Song
Allergy, Asthma and Immunology Clinic
|
| Suite A Manhattan Beach, CA 90266 (310) 802-8016 - Phone (310) 802-8031 - Fax |
| 927
Deep Valley Drive, #135 |
Antigen: Any substance that causes immune reactions. Antigens are usually protein-compounds such as pollens, foods, mites, etc.
Allergen: Any antigen that causes allergic reactions such as pollens, mites, foods,etc.
Antibody: People produce these molecules in response to antigen challenge. They are capable of producing myriad of different antibodies. As a group, they are called immunoglobulins(Ig). Ig can be sub-grouped into 4 different classes; IgG, IgA, IgM, and IgE. Antibodies to milk can be produced in any of the 4 classes.
IgE antibodies: Only allergic people can produce IgE antibodies.
Mast Cells: Residential cells (reside in the tissues such as nasal cavities and airway) which are involved in allergic reaction. IgE antibodies go to the surface of mast cells.
Hypersensitivity: Hypersensitivity refers to any immunological reaction which may be harmful to the host. Allergic reaction is one of the 4 classes of hypersensitivity.
Allergic reaction: Allergic people are genetically programmed to produce a special class of antibodies known as IgE antibodies. IgE antibodies go to the surface of mast cells that are present in various tissues such as nasal cavity. When allergens such as pollens arrive at the tissue (e.g. nasal cavity), mast cells interact with them through IgE antibodies on their surface. Once the interaction takes place, mast cells get activated and produce various mediators.
The best known and most important of all mast cell mediators are histamine and leukotrienes. These mediators produce allergic reactions; the major components of allergic reactions are;
• Smooth muscle spasm (as occurs in the airways of the
asthmatics).
• Tissue swelling (as occurs in the nose of the people with
hey fever).
• Mucus secretion (as occurs in the nose of a hey-fever patient.
• Irritation of the nerve endings causing itchiness as in
eczematous skin.
• Inflammation resulting from the infiltration of other circulating
cells.
• Tissue damage (fibrosis) if inflammation persists.
• Lungs > asthma
• Nose > allergic rhinitis (hey fever)
• Skin > atomic dermatitis (eczema) or urticaria(hives)
• Digestive system > allergic gastroenteritis
• Anaphylaxis > when allergic reactions occur involving
many sites all at once. The blood pressure may fall because of the fluid
may leave the circulation to the tissues. This is an emergency which needs
to be treated right away.
Allergy Skin testing: Introducing a small amount of allergen on the skin mast cells will cause swelling, if a person is allergic, i.e., if his/her mast cells produce mediators through IgE-mediated reaction.
RAST test: If skin testing is not feasible ( e.g., in eczematous skin), a blood test can be done to detect the amount of IgE antibodies. In general skin testing is considered more sensitive.
This is the most important procedure from which an allergist can obtain useful information on the patient’s condition. Test allergens include grass pollens, tree pollens, weed pollens, mold spores, dust mites, animal hair/dander, and foods. The most common and relevant allergens are selected and administered in groups on the patient’s back or arms/forearm in one to three separate sessions. Initially prick tests are done using plastic devices. If the test results are negative, more sensitive intradermal tests may be applied. By inspecting the skin swelling from the test sites, Dr. Song will determine to which allergens a patient is sensitive and will apply the information to the therapeutic plan. Please read the Skin Test Instruction, the Clinical Information section, and Skin Test Panels (appendix) of the guidebook for further information.
This test is done to find out if the patient’s skin rash is caused
by contactants such as cosmetics, leather, nickel, etc. This test is
especially useful for the patients with hand dermatitis. We use T.R.U.E.
Test by Glaxo-Wellcome Inc. Two plastic sheets ( 3” x 5”),
each containing 12 aluminum disks of test materials, are taped on the
back of the patient and are read in 72 hours
This test is done to assess the lung function of the patients. Many allergic patients have subtle asthma which may not be detected by physical exam alone. This test will help detect the early signs of respiratory compromise and follow the progress of the disease. This test is routinely used in our office to follow the patient with respiratory disease.
