Song Allergy, Asthma and Immunology Clinic
Patient's Handbook

400 South Sepulveda Blvd., Suite 220 Manhattan Beach, CA 90267-0249 (310) 374-4481 - Phone (310) 374-4584 - Fax

927 Deep Valley Drive, #135 Rolling Hills Estates, CA  90274 (310) 374-4481

Please Browse through the Handbook by clicking on a topic of interest below.

Definitions and Terminology Patient Evaluation and Procedures Basic concepts of Allergy Treatment Allergy Immunotherapy (Allergy Shots!) Common Allergic and Immunologic Diseases Asthma Hay Fever (Rhinitis) Sinusitis Eczema (Atopic Dermatitis Hives (Urticaria) Shock (Anaphylaxis) Food Allergies Immunodeficiency Genetics vs Environment Pregnancy and Allergic Disease Drug Formulary Environmental Control Skin Test Instruction Sheet Skin Test Panels Instruction for New Immunotherapy (Allergy Shot) Patients Normal Peak Flow Values General Health Tips Complementary/Alternative Medicine   Definitions and Terminology 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.

Triggers of Allergic Reaction:

Allergens
Irritants: When the tissues get inflamed due to allergic reaction, they respond to non-allergic substances such as smoke, viral infection, and temperature change. People do not produce IgE antibodies to irritants. Therefore, there are no skin test or blood tests that can measure the degree of sensitization to irritants.

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.

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Patient Evaluation and Procedures

Patient Evaluation

PROCEDURES

Skin Test

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.

Spirometry

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.

Peak Flow Meter

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.

Rhinoscopy

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. 

Audiogram/Typmanogram

To assess hearing and  to detect abnormal tympanic membrane activities. This test will detect the presence of fluid in the middle ear.

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Basic Concepts of Allergy Treatment

For chronic allergic diseases, no matter what they are, the treatment includes the following components.

Avoidance of allergens: mites, smoke, molds, foods, drugs, etc.

Drugs:  prepared inhalers(MDI), tablets, capsules.

Rescue medicines:

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.

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Allergen Immunotherapy (Allergy Shots)

Indications

• High allergen sensitivity
• Symptoms not controlled by other therapeutic means
• Desire to “cure” the disease
• Prevention of allergic diseases

Efficacy

• Effective for hay fever(allergic rhinitis) and asthma.
• Most effective for people with bee sting allergy: over 90 % success rate.
• More effective in early stage of the disease.
• More effective for people who have fewer allergies.

Adverse Effect

• About half of the patients experience some injection site swelling.
• Mild systemic reaction such as sneezing and rash affect ~10% of the patients.
• Severe reaction such as shock is reported in 1/10,000 patients.
• Most of these adverse effects can be immediately treated.

Injection Schedule

• Initially once or twice a week.
• The doses are increased gradually to a maintenance level over 3 – 6 month period
• Once the maintenance dose is achieved, the injection interval is increased gradually to 4 wks

Injection protocol

• Patients are observed in the office for a minimum of 20 minutes after receiving the injection so that adverse reactions can be treated.


• Patients are required to take an antihistamine before coming to an allergy shot appointment.
  

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Common Allergic and Immunologic Diseases

Asthma

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.

The incidence has been on the rise affecting one out of ten people in the USA and other developed countries. It affects all ages, ethnicities, and even the physically fit. One out of every five 1998 U.S. winter Olympic athletes reported having used asthma medicines. Although we cannot the cure the disease, new medicines have been reported to be much more effective in controlling the disease.

Causes:

Evaluation & 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. Studies have shown that controller medicines (inhaled steroids, etc) have few side effects, improve the quality of life, and reduce emergency room visits and hospitalization.

Most asthma experts agree that this is the single most important aspect of the asthma drug therapy.

• Avoidance of triggers: such as dusts, smoke, and certain foods.
• Drugs: Combination of drugs are used in accordance to the disease severity. See the Drug Formulary section for the dosage.
• Rescue medicines:  Albuterol(Proventil, Ventolin), Theophylline
• Controller: Steroids, Anti-leukotriens, Cromolyn, Serevent,  Combination drugs

Steroids and Beta-agonists can be delivered through inhaler (MDI) devices or nebulizers. Nebulizers are used for infants and old patients who cannot use inhaler devices effectively.  Nebulizers are not necessarily more effective than inhalers, but deliver a large amount of the drug.

