Why do we still have bronchial Asthma related morbidity and mortality?

Bronchial Asthma is an age old disease being treated by all systems of medicines . There is tremendous progress in diagnosis as well as treatment modalities which are easy and affordable yet Bronchial Asthma remains a major challenge especially in our country . Diagnosis is very obvious when patients present . However in childhood all that wheezes is not Asthma but at the same time Cough variant Asthma is not diagnosed early and children are put on frquent unnecessary antibiotics cough syrups etc whereas what they need is simple and specific treatment for asthma by inhaled stetoids . Eye irritation , itchy throat and nose , recurrant Coryza sore throat runny nose etc are symptons for allergic rhinitis which often progresses to Asthma if left untreated as it is the one airway disease . Especially in children extrinsic asthma is more common therfore Allergy tests particulrly for the food allergens like milk egg fish etc if diagnosed early can help in better control . The allergy tests are simple and very useful provided performed by an expert by Skin tests which is a gold standard . Yet inhaler therapy is the conrnerstone of treatment . There are state of art molecules of steroids inhalers which are preventive inhalers and are meant for regular long term use to take care of inflammation which is the main pathology of Asthma . They are safe and essential , are the surest method for drug delivery into the inflamed airways which are causing reversible obstruction resulting into asthma . The second group of inhalers are bronchodialators which are necessary in emergency and for long term management too but are temporarily helpful without steroid inhalers . Inspite of affordable inhalers people often worry a lot and reject the inhaler use due to many myths associated with the word stetoid . People are not willing to accept the diagnosis of Asthma as though its a tabboo ! inspite of very good tests to test food allergy people often stop mamy food like rice curd banana etc nutritious food just due to myths of not giving white food ! Due to myths children are nutrionaly deprived and also life becomes complex . Why stop food on presumptions when allergy tests are easy .Just a word of caution that allergy tests must not be done simply by sending blood sample to lab without consukting the allergy specialist . Labs have to be guided by the allergy specialist about what to test in the particular patient . Each patient is an individual general rules of testing every thing is a disaster . The Allergy tests are best performed by the doctor after detailed history and examination of patient to decide what to test . Thus in Bronchial Asthma Health education at every step is most important for acceptance of diagnosis , for acceptance of inhalers , for not getting scared with name steroid inhaler , for understanding the technique , for recognising allergy diagnosis early rather than indiscriminate use of antibiotics ,not stopping food based on myths , if test is needed not to fall pray to remote testing by labs without allergy specialist deciding what to test . Patients must follow the treatment diligently rather than stopping it as soon as there is relief in that particular attack . Lets attack Asthma by all means and let everyone breath lung full !

TELEMEDICINE in Asthma & Allergy patients in COVID days.

These are difficult days because of pandemic of COVID 19.

At the same time it is also important to safeguard health of patients who are suffering .

Day to day problems and acute problems are handled differently than the chronic problems. 

A known case of Allergic rhinitis , Asthma or  allergies must be already on treatment and needs continuity of care. The seasonal respiratory allergies are expected to have exacerbation of symptoms in April May & September October.  Those who are completely asymptomatic can become symptomatic or those who have perennial symptoms may have exacerbations.

The patients who are already on treatment must be having a written emergency protocol to deal with Asthma attack and they must have been repeatedly been explained how to use the salbutamol inhaler multiple puffs inhalation at the time of need. They must have already been imparted with the knowledge of how to identify Asthma attack.

If a doctor gets a phone call , it is important to assess the emergency on video call. 

Patients blue lips , working of alae nasi , chest retractions , rapid respiratory rate-the signs of respirator distress are easily visible on video. Such patients who have tendency to go into acute attack must be keeping home nebuliser and salbutamol and budecort respules.  They must start home nebulisation immediately & an oral dose of prednisolone as per body weight should be advised immediately. The doctor  should also alert emergency care because if cyanosis does not settle patient will require oxygen & hospitalisation . If this is needed nebulisation should continue in the car. Nebulisation is an aerosol generating procedure & is being done in hospitals under extreme care & protection but at home this is safe. However  even for emergency multiple puffs of MDI are preferred over nebulisation and are most of the times helpful in reversing the attack of asthma.

The most important aspect of chronic disease is routine regular follow up so that emergencies do not arise.

Every patient of NASOBRONCHIAL ALLERGY must adhere to follow ups . Allergic Rhinitis though it sounds simple has tendency to march to Asthma , therefore requires good control. If the rhinitis becomes worst it can be confused with Covid because both have flu like symptoms. Generally in Rhinitis there is no fever , cough and breathlessness which are hallmarks of Covid. Rhinitis has excessive sneezing , blocked nose , itchy ears , throat , nose , red itchy eyes , post nasal drip & a nasal twang in voice. But to give benefit of doubt Covid test should be done if evidences point towards that.