This is a simple test used for assessing the lung function and may not be as complete as spirometry but is less time consuming. Patients will often be asked to measure the peak flow at home with a portable one.
This procedure is performed to assess the anatomy of the nasal cavity. After the lining of the nose is numbed with a local anesthetic, a small caliber tube is inserted into the nasal space for inspection. . The degree of swelling and inflammation of the nasal tissue and the presence of polyps will be determined.
To assess hearing and to detect abnormal tympanic membrane activities. This test will detect the presence of fluid in the middle ear.
For chronic allergic diseases, no matter what they are, the treatment includes the following three components.
Avoidance of allergens: (mites, smoke, molds, foods, drugs, etc.)
Drugs: Available in inhalers(MDI), tablets, capsules.
Allergen Injection Therapy:Rescue medicines:
• Beta-agonists(for asthma)
• Theophylline(for asthma)
• Antihistamines(for rhinitis)
• Decongestants( for rhinitis)Controller medicines:
• Steroids(asthma, rhinitis,etc)
• Long acting beta-agonist(asthma)
• Anti-leukotriene drugs(asthma)
• Cromolyn (asthma, rhinitis)
• Nedocramil(asthma)
• Combination of Steroid MDI and long acting beta-agonist(asthma)
Please do not be afraid of using steroid when necessary!
Many studies have shown that steroid inhalers( MDI) are not associated any long term side effects. On the contrary, most adverse outcomes such as ER visits and hospital admission are associated with the lack of steroid inhaler use.
People with asthma have difficulty breathing due to temporary narrowing of the airways in their lungs. The symptoms include wheezing, chest tightness, and coughing. Coughing, especially at night time, or exercise intolerance may be the only manifestation at the beginning. Like in other allergic diseases, the incidence of asthma has been on the rise (why? - see the discussion under separate topic) in the USA and other developed countries of the world. In the USA, 7 -10% of the population have experienced asthma and in Australia ~25% have!! Children growing in developing countries and farms are reported to have less incidences. It affects all ages, ethnicities, and even the physically fit. One out of every five 1998 U.S. winter Olympic athletes have reported using asthma medicines. There is some evidence suggesting that exposures to virus, other microbes, and animals early in life may prevent the disease. However, later in life, the same exposures may provoke asthma attacks. Although we cannot cure the disease, new medicines have been reported to be much more effective in controlling the disease
Causes: In children, allergies are the predominant cause, but, in adults, allergies are demonstrated in only half of the patients. Allergic tendencies are inherited; maternal transmission rate is ~40%, paternal 30%, and 60-70% from both parents. Research shows that there are many genes involved. Some combination of genes probably produces more potent allergic manifestation. Non-allergic causes of asthma are not known. Whether allergic or non-allergic, asthma attacks can be triggered by irritants including smoke, fumes, wind, emotion, and physical exertion.
Evaluation:
It is important to realize the value is only as good as the patient’s effort. Therefore the results need to be interpreted with this in mind.
Prognosis
For most adults, the disease activity, unfortunately, tends to stay the same or may get progressively worse (unfortunately there are no good prognosticators for this). Some children grow out of asthma, but most allergic children don’t. One study (Martinez, Tuscon) reported that 2-3 yr old children have a 75% chance of continuing to wheeze at the age of 6-13 years when they have met the following criteria (2 major and 1 minor).
Another study showed that if a child is wheezing and has positive reactions to an
allergy skin test at the age of 6, there is a greater than 85% chance of wheezing at the age of 11 years.
. 
Treatment:
Depending on the severity and the causes of asthma, the patient and doctor need to develop a comprehensive treatment plan including the components listed below. Some patients need to be on controller medicines all the time.
Trigger avoidance and allergen immunotherapy will be discussed under separate headings.
