Most Effective Asthma Treatments

Asthma Free Forever By Jerry Ericson

Jerry Ericson is a researcher and alternative medical practitioner. Jerry created this asthma treatment book basing on over 20 years of his personal experience in helping asthma sufferers relieve their symptoms within minutes, and get rid of asthma permanently without medications. This downloadable eBook format of the program is all about suggesting you right kind of lifestyle and strategies towards keeping the symptoms of asthma at bay and initializing the complete treatment to get you back to the normal life. Devised by inputting his self tested asthma recovery solutions, Mr. Ericson has got it right as there are many positive feedbacks are coming across all the corners enough to advocate the use and relief by this digital product. Conventional medicine offers no real solution to the seventeen million Americans suffering from this disease. But in this remarkable book, Jerry Ericson, shares his natural alternative that can help asthma sufferers worldwide break the bonds of asthma forever in only minutes a day! Read more here...

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Asthma Exacerbationstatus Asthmaticus

Most asthma exacerbations can be successfully managed at home, as shown in Fig. 4. However, if the child is not responding to outpatient therapy, hospital admission may be needed. Management of asthma exacerbations in the emergency room and hospital-based care is shown in Fig. 5. Exacerbations may progress over several days or occur suddenly Fig. 4. Management of asthma exacerbations home treatment. (From National Asthma Education and Prevention Program. Practical Guide for the Diagnosis and Management of Asthma. NIH Publication 97-4G53. Bethesda, MD U.S. Department of Health and Human Services, 1997. Fig. 4. Management of asthma exacerbations home treatment. (From National Asthma Education and Prevention Program. Practical Guide for the Diagnosis and Management of Asthma. NIH Publication 97-4G53. Bethesda, MD U.S. Department of Health and Human Services, 1997. and can range in severity from mild to life-threatening. Significant respiratory distress, dyspnea, wheezing, cough, and a...

Exercise Induced Asthma

Exercise is a well-established nonspecific stimulus to airflow obstruction, and this phenomenon can be demonstrated in most patients with asthma. Thus, exercise-induced asthma might better be thought of as a reflection of increased nonspecific airway hyperresponsiveness than as a distinct form of asthma. It is most common in children and adolescents (probably because they exercise more strenuously than do most adults). The problem is clinically important in at least two-thirds of adolescents with asthma because it interferes with school and recreational activities. The mechanisms by which exercise causes bronchial obstruction is unknown, but a fall in the temperature and humidity of the intrathoracic airways is a critical initiating event. The exact roles of mast cell mediator release and reflex responses (perhaps regulating blood flow in response to the temperature change) in this syndrome are unclear. Exercise asthma usually begins after about 6-10 min of exercise or after the...

Define reactive airway disease in particular asthma

The term reactive airway disease (RAD) is used to describe a family of diseases that shares an airway sensitivity to physical, chemical, or pharmacologic stimuli. This sensitivity results in a bronchoconstrictor response and is seen in patients with asthma, chronic obstructive pulmonary disease (COPD), emphysema, viral upper respiratory illness, and other disorders. Asthma is defined by the American Thoracic Society as a disease characterized by an increased responsiveness of the trachea and bronchi to various stimuli manifested by a widespread narrowing of the airways that changes in severity either spontaneously or as a result of therapy. Asthma is manifested by episodes of dyspnea, cough, and wheezing. These symptoms are related to the increased resistance to airflow in the patient's airways.

What are the different types of asthma

Although the common denominator lies in airway hyperreactivity, patients may fit into two subgroups allergic (extrinsic) and idiosyncratic (intrinsic). Many believe that the terms extrinsic and intrinsic should be discarded. Underlying all types of asthma are airway hyperreactivity, inflammation, and an interaction between allergic and nonallergic stimuli. Allergic asthma is thought to result from an immunoglobulin E-mediated response to antigens such as dust and pollen. Among the mediators released are histamine, leukotrienes, prostaglandins, bradykinin, thromboxane, and eosinophilic chemotactic factor. Their release leads to inflammation, capillary leakage in the airways, increased mucus secretion, and bronchial smooth muscle contraction. Idiosyncratic asthma is mediated by nonantigenic stimuli, including exercise, cold, pollution, and infection. Bronchospasm is caused by increased parasympathetic (vagal) tone. Although the primary stimulus differs, the same mediators as allergic...

What physical findings are associated with asthma

The most common physical finding is expiratory wheezing. Wheezing is a sign of obstructed airflow and is often associated with a prolonged expiratory phase. As asthma progressively worsens, patients use accessory respiratory muscles. A significantly symptomatic patient with quiet auscultatory findings may signal impending respiratory failure because not enough air is moving to elicit a wheeze. Patients also may be tachypneic and probably are dehydrated they prefer an upright posture and demonstrate pursed-lip breathing. Cyanosis is a late and ominous sign.

Describe the mainstay of therapy in asthma

The mainstay of therapy remains inhaled p-adrenergic agonists. Selective p2-agonists such as albuterol, terbutaline, and fenoterol offer greater specificity for p2-mediated bronchodilation and fewer side effects (e.g., p1-associated tachydysrhythmias and tremors). Albuterol can be nebulized or administered orally or by metered-dose inhaler (MDI). Terbutaline is effective via nebulizer, subcutaneously, or as a continuous intravenous infusion (beware of hypokalemia, lactic acidosis, and cardiac tachydysrhythmias with intravenous use). Epinephrine is available for subcutaneous use in severely asthmatic patients. Patients with coronary artery disease have difficulty with tachycardia and need the more p2-specific agents. Routinely the inhaled route is preferred.

Clinical Efficacy Asthma

Nedocromil sodium and cromolyn sodium have demonstrated the ability to prevent asthma exacerbations leading to emergency department visits and hospitalization, especially in children. Nonetheless, the role of chromones in asthma management is still debated. The updated National Heart, Lung, and Blood Institute asthma guidelines, the Cochrane Database Systematic Reviews, and the Childhood Asthma Management Program study suggest that inhaled steroid preparations should be first-line agents in all patients with persistent disease, effectively relegating cromolyn and nedocromil to second-line agents (i.e., they are not preferred). The Cochrane Database Systematic Reviews suggests that publication bias has overestimated the beneficial effects of Asthma-Inducing Agents Inhibited by Cromolyn and Nedocromil cromolyn as maintenance asthma therapy and concludes that efficacy of cromolyn over placebo is unproven. Others argue strongly that cromolyn and nedocromil effectively preserve lung...

Bronchospasm and Severe Bronchitis A Real Chokehold on Ventilation

Although a mild-to-moderate degree of bronchoconstriction is a completely normal event, bronchospasm (BRAHNG-koh-spazm) is quite another matter A spasm in general is any ''convulsion'' - a powerful, sudden sequence of involuntary muscle contraction, then relaxation. Bronchospasm, then, is a powerful and sudden contraction of the circular smooth muscle in the bronchiole wall. If strong and sustained enough, bronchospasm can produce a deadly chokehold of complete bronchoconstriction of important airways. Bronchospasms often accompany both asthma attacks and bronchitis (brahng-KEYE-tis) or ''inflammation of the bronchial tubes.'' Asthma is literally a ''panting.'' In asthma, the affected person's immune system But in asthma, the airways are too severely bronchoconstricted, often with powerful bronchospasms. As a result, the person ''pants'' (asthma), breathing rapidly and shallow in an effort to inhale enough air. In such severe cases, where there is a real ''chokehold'' on pulmonary...

Anticholinergic Drugs In Asthma And Copd

When ipratropium and tiotropium are compared with p2-adrenergics in asthma, the adrenergic agents show superior bronchodilation. The bronchodilatory activity of ipratropium is more gradual, although more sustained, than that of albuterol. Thus, ipratropium should not be used alone as a bronchodilator in asthma. However, ipratropium in combination with a p 2-adrenergic agent such as albuterol produces better bronchodilation than either agent alone when delivered by nebulization in the setting of acute severe asthma, especially in the pediatric population. In a study of children who visited the emergency department with a severe exacerbation of asthma with a peak flow of less than 50 of predictive value, the addition of ipratropium bromide to albuterol and corticos-teroid therapy significantly reduced the hospitalization rate. This effect was not seen in those with a moderate (peak flow rate between 50 and 70 predicted) exacerbation. Another study in children with mild and moderate...

Definition and epidemiology of asthma

Asthma is defined by episodic airflow obstruction, increased airway responsiveness, and airway inflammation characterized by infiltration with eosinophils and T-lympho-cytes, particularly CD4+ T-lymphocytes that express T-helper (Th) cell type 2 cytokines such as interleukin (IL)-4, IL-5, and IL-13. The histopathological appearance of the airways includes denudation of the airway epithelium, thickening of the basement membrane, mucus production, and airway smooth muscle hypertrophy (5). Although asthma is a chronic often lifelong disease that affects humans of all ages, the onset of the disease occurs primarily in early childhood. Fifty percent of all male asthma cases are diagnosed by age 3, and 50 of all female cases are diagnosed by age 8 (6). This increase of asthma in early childhood has been most marked in minority populations, particularly African Americans and Puerto Rican Hispanics (7).

FDA Approval of AntiIgE for Adults with Moderate to Severe Asthma

As the number of patients using anti-IgE increases and the safety profile becomes more established, regulatory agencies and their advisory bodies may become more assured of approval for pediatric asthma patients and for other indications. Also, if anti-IgE is found to modify allergic disease processes and ameliorate underlying disease states or if regi mens that may bring about a long-term remission are developed, perhaps less severe patients may also benefit considering overall pharmaco-economic equations. Finally, since the involvement of IgE in the pathogenesis of allergic rhinitis is firmly established, a concept being adopted by increasing numbers of allergists is that those asthma patients with concomitant allergic rhinitis are very suitable patients. This rationale has been backed up by the positive results of a phase 3 trial investigating the effects of omalizumab on patients with both asthma and allergic rhinitis.