It is very important to use peak flow meters and spacers properly (page24):

Please confirm with Dr. Song or his nurse that you are using the techniques correctly.

Allergen injection therapy :To change the immune system to have a better control of allergic tendencies in the long run.

Monitor symptoms and peak flow (AM and PM as well as pre- and post-medications as necessary). Note day and night changes in peak flow, night-time asthma, inability to control  symptoms  with exercise, and increased need for bronchodilators. Please call M.D. if any of these changes occur.

Written treatment plan (Action Plan), step-wise plan listing medications to be added based on peak flow and symptoms parameters should be available. It is essential to work with the doctor on a regular basis. For an acute episode know when, where and whom to call, do not delay!

Asthma Action Plan

Prognosis

Two out of three children may grow out of it. The disease , however, may return during adulthood after a long "honey moon" period . When the disease starts in adulthood, it tends to last.

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Hay Fever Allergic/Non-Allergic(Vasomotor) Rhinitis

Hay fever refers to nose symptoms occurring during the ragweed season in the east and mid-west USA , but is a misnomer in that this condition has nothing to do with “hay“ or “fever”. The term, hay fever, is being used loosely to include all symptoms caused by environmental allergens.

The symptoms include itching, sneezing, runny and stuffy nose, and post-nasal drainage coughing secondary to post nasal drip, sore throat, mouth breathing, loss of smell, loss of taste, or poor sleeping patterns (fatigue), nasal polyps, asthma, sinusitis. It affects one out of five people in the USA and is one of the most common diseases. Most people respond to the drug therapies, but some do not and may require allergen immunotherapy(“allergy shots”)

Associated conditions
Causes: As in asthma, allergies are the predominant cause for children, but for adults allergies are demonstrated in only half of the patients. The most common form of non-allergic rhinitis is called “vasomotor rhinitis”.

Evaluation
History and physical, skin testing, rhinoscopy,  spirometry (to rule out the co-existence  of  asthma), X-ray of the sinuses or  Sinus CAT-scan

Treatment

• Avoidance
• Rinsing
• Drugs: Please minimize using rescue medicines and instead use a controller medicine on a long-term basis. Studies have shown the steroid sprays are superior to antihistamines.and decongestants . See the Drug Formulary section for the dosage
  • Rescue medicines: For immediate relief. Antihistamines are used for drying the nose and decongestants are used to relieve the stuffiness of the nose.
    • Antihistamines
    • Decongestant nose drops or spray: Afrin, Neosinephrine. Frequent use of nasal sprays can cause rebound congestion. Please do not use these sprays more than 3 days a week.
    • Oral Decongestant: Sudafed
    • Combination of antihistamines and decongestants
  • Controller Medicines: For long term control of symptoms
    • Nasal Steroid Sprays: Flonase, Nasonex, Rhinocort, Vancenase, etc
    • Nasal Cromalyn inhalers
    • Oral Steroids: Prednisone tablets, Medral pack
• Allergen injection therapy: Effective in the majority of patients with allergic rhinitis as a long term therapy.
  

Sinusitis

A typical case of sinusitis may be associated with facial pain and nasal drainage. The symptoms could be very subtle, however, and may include coughing, tiredness, loss of smell sensation, and worsening of existing conditions such as asthma or hay fever. In my practice, it is one of the most common causes of persistent coughing in otherwise healthy patients. Surgical procedures may be necessary in the presence of anatomical abnormalities or drug resistance, but it is important to treat underlying allergies to maximize the surgical benefit on a long-term basis.

Associated conditions
Asthma, Allergic rhinitis, Immunodeficiency.

Triggers
Viral infection of the nose, allergen exposure.

Treatment

• Nasal rinse: Salt water solution is sprayed or squirted to the nose, 3-4 times a day
• Antibiotics: The most common reasons for chronic recurrent sinusitis are the wrong choice of antibiotics and sub optimal duration of treatment. It may require several weeks to adequately treat chronic sinusitis.
• Treatment of allergic conditions such as hay fever and asthma.
• Avoidance of Aspirin or other analgesics may be necessary for some patients.
  