DRUGS
The standard guidelines for pharmacotherapy is published every 5 years by then AEPP (National Asthma Education Prevention Program). The current one is from 2002 and the 2007 version is about to be released.
The 2007 guidelines recommend 6 different steps of treatment, depending on the degree of severity, control, and responsiveness. Listed below is the summary, which I will follow in general after a full discussion with patients.
|
Day Sxs |
Night Sxs |
Peak Flow |
Controller Meds |
Rescue Meds |
Intermittent |
< 2 x /wk |
< 2 x / month |
>80% |
|
PRN |
Mild persistent |
> 2 x / wk |
> 2 x / month |
> 80% |
Step 2, |
PRN |
Moderate persistent |
daily |
> 1 x / wk |
>60%, <80% |
Step 3 |
PRN |
Severe peristent |
constant |
frequent |
<60% |
Step 4 or 5 or 6 |
PRN |
Normal peak flow rate can be estimated by 30 + 30 x age from 5 to 16 yrs of age.
Step1 : SABA
Step 2: low dose ICS or LTRA
Step 3: medium dose ICS or low dose comb or low dose steroid inhaler + LTRA
Step 4: medium combo or med ICS+ LTRA
Step 5: high combo, Xolair
Step 6; high combo + oral steroid, Xolair
If the symptoms are well controlled for 3 months, consider stepping down or lowering ICS by 25-30% every 3 months until the lowest dose is achieved.
If the symptoms are not controlled, one needs to step up.
A written step-wise written plan, listing medications to be added based on peak flow and symptom parameters, should be prepared for patients. It is essential to work with the doctor on a regular basis. For an acute episode, know when, where and whom to call,and do not delay!
Peak Flow |
Condition |
Symptoms |
Treatment |
80-100% |
GREEN: Safe |
Easy breathing |
Controller |
60-79% |
YELLOW: caution |
Cough, wheezing, tight chest |
Controller |
<60% |
RED: Danger |
As above |
Above meds |
Some patients wheeze only with physical exertion, typically 5-10 minutes into exercise. The symptoms can be controlled with an albuterol inhalation 10-15 minutes before exercise. Other preventive programs may include taking Singulair or Advair 100/50 on a daily basis if one engages in sports every day.
Rhinitis means an inflammatory condition of nasal cavity. The symptoms include
itching, sneezing, clear watery discharge or blockage, and post-nasal drainage. The symptoms often extend to throat areas, because it is believed that the inflammatory changes also take place in other parts of the upper and lower airway (“unified airway theory”). Associated symptoms include coughing secondary to post nasal drip, sore throat, mouth breathing, loss of smell sensation, loss of taste, or poor sleeping patterns (fatigue), nasal polyps, asthma (1/3 of patients with rhinitis may develop asthma later in life), and sinusitis.
The condition is caused by allergies in ~70-90% of children and ~50% of adults. Symptoms may be seasonal (“seasonal rhinitis”) or non-seasonal (“perennial rhinitis”). Seasonality is due to exposures to different allergens: tree pollens in spring, grass pollens in summer, weed pollens and mold in fall, and mites and animal dander throughout the year. Hay fever typically occurs in ragweed-pollinating weeks of autumn in the East and Midwest. Some use this term loosely to include all allergic rhinitis conditions.
It is not clear what cause the symptoms in patients without allergies. There are evidences suggesting that autonomic nerve endings in the nasal cavity of these non-allergic patients are extremely sensitive and more readily respond to irritants in the air (hence the name, “vasomotor rhinitis”). These nerve endings, once stimulated, will send messages to the cells (mast cells) in the nose. Mast cells, in turn, produce mediators, which will cause inflammatory changes in the nasal cavity.
