Foods to help when you have Asthma

Asthma Free Forever By Jerry Ericson

With Asthma Free Forever, asthma sufferers worldwide will learn how they can cure asthma easily, naturally, and permanently in Asthma Free Forever. This guide was written by Jerry Ericson, an alternative medical practitioner and former asthma sufferer. Inside this guide, users will discover the methods that helped the author cure his asthma without useless and harmful medications. A well organized and precisely explained all natural asthma recovery methods keeps you out from having on the counter drugs pr from so highly priced medicines prescribed by the doctors, even you need to revolve around the doctor for good results to be shown, there is all consists inside the content of this online health guide and by following it properly and timely you will get treated soon. With the help of Asthma Free Forever, anyone can solve its asthma problem for good in just a few days right in the comfort of their own home. This treatment is based on proven medical research, so users can be sure that it's safe and guaranteed to work. Read more...

Asthma Free Forever Summary


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Late Asthmatic Reactions in the Lung

Over 50 of asthmatics have secondary reactions occurring 4 to 8 hr after the initial asthmatic episode. Late-phase reactions are characterized by prolonged contraction of smooth muscle, increased mucus secretion, and an inflammatory response. Another proposed mechanism requires histamine releasing factor (HRF) and the presence of IgE on the mast cell surface. It is proposed that HRF reacts with cell-bound IgE in a way that cross-links or bridges two IgE molecules. Cross-linkage initiates the signaling process that releases mediators. However, HRF releases histamine from only 50 of asthmatic cells. It is possible that there are two IgE subtypes reflecting differences in glycosylation or alternative gene splicing. Only one subtype will react with the HRF. A third mechanism implicates hypodense eosinophils as the effector cells in the late-phase reactions. PAF and LTB4 are chemoattractants for the eosinophils. Accumulation of the hypodense eosinophils enriches most inflammatory...

Bronchodilators Sympathomimetic

A bronchodilator is a drug used to relieve bron-chospasm associated with respiratory disorders, such as bronchial asthma, chronic bronchitis, and emphysema. These conditions are progressive disorders characterized by a decrease in the inspiratory and expiratory capacity of the lung. Collectively, they are often referred to as COPD. The patient with COPD experiences dyspnea (difficulty breathing) with physical exertion, has difficulty inhaling and exhaling, and may exhibit a chronic cough. The two major types of bronchodilators are the sym-pathomimetics and the xanthine derivatives. The anti-cholinergic drug ipratropium bromide (Atrovent) is used for bronchospasm associated with COPD, chronic bronchitis, and emphysema. Ipratropium is included in the Summary Drug Table Bronchodilators. Chapter 25 Examples of sympathomimetic bronchodilators include albuterol (Ventolin), epinephrine (Adrenalin), salme-terol (Serevent), and terbutaline (Brethine). Many of the sympathomimetics used as...

Summary Drug Table Bronchodilators

Bronchospasm, induced bronchospasm Asthma, bronchospasm Asthma, bronchospasm Asthma, bronchospasm of asthma, prevention Asthma, bronchospasm Bronchospasm during Bronchospasm Asthma, bronchospasm Maxair Autohaler, Asthma, bronchospasm Asthma, bronchospasm Asthma bronchospasm

Early Asthmatic Reactions in the Lung

Asthma is a disease characterized by partial airway obstruction that is reversible either spontaneously or with treatment. Up to 80 of patients with asthma have positive skin tests to common aeroallergens such as pollens or grasses. Over 75 of asthmatic patients have associated rhinitis (Nelson, 1985). When exposed to the allergen for the second time, histamine, heparin, and trypase are extruded from the mast cells or basophils within 15-20 min. The preformed mediators have diverse biological functions. Histamine is a major pharmacological mediator released from mast cells and basophils. Interactions between histamine (H-l) receptors on smooth muscle induce contraction of smooth muscle. This causes a reduction in airway caliber and the characteristic wheezing associated with asthma. Histamine H-2 receptor interactions increase mucus secretion and blood How. Heparin is released as part of the histamine granule and functions as an anticoagulant. The most abundant protease in mast cells...

Roles of Mast Cells in Asthma

Mast Cell Recruitment Skin

Allergic asthma is a chronic disease of the respiratory tract (41). It is characterized by relapsing-remitting episodes of reversible airway obstruction. Clinical symptoms include shortness of breath, wheezing, chest discomfort, and coughing, which can lead to respiratory failure. Eosinophilia, lung inflammation, elevated serum IgE, mucus hypersecretion, and hyperreactive airways are typical. Like immediate hypersensitive responses, allergens elicit the initial symptoms, and mast cell mediators promote early bronchial constriction, airway edema, and mucus plugging as well as recruitment of eosinophils. Lymphocytes and eosinophils are recruited within 24 h and contribute to the disordered airway physiology and early remodeling. Because mast cell-stabi- lizing drugs have little value in treating chronic asthma, it has been assumed that mast cells do not contribute to later events in the pathophysiology of this disease. However, recent data from human studies strongly suggest that mast...

The Asthmatic Patient

Patient Mechanical Ventilation

Acute changes in lung mechanics experienced by patients with severe bron-chospasm due to asthma attacks are similar to those observed in COPD during acute exacerbations. However, the pathophysiology of asthma may differ substantially from that of COPD. Increased airway collapsibility due to destruction of the lung parenchyma and loss of lung elastic recoil is a main feature of COPD patients. In asthma, the increases inbronchomotortone, and inflammatory infiltration may stiffen the airway walls and decrease collapsibility, despite considerable reduction in airway caliber 1, 37 . Additionally, in asthmatic patients, a decrease in lung compliance due to hyperinflation and widespread airway closure has been described, and in these circumstances end-inspiratory plateau pressure may be a better marker of hyperinflation than PEEPi 38 . Moreover, contrary to what occurs in COPD, these factors are usually generalized and reversible with pharmacologic treatment in the case of severe asthma 37 ....

