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.

ALLERGIC RHINITIS MARCH TO ASTHMA

Symptoms which begin as watery , itchy , blocked nose,  persist for days and keep recurring every now and then could be due to Allergic rhinitis.
People just manage this with home remedies or over the counter pills and carry on for years together.
This results into chronic sinusitis , Asthma , headaches spread of allergy to eyes resulting into red itchy eyes.
Allergy is like growing tree , if the roots are intact new branches are bound to come .
Allergic rhinitis may become quiet but can erupt as Urticaria , rashes , iching etc.
Migraine may also be due to allergy.
Abdominal symptoms can also be due to food allergy or even an accompniment of allergic rhinitis , asthma , skin allergy etc.
the severe manifestations can be recurrent  angioedema which can be life threatening.
I have seen patients with swelling of tongue so that it is difficult to fit tongue within the mouth
resulting into medical emergency.
Laryngeal edema causes choking and is always life threatening.
Therefore nasal allergy should not be neglected.
Treatment is succesful if scientific and persistent.

ALLERGY SEASON APRIL MAY RESPIRATORY ALLERGY.

 Allergy season has started , patients who suffer from seasonal allergies alone have started developing rhinitis and Asthma symptoms.
Even those who suffer from perennial allergy have started having aggravation in symptoms.
All this can be prevented if patients start  preventive treatment in preseason even when they are not suffering.
Its important to educate the patients to visit doctor surely in early March and August for preventive treatment.
Those who are already on treatment have to ensure that they are regular on their nasal spray and inhalers and follow up with doctors.
Nasobronchial seasonal allergy can best be tackled by scientific approach.

ASTHMA EMERGENCY

Every time I see an Asthma  patient in emergency I realize that  its communication by us doctors
which was not effective otherwise nothing could land him in emergency.
He started feeling confident of his Asthma control that he stopped coming for follow up and stopped use of inhaler in Sept October on his own. Remained well for 4 days but landed in emergency on 5th day. He did not have any written protocol , he panicked and started with multiple puffs on Steroid inhale instead of the bronchodilator salbutamol.
This is one of the stories.
Its wrong to abruptly stop the inhaler in the aggravating season even if you feel well.
Inhalers could be changed stopped only  on advise of doctor. Even after stopping ,
one should make use of peak flow meter to judge that airways are not in spasm. If they are ,use brochodilator followed by steroid preventive inhaler
If you get into spasm and have a written protocol you will be more confident to handle
the bronchospasm. Multiple puffs of salbutamol inhaled properly without panic is the key to
reversing the spasm.
There are many other reasons for patients to stop inhalers inappropriately.
Inhalers are safe. Do not be in a hurry to stop them.
Doctors ought to hammer into patient the science and art of inhalers and disease.
Doctors ought to give written protocols to handle emergencies.
Lets win  Asthma , Let there never be an emergency and asthma related death. 

Immunotherapy in allergic diseases.

Conclusions of Allergy conclave.

• Allergy is a global problem with ever growing prevalence.
• While pharma co therapy is good for control of symptoms , immunotherapy is the only answer for disease modification.
• For effective immunotherapy allergen identification should be accurate.
• Accurate allergen identification depends on purified allergenic extracts , right technique and selection of subjects.
• It is common to have multi-allergen sensitivity in a patient, in such situation most appropriate allergen need to be selected based on scientific evidence.
•  Detailed history is most crucial in allergen identification correlation.
• SPT is the preferred method of  allergy tests , SIgE may be necessary only in select situations and certainly remote testing just by  sending blood to some laboratory must be condemned.
• Purified extracts  with standardized  biological value should be available to deal with this problem.

collaborating as faculty for the 1st Allergo Conclave “Newer paradigms in Allergy Management” held on April 24, 2015.

 I collaborated as faculty for the 1^st Allergo Conclave “Newer paradigms in Allergy Management” held on April 24, 2015.. Conclusions were very pertinent. 

Allergies are increasing worldwide , human airway disease is an immense economic burden globally.

Correct Allergen identification is of immense importance in planning treatment.

Detailed history is first important step. The history must focus on environment ,occupation,food and drug intake

by any route personal care products , meteorological and geographical variations etc, 

Skin prick test is the gold standard in tests if performed with purified allergens with correct technique.

Specific IgE is of value where skin tests are not possible but practice of just doing this in a lab without 

expert consultation must be condemned. Total IgE is nonspecific , associated with many other common conditions like parasitic infections , and is not recommended.

 Provocation tests , nasal and bronchial should be used to identify major allergens.

Food allergies also have an important role in respiratory allergies.

For Food Allergy double blind placebo controlled challenge test is gold standard.

Poli Sensitisation in different studies is from 27 to 78 percent in respiratory allergies..

Pharmacotherapy and Immunotherapy are methods of treatment.While inhaled steroid is the cornerstone in reducing inflammation, immunotherapy is useful in long term management.

Immunotherapy if done scientifically with purified allergen extracts, after accurate identification of major allergen can help in reducing doses of medicines and is steroid sparing .

Most important step is to select the  relevant allergen useful for Immunotherapy.

Relevant allergen is not the one which has maximum positivity on skin test but is the one which has maximum correlation with history and other factors.

European studies do not recommend mixing of allergens.

American studies do not recommend mixing of more than 4 allergens.

While mixing compatibility with each other and degradation of proteolytic enzymes must be considered.

Certain groups like fungi with dusts should never be mixed for immunotherapy.

It is preferable to give single allergens on two arms.

Subcutaneous immunotherapy ( SCIT) and sublingual immunotherapy (SLIT) are two methods in use.

Studies have  found SCIT to be superior but SLIT has the advantages of ease of home administration and no harmful effects like anaphylaxis.

Minimum duration of immunotherapy is 3 to 5 years.

Pharmacotherapy is useful in everyday management of patients but Immunotherapy is the only method by which long term disease modification is possible.

Immunotherapy has stood itself on firm scientific grounds , certainly helps in reducing symptom score and medication requirements. It also helps in preventing new sensitization. It stops the march of Allergic rhinitis towards Asthma development.

Health education is most important aspect for better compliance.