Triggers:
Back to the top
Symptoms:
Associated conditions: asthma, allergic rhintis, gastro-esophageal entertis, immunodeficiency (for recurrent sinusitis)
Causes:
Diagnosis
Treatment:
NASAL POLYPS
Symptoms: Nasal congestion and other symptoms of rhinitis. Most often nasal polyps are associated with chronic rhino-sinusitis. Patient may be allergic, but more commonly not allergic.
Associated conditions: asthma, rhinitis, sinusitis, cystic fibrosis ( in children), aspirin-sensitivity
Treatment:
ASPRIN(ASA) INDUCED RESPIRATORY ILLNESS
Symptoms: ASA and other nonsteroidal anti-inflammatory drugs may induce asthma, rhinitis, nasal polyps, or urticaria. The subject is very complicated and you need to ask Dr. Song for further information. You may avoid the drugs or may be desensitized at his office over three day period and stay on ASA for long time to have your symptoms undercontrol;
Back to the top
Eczema is a descriptive terminology referring to dry, itchy, and scaly skin condition. Atopic dermatitis is a clinical diagnosis in which eczematous skin is a major component. The majority of children with atopic dermatitis are allergic, but many adults are not, indicating that there is an intrinsic defect in the skin itself. It affects up to 20% of children in USA and the incidence rate is rising. It tends to improve as children get older: remits in 17% and less severe in 65%, but may relapse later in life.
Diagnosis:
Diagnostic test
Triggers:
Treatments:
Associated condition
Psoriasis or extremely dry skin condition.
People with atopic dermatitis are less likely to have contact dermatitis.
Causes
Most common contactants include cosmetics, lanolin,nickel, hair dye,
and other dyes.
Treatment
HIVES (URTICARIA) and ANGIOEDEMA
Patients with urticaria experience itchy welts of varying size on any part of their skin. This condition affects 15-20% of the general population and is accompanied by angioedema (body swelling) in up to half of the patients. Angioedema is not itchy, but causes a burning sensation deep under the skin and involves tissues where blood supply is ample such as lips, tongue, eye socket, hands, feet, and scrotum. Angioedema occurring alone without hives deserves special consideration.
Urticaria may be of a short duration, resolving itself after only a few days spontaneously, in response to elimination of the causative agents, or due to administration of anti-histamines. However, the symptoms may last much longer, sometimes months or even years. When symptoms persist longer than six weeks, the condition is defined as chronic (versus acute).
Most common causes for acute disease are drug or food hypersensitivities and viral diseases (see the list below). In chronic disease, the causes cannot be found in the majority of cases. In less than 10% of the cases, one may find causes such as physical stress (pressure, vibration, cold or warmth), hepatitis, or vasculitis (disease of small blood vessels) as in systemic lupus. In vasculitis, the hives tend to stay in one place, often involve hands and feet, and do not blanch when pressed.
Current thinking is that majority of these “idiopathic” (cause unknown) hives are due to an autoimmune phenomenon. In other words, these patients develop antibodies which attack their own skin! This may be one reason why in 20-30% of patients, thyroid auto antibodies are found and even thyroid function may be abnormal. This can be tested by doing a skin test using patient’s own serum (Ask the lab technician to draw 0.5 cc of extra serum and put it in a test tube to bring, personally, to Dr. Song’s office).
Although more than 2/3 of patients recover in one year, chronic urticaria is one of the most annoying and frustrating diseases for patients and doctors alike. So patients need patience and tincture of time!