Causes Of Bronchial Asthma Allergic Asthma

About 90 of asthmatics between the ages of 2 and 16 yr are allergic, 70 less than 30 yr are allergic, and about 50 of patients older than 30 yr are concomitantly allergic (Table 2). Thus, coincidental allergies are far and away the most common underlying condition associated with the development of asthma. One should suspect allergy as a contributing factor when (1) there is a family history of allergic diseases, (2) the clinical presentation includes seasonal exacerbations or exacerbations related to exposures to recognized allergens, (3) there is concomitant allergic rhinitis or other allergic disease, (4) a slight-to-moderate eosinophilia is present (300-1000 mm3) or eosinophilia in the sputum is observed, or (5) the patient is less than 40 yr old. Skin testing can be used to confirm immunoglobulin (Ig)E directed against incriminated allergens but does not establish a cause-and-effect relationship. Thus, patients may have a positive skin test but not have clinical symptoms of...

Theophylline Toxicity

Theophylline Toxicity Signs

Like its bronchodilator activity, adverse effects are related to the logarithm of the serum concentration. Hendeles and associates demonstrated a relationship between serum concentration and symptoms of theophylline toxicity. Few toxic symptoms were noted when the steady-state serum concentration was less than 14.6 g mL. Adverse effects appeared as the serum concentration rose beyond 20 g mL. These included gastrointestinal, CNS, and cardiovascular effects (Fig. 1). Of all adverse effects, those involving the gastrointestinal tract are most common. Vomiting, particularly if persistent, is very suggestive of theophylline toxicity. Hematemesis has been reported primarily in children its exact pathogenesis is not clear. Gastrointestinal symptoms occur most often as a result of a central effect of an excessive serum theophylline concentration on the medulla rather than because of a local irritative effect on the stomach. Relaxation of cardioesophageal smooth muscle may lead to reflux and...

Clinical Use Of Theophylline In Asthma

Although intravenous aminophylline has been standard treatment for status asthmaticus since the early 1940s, the value of aminophylline in the emergency room setting for acute asthma has been questioned recently. Various authors have suggested that theophylline adds little in terms of bronchodilator activity while increasing adverse effects when optimal therapy with aerosolized p-agonists have been given. In an early study of the use of intranenous theophylline in the treatment of acute asthma, theophylline was compared with subcutaneous epinephrine in an emergency department. The bronchodilator effect of theophylline was inferior to that achieved by the epinephrine. Subsequent studies have generally confirmed the observation that in acute asthma, the bronchodilator effect of aminophylline is less than that of optimal administration of aerosolized p2-agonists. However, published data support the addition of intravenous aminophylline in the treatment of patients who fail optimal...

What are the causes of intraoperative wheezing and the correct responses to asthmatic patients with acute bronchospasm

Causes include airway secretions, foreign body, pulmonary edema (cardiac asthma), obstructed endotracheal tube, endotracheal tube at the carina or down a main-stem bronchus, allergic or anaphylactic response to drugs, and asthma. A number of medications cause wheezing in asthmatic patients, including p-blockers, muscle relaxants, and aspirin.

Ciclesonide Asthma Copd [69

Ciclesonide, a new inhaled corticosteroid (ICS), is indicated for the prophylactic treatment of persistent asthma. ICS treatment is a widely accepted standard of care for maintenance therapy of chronic asthma, and the currently available agents include fluticasone propionate, budesonide, triamcinolone acetonide, flunisolide, and beclomethasone dipropionate. These agents exert their potent anti-inflammatory effects via modulation of the glucocorticoid receptor (GR). Although ICS drugs are generally safe and well tolerated compared with oral corticosteroids, many have measurable systemic exposures, and concerns over potential side effects resulting from it severely limit the dose at which they can be administered for long-term therapy. Systemic adverse effects associated with corticosteroids include HPA axis suppression, osteoporosis, abnormal glucose metabolism, cataracts, and glaucoma, some of which could potentially occur with the long-term use of high dose ICS. The key...

Other Therapeutic Uses for Cromolyn or Nedocromil

One report of a placebo-controlled, randomized, crossover study suggests that topical cromolyn may potentially benefit patients for whom the above therapeutic modalities have failed. Cromolyn prepared in an emollient base was applied to the skin of children and adolescents with moderate to severe atopic dermatitis. All subjects concomitantly applied a mid-potency topical steroid. Objective severity decreased significantly in the cromolyn-steroid group compared to the group treated with steroid alone. The study authors posit an additive anti-inflammatory effect based on the different mechanisms of action employed by corticosteroids and cromolyn. Nedocromil may inhibit sensory nerve activation to reduce neurogenic itch and flare from histamine but does not modulate wheal diameter. It has not yet been evaluated clinically as a topical preparation. Other reports have proposed that intranasal cromolyn or nedocromil (not commercially available in the United States as an intranasal...

Review the pros and cons of induction agents in asthmatic patients

Intravenous induction agents used in asthmatic patients include oxybarbiturates, thiobarbiturates, ketamine, and propofol. Thiobarbiturates constrict airways in laboratory investigations and may have a loose association with clinical bronchospasm. The most common cause of bronchospasm is the stimulus of intubation, and large doses of barbiturates are required to block this effect successfully. Ketamine has well-known bronchodilatory effects secondary to the release of endogenous catecholamines with p2-agonist effects. Ketamine also has a small, direct relaxant effect on smooth muscles. Propofol decreases both airway resistance and airway reflexes after administration. Intravenous lidocaine is a useful adjunct for blunting the response to laryngoscopy and intubation.

Conditions Associated With Exacerbations Of Asthma

Several clinical conditions are closely associated with and may worsen asthma by diverse mechanisms. An association between asthma and concomitant sinus disease has been recognized since the early part of the century and has been reconfirmed repeatedly both in children and adults. It is estimated that 60-75 of severe asthmatics have concomitant sinusitis and that 20-30 of sinusitis patients have asthma. Slavin treated 33 adults with asthma and concomitant sinusitis medically or surgically. After therapy, 28 of 33 subjects believed their asthma was improved, and 15 of 18 reduced their steroid requirement by 85 . Anecdotal observations suggest that the difficulty of treating asthmatics with sinusitis is proportional to the degree of sinusitis present. Physicians treating asthmatics should be alert to the possibilities that sinusitis frequently coexists in their patients and that the severity of the sinusitis may influence the course of the bronchial asthma. Although the precise...

Efficacy of Oral Glucocorticoid Therapy in Asthma

Bronchial hyperresponsiveness (BHR), or airway twitchiness, is an essential feature of asthma. BHR has been shown to correlate with disease severity, frequency of symptoms, and need for treatment. Although the precise relationship remains elusive, airway inflammation is thought to contribute to BHR. High-dose prednisone therapy has been shown to improve pulmonary function and BHR in both adults and children with asthma. Reductions in bronchoalveolar lavage fluid eosinophil counts and reductions in the number of T lymphocytes expressing pro-inflammatory cytokines have also been associated with improved BHR following a short course of high dose prednisone. These observations suggest that GCs, by inhibiting cytokine synthesis, inhibit airway eosinophilia and subsequently lessen BHR. Effects of Systemic Glucocorticoid on Acute Exacerbations of Asthma in Adults Systemic GC therapy is considered first-line therapy for the treatment of acute severe asthma. Over the past 50 yr, numerous...

Differential Diagnosis Of Asthma

Not all that wheezes is asthma Diseases in which wheezing is a component are listed in Table 7. Asthma, chronic bronchitis, and emphysema affect the airways diffusely, cause airway obstruction, and may coexist in the same patient. Generally, chronic bronchitis occurs in cigarette smokers who develop chronic cough that persists for years before airflow becomes symptomatically obstructed. The bronchorrhea may vary in intensity in relation to infectious or irritant exposure, for example. Chronic bronchitis involves hyperplasia and hypertrophy of the submucosal glands, inflammation of the small airways, and hypersecretion of mucus. Emphysema may also be heralded by longstanding cough and mucus production, but this is a diagnosis confirmed only histo-logically. Emphysema is suggested by the presence of a reduced diffusing capacity and obstructing airways disease. Most adults have some degree of emphysema at autopsy, but severe emphysema is seen only in about 10 . Emphysema is another...

Classification of Asthma

Asthma may be divided into four clinical phases, based on symptoms and pulmonary function testing. These stages allow physicians to communicate about asthma severity and provide general guidelines on treatment. The four categories include mild intermittent asthma, mild persistent asthma, moderate persistent asthma, and severe persistent Table 13 Classification of Asthma Severity Table 13 Classification of Asthma Severity asthma. These categories advance in severity and a patient may move from one to another depending on various circumstances. Table 13 shows details of the current classification scheme. Mild intermittent asthma occurs less than twice weekly, and the patient is asymptomatic otherwise. Pulmonary function is normal except during periods of disease, and exacerbations are brief and usually easily treated. Mild persistent disease occurs more than twice a week, but less than once a day. Symptoms are severe enough to interfere with daily activities and may interrupt sleep up...