Fighting Asthma Gastrointestinal Disorders Parasites

The major anti-asthma drugs come from ephed-rine, extracted from the ma huang plant (Ephedra sinaica), and its structural derivatives. Plant-derived drugs that affect the gastrointestinal tract include castor oil, senna, and aloes as laxatives, opiate alkaloids as antidiarrheals, and ipecac from Cephaelis acuminata as an emetic. The most useful

Occupational Asthma

Occupational asthma differs from classical aeroallergen atopic asthma in several respects. The disease often develops in people who are not atopic. Unlike classical asthma, the onset of asthma may require a latent period of several months to several years. When subjects are fully sensitized, they have demonstra- Workplace asthma can be associated with substances such as high-molecular-mass proteins (usually 20-50 kDa) or small haptenic compounds. Workers in printing, fertilizer, enzyme producing, and soldering plants are at most risk for sensitization by high-molecular-mass compounds. In contrast, persons working with low-molecular-mass haptens such as anhydrides or isocyanates are at risk of sensitization (D. I. Bernstein etal., 1982). The role of the immune system and IgE production varies with the hapten. There is a strong association between anhydride-specific IgE and symptoms of immediate hypersensitivity (Zeiss et al., 1980). In contrast, there is no clear association between...


Accumulating data indicate that airway obstruction, which is thought to be caused by smooth muscle constriction, mucosal edema, and secretion of fluid into the airway lumen, may partly be due to a dysfunction of pulmonary surfactant (54,55,109,110). Surfactant obtained from BAL and sputum of patients with asthma has decreased surface activity and changes in composition (17). It has been shown in animal models of asthma that though the change in the amount of surfactant is little, it may be in a less functional form (111). Cheng et al. (112) demonstrated that, in a guinea-pig model of chronic asthma, the surfactant pool size and content of large surfactant aggregates was decreased.

Bronchial Asthma

The efficient treatment of asthma depends to a great extent on the empowerment of the patient, who is able to conduct regular self-observations and self-measurements. The monitoring of asthma course relies on regular measurements of airway obturation with a portable device. The appropriate preparation to self-management of asthma is based on education and training delivered by health professionals or specialised educators. This process may be considerably supplemented and enhanced with Internet-based applications. The advantage of such approach is continuous availability of the resources to the patient. The results from feasibility studies indicate that airway obturation measurements performed by patients at home and sent via telecommunication links are reliable 17 18 . Patients with asthma usually show high acceptance for the use of telemonitoring systems and even patients without a computer background are able to use such systems properly. The systems used for remote telemonitoring...

Antiasthma Drugs

Asthma is a respiratory condition characterized by recurrent attacks of dyspnea (difficulty breathing) and wheezing caused by spasmodic constriction of the bronchi. With asthma, the body responds with a massive inflammation. During the inflammatory process, large amounts of histamine are released from the mast cells of the respiratory tract, causing symptoms such as increased mucous production and edema of the airway and resulting in bronchospasm and inflammation. With asthma the airways become narrow, the muscles around the airway tighten, the inner lining of the bronchi swell, and extra mucus clogs the smaller airways. (See Fig. 37-1.) Along with the bronchodilators, several types of drugs are effective in the treatment of asthma. These include corticosteroids, leukotriene formation inhibitors, leukotriene receptor agonists, and mast cell stabilizers. Antiasthma drugs are used in various combinations to treat and manage asthma. Using several drugs may be more beneficial than using a...

The Impact on Relations in Healthcare

Nowadays, self-management has become a well-evidenced target of national and international strategies for management of specific medical conditions (e.g. Global Initiative for Asthma GINA 9 , Global Initiative for Chronic Obstructive Lung Diseases GOLD 10 ). This has resulted in the eruption of e-health solutions in the area of chronic care, which offer the provision of information adjusted to patient needs, feedback communication with health professionals at monitoring centres, prompt response from health providers in case of unfavourable trends in patients' health status and opportunity to participate in support groups with other patients and their families. Even if some risk may be related to access to unreliable health-related contents on the Internet, the role of e-health solutions in patient education cannot be overestimated.

Nursing Responsibilities

The primary nursing responsibility is to provide the patient with proper instructions for administering the drug. For example, many patients with asthma use a metered-dose inhaler to dilate the bronchi and make breathing easier. Without proper instruction on how to use the inhaler, much of the drug can be deposited on the tongue, rather than in the respiratory tract. This decreases the therapeutic effect of the drug. Instructions may vary with each inhaler. To be certain that the inhaler is used correctly, the patient is referred to the instructions accompanying each device. Figure 2-9 illustrates the proper use of one type of inhaler.

The Mediators Expressed by Mast Cells and Their Role in the Inflammatory Response

It is likely that heterogeneity of human mast cells exists in regards to cytokine expression in vivo and studies by Bradding et al. (63), demonstrated this phenomenon in mast cells obtained from bronchial biopsies of patients suffering from asthma. By immunocytochemistry, these investigators noted that although MCtc cells predominantly expressed IL-4, the MCtc cells expressed both IL-5 and IL-6 (63). In our studies, cord blood-derived mast cells expressed the eosinophil-active growth factors IL-5 and GM-cSF and the eosinophil chemotactic C-X-C chemokine, IL-8, after activation (42). The production of these cytokines in cord blood-derived mast cells was further enhanced by the addition of the monokines IL-1P and TNF-a in a dose-dependent manner while dexamethasone inhibited production of these cytokines. How these various cytokines and chemokines interact with the inflammatory response is summarized below. Mast cells have been incriminated in such diverse diseases as allergy, asthma,...

Specific Issues Relating To Chronic Obstructive Pulmonary Disease And Emphysema

Chronic obstructive pulmonary diseases (COPD) are characterized by reduced maximal expiratory flow and include various disease entities such as chronic obstructive bronchitis, asthmatic bronchitis, and emphysema. At least 14 million people in the United States suffer from COPD, and the prevalence of this disease seems to be increasing (13-16). As many as 2 million people suffer from emphysema, and the overall death rate for emphysema in the United States has been estimated at 20 000 yr, the fifth leading cause of death in North America (13,16-18). Exercise testing in patients with COPD has been stimulated by the increasing numbers of patients entering pulmonary rehabilitation programs (19), in addition to the availability of specific treatments for this condition, i.e., pulmonary transplantation and lung volume reduction surgery (LVRS).