MAJOR CAUSES OF URTICARIA
MAJOR CAUSES OF ANGIOEDEMA
TREATMENT
LAB STUDIES
Lab tests |
Associated Diseases |
CBC with ESR |
Eosinophila :allergy and parasites. |
UA |
Urobilinogen in hepatitis, blood and/or protein in some vasculitis |
LFT |
in viral hepatitis |
(TFT, thyroid antibodies) |
TFT or ¯ in autoimmune thyroid diseases, anti-thyroglobulin and /or anti-microsomal antibodies in thyroidtis and some euthyroid patients |
DIAGNOSTIC CLUES
By History |
Associated Diseases |
Temporal relationship to drugs, foods, and contactants |
Adverse reactions to, e.g, penicillin, fish, latex, etc |
Travel History |
Hepatitis, parasites |
History of physical exposure |
Physical urticaria (Cold, heat, pressure, vibratory, aquagenic, solar, etc) |
Induced by exercise |
Cholinergic, exercise-induced urticaria and anaphylaxis |
History of trauma |
Hereditary angioedema |
Systemic illness |
Viral/bacterial/mycoplasma infections, vasculitis including systemic lupus erythematosus and serum sickness, Henoch-Schonlein purpura |
Family Hx |
Hereditary angioedema, amyloidosis with deafness and urticaria, C3b inactivator deficiency |
By Physical Exam |
|
Size of urticaria |
Cholinergic, cold-cholinergic ,aquagenic, insect bites, scabies |
Exposed areas |
Physical urticaria (cold, dermatographism, solar, pressure, vibratory, aquagenic) |
Angioedema: |
Hereditary angioedema, acquired angioedema associated with malignancy, drug or contactant –induced angioedema |
Dependent area |
Vasculitis |
Involves palms and soles |
Vasculitis |
Thyroid enlargement |
Thyroiditis |
DISEASE MECHANISM
|
Mechanism |
Hx |
PE |
LAB |
By |
|
|
|
|
By HX |
|
|
|
|
Specific antigen sensitivity |
IgE mediated |
Temporal relationship to ingestants or |
|
ST, RAST |
Physical urticaria |
IgE mediated in some. |
Temporal relationship to application of physical stimuli |
Demonstrable lesions from application of physical stimuli |
|
Dermographic |
|
|
Demonstrated after skin is stroked. |
|
solar |
|
|
Demonstrated after sun light. |
|
Aquatic |
|
|
Demonsrated after water is applied. |
|
Cholinergic |
|
Exercise and heat |
Application of heat |
Methacholine challenge is positive in 1/3 |
Exercise induced |
|
Wheezing, angioedma, shock |
Exercise challenge test |
|
Cold urticaria |
|
|
Confined to the exposed parts of the body |
Ice cube test |
Contact urticaria |
|
History of exposure to contactants |
Confined to the the exposed parts of the body |
Patch test |
IgG mediated |
|
|
|
|
Cold |
|
|
|
|
Dermographic |
|
|
|
|
Chronic idiopathic |
|
Hx not helpful |
|
IgG ab to IgE or IgE R |
Immune complex |
|
|
|
|
Serum sickness |
|
History of systemic illness |
Erythema, angioedmea |
¯CH50, ¯C3, ¯C4 |
HAE |
|
Family history(AD) |
Angioedma without urticaria |
¯CH50, ¯C3, ¯C4 |
Acquired abgioedema |
|
|
|
|
Necrotizing vasculits |
|
|
|
Skin biopsy |
Transfusion |
|
Hx of transfusion |
Hematuria |
|
Infection |
|
Especially heaptitis |
May evolve into erythema multiforme |
LFT |
Cold urticaria |
|
|
|
|
Heat urticaria |
|
|
|
|
Non-immunolgical |
|
|
|
|
Direct MC degranulating |
|
|
|
|
Physical Urticaria |
|
|
In the area where physical force is applied such as belted area. |
|
Urticaria pigmentosa |
|
Early childhood |
|
|
Arachdonic acid metabolism altering |
|
Hx of drug ingestion |
|
|
ALGORITHM FOR URTICARIA/ANGIOEDEMA
When the initial history/exam(1) yields a specific diagnosis, such as cholingeric urticaria or food allergy, manage accordingly. When it yields no result, do screening lab tests(2) and start symptomatic treatment. If the screening lab tests indicate a specific diagnosis such as thyroiditis or hepatitis, manage accordingly. If no etiology is found, repeat the evaluation in 6 weeks (3). If still no diagnosis is obtained, manage it as idiopathic urticaria.
