis, bronchiectasis, interstitial pneumonitis, TB, and cancer, that can be diagnosed by imaging (X-Ray, etc.). Heart failure can also cause cough, as can blood pressure medication (ACE inhibitors). 

Smoking is an obvious cause; chronic smoking, chronic cough. Smokers know what is causing their cough, and usually don’t bother coming to the Doctor unless they cough up some blood, or develop one of the myriads of diseases caused by their habit.

If you have a chronic cough, check with your Primary Care Doctor, who may refer you to an Allergist or Pulmonologist. The following article will be useful to your understanding of cough, and will provide a LIST OF QUESTIONS the DOCTOR will likely ask you.

—Dr. C.

Further reading #1

Further reading #2

DOCTORS CALL: “CHRONIC COUGH – DIAGNOSIS AND TREATMENT” (MAYO CLINIC)

On the Mayo Clinic Radio program, Dr. Kaiser Lim, a Mayo Clinic pulmonary and critical care physician, explains chronic cough and how it can be treated.

Read more

COMMENTARY

If you have had a cough for more than 8 weeks, the good news is that you don’t have Covid 19. The bad news is that you need a Medical evaluation, tests and imaging to find out what is going on.

COUGH is not a disease, but is a manifestation, a SYMPTOM of a disease.

Your Primary Care Doctor will do a Medical History, an examination and a chest X-Ray which may allow her to DIAGNOSE what disease or problem Is causing the cough, and allow her to treat it.

If you continue to cough, you will be referred to a specialist, such as an Allergist or a Pulmonologist. ENT (sinusitis) and Gastroenterology (GERD) are 2 other medical fields often involved.

Usually blessed relief comes when Chronic Cough is properly diagnosed and treated, but a few Patients continue to suffer, challenging the best of medical care. 2 of my friends continue to cough after Medical School Level evaluations.

Nature continues to hide some of her secrets from Medical Science.

—Dr. C.