Roles of Mast Cells in Immediate Type Hypersensitivity

Although allergies can cause extreme discomfort and alter quality of life, they also have the potential to be life threatening. Allergic responses generally are classified as immediate, occurring within minutes of allergen exposure late phase, occurring within hours or chronic, during which symptoms can relapse and remit over time, as is the case with asthma (1). These responses generally occur locally at mucosal surfaces, such as the airway passages and the gut, as well as in the skin, where mast cells are prevalent. Although there are differences in the particular manifestations of immediate-type allergic reactions at various sites, all pathology is the direct result of inflammation that gives rise to itch, redness, edema, and cellular influx. When allergen is encountered systemically, anaphylaxis occurs, resulting in rapid onset of these symptoms at several sites simultaneously (31). The precipitous drop in blood pressure can be deadly in this circumstance.

Side Effects And Radiation Dose

The radiopharmaceuticals used for lymphoscintigraphy are protein derivatives in some form or other. Consequently, allergic reactions may occur. An allergic reaction may present as a skin rash but also as bronchospasm, anaphylactic shock, and even cardiopulmonary arrest. Fortunately, such events are rare. No complications arose in a study of 160 patients with the 99mTc sulfur colloid and the 99mTc-labeled HSA 11 . Over the years, we have seen one allergic reaction (rash) in 25,000 patients undergoing lymphoscintigraphy for various indications. Allergic reactions are treated in the usual fashion depending on the symptoms and severity.

Complications of GERD Esophagitis Stricture Barretts and Cancer

Gastroesophageal reflux disease (GERD) has become a very prevalent disorder in the United States and the Western hemisphere. It has been estimated that as many as 44 of adults in the United States experience GERD symptoms described as heartburn at least once a month.1 In addition, as many as 10 of adults in the United States experience daily heartburn.2 The true prevalence of reflux disease may be largely underestimated when taking into account atypical manifestations of the disease as well as those patients who self-medicate.3,4 Unfortunately, many of these atypical manifestations often go unrecognized, and may take the form of ear-nose-throat, pulmonary, or laryngeal manifestations such as laryngitis, sinusitis, asthma, bronchitis, chronic cough, chest pain, and halitosis.4 A study by Harding and col-leagues5 showed that among those patients studied with a diagnosis of asthma and who denied reflux symptoms, 29 had abnormal esophageal pH studies. Irwin and Richter,6 when evaluating...

Method of Ventilation and Outcomes

Provision of ventilatory support without endotracheal intubation conceptually could reduce these complications of mechanical ventilation. There is convincing evidence from multiple randomized controlled multicenter trials of non-invasive positive pressure ventilation (NPPV) versus endotracheal intubation and mechanical ventilation in patients with acute respiratory failure from COPD that show improved mortality, morbidity, and shortened ICU and hospital stay 46 . NPPV may play a role in the support of patients with other causes of respiratory failure, including asthma, cardiogenic pulmonary edema, pneumonia, ARDS, and post-lung resection, but the data are still quite preliminary. To date, there are no studies of long-term outcomes of patients treated with NPPV, but it is conceivable that there would be a reduction in sequelae associated with intubation (airway trauma) and excessive sedation.

Step 4 Provide a Motivational Intervention for Smokers Currently Unwilling to Quit

Acute risks shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility, etc. c. Environmental risks increased risk of heart disease and lung cancer in spouses higher rates of smoking in children of smokers sudden infant death syndrome, asthma, middle ear disease, respiratory infections in children of smokers.

Physiological action of leukotrienes

Leukotrienes have potent biological activity. A summary of some of their more important actions is provided in Table 2.15. The peptidoleukotrienes contract respiratory, vascular and intestinal smooth muscles. In general LTC4 and LTD4 are more potent than LTE4. By contrast, LTB4 is a chemotactic agent for neutrophils and eosinophils. Although it can cause plasma exudation by increasing vascular permeability, it is less potent than the peptidoleu-kotrienes. These actions of the leukotrienes have implications for asthma, immediate hypersensitiv-ity reactions, inflammatory reactions and myo-cardial infarction.

Patients with Airway Manifestations of GERD

Patients with GERD and related airway symptoms represent a significant management challenge. When compared with patients with typical symptoms, medical therapy is more often ineffective, making surgery a more attractive alternative for these patients.3 The greater problem is that there is no current diagnostic test to conclusively link GERD and airway symptoms. The gold standard, 24-hour pH monitoring, is helpful, but reflux, although present, may not be the cause of the symptoms. Furthermore, abnormal reflux may be caused by pulmonary diseases such as asthma.4

Control of Airway Secretions

In addition to their bronchodilator properties, -agonists have been shown to increase tracheobronchial mucociliary clearance, presumably by increasing ciliary beat frequency. Theophylline As aforementioned, theophylline has also been shown to increase tracheobronchial mucociliary clearance. N-acetyl-L-cysteine breaks the disulfide bonds of mucoproteins. It liquefies and lowers the viscosity of mucus, and is given in 10-20 solution by nebulizer. It can cause bronchospasm, so it is usually given in combination with a -agonist. Acetylcysteine can decrease the volume and viscosity of sputum.

Adverse Reactions

Gastric upset, heartburn, nausea, vomiting, anorexia, and gastrointestinal bleeding may occur with salicylate use. Although these drugs are relatively safe when taken as recommended on the label or by the primary health care provider, their use can occasionally result in more serious reactions. Some individuals are allergic to aspirin and the other salicylates. Allergy to the salicy-lates may be manifested by hives, rash, angioedema, bronchospasm with asthma-like symptoms, and ana-phylactoid reactions.

Finasteride Molecular Kinetics

Been identified, and specific testing has been conducted with digoxin, propanolol, theophylline, warfarin, and antipyrine. As a result of 5a-reductase inhibition, the mean serum concentration of testosterone increases by 10-20 . However, these levels typically remain within normal physiologic limits (19).