Eczema (Atopic Dermatitis)

This condition is associated with itchy and dry skin and leads to skin scarring and discoloration if it persists for long time. Infants and children may grow out of it only to be affected later by other allergic diseases such as asthma or hay fever. Although “atopic” means allergic, this condition may not be associated with allergies.

Associated conditions
Asthma, allergic rhinitis

Triggers
Allergens:  foods, dust-mites
Irritants to the skin: wool clothing, heat, emotional upsets, and other factors.

Treatment

• Avoidance of triggers
• Moisturizing creams or ointment: Vaseline
• Steroid ointment ( ointment preferred over cream, because of its occlusive nature
• Anti-histamines to alleviate itching
• Antibiotics to decrease the bacterial load on the skin
• In severe cases, newer drugs (Prtopic and Elidel) have produced good results.

Hives (Urticaria)

People with this condition experience itchy welts (swelling) of varying sizes on their skin. If they last longer than 6 weeks, the condition is defined as chronic urticaria. Finding causes or contributing factors is like detective work. Most common causes are drug or food hypersensitivities and viral diseases. In rare instances one may find systemic diseases such as thryroditis or systemic lupus. In over 80% of the cases, the causes cannot be found.

The current thinking is that these “idiopathic(cause unknown)” hives are due to an autoimmune phenomenon. In other words these patients develop antibodies which attack their own skin! Although the prognosis for “idiopathic hives” is generally good (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!

Associated condition
Urticaria may be a manifestation of systemic illness such as Lupus

Triggers
Allergens, especially foods such as nuts, drugs, etc
Physical stimuli such as pressure, cold, etc
Unknown: in 80% of all case, the trigger is not known

Treatment

• Treatment of underlying disease if detected.
• Symptomatic treatment with drugs sufficient enough to suppress symptoms.
  • Antihistamines: Allegra, Claritin, Clarinex, Atarax, Benadryl
  • Prednisone, When antihistamines alone do not relieve symptoms, oral steroids are added. It may be necessary to use a steroid for a long period.

Shock(Anaphylaxis)

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.

• Call 911
• Self-inject Epipenephrine(Epipen, Anakit)into the thigh: Please learn how to use the kit. If you do not, ask Dr. Song to demonstrate the usage for you.
• Quick acting antihistamines: Atarax and Bendaryl are preferred. Zyrtec, Allegra, and Claritin can be used, but the onset of action for these medicines is slower.
  

Food Allergy

Foods could be a cause of  many  allergy/hypersensitive diseases listed above although incidence( ~8 % in children and ~1% in adults) is much lower than generally believed.  If indicated, Dr. Song  can administer food allergy tests. The results of the tests need to be interpreted with caution,  because positive tests do not always mean clinical allergy. 

If foods are suspected as contributing factors to symptoms such as dermatitis or gastroenteritis, and  the skin tests/RAST are negative,  elemental diet can be tried.  The following is one example of such diet.

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

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Immunodeficiency

Symptoms
Recurrent infections such as sinusitis, pneumonia, or skin infections

Evaluation
History and Exam, Lab tests to check the immune function

Causes and Treatment
There are many forms of immunodeficiencies:

Humoral (Antibody) defect

• X-linked Immunoglobuline deficiency: Complete absence of antibodies. Starts during infancy and need IVIG replacement therapy. Bone marrow transplantation(BMTP) cures the disease.
• Transient Hypogammaglobulinemia of Early Childhood: Usually transient and requires IVIG treatment.
• Common Variable Immunodeficiency: Usually starts in late childhood or adulthood. Presentation may be subtle. Requires Treatment with IVIG.

Cellular Defect: Absence of deficiency of lymphocytes. Presentation is usually severe and complicated. Discussion is beyond the scope of our discussion.

Combined Immunodeficiency: Severe presentation. Incompatible with life unless bone marrow transplantation is done .

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Genetics vs Environment in the Allergic Diseases

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.