This is the most dreaded condition in allergy by patients and doctors alike. It often occurs after eating allergic foods such as peanuts or after exposure to insect stings. The patient feels generalized weakness, dizziness, cold sweating, itchiness, chest tightness, and feeling of “impending doom”. The most important aspect of treatment is “quickness” in responding to this potential life-threatening emergency. If you have experienced an episode like this, you must always prepared for another one.
Food intolerance (adverse reactions) may be due to allergic or non-allergic cause. However, it may be hard to distinguish the two. The symptoms include eczema, hives, gastrointestinal complaints and rarely rhinitis and asthma. Allergic reactions occur immediately (in a few minutes or hours) and caused by IgE mediated mechanism as demonstrated by positive skin test or RAST. In contrast non-allergic reactions tend to occur late (in hours to days) and the skin test and RAST are negative.
The true incidence rate is lower than reported by patients ( ~8 % in children and ~1% in adults). Unfortunately the incidence rate has been rising recently. So is the mortality rate from food anaphylaxis.
The most common foods associated with food allergy are;
For young children: milk, egg, soy, wheat, peanut
For adults: shell fish, peanut, tree nuts, fish, milk, egg
COMMON ALLERGIC FOODS
DIAGNOSIS
SKIN TEST: If negative, food allergy is unlikely (95%). If positive, only 30-50% may have real manifestation when challenged with the particular food.
RAST (radio-allergo-sorbent test): The test measures the amount of IgE antibodies to particular foods in the blood. This test is much more reliable than the skin test in predicting food allergy symptoms. However the test is not sensitive enough to be used as a screening tool.
If the IgE levels are above the following value, the patient has greater than 95% chance of experiencing an allergic reaction.
Egg-7 (kUa/L). Milk-15. Peanut-14. Fish-20. Tree nuts-15.
If the IgE levels are above the following value, the patient has greater than 75% chance of experiencing an allergic reaction.
Soybean-30 (kUa/L). wheat-26
FOOD CHALLENGE
Even when skin test is negative or RAST value is low, patient may, in rare instances, experience allergic symptoms. Therefore it is necessary that patient be put to test with real foods. This can be done in our office before the patient tries the food at home. If the patient reacts to the food adversely in the office, he/she may be treated. It takes usually ~ 3 hours to perform the test since the amount of the challenge food is increased incrementally.
PROGNOSIS
Most infants tend to grow out of milk and egg allergy.
Most children do not grow out of peanut or tree nut allergy. But some do when they have low level of RAST.
TREATMENT
AN EXAMPLE OF ELEMENTAL DIET
FOR INFANTS: amino acid powder such as Vivonex or Neocate may be tried.
FOR ADULTS.
Rice, puffed rice, rice flakes, rice krispies
Pineapple(canned), apricots(canned),
Cranberries,peaches, pears, apples : fresh or juice/nectar of these
Lamb, chicken
Asparaguss, beets, carrots, lettuce, sweet potato
Tapioca
White vinegar, olive oil
Honey, 2oz a day, cane sugar, salt
Neocate, Vivonex
PREVENTION
Symptoms: recurrent infections such as sinusitis(more than one documented infection /yr), pneumonia(more than one/yr) , ear infections( more than 8x /yr), deep skin infections, & deep seated infections.
Causes and Treatment: Although there are many different kinds, severe ones are rare.
EVALUATION
Goal of our immune system is to protect our body from invading micro-organisms. These organisms are destroyed by the cells with the help of antibodies and other components in the blood and tissues. The following are the most commonly ordered lab tests
Allergic tendencies are generally inherited. Studies have demonstrated that strongly positive allergy test results are the single most important predictor for the persistence of asthma in childhood. Scientists have been investigating the genes responsible for allergies. Currently many promising genes have been reported and the allergic diseases result most likely from the interaction of these multiple genes and environmental factors. The following information may serve as a useful guide.