Antileukotrienes In Chronic Asthma Studies

The CysLT1 receptor antagonists montelukast and zafirlukast have been shown to improve asthma control in adult and pediatric asthmatics when given alone and in combination with inhaled steroids*. These studies are described here. The efficacy of montelukast and zafirlukast were demonstrated in placebo-controlled trials submitted to the US Food and Drug Administration for the approval for use in chronic asthma. Compared to placebo, montelukast has been shown to improve pulmonary function (forced expiratory volume in 1 s FEV1 and peak expiratory flow rate PEFR ), daytime and nighttime symptoms, asthma attacks, quality of life, and decrease short-acting p-agonist use and peripheral blood eosinophils in adults. Onset of action occurred on the first day of dosing. A retrospective analysis of seven published studies demonstrated that, compared with placebo, montelukast significantly improved FEV1 and peripheral blood eosinophil counts in patients with purely mild persistent asthma....

Allergic Asthma Overview

More than 50 controlled immunotherapy trials have been performed with a variety of allergens for seasonal, perennial and animal-induced asthma. Vaccines of rye grass, mixed grasses, ragweed, birch, mountain cedar, Alternar a spp, Cladospor um spp, house dust mites, cat, dog, and cockroach have been used in these trials. Collective analysis of these studies provides important insight, but comparisons among studies are difficult because of varied study designs. Of these studies, 42 demonstrated significant clinical improvement in treated subjects 23 of these showed a significant increase in the bronchoprovocation threshold to the allergen used for immunotherapy. Of the trials in which immunological parameters were monitored, 16 demonstrated an increase in allergen-specific IgG-blocking antibody, and one showed a decline in specific IgE. Nine reported decreased skin test reactivity to the allergen used for immunotherapy, and two demonstrated reduced in vitro basophil histamine release...

Pediatric patient with accidental theophylline overdose

A 3-year, 10-month female child with a two-year history of asthma developed tachynea, respiratory difficulty and fever. She was accidentally given 750mg of theophylline, an amount 10 times in excess of that prescribed. She became restless, developed tachycardia, and vomited coffee-ground material positive for occult blood. Her serum theophylline level was 67 g ml 1 h and 45 min after being given the drug. She was transferred to the intensive care unit. The hospital immediately referred the patient to me for possible treatment with ACAC hemoperfusion. It was decided to carry out the procedure immediately because 1) The theophylline level varied from 67 to 74 g ml and 40 g ml being considered a potentially lethal dose (2) It is known that if the level is not lowered quickly, the child would suffer irreversible brain damage as in an earlier case when the child was referred to us too late and (3) Available dialysis systems at that time were not effective in removing theophylline. A 3 h...

Clinical Asthma Symptoms

The classic symptoms of asthma include intermittent, reversible episodes of airflow obstruction manifested by cough, wheezing, chest tightness, and dyspnea (Table 10). When the clinical situation permits, a detailed history (Table 11) should be taken that includes the following (l) family and personal history of atopic disease (2) age of onset of asthma, frequency and severity of attacks (3) times (including seasons) and places of occurrence of asthmatic attacks (4) known provocative stimuli and any previous correlating skin-test reactions (5) the severity of the disease as reflected in the wheezing episodes per day, the number of missed school or work days per year, whether sleep is interrupted, the necessity for emergency room visits, and the number of hospitalizations for asthma and (6) previous pharmacological or immunological therapy and its efficacy. Early symptoms often include a vague, heavy feeling of tightness in the chest, and, in the allergic patient, there may be...

Occupational Asthma

The air we breathe may contain allergens of natural origin or generated as a consequence of industrial or environmental processes. In addition, chemicals in the air may irritate the airways and lower the threshold for airway responsiveness. These same irritants may in addition be allergens for susceptible individuals. Besides industrially related exposure, modern life generates pollutants that linger in the air, generally in or around cities, which may damage the lungs. Thus, everyone is at risk of breathing potentially harmful substances, but asthmatics are at much greater risk to react adversely to them. Certain pollutants such as ozone increase airway reactivity even in normal subjects, and asthma may be exacerbated during pollution with either industrial or photochemical smog. Approximately 2-15 of all cases of adult-onset asthma in men are of occupational origin (depending on the level of airway irritants and allergens in any working area). Suspicion of occupational lung disease...


Th2 lymphocytes are thought to play a key role in the initiation and maintenance of the inflammatory response in asthma. The standard mouse model of allergic asthma is the ovalbumin (OVA) challenge model where acute eosinophilic airway inflammation is measured. Simvastatin (40 mg day) was found to suppress eosinophil recruitment to the lung in response to OVA in animals pre-sensitised to the protein 101 . Both eosinophils and macrophage lung infiltrates were reduced and levels of the Th2 cytokines, IL-3 and IL-5, in the bronchoalveolar fluid were reduced. In vitro, simvastatin inhibited OVA specific secretion of IL-4 and IL-5. As a general marker of inflammation, IL-6 levels were also decreased in the mice. In this study, in contrast to the CIA and EAE models, statin treatment did not significantly reduce antigen induced cell proliferation.

Airway Inflammation

The mucosa of patients who have died in status asthmaticus contains mixed cellular infiltrates consisting of eosinophils, neutrophils, macrophages, lymphocytes, mast cells, and plasma cells. In the airway lumen, admixed in the abundant secretions are eosinophils and eosinophil-derived Charcot-Leyden crystals, neutrophils, and desquamated clumps of epithelial cells (Creola bodies). The same pathological changes are found in the lungs of allergic or nonallergic asthmatics, suggesting that there is a commonality in the pathophysiological events. Recent biopsy studies of the airways of asthmatics after allergen challenge have shown the following observations Within minutes of allergen exposure mast cells degranulate (and release mediators detectable in the broncho-alveolar lavage fluid), the superficial vessels swell and become permeable, and mucosal edema forms. Biopsies done several hours later reveal persistent edema, the increased expression of adhesion molecules on blood vessels, and...

Diagnostic Tests in Allergy

The concept of diagnostic testing in allergy has been confusing for many years. Although there are many potential sources for the confusion, a major source has been commercial companies that market diagnostic tests as if a laboratory test could diagnose a patient with allergic disease. These companies imply that the diagnosis of allergic disease is as simple as drawing a blood sample and sending it to them. Allergic diseases can be diagnosed only from the patient's history of symptoms and compatible physical findings. Without a detailed history and physical, the results of skin tests or tests for allergen specific immunoglobulin (Ig)E are meaningless. For example, what does a positive test for cat-specific IgE mean A patient with a positive test for cat-specific IgE may be asymptomatic, have rhinitis, have asthma, or have hives from exposure to cats. The test result is meaningless without the clinical history. If the patient has a consistent history of rhinitis every time he or she is...

Replication and Its Importance

A handful of susceptibility genes for common and complex diseases such as BRCA1 and BRCA2 in breast cancer (19,20), Calpain10 in NIDDM (21), NOD2 in Crohn's disease (22,23), Neuregulin 1 in schizophrenia (24), and ADAM33 in asthma (25) have been identified. Despite these successes, linkage studies of complex diseases have been difficult to replicate. A review of the linkage findings of 31 complex human diseases based on whole genome scan concluded

Selection of Individuals

All individuals who have severe symptoms of anaphylaxis and have positive venom skin tests should receive VIT (Table 1). Children who have had very mild reactions with dermal symptoms only do not require therapy. Their families should be advised to keep epinephrine and antihistamines available. Adults who have had similar mild anaphylaxis can probably be treated in a similar fashion, but there is less evidence to support this practice in adults than in children. Currently VIT is still recommended for these adults. Those individuals who have had reactions of moderate intensity such as mild asthma, nausea, and urticaria, without serious life-threatening reactions, might also be treated without immunotherapy and with the availability of emergency medication. They are likely to have similar moderate reactions to subsequent stings. This decision is influenced by other factors such as risk of exposure, other disease processes, such as cardiac disease, and medication use.

Recent Developments in Antitussive Therapy

Introduction - Cough is a forceful defensive reflex maneuver that leads to expulsion of irritants, fluids, mucus or foreign material from the respiratory tract. Specifically, the reflex triggers a complex, multiphasic motor pattern characterized by sequential coordination of large increases in motor output to an array of inspiratory and expiratory skeletal muscles. This highly coordinated musculoskeletal activation process consists of three sequential phases, namely deep inspiration, compression (i.e. contraction against a closed glottis) and vigorous expulsion. The expulsion is ultimately attained through the combined forceful contraction of thoracic, abdominal and diaphragm muscles through the generation of rapid airflow (1, 2). While generally beneficial, cough is a prominent pathophysiological feature associated with many airway and lung diseases such as asthma, upper respiratory viral and bacterial infections, post-nasal drip syndrome, gastroesophageal reflux disease, pulmonary...

Differential Diagnosis

Establishing the diagnosis of asthma in children can be difficult. In early childhood, asthma is often underdiagnosed, especially in infants and young children who wheeze and cough only with respiratory illnesses. Also, in this young age group the diagnosis is based primarily on clinical grounds and symptom reporting by a caregiver as there is a lack of tools to objectively measure lung function. It is also important to note that not all wheeze and cough is due to asthma, and alternative diagnoses should be excluded. Misdiagnosis can expose children to inappropriate prolonged asthma therapies. Other conditions that can masquerade as asthma include cystic fibrosis, gastroe-sophageal reflux, foreign body aspiration, bronchopulmonary dysplasia, congenital heart disease, congenital airway anomalies such as laryngeal webs, vascular ring, and tracheoesophageal fistula. In older children and adolescents, vocal cord dysfunction can masquerade as asthma, especially for those patients who fail...