• 20% of the population have allergic tendencies
• If one parent has allergy, 30-50% of the children are affected.
• If two parents have allergy, two thirds of the children are affected.

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

Pregnancy and Allergic diseases

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.

• 1/3: Asthma worsens
• 1/3: Asthma does not change
• 1/3: Asthma improves.

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.

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

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Drug Formulary

Summary of commonly used allergy medications

MDI =metered dose inhaler

For Asthma

• Rescue meds: To open airways before exercise and with acute episodes.
  • Albuteral MDI( Proventil, Ventolin, Maxair): 2 puffs every 4-6 hrs.
    
• Controller meds: To heal the airway and prevent symptoms.
  • Steroid MDI
    • Low strength
      • Vanceril /Beclovent MDI:2 puffs x 4/day
      • Azmarcort MDI; 2 puffs x 4/day
      • Flovent 44mg/puff: 2 puff x 2/day
    • Medium strength
      • Aerobid MDI: 2 puffs x 2/day
      • Flovent 110mg/puff x 2/day
    • High Strength
      • Flovent 220mg/puff x 2/day
      • Pulmocort 2 puff x 2/day
  • Steroid, Nebulized
    • Pulmicort respule  0.25mg/2 cc , 0.5mg/2cc, for infants
      
  • Singular tabs
    • 2-5 years: 4 mg chewable x once evening
    • 6-14 years: 5 mg  x once evening.
    • Over 14 years : 10 mg x once evening.
      
  • Long acting Beta-agonists
    • Serevent MDI: 2 puffs x 2/day (Do not exceed the recommended dose. It may lead to toxicity)
    •   Foradil MDI: 1 puff x 2/day
      
  • Combination of steroid and long acting beta-agonist
    • Advair MDI 1 puff x 2/day :  3 strengths available:  low potency- 100/40, medium potency-250/40, high potency-500/40

For Nasal Symptoms  

• Rescue Medicines
  • Antihistamines : Primarily for drying the nose
    • Non-sedating
      • Claritin 10mg: either 12 or 24 hr preparations, Available in syrup 5mg/5cc
      • Clarninex 5 mg (24 hrs)
      • Allegra 60mg (12 hrs), or 180mg (24 hrs)
    • Less-sedating
      • Zyrtec 5mg, 10mg, 5 mg/5cc : 24 hr
    • Sedating
      • Benadryl , Atrax, Chlotrimeton, etc: usually every 6 hrs
  • Atrovent Nasal spray: for drying the nose. 2 puffs  x 4/day
    
  • Decongestants: To open up the nasal passage. Not to dry
    • Afrin or neosinephrine nose spray or drops: use not more than 3 days a week. Long term  use not recommended, because of the nasal congestion may get worse
    • Sudafed: oral decongestant, over the counter. Consult doctor if you have high blood pressure , arrhythmia, prostate problems, etc.
      
  • Combination of antihistamines and decongestants
    • Claritin-D, Allegra-D, etc.
      
  • Rinsing agents
    • Ocean Spray, Sinus-Rinse, etc
    • Make it yourself:  1 cup water + 1/2 tsp salt + a pinch of baking soda. Put them in a Mustard Dispenser or other dispenser with a tip.
• Controller Meds: To heal the nasal passage and prevent the symptoms.
  • Nasal steroid MDI: Flonase, Nasonex, Rhinocort, etc.  To be sprayed to the nasal cavity 2 puffs once or twice a day.  It is important to use regularly at least 4 wks at a time, otherwise the optimal preventive effect is not reached. Use after rinsing. Aim towards the ear on the side of the nostril being sprayed

For the Eyes

• Rescue  meds: usually one drop x 4/day
  • Decongestants: Vasocon, Naphcon
  • Antihistamines:Livostin
    
• Controller meds: heals and prevent allergic eye symptoms
  • Opticrom(Cromolyn): 1-2 drops x 4/day
  • Alomide: 1-2 drops x4/day
  • Patanol : 1-2 drops x 2/day
    