It has been the focus of investigation why the incidence of asthma has been on the rise in the industrialized countries. Is it due to environmental pollution? The answer seems to be “no”, since the developing countries have the worse pollution, but the lower incidence rate.
Epidemiological evidences suggest that viral infections during early childhood play a suppressive role against the development of allergies. In other words, children growing up in the developed countries are more vulnerable to the allergic diseases because they are protected against infections by improved vaccines and hygiene
The effects of pregnancy on asthma have been extensively studied. However they vary from one individual to another. The following is the rough estimate of the outcome.
The pattern present during the first pregnancy tends to repeat itself
during the subsequent ones.
The allergy drugs are classified (see below) according to their tumor-producing
effects on the fetus.
| CATEGORY | ANIMAL STUDIES | HUMAN STUDIES |
| A | Negative | Negative |
| B | Positive | Negative |
| C | Positive | Not done |
| D | Positive | Positive |
During pregnancy, the category A and B are preferred.
The C drugs can be used if A and B drugs are not adequate for treatment
and the potential benefits outweigh the risks.
Listed below are the classifications of commonly used allergy medicines
| B | C | |
| Steroid inhalers | Pulmicort | Vanceril, Azmacort, Flovent |
| Oral steroids | Prednisone, Medral | |
| Anti-leukotrienes | Singulair, Accolate | |
| Bronchodilators | Brethine, Atrovent | Proventil, Albuterol, Ventolin, Serevent. Foradil, Slo- Bid, Theo-Dur |
| Combination drugs | Advair | |
| Antihistamines | Benedryl, Chlortrimeton,Claritin, Zyrtec | Atarax, Allegra, Clarinex |
MDI =metered dose inhaler
Dust mite control
Mold Control
Pollen Control
Dander Control
The skin tests are administered either on the forearm/arm or on the back to determine if you have allergic diathesis. Allergen extracts are pricked on the surface of your skin by plastic devices. If the initial prick test results are negative, intradermal skin tests may be injected to your skin using very small gauge needles.
Although skin testing is generally safe, you may experience skin discomfort and rare systemic reactions such as skin itching, coughing, wheezing or even anaphylaxis. For this reason it is important that we test you under our close observation and you should let us know if you feel any untoward reactions.
Click Here To Download Skin Test Instruction Sheet.
Adult Panel 1
Adult Panel 2
Food Allergy Panel
Infant/Child Panel
Daily peak flow recording is a very important tool in asthma management and planning. As discussed in asthma treatment section, the drug therapy is partially based on such records. Dr. Song would want to know what your reading is when you call him for an advice on asthma exacerbation. Based on your height and ethnicity, the normal value can be found on the published normograms. There is, however, a practical way of estimating the normal value for patients with average height based on their age.
The full discussion is beyond the scope of this guidebook. As some say we become what eat. Food is more than calories - it could harm us or keep us healthy. Most of us lead a sedentary life – we can not live on a menu of bacon and steak meant for hardy life with heavy physical. Work. Some foods harbor many ingredients that have preventive powers. Time magazine (1/21/2002) selects the best 10 foods for their potential benefits.
| FOODS |
BENEFICIAL INGREDIENTS |
PREVENTIVE EFFECTS |
| Tomato |
Contains the most powerful anti-oxidant. Released best when cooked. |
Prostate CA |
| Spinach |
Iron, folate, phytochemicals* |
Heart disease, macular degeneration |
| Red wine |
Antioxidant |
Heart disease |
| Nuts |
Unsaturated fats |
Heart disease |
| Broccoli |
Phytochemicals |
Breast, colon, stomach CA |
| Oats |
Fibers, anti-oxidants |
Heart disease |
| Salmon |
Omega-3 fat |
Heart disease, rheumatoid arthritis, lupus, Alzheimer’s |
| Garlic |
Phytochemicals |
Heart disease, antibacterial, anti fungal |
| Green tea |
Phytochemicals |
Stomach, liver, esophageal CA, antibacterial |
| Blueberry |
Antioxidants |
Heart disease, cancer, boost brain power. |
* phytochemicals : chemicals produced by plants
One should also curtail salt consumption, because it is the best way to prevent and lower high blood pressure.