Environmental Control

Because children with asthma tend to have coexistent allergies, steps to reduce allergen exposure should be implemented (Table 4). A long-term commitment is necessary. Exposure to higher house dust mite concentrations in childhood has been associated with more severe asthma. However, there are conflicting reports as to whether house dust mite avoidance is both achievable and associated with subsequent clinical improvement. Asthma For those children who are pet allergic, a candid discussion with the family needs to occur about removing the pet from the home. Pet removal can result in major improvement in asthma symptoms for these children, but doing so can be quite difficult, especially after an emotional bond has been made. Families are often unable to deal with the loss of a pet, putting asthma lower on the priority list than other psychosocial issues. Also, it is important to discuss with families that immediate benefit may not be observed after the pet is removed because dander...

Potential Therapeutic Applications

Rhinitis and Nasal Congestion - Nasal obstruction and rhinorrhea present in allergic rhinitis are at least partly influenced by neuropeptides released from sensory, parasympathetic, and sympathetic nerves. NPY is co-localized with norepinephrine in sympathetic perivascular nerves. NPY is released with norepinephrine on sympathetic nerve stimulation and produces long lasting vasoconstriction of the nasal vascular bed through postsynaptic NPY Y1 receptors (35). In addition to direct vasoconstriction, there is evidence to suggest that NPY modulates the release of transmitters originating from parasympathetic and sensory nerves by acting on prejunctional NPY Y2 receptors. This would then attenuate the vasodilator response to the subsequent parasympathetic nerve stimulation in the nasal mucosa via non-adrenergic and non-cholinergic mechanisms (36). Putative therapeutic application of NPY in rhinitis has been recently suggested because intranasal administration of exogenous NPY in human...

Suggested Reading

Effect of long-term treatment with inhaled budesonide on adult height in children with asthma. N Engl J Med 2000 343 1064-1069. American Academy of Allergy, Asthma & Immunology, Inc. Pediatric Asthma Promoting Best Practice. American Academy of Allergy, Asthma, and Immunology, Milwaukee, WI, 1999. Castro-Rodriguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med 2000 162 1403-1406. Childhood Asthma Management Program (CAMP) Research Group. Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med 2000 343 1054-1063. Lemanske RF Jr. RF, Green CG. Asthma in infancy and childhood. In Middleton E Jr, Reed CE, Ellis EF, et al., eds. Allergy Principles and Practice, 5th ed. St. Louis Mosby-Year Book, Inc., 1998 877-900. Liu A, Martinez FD, Taussig LM. Natural history of allergic diseases and asthma. In Leung DYM, Sampson HA, Geha RS,...

Review obstructive airway diseases and their pulmonary function test abnormalities

Obstructive airway diseases, including asthma, chronic bronchitis, emphysema, cystic fibrosis, and bronchiolitis, exhibit diminished expiratory airflow and involve airways distal to the carina. The FEV1, FEV1 FVC ratio, and the forced expiratory flow at 25 to 75 of FVC (FEF25-75) are below predicted values. A decreased FEF25-75 reflects collapse of the small airways and is a sensitive indicator of early airway obstruction. The FVC may be normal or decreased as a result of respiratory muscle weakness or dynamic airway collapse with subsequent air trapping. Table 9-1 compares the alterations in measures of lung function in various obstructive lung diseases. Table 9-2 grades the severity of obstruction based on the FEV1 FVC ratio.

Peripherally Acting Agents

GABAb Agonists - A peripheral site of action to inhibit the efferent function of sensory afferents may also contribute to the antitussive activity of GABAb agonists. Specifically, 3-aminopropylphosphinic acid (3-APPI, 18), a GABAb agonist that does not cross the blood-brain-barrier, inhibits tachykinergic-mediated airway pathophysiological responses such as bronchospasm, vagally-induced airway microvascular leakage and cough (inhibition of capsaicin-induced cough in guinea pigs, ED50 0.36 mg kg, s.c.) in experimental animals by attenuating the release of pro-inflammatory neurogenic neuropeptides from pulmonary afferent nerve terminals (9, 19).

Neural Regulation Of The Cough Reflex

Afferent Mechanisms of the Cough Reflex - Coughing is elicited by stimulation of specialized sensory nerves in the airways. A variety of different stimuli including airway inflammation, chemical irritants (e.g. capsaicin) and mechanical stimuli can trigger coughing in humans and animals. The polymodal sensory nerves that are prominently involved in neural regulation of cough are myelinated AS rapidly adapting receptors (RAR) and unmyelinated bronchial and pulmonary C-fibers (8). Their nerve endings appear to be prominently localized within the epithelial layer of the trachea and lower airways (2). The afferents transmitting the tussigenic impulses are carried by the vagus nerve to the nucleus tractus solitarius (NTS) in the medulla oblongata.

Who gets osteoporosis

Children, adolescents, and young adults can get osteoporosis too, particularly those with genetic or nutritional disorders, and eating disorders such as anorexia nervosa and bulimia, because they do not make hormones or absorb calcium, Vitamin D, and other nutrients and protein required for normal bone development. Those who are treated with medications that interfere with bone development may also get osteoporosis. People who are treated with long-term methotrexate (> 1 month), usually for cancer or arthritis, are more at risk. Long-term use of the gonadotropin-releasing hormone analogs, such as Lupron, for the treatment of endometriosis in young women can contribute to the development of osteoporosis as well. And the most common class of medication to cause osteoporosis or osteopenia at any age is corticosteroids, used for such problems as lupus, arthritis, or asthma. Osteoporosis occurring after taking a glucocorticoid is so common that it has its own name glucocorticoid-induced...

Gastroesophageal Reflux

It has been reported that as many as 45-65 of adults and children with asthma have GERD. The mechanism by which GERD produces asthma appears to involve triggering intraesophageal reflexes by acid stimulation, resulting in cholinergic reflexes into the airways and resultant bronchial constriction. While GERD may be asymptomatic in asthmatics, the strongest association is with nighttime asthma symptoms especially night cough and nocturnal wheezing. GERD should be highly suspect in patients (especially children) with nocturnal exacerbations (especially cough) and recurrent heartburn. Effective management of GERD may concomitantly reduce asthma in some, but not all patients.

What are the typical side effects of opioids

Opioid side effects include respiratory depression, nausea and vomiting, pruritus, cough suppression, urinary retention, and biliary tract spasm. Some opioids may induce histamine release and cause hives, bronchospasm, and hypotension. Intravenous opioids may cause abdominal and chest wall rigidity. Most opioids, with the notable exception of meperidine, produce a dose-dependent bradycardia.

Bronchial Hyperresponsiveness

One of the absolute features of asthma is exaggerated nonspecific airway reactivity to a variety of irritating stimuli. Thus, asthmatics develop airway obstruction in response to natural exposures (cold air, exercise, irritating chemicals, laughing, and coughing) or to provocations in the laboratory (histamine, methacholine, cold air hyperventilation) (Table 9). Airway hyperresponsiveness is found universally in asthmatics, in a portion of subjects with chronic bronchitis, in some subjects with allergic rhinitis, and in 3-8 of otherwise normal subjects. There is a close correlation between the degree of increased responsiveness and disease severity patients with the most reactive airways often require oral CCSs for control, whereas milder degrees of abnormality predict the requirement for fewer medications. Hyperresponsiveness increases after allergen exposure, late-phase allergic reactions, viral infections (especially influenza-type infections), and ozone exposure. Conversely,...

Other Pathological Events

Denudation of airway epithelial surfaces with the appearance of epithelial clumps in expectorated secretions accompanies severe asthma. The denuded epithelial surfaces Table 8 Pathology of Asthma FACTORS PREDISPOSING TO ASTHMA Genetic Factors When differentiating asthma from other obstructive airways disease, it is always relevant to ask if family members experience the same symptoms. It is well recognized that asthma is the result of both genetic and environmental influences. Asthma, as with many other medical conditions, such as hypertension and diabetes mellitus, is a complex genetic disorder. It cannot be classified as an autosomal-dominant, recessive, or sex-linked pattern of inheritance. At the present time, several chromosomal regions have been identified to be strongly associated with asthma, such as 5q31, 6, 11q13, 12q, 13q14, and so on. The 5q31, for example, is on chromosome 5. It influences total IgE production, eosinophil count, IL-4, IL-5, and IL-13 production, CD14...

Autonomic Dysfunction

An imbalance of the autonomic nervous system with a blunted p-adrenergic response and hyperresponsiveness of the p-adrenergic and cholinergic systems have been documented in asthmatics, although this defect is not unique for asthma. The exact contribution of the disarray of autonomic imbalances found in asthmatic subjects is not clear. Some of the abnormalities are also found in allergic subjects and in patients suffering from cystic fibrosis. These data suggest that asthmatics have an inherently reduced ability to sustain open airways and a tendency for airflow obstruction based on an inherent defect in their autonomic balance.

Experimental Animal Models of Atrial Fibrillation

Oilier less commonly used experimental models of AFIB have been described, including induction of AFIB by continuous infusion of theophylline in the sheep, which shortens atrial refractoiy period and wavelength, increasing atrial vulnerability 75J. Atrial fibrillation may also be induced in the caninc sterile pericarditis and right atrial enlargement models 22-25 , and in a small percentage of

Symptoms And Signs

After an incubation period of 2-4 days, the illness starts with symptoms of nasal congestion blockage and irritation, sneezing and a sore throat. Excess nasal secretion follows which is serous at first and later becomes purulent if secondary bacterial infection ensues. Cough is a frequent symptom, as is headache during the first days of illness. Fever occurs seldom, and if so, it is moderate. Rhinovirus infection causes the same symptoms in all age groups. The infection is limited to the respiratory tract. It has been suggested that rhinoviruses may cause a more serious infection of the lower respiratory tract in small children. Rhinovirus infection has also been shown to precipitate attacks of asthma in children and aggravate chronic bronchitis in adults. Asymptomatic infections are reported to occur in about 25 of individuals infected with rhinovirus.