How To Communicate the Benefits and Risks of Surgery to the Patient

It is very helpful to have the patient's CT scans with you to illustrate what is happening in their sinuses and what procedure is planned, and to show the proximity of the orbit and brain when discussing possible complications (Fig. 9.1). An alternative is to have a diagram of the sinuses available. We normally describe sinus surgery to patients who have little medical knowledge as plumbing of the sinuses. Another analogy that patients understand is describing the sinuses as 14 little rooms connected by corridors on either side, and sinus surgery as like these being converted into a big hall on each side (Fig.9.2a, b). We say that surgery helps drainage, reduces the surface area from which polyps can form, and allows access to topical nasal medication. However, it is important to emphasize that surgery is not always a cure for all of the patient's symptoms, particularly in the presence of allergic rhinitis or when the patient also has late-onset asthma. Tempering patients'...

Summary Of General Approach To Medical Management Of Copd

Stepwise fashion according to the severity of symptoms and airway obstruction. In mild disease with only intermittent symptoms, inhaled -agonists can be used on an as-needed basis. If the symptoms are more persistent, inhaled ipratropium bromide should be added on a regular basis. In more advanced disease stages with increasing symptoms, progressive addition of inhaled -agonists (used on a regular basis or as long-acting preparations) and theophylline may be helpful. Dosage of these medications should be adjusted to minimize side effects. With severe disease and continued symptoms, a trial of inhaled or systemic corticosteroids is indicated.

Specific Complications

Lastly, when counseling a patient with nasal polyposis associated with late-onset asthma or aspirin sensitivity, it is wise to mention that, in spite of good surgery and postoperative medical treatment, the majority of patients will have a recurrence of their polyps. This will avoid the return of a disgruntled, rather than an informed patient.


All narcotic analgesics are contraindicated in patients with known hypersensitivity to the drugs. These drugs are contraindicated in patients with acute bronchial asthma, emphysema, or upper airway obstruction and in patients with head injury or increased intracranial pressure. The drugs are also contraindicated in patients with convulsive disorders, severe renal or hepatic dysfunction, acute ulcerative colitis, and increased intracranial pressure. The narcotic analgesics are Pregnancy Category C drugs (oxycodone, Category B) and are not recommended for use during pregnancy or labor (may prolong labor or cause respiration depression of the neonate). The use of narcotic analgesics is recommended during pregnancy only if the benefit to the mother outweighs the potential harm to the fetus.

Chargebased Targeting Of Liposomes

In murine models of pancreatic islet cell carcinoma or chronic Mycoplasma pulmonis-induced airway inflammation, cationic liposomes were shown to be preferentially taken up by the activated (angiogenic) endothe-lium. Degree of uptake in these areas was approximately 15- to 30-fold higher than by quiescent endothelium in disease-free animals (64). The majority of EC-associated liposomes were already internalized at 20 minutes postinjection. Within the angiogenic endothelium, uptake was not homogenous. Certain areas displayed pronounced uptake, whereas uptake in other regions was much lower. This heterogeneity in angiogenic EC uptake may reflect differences in phase of angiogenesis and EC activity.

Ongoing Assessment

During the ongoing assessment, the nurse observes the patient for the effect of the drug, such as improved breathing of the patient with asthma, response of the blood pressure to the administration of the vasopressor, or controlled orthostatic hypotension. During therapy, the nurse evaluates and documents the drug effect. The nurse also takes and documents the vital signs. Comparison of assessments made before and after administration may help the primary health care provider determine future use of the drug for this patient. It is important to report adverse drug reactions to the primary health care provider as soon as possible.

Educating the Patient and Family

EDUCATING THE PATIENT PRESCRIBED A BRONCHODI-LATOR. If an adrenergic drug, such as ephedrine or iso-proterenol, has been prescribed as a bronchodilator, the nurse explains the drug regimen to the patient (see Chap. 37 for additional information). It is important to stress the importance of reporting adverse reactions to the primary health care provider as soon as possible. If the drug is prescribed in sublingual form, the nurse demonstrates the technique of placing the drug under the tongue. The nurse warns the patient not to use any OTC drug unless use has been approved by the primary health care provider. The nurse encourages patients receiving a bronchodilator to contact their primary health care provider if the drug fails to produce at least partial relief of their symptoms.

Contraindications Precautions And Interactions

These drugs are contraindicated in patients with an allergy to the p blockers, in patients with sinus bradycardia, second- or third-degree heart block, heart failure, and those with asthma, emphysema, or hypotension. The drugs are used cautiously in patients with diabetes, thyrotoxicosis, and peptic ulcer.

Strong Recommendation

Asthma The success of NIV in treating COPD raises the possibility that it would also be beneficial in acute asthma. However, the lack of randomized controlled trials to confirm this hypothesis weakens the indication. Furthermore, the pathophysiologies and natural histories of COPD and asthma differ markedly and, thus, it is not fair to assume that one would respond to NIV in the same way as the other. However, cohort studies have reported successful outcomes with NIV in severe status asthmaticus complicated by CO2 retention 27, 46 . In one study, only two of 17 asthmatics required intubation after starting NIV, with PaCO2 falling from an average of 65 to 52 mmHg and respiratory rate from 29 to 20 min (p 0.002 and 0.0001, respectively), after 2 hours of therapy 46 . In a retrospective analysis of 33 asthmatic patients who were deemed to be candidates for NIV, the outcomes of 11 patients managed with invasive mechanical ventilation were compared with 22 managed non-invasively 47 . Gas...

Roles Of Collectins In Resisting Allergic Inflammation And Hypersensitivity Induced By Fungal Allergens And Antigens

A. fumigatus causes systemic infection via the lungs (IPA or IA) in the immuno-suppressed subjects. However, in the immunocompetent individuals (probably with genetic susceptibility), it can cause an allergic disorder, called allergic bronchopulmonary aspergillosis (ABPA), which is different from other hypersen-sitivity responses to inhaled allergens in that the A. fumigatus spores grow in the respiratory tract and continually shed soluble and particulate antigens and allergens in the large subsegmental bronchi. Thus, the interaction of SP-A and SP-D with glycoprotein allergens of A. fumigatus, and the subsequent outcome of these interactions has been examined in vitro and in vivo (Madan et al. 1997b, 2001). SP-A and SP-D have been previously shown to bind allergens derived from pollen grains and dust mite (Kishore et al. 2002). SP-A, SP-D and rhSP-D can also bind to the three-week culture filtrate (3wcf) of A. fumigatus as well as purified glycoprotein allergens, gp55 and gp45,...