All this can be assessed by intelligent observations and questions on video call.  Sinuses are also involved in Allergic rhinitis resulting into typical headache. Patients will also have past history of exacerbations of allergic attacks.

Bronchial Asthma patients should also remain on regular follow up so that it can be ensured that they do not miss the preventive inhalers and do not get into emergency.

Inhalation techniques & PEFR can also be assessed on video calls.

Thus most of it is possible on telemedicine so patients must prefer this and should go for physical examination only if doctor finds it absolutely unavoidable.

COVID 19 FOR ASTHMATICS

Ever since  Corona pandemic is spreading its tentacles and engulfing many all over the globe the fear and anxiety of Asthma patients 

have increased manifolds

The main questions are "am I more susceptible because of weak lungs?""Can my steroids put me more at risk ?"Should I stop inhalers ?"

What can Ï take to boost immunity ?"How should I sanitise my inhaler and peak flow meter "

"But Ï took the flu vaccine so am I protected ?""Should I repeat the pneumonia vaccine , should I keep oxygen cylinder and nebuliser at

 home in case.I get into trouble?

To allay all the anxiety in one sentence I would urge to all Asthma patients that so far there is no scientific evidence that Asthmatics are 

more prone to infection due to Coronavirus or its complications. They need to follow the same rules of prevention like social distancing

,use of clean mask , hand washing and personal & environmental hygiene.

Taking specific questions it is recommended that they should continue to keep their Allergic rhinitis as well as Asthma under good control

with use of steroid nasal spray and inhalers so that rescue medicines are needed seldom. In fact seasonal allergies are at its peak therefore 

optimum control is desired. If you sway from this the emergency room visit might put you more susceptible to exposure to Corona though 

best practices are being followed in hospitals. In fact by proper control of Asthma with inhalers, nebulisation can be avoided which is the aerosol 

generating method and should be avoided during pandemic . Your inhaler and peak flow meter are your personal equipments , you should handle 

them after washing hands and clean them as you do on normal days. Sanitisers can be used if needed . If you keep good control of Asthma you will

 not need oral steroids or oxygen for emergencies. Asthma is a disease of airways , it is the reversible airway disease so don't think that your lungs are

 weak or your immunity is low. Keep eating normal healthy balanced food  , of course avoid your identified food allergens if any. Keep hydrated.

Don't use fumes or perfumes , dont smoke , don't take Aspirin , Brufen etc which are the usual precautions for all times.

The Influenza vaccine will protect you against those strains of viruses for which it is meant. No doubt Coronavirus affects lungs but taking  additional

pneumonia vaccine is not the answer . In any case Pneumonia vaccine is to prevent specific bacterial pneumonias.

Healthy food & no anxiety are the best for immunity. you don't need immunomodulators to prevent risk of Coronavirus infection.

Stay safe with discipline of avoiding Asthma triggers ,  Asthma control with proper medication &  positive attitude.

Follow all discipline to avoid corona virus as is applicable to general public.

  

IMPACT OF ALLERGY ON QUALITY OF LIFE.

He walked  swiftly in my clinic with newspaper in hand and uttered aggressively "'I bet you cant make me alright , no body could !'' I could gauze his angry mood , I thought he must be so upset because of his unbearable malady . I gave him a comforting look and requested him to sit down. He understood my unspoken words and my utmost desire to help him.
He said 'I read your article in Tribune and I thought I should try you also for my misfortune of nose allergy.But I have just one hour with me , my bus for Haridwar is after an hour , I am coming from Solan after submitting my resignation in the school."I said oh my God , why did you resign and what will you do now ? He said I have such severe running of nose all the time that it is impossible for me to even lift my head to take a class . Children make fun of me , I have to  use not a hanky but a towel to wipe my secretions." I said  "so what will you do in Haridwar , you have a new job "? He said , I am a PhD but I will simply run my fathers tiny shop as I am not suited for teaching or anything else due to my  severe allergy.
I thought to myself that what is the use of my super specialisations in Allergies if a young Ph D has to resign from job due to allergy and he has to  severely compromise with his aspiration .
I told my assistant , "Nadeem please go with him and help him take a room in nearby dharamshala "I insisted upon the man that please help me by staying here for two days. I promise I will do my best. He found me very convincing , he stayed back.
Meanwhile I called up his principal as luckily he used to come to me those days for his sons Asthma treatment. He said "yes doctor , how can I help you " I said so and so has submitted his resignation to you , please don't process it for next ten days."He said "Is he your relative , you never told me , well surely I can do it for you , first time in life you asked me for something "I said thanks and thought to my self that he had become my patient so he was indeed my relative!
 I tested him for two days and started treatment . He came back the fourth day and said "doctor I extended my stay as I have some hope in the treatment. I said treatment in Allergies is long so don't over expect. "He was firm on staying back . He came back after five days and he said 'Ok please prescribe for ten days I will keep coming to you from Haridwar."
I said come to me tomorrow. I spoke to the principal and reminded him of that resignation and told him how did he become my relative after reading my article in the bus and now he is ready to come back to the school for his job."The principal found it really strange and complimented me for thinking beyond my duty, he was happy to ignore his resignation. Next day when the gentleman came for his prescription my note also included "FIT to join duties in the school & request school to send him for review periodically as advised."
He was surprised and couldnt believe me . I told him the whole thing . Tears started rolling out of his eyes , he said I never knew doctors could think like this & tears wont stop. I told him stop your tears you are failing my treatment , your nose may also start crying . Me and my assistant treated him to samosa and Lassi and bid him bye. After so many years when I recall that day I am amazed at power of an article which has prevented  a teacher from failing in life due to ailment of allergy!