• A cool pack to the eyes, plus the liquid tears can be very helpful    

For the Skin

• Limit soap exposure as much as possible  because it dries out sensitive skin
• Put lotion on the skin immediately after toweling down while the skin is still wet, absorption is maximum at that time
• Antihistamines can help the itch
• Use steroid ointments ( preferred over cream).  Be careful as the stronger steroids can blanch the skin, and should not be used on the face

Environmental Control Measures

Call 1-800-9-POLLEN for mold/pollen count

Dust mite control

• Encase mattress, box-spring, pillows
• Wash bed linen in hot water(130F) setting of washing machine
• Remove carpets and put wood, tile or linoleum on the floor
• Avoid heavy curtains. Shades or vertical blinds catch less dust
• Avoid clutter, stuffed toys, dust catchers and upholstered furniture in bedroom
• Avoid air turbulence caused by fans and forced air heating. Cover hot air vents. Use radiant space/room heaters in winters and AC instead of fans in hot weather
• Clean surface with wet cloth instead of dry dusting.
• Use a well fitting face mask with filter when cleaning and stay out of the room for 1 hour after cleaning
• Use a vacuum cleaner with HEPA filter or multi-layer bag for dust containment
• Avoid excessive heat and humidity which helps dust mites to grow

Mold Control

• Check for mold in bathrooms, basements, closets and behind heavy furniture in North facing rooms during rainy weather. Use dilute bleach solution to clean and spray with Lysol to prevent mold growth
• Do not keep live potted plants indoors
• Do not allow foods or produce to get moldy
• Fresh or dry flower arrangement and potpourris can have mold
• Avoid heat, humidity and dark areas which encourage mold growth
• Damp shoes and clothes, if put inside closets without dry, can have mold growth
• Avoid collection of dead plants /leaves outdoors. If present, either use a mask when clearing them or get someone else to clear it

Pollen Control

• Avoid exercising outside during daytime in high pollen season
• Keep windows and doors closed between 4AM and 4PM
• Closed bedroom door and start HEPA filter 1-2 hrs before retiring

Dander Control

• Avoid having pets you are allergic to. Next best measure is to keep the pet out of the house/bedroom/carpets and furniture
• Have someone else do the grooming, feeding and walking of the pet. Washing the animal once a week with plain water decreases shedding of dander

Skin Test Instruction Sheet

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.

• Please avoid all antihistamine containing drugs. The following medicines are the common ones.  Actifed, Allegra, Bendaryl, Claritin, Contac, Deconamine, Dimetapp, Dramamine, Trinalin, Ornade, Periactin, Phenergan, Rondec, Tavist, Triaminic, Zyrtec
• If you are on anti-depressants, please call us for instructions
• Do not stop taking asthma medicines including steroids
• Continue nasal inhalers
• If you are taking beta-blocker medicines, please notify us. Examples are some anti-high blood pressure medicines such as Atenolol, Inderal, and Lopressor or eye droppers used for glaucoma such as Timoptic or Betapacdrops
• We cannot test if your arms or back is sunburned or infected
• We need to postpone the tests if you are ill

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.

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Skin Test Panels

If you would like copies of the skin test panels, you may down load them here.

Adult Panel 1
Adult Panel 2
Food Allergy Panel
Infant/Child Panel

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Instruction for New Immunotherapy (Allergy Shot) Patients

Information For New Patients Starting Immunotherapy

1. From your skin test results, we have prepared allergen sets. They have been diluted to a very weak concentration. Each time you come in we will increase your dose, thereby increasing your tolerance to those things you are allergic to. Therefore, it is important for you to come in on a regular schedule. For the first 2-3 months, you will need to come in twice a week. Then the injection frequency will decrease to once a week, every 2 weeks, every 3 weeks, and eventually every 4 wks.
   
2. Studies have shown that allergen injection therapy, if administered properly, is successful in relieving symptoms in the majority of patients with allergic rhinitis and allergic asthma. The rate and degree of improvement vary with individual patients. For these reasons, you will require visits with the doctor every 3 months to monitor your progress. We will inform you when to schedule these visits.
   