Your patient states that he was told he is allergic to Novocain which he received for a tooth extraction Should you

Allergy to local anesthetics is rare despite frequent use of local anesthetics. Less than 1 of adverse reaction to local anesthetics is true allergy. Most reactions labelled as allergy are probably one of the following vasovagal response, systemic toxicity, or systemic effects of epinephrine. True allergy would be suggested by history of rash, bronchospasm, laryngeal edema, hypotension, elevation of serum tryptase, and positive intradermal testing.

Therapy And Prophylaxis

In addition to inhalation of droplets, spread of infection by contact is considered to play a significant role. Measures should be taken to avoid infection from virus-contaminated hands. Persons suffering from asthma and from chronic bronchitis should avoid close contact with common cold patients.

Classification Of Allergic Rhinitis

On Asthma (ARIA) Workshop, in collaboration with the World Health Organization, recommended a different classification, using the terms intermittent and persistence and the severity classifications of mild, moderate, and severe. Intermittent is defined as having symptoms for less than 4 wk of the year. Mild is defined as not affecting quality of life. Most subjects who seek medical care are expected to be in the moderate to severe persistent category, because over-the-counter products are available for treatment of less severe disease. Published studies report that the ARIA classification is more useful in clinical assessments than the seasonal and perennial terminology, suggesting that persistent rhinitis as defined is not equivalent to perennial rhinitis and intermittent is not equivalent to seasonal. Both classifications are used clinically and in the medical literature.

Nonallergic Rhinitis with Eosinophilia

Described as suffering from perennial nasal congestion, rhinorrhea, sneezing, and pruritus but do not have specific IgE for allergens, an increase in total IgE, or a personal or family history of atopy. The nasal secretions contain eosinophils, which distinguishes this condition from other forms of PNAR. The lack of an atopic personal and family history in NARES makes an undefined allergy unlikely as the cause. The condition may be part of the spectrum of eosinophilic rhinitis and nasal polyposis. Subjects with aspirin triad (nasal polyps with eosinophils, asthma, aspirin sensitivity) experience eosinophilic rhinorrhea and nasal congestion prior to the development of nasal polyps, suggesting a spectrum of eosinophilic nasal disease (Fig. 4). However, most subjects with NARES do not develop aspirin triad.

Evaluation Of Pde4 Inhibitors In Animal Models

Respiratory Disorders - The efficacy of PDE4 inhibitors in animal models of asthma and COPD is well documented. A large number of structurally diverse, selective PDE4 inhibitors have demonstrated their ability to inhibit bronchoconstriction and airway hyper-responsiveness, eosinophil infiltration and local cytokine recruitment in a variety of models involving a range of stimuli. Efficacy has been shown in mice, rats, guinea pigs, dogs and monkeys, and the therapeutic potential of PDE4 inhibitors in asthma, allergic rhinitis and COPD has been extensively reviewed (7-9,36-39). The activity of recently disclosed PDE4 inhibitors in these models will be discussed in the Medicinal Chemistry Developments section in this chapter. A potential role for PDE4 inhibitors in the treatment of exacerbations of asthma triggered by viral infection has been proposed, based on the ability of rolipram M and Ro-20-1724 15 to reduce both airway hyper-responsiveness and eosinophilia following RSV infection...

Regulators Of Lipid Mediators

LTD4 Antagonists - While definitive clinical evidence of a major role for the peptide leukotrienes in asthma allergy was not presented this year, many antagonists are in the clinic and expectations remain high. A perceptive overview of the area appeared recently (13). The orally active LTD4 LTE4 antagonist LY171883 (1) showed small beneficial effects on pulmonary function (increase in FEV,, decrease in use of broncho-dilators) in mild asthmatics given 600 mg. b.i.d. for six weeks (14). SKF 104353-Z2 (2) has been shown to block LTD,,- and antigen-induced bronchoconstrietion in asthmatics upon aerosol administration (15,16). Early clinical data for ICI 204219 (3) and MK-571 (4), previously known as L-660711, are now available after oral administration of 3 or i.v. infusion of 4, both drugs were effective blockers of aerosol LTD4 challenges (17, 18). The chemistry leading to the novel unsymmetrical dithioacetal unit present in 4 was described (19). Chemistry (20) and pharmacology (21,22)...

Caesarean section under general anaesthesia

NSAIDs are contraindicated in women with severe pre-eclampsia because of their effect on platelet function and should also be used with caution in asthmatics. The potentially adverse effect of NSAIDs on renal function should be considered in women who are hypovolaemic and in those who have compromised renal function.

Pulmonary Pathophysiology

3.8.3 Asthma Asthma is a chronic disease which affects 5 million children in the United States. In asthma, the airways become overreactive with increased mucus production, swelling, and muscle contraction. Because of the decreased size of the bronchi and bronchioles, flow of air is restricted and both inspiration and expiration become more difficult. Chronic obstructive pulmonary disease (COPD) is a slowly progressive disease of the lung and airways. COPD can include asthma, chronic bronchitis, chronic emphysema, or some combination of these conditions. The disease is characterized by a gradual loss of lung function. The most significant risk factor for COPD is cigarette smoking. Other documented causes of COPD include occupational dusts and chemicals. Genetic factors can also play a significant role in some forms of this disease. Figure 3.12 shows the volume versus time curve for a normal lung compared to that for a patient with fibrosis, asthma, and emphysema. In the patients with...

CCR3 Antagonists for the Treatment of Respiratory Diseases

Introduction - Bronchial asthma and allergic rhinitis are chronic inflammatory diseases characterized by the selective migration of leukocyte subtypes from the vasculature into the bronchial epithelium and nasal mucosa, respectively. One of the most striking aspects of these diseases is the accumulation of the eosinophil leukocyte (1). It was this observation that led to the search for, and subsequent identification of the molecular entities responsible for this phenomenon. One such molecule, designated eotaxin, was isolated from the bronchoalveolar lavage fluid from allergen-challenged guinea pigs, and early results demonstrated that this protein was an eosinophil-selective p-chemokine (2). Chemokines, or chemotactic cytokines, are members of a large family (> 50) of small molecular weight proteins (-8-10 kD). These proteins were initially characterized by their ability to stimulate migration of distinct subsets of leukocytes in the direction of a molecular gradient (chemotaxis)....

Atopic Keratoconjunctivitis

AKC is a chronic inflammatory process of the eye associated with a familial history for atopy such as eczema and asthma primary care physicians should expect to see 25 of their elderly patients with eczema to also have some form of AKC. AKC can be seen in individuals as early as their late teens it commonly persists until the fourth and fifth decades of life. AKC is an eye disorder with disabling symptoms when it involves the cornea, it can lead to blindness. Ocular symptoms of AKC are similar to the cutaneous symptoms of eczema and include intense pruritus and edematous, coarse, and thickened eyelids. Severe AKC is associated with complications such as blepharoconjunctivitis, cataract, corneal disease, and ocular herpes simplex it is primarily associated in 40 of the older patients, with the peak incidence occurring in the 30- to 50-yr age group. The symptoms of AKC commonly include itching, burning, and tearing, which are much more severe than in AC or PAC and tend to be present...

What is intrinsic or autopositive endexpiratory pressure

Intrinsic PEEP (PEEPi) is unrecognized positive alveolar pressure at end exhalation during MV. Patients with high minute ventilation requirements or patients with chronic obstructive pulmonary disease (COPD) or asthma are at risk for PEEPi. In healthy lungs during MV, if the respiratory rate is too rapid or the expiratory time too short, there is insufficient time for full exhalation, resulting in stacking of breaths and generation of positive airway pressure at end exhalation. Small-diameter endotracheal tubes may also limit exhalation and contribute to PEEPi. Patients with increased airway resistance and decreased pulmonary compliance are at high risk for PEEPi. Such patients have difficulty exhaling gas because of small airway obstruction collapse and are prone to development of PEEPi during spontaneous ventilation and MV. PEEPi has the same side effects as PEEPe, but detecting it requires more vigilance. Failure to recognize the presence of auto-PEEP can lead to inappropriate...

What is controlled hypoventilation with permissive hypercapnia

Protecting the lung than on maintaining eucapnia. The set VT is lowered to a range of approximately 4 to 6 ml kg IBW in an attempt to keep the Peak airway pressure (Paw) below 35 to 40 cm H2O and the static plateau pressure below 30 cm H2O. Several studies in ARDS and status asthmaticus have shown a decrease in barotrauma, intensive care days, and mortality. The PCO2 is allowed to rise slowly to a level of up to 80 to 100 mm Hg. If pH falls below 7.20, it may be treated with a buffer. Alternatively one may wait for the normal kidney to retain bicarbonate in response to the hypercapnia. Permissive hypercapnia is usually well tolerated. Potential adverse effects include cerebral vasodilation leading to increased ICP, and intracranial hypertension is the only absolute contraindication to permissive hypercapnia. Increased sympathetic activity, pulmonary vasoconstriction, and cardiac arrhythmias may occur but are rarely significant. Depression of cardiac contractility may be a problem in...