Genetics (obesity genes) play a significant role in controlling our body weight. Some of us who are borne with “bad” genes need to try harder to control weight with diet and exercise. Even a few calories of over intake/ a day would eventually result in a significant weight gain. Studies have shown that short term weight loss programs are not effective. One needs to go on a long term program that includes an appetite control approach.
Time magazine (1/21/2002) lists walking as the perfect exercise, quoting Dr. Manson, chief of preventive medicine at Harvard, “ If everyone walks in the US were to walk briskly 30 minutes a day, we could cut the incidence of chronic disease 30 to40%.”
Many studies have shown that mental relaxation and happiness bring good physical health.
The complementary or alternative remedies to various medical disorders, including allergy and asthma, are becoming increasingly popular. Dr. Song is very much interested in any approaches that are helpful to patients, since he is aware of the limitation of the traditional medicine. He may be familiar with some of these techniques and is happy to discuss about them. However, he is of the view that these remedies should be evaluated on the same scientific basis as the traditional remedies. Probably the best way to study these approaches is by DBPC(double blind placebo control) method. For example, a herb extract of interest (treatment) and sugar(control) are put in the identical capsules and are given to patients. Doctors and patients do not know which are which. After completion of treatment, the codes are broken and the clinical results are evaluated.
The following summary table is extracted from the Journal of Allergy and Immunology (10/2000).
| CLASS |
EXAMPLES |
| Herbal, Western |
Herbs, phytochemicals*, botanical |
| Herbal, Chinese |
CTM, Kanpo, Jamu |
| Nutritional |
Magnesium, selenium, omega-3-fatty acids, antioxidants, teas Fruit and vegitable diets |
| Homeopathy |
Classical, isopathy |
| Exercise |
Breathing technique, yoga, Chinese exercise (e.g, qi gong, tai chi) |
| Massage |
Shiatsu, reflexology, etc |
| Acupuncture |
Classical, electroacupuncture, acupressure, moxibustion |
* Chemicals produced by plants.
The typical herbal prescription may contain 10 to 16 herbs, which are boiled and used as a soup. Although some ingredients including ma huang(ephedra) are shown to be therapeutic for asthma and hay fever, none of these herbs are as efficacious as currently used western drugs.
Homeopathic Remedies
Classical homeopathy uses single herbs diluted to the point the final prescribed solution may be totally free of any physical remnants of the original drug. A more recent form, termed isopathy, uses dilution of allergens or drugs that provoke symptoms. Some studies have shown the efficacy of homeopathic treatment by DBPC studies. It is a mystery how it works since the homeopathic concentration may be so dilute that it may not contain any molecules of the drugs or allergens.
Physical manipulations including yoga, breathing exercises, postures, and Chinese qi gong practices may be a helpful adjunctive therapy for asthma.
Prayer, biofeedback , transcendental meditation, and related practices help improve autonomic imbalance in diseases such as asthma.
At present, acupuncture is one of the most popular alternative therapies for asthma in the United States. Acupuncture involves the insertion of thin needles into the skin at specified locations to regulate the flow of energy (Chi). Acupuncture has the appeal offered by a nearly risk-free, relatively low-cost, nonpharmacologic form of treatment.
Of the 6 double-blind studies for the acupuncture treatment of asthma, 4 were negative, whereas 6 of the 7 single-blinded studies were positive. Although, efficacy of acupuncture has not been convincingly demonstrated, the use of acupuncture as a complementary or adjunctive therapy need to be explored. Dr. Song has been interested in this area for some time and has had some experience in the use of acupuncture for various conditions, including headache and backache.
Allergy, Asthma and Immunology
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