3. Local reactions are the reactions occurring in the injection site. Systemic reactions refer to any symptoms (shortness of breath, generalized itchiness, feeling dizzy etc) occurring away from the site of injection. Systemic reactions are rare, but if they occur, they would do so during the first 20 –30 minutes. Therefore, it is mandatory to wait 20 minutes in the office so that we can treat you. To minimize the risk of reactions, you are requested to take an antihistamine such as Allegra or Claritin 1 – 2 hours before your appointment. Please show the nurse your arms before leaving the office so that we can record the extent of your local reaction.
   
4. If you have a systemic reaction outside of our practice, please contact our office immediately by phone. If you are in the vicinity, return promptly to our office. In the event that you cannot reach our office, report to the nearest emergency room.
   
5. When starting your injections, your first shot may be a skin test (intradermal) to make sure the concentration is not too strong. The doctor must be in the office during your first injection.
   
6. Check your injection sites 4 hours later. If there is an area of redness, swelling or both 1 inch diameter or larger, it is important for you to report it to us on your next visit.
   
7. No shots can be given if you are running a fever of over 99 degrees, are having an increased asthma symptoms, or you are having an acute allergic episode.
   
8. Check with us to see if your current medicines are safe during immunotherapy. If you are pregnant or planning pregnancy, please let us know.
   
9. It is important that you do not engage in any strenuous physical activity for 90 minutes after injections.
   

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Normal Peak Flow Values

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.

• From the ages 6 to 16: 30 x Age + 30
  • For example: The value for 10 year old patient = 30x10 +30=330
• From the age 17 to 55 : Above 450 for men, Above 500 for women
  

General Health Tips

NUTRITION

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 ( /21/2002) selects the best 10 foods for their potential benefits.

            * phytochemicals : chemicals produced by plants

One should also curtail salt consumption, because it is the best way to prevent and lower high blood pressure.

WEIGHT CONTROL

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.

•        Eat plenty of fruits and vegetable especially the one listed above.
•        Good source of protein: nuts, soy, fish, chicken and turkey.
•        Good source of fat: unsaturated fat such as olive oil.
•        Use fillers such as celery and carrot sticks.
•        Avoid junk foods such as cookies, chips, etc.
•        Learn to control appetite by; meditation, positive thinking, acupuncture, etc.
•        Exercise every day; Walk for an hour a day: Please read exercise section below.

EXERCISE

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%.”

Some of the areas where health benefits are demonstrated are;

• Heart disease: Exercise lowers blood pressure and decrease coronary heart disease.
• Stroke: One study showed those walking more than 20 hrs/wk decreased their risk of stroke by 40%.
• Weight control: Waking not only consumes calories but also boosts the metabolic rate for the rest of the day.
• Weight loss: Walk at least an hour a day:  Exercising too intensely can work against you by interfering with the body’s ability to pull energy from fat cells.
• Diabetes: Walking may be more effective in preventing diabetes than some medicines.
• Osteoporosis: Walking during young age can prevent osteoporosis later in life.
• Arthritis: You may need to exercise every other day to give  joints time to recover.
• Depression: Walking  may prevent relapse of depression for those on medication.
• Cancer: May lower the risk of colorectal cancer by facilitating bowel wall movement.

SMOKING CESSATION

• Best result is obtained when one stops smoking on will power alone.
• Nicotine patches may be helpful and are available over the counter.
• Zyban, oral anti-depressant, is also shown to be effective.
• Facilitator devices such acupuncture needle insertion may be helpful to some people.

MENTAL HEALTH

Many studies have shown that mental relaxation and happiness bring good physical health. 

• Studies have shown that relaxation program can lower blood pressure.
• Nervous and immune system are shown to be communicating at various levels.
• Emotion can trigger many chronic diseases including asthma.
• Prayers and religious experiences have shown to have a healing power
• We are borne with tremendous healing powers, which can be augmented by positive thinking.

COMPLEMENTARY/ALTERNATIVE  MEDICINE

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). 

* Chemicals produced by plants.

Chinese herbal therapy

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 manipulation

Physical manipulations including yoga, breathing exercises, postures, and Chinese qi gong practices may be a helpful adjunctive therapy for asthma.

Psychological Therapies

Prayer, biofeedback , transcendental meditation, and related practices help improve autonomic imbalance in diseases such as asthma.

Acupuncture

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.

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