How is compliance calculated

Both dynamic and static compliance should be calculated. Dynamic compliance is calculated as VT (Paw - total PEEP), and plateau or static compliance is VT (plateau pressure - total PEEP). Normal values for both dynamic and static compliance are 60 to 100 ml cm H2O. A decrease in dynamic compliance without a change in the static compliance suggests an acute increase in airway resistance and can be assessed further by comparing peak pressure and plateau pressure. The normal gradient is approximately 10 cm H2O. A gradient > 10 cm H2O may be secondary to endotracheal tube obstruction, mucous plugging, or bronchospasm. If volume is constant, acute changes in both dynamic and static compliance suggest a decrease in respiratory system compliance that may be caused by worsening pneumonia, ARDS, atelectasis, or increasing abdominal pressures.

How is the patient who is fighting the ventilator approached

Initially the potential causes are separated into ventilator (machine, circuit, and airway) problems and patient-related problems. Patient-related causes include hypoxemia, secretions or mucous plugging, pneumothorax, bronchospasm, infection (pneumonia or sepsis), pulmonary embolus, myocardial ischemia, gastrointestinal bleeding, worsening PEEPi, and anxiety. The ventilator-related issues include system leak or disconnection inadequate ventilator support or delivered FiO2 airway-related problems such as extubation, obstructed endotracheal tube, cuff herniation, or rupture and improper triggering sensitivity or flows. Until the problem is sorted out, the patient should be ventilated manually with 100 oxygen. Breath sounds and vital signs should be checked immediately. Arterial blood gas analysis and a portable chest radiograph are valuable, but, if a tension pneumothorax is suspected, immediate decompression precedes the chest radiograph.

Metabolism And Inactivation

Reactions to intravenous protamine include rash, urticaria, bronchospasm, hypotension, and or pulmonary artery pressure elevation (Sodoyez and Sodoyez-Goffaux, 1984). Intermittent insulin treatment increases the risk of immune complications (resistance and allergy) (Orlander, 1985).

Classification And Etiological Considerations

Acute urticaria can result from nonspecific stimulation of mast cells as well. This occurs when a physiochemical process degranulates mast cells in the absence of an allergen. Thus, IgE on the surface of mast cells is not directly involved. An example in which mast cells can be degranulated directly is exposure to certain radiocontrast media (RCM). This type of exposure to RCM during a radiographic procedure will change the osmolality of the environment in which the mast cell resides and can result in degranulation. Complement may also be directly activated by these agents, and C5a anaphyla-toxin can contribute to mast cell degranulation. These patients will develop acute urticarial eruptions that can progress to anaphylaxis with hypotension and bronchospasm. The use of low-ionic radiocontrast media has lessened the occurrence of this acute urticarial event. Other etiological factors that should be considered in individuals with acute urticaria include coincident viral illnesses....

Skin Anomalies Pathological Noninfective

Classically this condition is the end-result of intense, chronic pruritus that results from repetitive rubbing or scratching. The skin responds by thickening and the increase in skin markings is referred to as lichenification. This occurs mostly in individuals with a history of allergies, eczema, hay fever or asthma. They have sensitive and easily irritated skin.

Stacie M Jones MD Ariana Buchanan md and A Wesley Burks MD

Atopic dermatitis is a complex, multifactorial disorder that first develops in most patients before the age of five. The diagnosis relies on information compiled from all aspects of clinical history, physical examination, and laboratory data. Strong correlations exist between atopic dermatitis and other atopic conditions such as asthma and allergic rhinitis. Underlying IgE-mediated sensitivitiy to both aeroallergens and foods have been shown to be strong triggering factors in atopic dermatitis. In addition, Staphylococcus aureus can exacerbate atopic dermatitis both by causing secondary infection of compromised skin and by secreting exotoxins that function as superantigens directly stimulating T-cell proliferation. Successfut treatment of atopic dermatitis involves a multifaceted approach that addresses avoidance of underlying triggering factors, proper care of dry skin, and pharmacologic management, including oral antipruritic agents, topical corticosteroids, and oral antibiotics...

Natural History Prevalence

Although AD is known to be a common skin disorder, its true prevalence has been difficult to define. With wide variation in the severity and time course of disease as well as differing diagnostic criteria used, the prevalence of AD has been the subject of much debate among physicians and clinical investigators. However, within the last decade, the development of unifying diagnostic criteria and methodology for epidemiological studies has allowed a better understanding of how much of the population is affected by this disease. Estimates place the lifetime prevalence of AD in industrialized nations in children between 10 and 20 and the 1-yr prevalence in adults at 1 to 3 . It is well recognized that AD is more prevalent in industrialized countries compared with non-industrialized countries or tropical regions. Over the past three decades, the prevalence has increased two- to three-fold, following the trend for increasing prevalence in other atopic disease, especially asthma.

Neutrophil elastase inhibitors

The release of NE from azurophil granules upon neutrophil activation has been suggested to play an important role in the exacerbation of asthma 50 . Cystic fibrosis and COPD are marked by neutrophil infiltration, with NE present at high concentration 51 . Therefore, targeting NE for airway diseases has been an active area for the past two decades. However, a number of compounds that advanced into the clinic for COPD eventually dropped out due to poor pharmacokinetic profiles or a narrow therapeutic window 52 .

Proteinase 3 inhibitors

Cells found to release cathepsins include, but are not limited to, macrophages (Cats B, K, L, and S), mast cells (Cats L and C (dipeptidyl-peptidase I)), and smooth muscle cells (Cats K and S) 65 . The elastinolytic cysteine proteases Cats K, L, and S have been implicated in the degradation of the main constituents of the basement membrane and elastin fibers of the pulmonary extracellular matrix, suggesting that these cathepsins may be involved in asthma and COPD 66-68 .

Protecting Your Lungs

Lung disease is directly related to specific risk factors such as cigarette smoking and working in occupations that carry risks for developing lung disease. Plastics, wood, metal, and textile workers bakers millers farmers poultry handlers miners grain elevator workers laboratory technicians drug manufacturers dry cleaners and detergent manufacturers are all exposed to airborne agents that can cause occupational asthma, lung cancer, and other respiratory disorders.

Matrix Metalloproteinases Inhibitors

MMPs have been implicated in the pulmonary remodeling processes that are common to both asthma and COPD 85 . The MMP profile in asthma differs from that in COPD with MMP-9 most closely associated with asthma and MMP-12 showing a strong connection to COPD. Work is progressing toward understanding the potential application of these MMPs as possible therapeutic targets in overcoming the pathophysiology of asthma and COPD 14,86-89 .

Disorders That Obstruct Air Flow245

The flow of air from the lungs can be limited or obstructed by a variety of structural changes in the lungs. Chronic obstructive pulmonary disease (COPD), a major cause of disability and death in men, refers to asthma, chronic bronchitis, and emphysema. With COPD the airway obstruction is generally irreversible. With asthma the obstruction is reversible with treatment, although the disease itself may not be cured. Asthma Asthma affects the lining of the bronchi and the bronchioles. These airways become inflamed and produce extra mucus. Smooth muscle tissue in the airways contracts, narrowing the passageways even further. Common symptoms of asthma include wheezing (a faint whistling noise that occurs with each breath), shortness of breath, chest tightness (feeling as if someone is squeezing your chest), and coughing. Signs of an asthma emergency include extreme difficulty breathing, bluish tinge (cyanosis) to the lips and face, severe anxiety, rapid pulse, and sweating. People who do...

LO and FLAP inhibitors

The non-redox, non-competitive 5-LO inhibitor AKBA (14), isolated from frankincense, has demonstrated clinical efficacy in the treatment of colitis and bronchial asthma. The boswellic acid analog 15, an artifact observed upon isolation and purification of 14, is a 4-fold more potent 5-LO inhibitor than 14 in intact PMNs 81 . A new activity has been reported for the marketed LTD4 receptor antagonist montelukast (16). Montelukast inhibits 5-LO in a non-competitive manner with an IC50 of 2.5 mM in a rat mast cell model and at concentrations greater than 1 mM in a human PMNL assay 82 . This inhibition may have potential clinical relevance since the therapeutic dose of montelukast that is normally recommended in asthma treatment (10 mg) provides maximal plasma concentrations of approximately 0.6 mM.

Immunological Diseases

Selective IgA deficiency is the most common immune deficiency disorder, affecting approx 1 in 400 individuals. It is characterized by decreased mucosal immunity, resulting in recurrent sinopulmonary, gastrointestinal and genitoureteral infections. Some patients remain asymptomatic while others manifest evidence of disease. IgA deficiency may be seen in association with atopic disease in some patients. These patients may develop asthma, allergic rhinitis or atopic dermatitis. The dermatitis is more typical of AD, both in character and distribution.

Other dual inhibitors

The dual 5-LO inhibitor H1 histamine receptor antagonist UCB-62045 (38), combining the pharmacophores of zileuton and cetirizine, inhibited histamine-induced bronchoconstriction and ex vivo calcium ionophore-induced LTB4 production in a guinea pig model 105 . E3040 (39) is a dual 5-LO thromboxane A2 synthase inhibitor that exhibits balanced inhibition in human blood cells 106 and inhibited LPS-induced large intestine vascular permeability in a rat model 107 . The dual 5-LO thromboxane A2 synthase inhibitor F-1322 (SOA-132, 40) inhibited antigen-induced late phase asthmatic response and prevented airway and BAL fluid eosinophilia upon oral administration to guinea pigs 108 . LDP-392 (41), a dual 5-LO inhibitor PAF receptor antagonist, is 7-fold less potent than zileuton in a human whole blood assay for LTB4 inhibition and inhibited (ED50 2.5mg kg) AA-induced ear edema in rats 109 .