Case Study for Chapter

A 27-year-old accountant recently drove cross-country to start a new job in Denver, Colorado. A week after her move, she started to experience chest pains. She drove to the emergency department after experiencing 24 hours of right-sided chest pain, which was worse with inspiration. She also experienced shortness of breath and stated that she felt warm. She denied any sputum production, hemoptysis, coughing, or wheezing. She is active and walks daily and never has experienced any swelling in her legs. She has never been treated for any respiratory problems and has never undergone any surgical procedures. Her medical history is negative, and she has no known drug allergies. Oral contraceptives are her only medication. She smokes a pack of cigarettes a day and consumes wine occasionally. She does not use intravenous drugs and has no other risk factors for HIV disease. Her family history is negative for asthma and any cardiovascular diseases.

Medical device use in children

Pediatric diseases and conditions that lead to device use, when compared to those in adulthood, differ by their etiology, consequences, and rates of occurrence. Heart failure during childhood usually results from congenital heart defects, not myocar-dial infarction, and the rapid onset of life-threatening infections, asthma, and accidents are common causes for pediatric hospitalization, with high rates of morbidity and mortality. It is therefore important to focus on the intended age group in which a device will be used, whether it is intended to diagnose, manage a temporary disease state, treat an injury, or cosmetically correct a defect or other condition. Also, within the pediatric population, the incidence of medical conditions varies with the age of the child, and while certain devices may be designed or modified for use in a specific targeted age group, they must often be safe, effective and adaptable for use in children of other ages as well. Key age-dependent factors of body...

Operations On The Nervous System

Abbott et al. were the first investigators to propose denervation of the lung as a treatment for emphysema (22). Such operations were undertaken in an attempt to decrease bronchospasm and secretions, as well as to improve pulmonary circulation. Abbot's technique included pulmonary plexectomy, pulmonary artery periarterial sympathectomy, upper dorsal sympathectomy and partial lung resection. Brantigan and Mueller likewise added a complex denervation procedure to their partial lung resection (7-9). This procedure included complete removal of the posterior pulmonary plexuses by ligation of all branches of the vagus nerve to the heart, lung, and mediastinum, as well as an extensive perivenous and peribronchial stripping of symppathetic nerve fibers (see Fig. 2). The numerous different techniques and the lack of adequate control groups made it difficult to interpret the results of these operations and appropriate patient selection criteria were never identified. Nonetheless, these lung...

Nutritional deficiency

Salagen (pilocarpine hydrochloride) tablets are indicated for the treatment of symptoms of xerostomia from salivary gland hypofunction. As a cholinergic parasympathetic agent, pilocarpine can increase secretion of the salivary glands. The usual initial dose is 5 mg tid. It is contraindicated in patients with asthma, iritis, and narrow angle glaucoma. Side effects include abdominal cramps and sweating. Lubrication of the mouth and mild secretagogs, such as lemon-flavored juice or lubricating agents proper (water, methylcellulose), are useful. More potent secretagogs may exacerbate the signs and symptoms of parotitis. Prevention of states of dehydration in SS is very important, as dehydration may enhance the formation of parotid ductal calculi. Avoidance of drugs that may aggravate oral dryness (e.g., narcotics, antihistamines, anticholinergics) is also important.

Orthotopic Cardiac Transplantation

The vast majority of cardiac transplants today are orthotopic. Bicaval anastamoses are performed and there is retention of a substantial portion of the posterior walls of both atria of the recipient heart, along with their innervation. Bradyarrhythmias have been frequently described following orthotopic cardiac transplant, the majority caused by sinus-node dysfunction (57,58). Sinus-node dysfunction in this setting has been attributed to surgical trauma to the donor sinus node or to interruption of its blood supply (59). As surgical techniques have improved, however, the incidence of sinusnode dysfunction has decreased. There has also been the growing realization that sinusnode dysfunction in this setting is often benign and reversible, and there is currently a tendency to implant pacemakers only in severely symptomatic individuals (60,61). Theophylline may be utilized in the early post-transplant period as a temporary measure until sinus-node function improves (62). Currently, the...

Characteristics Of Allergic Patients

When compared with normals, asthmatics have a skewed profile of peripheral blood lymphocytes and clinical symptoms. The number ofCD4 Th2 cells is greatly increased in allergic subjects. However, there is considerable debate about whether this change is a cause or an effect ofasthma. Moreover, the surface of the Th2 cells has a higher density of a low-affinity receptor for IgE (CD23). The low-affinity receptor is a 30-kDa member of the C-type lectin family that includes the selectin adhesion molecules. Most asthmatics have hyperactive airways and respond to low concentrations of carbachol, a potent cholinergic stimulus, with bronchoconstric-tion. All have increased levels of IgE antibody in the serum.

Recurrent Atypical Symptoms

Asthma and GERD often coexist, although it is not always easy to determine if the two are truly related.61 However,medical and surgical therapy both have been demonstrated to improve or control both esophageal and pulmonary symptoms in many asthma patients.62,63 Objective evidence of improvement using pulmonary function testing has been more difficult to document. Because causality is so difficult to prove, recurrent asthma after anti-reflux surgery should not be blamed on failure of surgery unless pathologic acid reflux can be documented using ambulatory esophageal testing. Proving that reflux is causing cough is even more difficult because so many other common problems can cause cough such as postnasal drip, common medications, and occult asthma.64 When patients who have GERD and a cough that does not respond to medical therapy for reflux undergo surgery, it is our experience that the cough often returns. In addition, despite the return of that symptom, we are able to document...

Preoperative Evaluation

A careful history and physical examination are routine parts of any preoperative anesthetic evaluation. A history of previous general anesthetics, and, in particular, any difficulty with intubation or emergence from general anesthesia is noted. Airway anatomy is evaluated by the usual Mallampati criteria. Preoperative respiratory evaluation allows assessment of baseline breathing, laboratory values, and respiratory capacity. Attention to the degree of bullous disease, hyperinflation, bronchospasm, and resting oxygen requirements will allow preoperative plans to focus on problems that may occur during the period of anesthesia. This information is especially critical to the management of ventilation during the procedure and at the time of emergence and extubation. Preoperative blood gas analysis, in particular the degree of hypercarbia, may provide some guidelines for expectations at the time of extubation. All preoperative medications are noted at this time and the patient should be...