Cough variant Bronchial Asthma.

He was coughing off and on for past two months.
This  increases on lying down , on laughing and on speaking long sentences.
He visited several practitioners who treated  him  with antibiotics.
When there was no response they changed antibiotics and  added mucolytics.
Nothing improved his cough which was dry in nature and was persistent.
He was investigated  too . The blood workup was normal , the chest X ray also did not reveal any thing abnormal.
It was pulmonary function tests which showed evidence of obstructive airway disease which  reversed on bronchodilators.
Thus obvious diagnosis was Bronchial Asthma . The treatment was inhalers , the preventive inhaler of steroid and long acting bronchodilator inhaler. This comes as a combination inhaler too.
He took it  regularly and the cough was gone.
He was saved of many unnecessary medicines which cause many side effects.
Therefore its essential to keep the  entity COUGH VARIANT BRONCHIAL ASTHMA in mind. THe patients should  be diagnosed early and treated specifically.
l

BRONCHIAL ASTHMA REVIEWED .

Lot of new research is being done to control this old malady, but the time tested principals still are the gold standard.
First of all the persistent nasobronchial symptoms particularly cough and definitely recurrent wheezing , breathlessness on speaking long sentences , laughing etc should be investigated for bronchial asthma.
Next most important step is to accept the diagnosis and inhalers.
It is often seen that patients or parents do not  want inhalers for the fear of addiction.
They keep children on unnecessary nebulisation , antibiotics , oral bronchdilators and even oral steroids which are certainly undesired , unscientific and dangerous modes of treatment .
cornerstone of Asthma treatment is inhaled steroids.
Patients must be demonstrated the method of inhalation so the desired salts enter the airways in desired amount.
Patients must also understand that preventive doses of inhaler is essential in fixed doses even if patient feels fine because basically it is for controlling inflammation.
Patients should also know the use of emergency inhaler salbutamol.
In difficult cases and most children Allergy triggers must be investigated which can be  done by simple allergy skin tests.
Based upon the test  results , Food allergy as a factor can be removed . Food allergy is a significant factor in bronchial asthma.
Allergy tests  also help deal occupational and environmental factors too..
Thus inspite of advances in Asthma management , majority of patients would need basic effective tretment which can be made effective with health education.

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EOSINOPHILIC ASCITES.

She was only 12 yr old . went out for christmas break with family in a nearby resort

but had to be hospitalised due to severe abdominal pain.

Was kept on symptomatic treatment and was being investigated thoroughly as the pain was recurrent.

The only clue in investigations was significant  eosinophilia and  Ascites.

All the common causes of ascites were ruled out .

Ascitic fluid was tapped which revealed significant eosinophils in ascitic fluid.

Endoscopy was normal .

She was treated with steroids to which she responded.

Three months later she again developed pain abdomen with bleeding per rectum.

She was hospitalised as ultrasoung examination revealed ascites progressing rapidly.

Ascitic fluid was full of eosinophils,

Colonoscopy was done with biopsies at all levels.

Colon , cecum , ileum , rectum at various levels revealed significant eosinophilic infiltration

EOSINOPHILIC GASTROENTERITIS is a well known entity though is very rare.

She was investigated further for food allergy which revealed SIgE raised for Fish and ST also positive for fish.

History revealed that during both episodes she had consumed fish .

She was treated with steroids but was instructed to avoid all sea food strictly .

She is symptom free for past 7 months.

It does not mean that FISH or sea Foods are bad but it simply means that one mans food can be another ones poison . ROLE of FOOD ALLERGY testing in difficult situations is highlighted here.