Disorders of the Esophagus

Certain medications can interfere with the action of this muscle, including nitrates, calcium channel blockers, theophylline, and anticholinergics. Smoking and diet also contribute to GERD. Excessive consumption of chocolate, peppermint, coffee, alcohol, and fried or fatty foods can weaken the lower esophageal sphincter.

Infections And Their Management

Innocuous viruses increasingly recognised. For example, rhinoviruses, a cause of the common cold, are now known to be associated with severe lower respiratory disease in the immunocompromised and exacerbations of asthma (Gern and Busse, 1999 Greenberg, 2003). Similarly, though it is true that many viral infections remain untreatable, effective treatment is now available for several serious conditions, such as aciclovir in herpes simplex virus (HSV) encephalitis, ribavirin for Lassa fever, and combination antiretroviral therapy for human immunodeficiency virus (HIV).

Mode of action of FTY720

Two S1P1 independent mechanisms to explain the in vivo efficacy of FTY720 have been reported. FTY720 but not FTY720 phosphate inhibits sphingosine 1-phosphate lyase with an IC50 in the micromolar range. Sphingosine 1-phosphate lyase (SPL) catalyses the degradation of S1P therefore, inhibitors of SPL would be expected to raise S1P levels thereby perturbating immune function 40 . One group has reported that FTY720 but not FTY720 phosphate inhibits cPLA2, a key enzyme in eicosanoid formation, and that this mechanism contributes to the inhibition of Th2-cell-mediated airway inflammation seen with FTY720 41 . Given the low plasma concentrations of FTY720 and the relative weak potency of FTY720 on these enzymes, the degree to which these additional mechanisms contribute to the in vivo efficacy of FTY720 remains unclear.

PDE7 as a potential target for airway diseases

Immune cells are amongst the key players in the development of airway inflammatory diseases. The PDE4 inhibitors currently in development suffer from typical side effects like nausea and vomiting 30 . Accordingly, a new cAMP-PDE-specific isoform-based treatment could increase specificity and consequently reduce side effects. PDE7A1 is highly homologous between human, mouse 15 , and porcine cells 16 and is ubiquitously distributed among human pro-inflammatory, immune, and constitutive cells of interest for pulmonary diseases 9,16,31 . In addition, CD4+ and CD8+ T lymphocytes levels are increased in the airways of patients with asthma and COPD where they may play a critical role in the pathogenesis of these diseases 9 . PDE7 inhibition could represent an alternative additive treatment to PDE4 inhibitors in airway diseases. PDE7B1 and to a lesser extent, PDE7B3 are also expressed in the lung of rats 13 but no specific involvement in any respiratory diseases has been described. Finally,...

PDE74 dual inhibitors

Recently, IBFB-211913 (structure unavailable) was claimed as a new PDE4 7 inhibitor. It is reported under development for the treatment of asthma, autoimmune diseases and psoriasis 51 . Future data related to this compound will be helpful to assess and understand the intrinsic contribution of the PDE7 inhibition toward efficacy and side effects. In relation to this topic, several patents claimed the use of dual inhibitors (PDE7 PDE4) to synergize pharmacological effects and to increase the therapeutic index 32,33 . A series of phthalazinones have been disclosed as dual

Hand Eruptions In Health Care Workers

Nitrile gloves contain carbamates or 2-MBT. Neither vinyl (polyvinyl chloride) gloves nor nitrile gloves normally contain natural rubber latex protein (although one should read the label on the box carefully). Powder-free gloves are free of cornstarch. However, highly allergic persons may come into contact by handling objects (such as charts) that were also handled by physicians and nurses wearing powdered natural-rubber latex gloves, and glove powder in the air may transfer latex protein causing asthmatic symptoms in highly allergic persons. Persons with urticarial reactions to natural rubber latex proteins may also be allergic to certain foods, especially banana, avocado, chestnut, and kiwi, but the list of reported foods is long.

Spectrum of Disease

Severe pneumonia may occur in older or respiratory-compromised patients. Of note, asymptomatic infection or unrecognized, mildly symptomatic illnesses caused by C. pneumoniae are common. In addition, an association exists between C. pneumoniae infection and the development of asthmatic symptoms. Finally, an association between coronary artery disease and other atherosclerotic syndromes and C. pneumoniae infection has been suggested by sero-epidemiologic studies and the demonstration of the organism in atheromatous plaques (yellow deposits within arteries containing cholesterol and other lipid material). Such an etiologic role by this organism is currendy under intense scrutiny.

Are the Symptoms Truly Caused by ADHD

Such stressors, especially when more than one is present, may be the primary cause of the child's apparent ADHD impairments, or they may simply be exacerbating ADHD impairments that have been present since birth. The incidence of unemployment, marital conflict, substance abuse, and frequent changes of residence is elevated among individuals with ADHD. The presence of environmental stressors, even if they are many and severe, does not rule out a diagnosis of ADHD any more than such stressors would rule out a diagnosis of asthma.

Progress in the Development of Inhaled Long Acting P2Adrenoceptor Agonists

Long acting -adrenoceptor agonists are a highly precedented drug class used for the treatment of asthma and chronic obstructive pulmonary disease (COPD) 1,2 . There are currently two marketed long acting -adrenoceptor agonists, salmeterol 1 3 , and formoterol 2 4,5 , neither of which provides a once daily dosing regimen. Therefore, an opportunity may exist for a once daily agent both as a mono-therapy and as part of combination products, particularly with steroidal or muscarinic ligands. This review is not intended to cover the current state of potential combination therapies however, the final section of this review deals with an alternative paradigm of incorporating a second pharmacology within the same molecule as b2-adrenoceptor agonism. This concept is referred to as dual pharmacology 6 . Asthma is a chronic inflammatory disorder of the airways causing recurrent episodes of wheezing, breathlessness, chest tightness, and coughing 7 . These symptoms often occur at night or in the...

What preoperative tests should be ordered

The patient's history guides the judicious ordering of preoperative tests. A mild asthmatic maintained on as-needed medication who is currently healthy will not benefit from preoperative testing. Symptomatic patients with no recent evaluation deserve closer attention. The most common test is a pulmonary function test, which allows simple and quick evaluation of the degree of obstruction and its reversibility (see Chapter 9). A comparison of values obtained from the patient with predicted values helps to assess the degree of obstruction. Severe exacerbation correlates with a peak expiratory flow rate (PEFR) or forced expiratory volume in 1 second (FEVi) of less than 30 to 50 of predicted, which for most adults is a PEFR of less than 120 L min and an FEV1 of less than 1 L. Tests should be repeated after a trial of bronchodilator therapy to assess reversibility and response to treatment. Arterial blood gases are usually not helpful. Electrocardiograms, chest radiographs, and blood counts...

What agents may be used for maintenance anesthesia

Sevoflurane, halothane, and isoflurane are effective in blocking airway reflexes and bronchoconstriction sevoflurane appears to be the most effective. Inhaled anesthetics have been used in the intensive care unit to provide bronchodilation in intubated patients with severe asthma, improving indices of respiratory resistance (inspiratory and expiratory flows), decreasing hyperinflation, and lowering intrinsic positive end-expiratory pressure (PEEP). primarily on opioids may cause problems with respiratory depression at emergence (particularly in patients with COPD with an asthmatic component). Neuromuscular blocking agents with a benzylisoquinolinium nucleus such as d-tubocurarine, atracurium, and mivacurium release histamine from mast cells on injection. They also may bind directly to muscarinic receptors on ganglia, nerve endings, and airway smooth muscle. Both mechanisms theoretically may increase airway resistance. Relaxants with an aminosteroid nucleus such as pancuronium and...

Suggested Readings

Apter A Advances in the care of adults with asthma and allergy In 2007. J Allergy Clin Immunol 121 839-844, 2008. 4. Doherty G, Chisakuta A, Crean P Anesthesia and the child with asthma. Pediatr Anesth 15 446-454, 2005. 5. Jean L, Brown RH Should patients with asthma be given preoperative medications including steroids In Fleisher LA, editor Evidence-based practice of anesthesiology. Philadelphia, Saunders, 2004, pp 77-81. 6. Szelfler S Advances in pediatric asthma. J Allergy Clin Immunol 121 614-619, 2008. 7. Watanabe K, Mizutani T, Yamashita S Prolonged sevoflurane therapy for status asthmaticus. Pediatr Anesth 18 543-545, 2008.

Quinolinones 8hydroxycarbostyril

Indacaterol, 3 (QAB-149) is currently being developed as a once daily b2-adrenoceptor agonist for the treatment of COPD and asthma 9 . Indacaterol contains the familiar quinolinone head group that appears in the marketed short-acting p2-adrenoceptor agonist, procaterol, 4. This 8-hydroxycarbostyril moiety is known to have a high affinity for the -adrenoceptor and has been postulated to give potential slow offset properties to ligands to drive duration of action 10 . A recently published patent suggests that the maleate salt of indacaterol is highly crystalline, stable, and may be the preferred form of this compound for development and clinical use 11 . Data have recently been disclosed on the pharmacological profile of indacaterol. Using guinea-pig tissue preparations, potency data were generated in guinea-pig atria (EC50 21.6 mM) vs. guinea-pig trachea (EC50 45 nM), suggesting that the compound has selectivity over the -adrenoceptor. Further studies using guinea-pig trachea tissue...