NONlgEmediated Anaphylactoid Reactions Nsaids

Anaphylactoid reactions are not mediated by IgE, but they have symptoms and time courses that mimic allergic reactions. NSAIDs are a major cause of anaphylactoid reactions. NSAIDs such as aspirin alter the arachidonic acid pathway and increase asthmatic response. Pulmonary hyperactivity induced by aspirin and otherNSAIDs is not mediated by IgE reactivity. These patients manifest a cyclooxygenase blockade of arachidonic acid metabolism leading to preferential production of leukotrienes from the lipoxygenase pathway (Burrell et al., 1992).

Toluene Diisocyanate TDI

TDI is widely used in polyurethane production and in the manufacture of plastics, foam insulation, and synthetic coatings. The number of workers potentially exposed to TDI is large. Although the clinical signs and symptoms resemble classical asthma, TDI asthma may not be immunologically mediated. Less than 15 ofTDI asthmatics have IgE directed toward the hapten (Butcher et al., 1980). Moreover, the presence of isocyanate-specific IgE does not correlate with bronchial reactivity (Butcher et al., 1977).

PAdrenergic Blocking Agents Mechanisms of Action

B-Blockers function as competitive antagonists to the b-adrenergic receptors on cell membranes. Selective b-1 antagonists act at receptor sites found primarily in the myocardium, inhibiting catecholamine-mediated increases in cardiac contractility and nodal conduction rates. b-2 receptors are found mainly in vascular and bronchial smooth muscle inhibition at these receptor sites can lead to vasoconstriction and bronchospasm. These b-blockers exert their beneficial effect in the acute coronary syndromes by preventing catecholamine-mediated b-1 activation, leading to decreased contractility and heart rate, thereby improving the oxygen supply demand balance. These drugs also exert an antiarrhythmic effect, as evidenced by an increase in the threshold for ventricular fibrillation in animals and a reduction in complex ventricular arrhythmias in humans (7-9). Finally, b-blockers may prevent plaque rupture by reducing the mechanical stresses imposed on the plaque (10).

Pharmacokinetic and Pharmacodynamic Factors

Distribution of drugs to peripheral sites is substantially affected by aging, as adipose tissue increases and lean body mass decreases. Thus, there is a larger volume of distribution for fat-soluble drugs, which includes nearly all psychotropic medications. There are several consequences to this age-related change the half-life of lipophilic drugs increases, leading to the accumulation of drugs taken chronically and thus to greater potential for toxicity increased uptake in the peripheral sites (e.g., fat tissues) may result in less drug reaching the brain and in a potentially shorter duration of drug action after a single dose than is seen in younger persons. Conversely, total body water decreases with age so that the volume of distribution of water-soluble drugs decreases, more of the drug is present in the circulation, and proportionately more reaches the brain. Thus, water-soluble drugs such as ethanol and lithium may have increased effects in older persons. Elderly persons also...

Critical Thinking Exercises

Smith, age 68 years, returned to the clinic for a follow-up visit after receiving a diagnosis of COPD. She is taking theophylline daily and using a metered-dose inhaler 4 times a day. Determine what assessments would be most important for you to make at this time. 3. Discuss what to include in a teaching plan for a patient taking montelukast for asthma.

Therapeutic Implications

The effect of a single injection of human recombinant IL-10 on allergen challenge in patients with mild asthma. No significant difference compared to placebo was found for the early asthmatic response (EAR) or the late asthmatic response (LAR). Figure 4. The effect of a single injection of human recombinant IL-10 on allergen challenge in patients with mild asthma. No significant difference compared to placebo was found for the early asthmatic response (EAR) or the late asthmatic response (LAR).

Increased IL10 Synthesis

Corticosteroids.73 Inhaled corticosteroids and oral anti-leukotriene therapy have been reported to increase the circulating concentration of IL-10 in children with asthma.74 Therapeutic concentrations of theophylline have been reported to increase IL-10 production from monocytes and this may underlie the recently recognized immunomodulatory and anti-inflammatory action of this drug.75 Theophylline may be effective by inhibition of phosphodiesterases (PDE), thus increasing intracellular cyclic AMP concentrations. In mononuclear cells PDE inhibitors increase IL-10 release,76 although this does not appear to be the mechanism for inhibiting TNF-a release, as discussed above.26'27 We have demonstrated that therapeutic concentrations of theophylline in asthmatic patients, while reducing the numbers of airway eosinophils, do not increase IL-10 production by alveolar macrophages, in bronchoalveolar lavage or by blood monocyte or lymphocytes.77 This makes it unlikely that therapeutic doses of...

Concluding Remarks And Indications From Anticytokine Therapy

The cells that participate in the asthmatic response including macrophages, lymphocytes, eosinophils and fibroblasts produce a great number of chemokines during the inflammatory response. Th2 cytokines IL-4 and IL-13 are potent inducers of chemokine production by these cells. Several chemokines have been found to have essential roles in both the development and maintenance of fungal allergy. Considerable clinical and experimental research has demonstrated that chemokines mediate the recruitment and activation of a variety of cells to the airways in allergic airways disease. Much research has been directed toward the blockade of particular chemokines or chemokine receptors in order to attenuate the accumulation and or activation of leukocyte populations that drive asthmatic responses. Conversely, in treatment of IPA new therapeutics are sought to stimulate leukocyte generation, recruitment and activation all of which could be achieved by selective upregulation of cytokine-cytokine...

Pulmonary Function Evaluation

Pulmonary function studies are an important part of the evaluation of potential LVRS candidates (42). Routine spirometry measured both before and after bronchodilator administration serve to eliminate many COPD patients from consideration. A significant bronchodilator response suggests a significant airways disease component. Most centers eliminate patients with a postbronchodilator response of greater than 30 or greater than 300 mL. Recognizing that this procedure should only be considered in severely limited patients, most centers also require an FEV1 less than or equal to 45 predicted. The lower limit of FEV1 greater than 15 of predicted is, as aforementioned, reserved for patients over age 70.