Mechanisms Of Allergic And Allergiclike Intolerance Reactions To Foods And Food Additives

Asthma due to a preservative Exposure to food protein usually occurs orally. Occasionally, individuals can become sensitized or, after developing a food allergy, have a reaction to re-exposure of food through either the aerosol or contact route. Examples include bakery workers who develop IgE-mediated wheat protein sensitivity (and subsequent asthma called baker's asthma) from exposure and then re-exposure to wheat flour dust. Another example is the fish-allergic individual who may develop urticaria or systemic anaphylaxis when exposed to the odor steam of cooked fish. Inhalation reactions have also been reported with crab, egg, milk, peanuts, beans, rice, and potatoes. Contact reactions have occurred with eggs, milk, peanut, fish, and crab. Recently, attention has been called to the risk of lactose exposure in a severe-milk allergic individual using a dry powder asthma inhaler (DPI). Sufficient milk proteins to cause anaphylaxis was found in lactose USP and in the DPI containing...

Rationale for CCR5based entry inhibitors as antiHIV agents

More than 19 currently known chemokine receptors belonging to the 7TM class of receptors are involved in pathology of many diverse diseases such as sepsis, COPD, RA, transplant rejection, asthma, IBD, cancer, HIV and others 7-10 . There are more than 45 known endogeneous ligands of chemokine receptors, reflecting the significant redundancy and complexity of the chemokine signaling network. For example, while endogenous chemokines CCL3 (MIP-1a, Macrophage Inflammatory Protein type 1a), CCL4 (MIP-1p), and CCL5 (RANTES, Regulated on Activation, Normal T Expressed and Secreted) bind CCR5, CCL5 also binds two other chemokine receptors, namely CCR1 and CCR3.

Food Additive Intolerance Reactions

Allergic reactions have been reported to occur to the preservative sulfites (and SO2), sodium benzoate, butylated hydroxyzole (BHA), butylated hydroxytylene (BHT), the sugar substitute aspartame, artificial colors (especially yellow, red, and blue), and the flavor enhancer monosodium glutamate (MSG). The symptoms of principal concern are urticaria and asthma. In most cases, even if it is proven that the food additive is involved in the clinical symptoms, the exact mechanism of the reaction is unknown. Chewing foods containing sulfites may release SO2, which, when inhaled, may exacerbate asthma. In sulfite-induced asthma, the principal mechanism is believed to be the inhalation of SO2 as sulfite-containing foods are chewed in the mouth. In addition, a small number of individuals have been identified who have a sulfite oxidase enzyme deficiency, which prevents metabolism of this preservative and could result in high blood levels. In a few cases of documented urticarial reactions to...

Pulmonary Reactions Involving Food

Rhinitis and or asthma-like symptoms (wheezing, respiratory distress) occur as part of systemic anaphylaxis to foods. It has been shown in studies of children with atopic dermatitis who are allergic to foods that after specific food avoidance, followed by DBPCFC 2 wk later, one-third are likely, upon challenge, to develop respiratory symptoms, such as rhinitis or asthma, along with exacerbation of their skin rash. Other than these two situations, isolated rhinitis after food ingestion as a result of allergy is rare. The estimated prevalence of food allergy induce asthmatic reactions is also low (26 ) except in those with documented food anaphylaxis or concurrent atopic dermatitis (up to 24 ). From studies in the United Kingdom, there appears to be an increase risk (5- to 10-fold) of future respiratory allergy (rhinitis or asthma or both) in infants who have an allergy to eggs or egg and milk, especially if they have eczema.

Discuss the particular concerns regarding muscle relaxation and reversal in patients with chronic obstructive pulmonary

Anticholinesterases (neostigmine and edrophonium) reverse the effects of nondepolarizing relaxants. Theoretically they may precipitate bronchospasm and bronchorrhea secondary to stimulation of postganglionic muscarinic receptors. However, clinically bronchospasm is rarely seen after administration of these agents, possibly because anticholinergic agents (atropine or glycopyrrolate) are concurrently administered.

A3 Adenosine Receptor Antagonists Mrs1523 Kf26777 And Mre3008f20

There are major differences among species in the expression and function of the A3 AR subtype, which complicates the understanding of the functional significance of this receptor subtype in the pathogenesis of chronic inflammatory airway diseases 63 . It has been shown that the A3 AR mediates the adenosine-induced mast cell degranulation in rats, mice, and guinea pigs 64 , whereas A3 receptors have not been identified on human mast cells 65 . A3 ARs have been shown to play an important role in eosinophilia and mucus production in animal models 65 . Also, A3 ARs are found on human eosinophils, and elevated levels of A3 receptors are observed in lung biopsies of patients with asthma or COPD 66 . The classical xanthine antagonists of ARs, theophylline and caffeine, typically have low binding affinities for the A3 AR, and therefore, the search for A3 AR antagonists has been focused on novel heterocyclic systems. Initially, a dihydropyridine derivative that has good affinity for the A3 AR...

Changes In Disease Notification

When investigating time trends of disease it is important to remember about the change in disease notification which may occur between ICD revisions. This impacts on how you retrieve data from national statistics. As mentioned in Chapter 4, most publishers of national statistics incorporate a correction factor to apply to the current data set. Another factor which should be considered is changes which are due to diagnostic fashion. For example, national statistics in the UK show that the incidence of asthma is increasing. However, it is not clear whether this is due to a true change in the incidence rate or to a change in the willingness to diagnose the disease.

Targeting Nonhepatic Hmgcoa Reductase

Diminish, both through empirical observation and directed trials. This factor may already account for the variability in the results from some clinical trials. Taken together, these previous data suggest that there may be further opportunity for chemistry optimisation of statin class drugs achieving higher systemic exposure, to exploit these potential novel mechanisms, assuming that the mechanism behind muscle toxicity can be understood and avoided. Alternatively, there exists the possibility of delivering statins at high relative concentrations to local sites and optimising the structure of the statin to ensure it is rapidly metabolised to an inactive form, either on exposure to the systemic circulation, or through efficient clearance on first pass metabolism, i.e., a 'soft statin' approach. Clinical conditions amenable to this strategy include asthma, allergic rhinitis or dermatitis, psoriasis, or even arthritis.

Signs and Symptoms of Other Organ Specific Reactions

Type II immune reactions (see Table 2) to drugs such as p-lactam antibiotics may result in a hemolytic anemia, usually 7 d after beginning therapy. Quinine, quinidine, and heparin have been involved in immune thrombocytopenic-type reactions. Hepatitis has been shown to occur with several drugs, including sulfonamides, phenytoin, and halothane. Methicillin as well as sulfonamides have been involved in producing interstitial nephritis in rare patients. Phenytoin and gold have been involved in reactions characterized by systemic eosinophilia and pneumonitis. The Churg-Strauss syndrome, a systemic eosinophilic granulomatosis and vasculitic process involving asthmatics, has been reported in increasing numbers of patients receiving leukotriene antagonists, glucocorticosteroids, and macrolide antibiotics, although there may be no causal relationship.

How should any allergic reaction be treated

The typical presentation for a severe reaction is in a patient with prior exposure with symptoms developing soon after repeat exposure, although cross-sensitization with commercial products may permit a severe reaction on initial exposure. Respiratory symptoms include edema, especially of mucous membranes and the larynx, bronchospasm, and pulmonary edema. Cardiovascular symptoms include hypotension and tachycardia. Cutaneous manifestations include flushing and hives. These are the manifestations of the most severe, potentially fatal, IgE-mediated reaction known as anaphylaxis. Should a real or likely anaphylactic reaction be recognized, the following recommendations are made Nebulized albuterol 0.3 for bronchospasm.

Vivian P Hernandez TrujiUo md and Phil Lieberman md

Histamine is widely distributed throughout the body, with the highest concentrations in the lung, skin, and gastrointestinal tract. H1 receptors are the most important in producing allergic symptoms. Most first-generation antihistamines have a structural resemblance to histamine. The most important side effect of first-generation antihistamines is sedation. As a consequence, increasing numbers of second-generation antihistamines have become available. The activities of second-generation antihistamines are probably related to the fact that each of these mediators act through a G proteincoupled receptor that is analogous in structure to the receptor for histamine. The advantages of second-generation antihistamines include lack of sedation and ease of use (i.e., once-daily dosing). Antihistamines are important in the treatment of various allergic diseases. Antihistamines are the first-line therapy in the treatment of allergic rhinitis. Antihistamines are also becoming increasingly...

What is inhalation injury

Inhalation injury occurs when hot gases, toxic substances, and reactive smoke particles reach the tracheobronchial tree. These substances result in wheezing, bronchospasm, corrosion, and airway edema and should be suspected if the burn was sustained in a closed space. The presence of carbonaceous sputum, perioral soot, burns to the face and neck, stridor, dyspnea, or wheezing are indications for complete respiratory tract evaluation. Inhalation injury can cause damage to the upper airway (i.e., airway compromise, nasal obstruction, and acute laryngitis with varying degrees of laryngeal edema), damage to the conducting airway (i.e., tracheitis and bronchitis), and injury to the lower respiratory tract (i.e., pneumonitis, pulmonary edema, and adult respiratory distress syndrome). Chest radiographs during the initial phase usually underestimate the severity of lung damage because the injury is usually confined to the airways. Fiber-optic bronchoscopy has been quite useful in diagnosis of...

Dealing With Asthma Naturally

Dealing With Asthma Naturally

Do You Suffer From ASTHMA Chronic asthma is a paralyzing, suffocating and socially isolating condition that can cause anxiety that can trigger even more attacks. Before you know it you are caught in a vicious cycle Put an end to the dependence on inhalers, buying expensive prescription drugs and avoidance of allergenic situations and animals. Get control of your life again and Deal With Asthma Naturally

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