Antibody Responses Against Different Pathogenic Fungi

Over the past two decades Aspergillus fumigatus has become the most prevalent airborne fungal pathogen, causing severe and usually fatal invasive infections in immunosupressed patients (Denning , 1998 Marr et al., 2002 Patel and Paya, 1997). Invasive aspergillosis is now a major cause of death at leukemia treatment centers, and bone marrow and solid organ transplantation units (Denning , 1998 Marr et al., 2002 Patel and Paya, 1997). Other spp. of Aspergillus, such as A. terreus, A. flavus and A. niger can also cause invasive aspergillosis (Marr et al., 2002). This severe opportunistic fungal infection is characterized by a high mortality rate in these at-risk patients (Lin et al., 2001) (the crude mortality rate of invasive aspergillosis approaches 100 ). Although rarely, in immunocompetent patients this fungus can also cause aspergilloma (an overgrowth of the fungus on the surface of preexisting cavities in the lungs of patients treated for tuberculosis) and allergic brochopulmonary...

Pathogenesis and Immunity

In Chapter 9 we discussed the pathology of influenza, mentioning some host factors affecting the outcome. In brief, the virus replicates principally in ciliated columnar epithelium of the respiratory tract, producing tracheobronchitis features include enhanced airway reactivity (bronchospasm) and impaired mucociliary clearance. Primary viral pneumonia is uncommon, but secondary bacterial pneumonia is an important cause of death in the elderly, the very young, the chronically ill, or the immunocompromised.

Need for Specialty Carts

Pediatric crash carts present difficult logistic problems because a wide array of equipment and medications is required to meet the needs of the large range of ages and sizes of the patients. While our institution is not a pediatric facility, we have nevertheless prepared for the pediatric crisis (Figure 19.2). Although we rarely have a pediatric inpatient, children visitors are common, and they may have a medical crisis while visiting. The most common events are seizures, syncope, and asthma exacerbation. Obviously, for any child less than 40 kilograms, the medications and equipment used to care for adults are inappropriate. There are 2 techniques for pedi-atric crash carts that we will briefly discuss. The first is a cart that is organized according to equipment type for example, all airway equipment is stored together in a single drawer, and all medications in another. The second is the so-called Broslow cart. In this cart, each drawer is color-coded according with Broslow tape,...

Clinical Focus Box 302

Exercise causes bronchoconstriction in nearly every asthmatic patient and is the sole provocative agent for asthma in many people. In healthy individuals, cate-cholamine release from the adrenal medulla and sympathetic nerves dilates the airways during exercise. Sympathetic bronchodilation in people with asthma is outweighed by constrictor influences, among them heat loss from airways (cold, dry air is a potent bronchocon-strictor), release of inflammatory mediators, and increases in airway tissue osmolality. Leukotriene-receptor antagonists block exercise-induced symptoms in most people. The effects of exercise on airways are due to increased ventilation per se,- the exercise is incidental. Individuals with exercise-induced bronchoconstriction are simply the most sensitive people along a continuum, for example, breathing high volumes of cold, dry air provokes at least mild bron-chospasm in everyone.

Thiazides and Related Diuretics

The thiazide diuretics are contraindicated in patients with known hypersensitivity to the thiazides or related diuretics, electrolyte imbalances, renal decompensation, hepatic coma, or anuria. A cross-sensitivity reaction may occur with the thiazides and sulfonamides. Some of the thiazide diuretics contain tartrazine, which may cause allergic-type reactions or bronchial asthma in individuals sensitive to tartrazine.

Mass spectrometric identification of proteinous allergens

Nine patients with a long history in summer hay fever were tested for symptoms after inhalative and dietary contact with elderberry products. All of them reported rhinoconjunctivitis four of them even exhibited asthmatic symptoms. As patients may be exposed to the allergens hailing from S. nigra via the oral route flowers and fruits have been used in plant remedies and food for centuries it has been of special interest that one patient developed upper-airway obstruction when drinking elderberry juices. Four patients showed strong reactions after SPT, medium response was observed in two cases, and negative results were received for three persons including the patient exhibiting airway obstruction. IgE serum levels measured by RAST also varied significantly. In some cases no serum IgE was detectable in another case up to 4080 kU L was measured.

Ischemic heart disease

Chronic obstructive lung disease and asthma are the two forms of pulmonary disease seen most frequently in the preoperative setting. 2. Bronchodilator therapy. Patients who are taking bronchodilators on a long-term basis before surgery should be given their standard dose the night before surgery, and bronchodilator therapy should be administered postoperatively either systemically or by nebulizer.

Adverse Events From Cannabis Administration

Smoked cannabis causes bronchodilation (probably by THC) (42), pulmonary irritation from inhalation of the smoke, and increased absorption of carbon monoxide (43,44). The latter leads to elevated blood carboxyhemoglo-bin levels, resulting in decreased oxygen delivery to tissues. These effects rarely cause clinically significant adverse events with the limited exposure usually involved in cannabis administration research studies (45). However, even a single cannabis cigarette may trigger coughing or breathing difficulty (dysnpea) in a susceptible subject, e.g., one with active asthma or bronchitis.

Pharmacologic MRI Compared with PET and Autoradiography How Well Do Hemodynamic Changes Reflect Receptor Distributions

Monitoring hemodynamic changes after administration of a drug will lead to three obvious general outcomes. First, one may obtain no response or correlation whatsoever with other measured parameters. In such an instance the only conclusion to be drawn is that a drug targeted towards a specific receptor has no hemodynamic effect. This does not mean that it has no behavioral effect or even that it has no metabolic effect, since for instance the vasodilatory and vasoconstrictive properties of the drug may cancel one another. The second outcome one might envisage is that there is a hemodynamic effect that is measurable, but that it does not correlate with any obvious pattern of receptors, or that the targeted receptors have such a widespread distribution that distinguishing nonspecific from specific effects is quite difficult. We have observed just such effects with caffeine and theophylline where activation (more precisely, negative rCBV changes) is seen over almost the entire brain,...

General Assessment of Comorbid Status

For example, patients with underlying chronic obstructive pulmonary disease may benefit from pulmonary function testing and arterial blood gas sampling to determine whether they require the initiation or modification of bronchodilator therapy. Similarly, evaluation of cardiac risk using exercise-based (i.e., stress echocardiogram) or pharma-cologic (dobutamine echocardiography) stress testing may provide strategically important preoperative insight.

Intravenous Immune Globulin

Although not a classic fungal infection, brief mention will be made of the use of fungal antigens to treat allergic fungal sinusitis. Allergic fungal sinusitis has histologic features resembling those of allergic bronchopulmonary aspergillosis and is characterized by association with asthma, nasal polyps, and allergic mucin, a viscous secretion that contains degenerating eosinophils and Charcot-Leyden crystals (67,68). Aspergillus species are frequently cultured from mucin, but a variety of other fungal species have been cultured from patients with allergic fungal sinusitis including Bipolaris, Curve-laria, Alternaria, and Cladosporium (69). The standard therapy for allergic fungal sinusitis is surgical drainage and corticosteroid administration, but relapses are common (67). Because of the immunologic nature of this disease, immunotherapy has been suggested to be potentially beneficial (69). Immunotherapy for allergic fungal sinusitis involves the injection of fungal antigens to...

Lung Transplantation Vs Lvrs

The ideal candidate for lung transplantation or LVRS fits the original description of patients with emphysema (type A chronic obstructive pulmonary disease COPD ). This includes individuals with little cough, occasional and scanty sputum, fixed dyspnea, thin body habitus, large translucent lungs with low diaphragms and a small cardiothoracic ratio, absence of right ventricular enlargement, and a normal hematocrit (2). Optimal candidates for lung transplantation or LVRS should not manifest reversible airflow obstruction, copious sputum production, respiratory infection, obesity, or respiratory muscle weakness. By these criteria, optimal candidates tend to manifest less severe derangements of gas exchange (hypoxemia and hypercarbia) and less severe elevations of pulmonary arterial pressures (3,4). Experience indicates that even in the majority of patients with a mixed clinical picture, one of the types usually dominates to allow appropriate selection of patients for lung transplantation...

Biobehavioral Disorders

This group of disorders with clearly identified pathophysiologic origins and effects have been traditionally understood to have significant psychoemotional components. Examples include asthma, migraine, encopresis, Tourette's Syndrome, and inflammatory bowel disease, all of which are known to include psychological stress as just one stimulus which may 'trigger' exacerbations or promote difficulties with the disease. Teaching self-hypnosis as an integral component of a comprehensive Children with asthma easily learn to use self-hypnosis and biofeedback to modulate acute episodes of wheezing (Kohen, 1986 Kotses et al., 1991 Kohen & Wynne, 1997 Kohen, 1995b). Children with asthma who learn self-hypnosis experience fewer Emergency Room visits, fewer missed school days, and a better sense of control (Kohen, 1995b). Young people with juvenile migraine who learn RMI are more effective in reducing the intensity, frequency, and duration of their migraine headaches than control patients or...

The dosage is 100 mgd Sulfasalazine Azulfidine

Azulfidine is contraindicated in patients with porphyria and should be administered with caution in patients with hepatic or renal disease, blood dyscrasia, severe asthma, or allergies. Complete blood cell counts and liver function tests should be performed frequently. Urinalysis results should also be followed. Adequate fluid intake must be maintained to prevent crystalluria and renal stones. Patients with glucose-6-phosphate dehydrogenase deficiency should be followed closely for signs of hemolysis. Azulfidine should be avoided in patients with sulfa allergies and should not be given simultaneously with sulfa drugs.

Antigen Presenting Cells in Disease Models

The effect of a variety of tolerogenic APCs has been tested in organ transplantation and autoimmune disease models. Intravenous injection of myeloid immature DCs generated in vitro with granulocyte-macrophage colony-stimulating factor prolonged the survival of pancreatic islet or heart allografts 35 . Splenic CD8+ DCs use both contact-dependent and -independent mechanisms to suppress Th2 responses and reverse Th2-mediated pathogenesis in a mouse model of asthma 48 .

Late Phase Reactions Induce Localized Inflammatory Reactions

Early And Late Asthmatic Reaction

As a type I hypersensitive reaction begins to subside, mediators released during the course of the reaction often induce localized inflammation called the late-phase reaction. Distinct from the late response seen in asthma, the late-phase reaction begins to develop 4-6 h after the initial type I reaction and persists for 1-2 days. The reaction is characterized by infiltration of neutrophils, eosinophils, macrophages, lymphocytes, and basophils. The localized late-phase response also may be mediated partly by cytokines released from mast cells. The early and late inflammatory responses in asthma. sented at the top. The effects of various mediators on an airway, repre-The immune cells involved in the early and late responses are repre- sented in cross section, are illustrated in the center. Eosinophils play a principal role in the late-phase reaction, accounting for some 30 of the cells that accumulate. Eosinophil chemotactic factor, released by mast cells during the initial reaction,...

Mediastinoscopy Case Study

Case Study 11-1 Preoperative Testing in a Patient With Asthma A.D., 15 years old, was seen in the preadmission testing unit in preparation for her elective spinal surgery. She has a history of mild asthma since age 4, with at least one attack per week. In an acute attack, she will have mild dyspnea, diffuse wheezing, yet an adequate air exchange that responds to bron-chodilators. She was sent to pulmonary health services for a consult with a specialist and pulmonary function studies to clear her for surgery. The anesthesiologist reviewed the pulmonologist's report. Her prebronchodilator spirometry showed a mild reduction in vital capacity but with a moderate to severe decrease in FEV1 and FEV1 FVC ratio. After bronchodilator administration, there was a mild but insignificant improvement in FEV1. The postbronchodilator FEV1 was 55 of predicted and was considered moderately abnormal. The flow volume loops and spirographic curves were consistent with airflow obstruction.

Regulatory Position And Biological Significance

Or in vitro models that predict reactions in the lung or skin. Animal models for asthma should mimic the pathophysiology and immunopathology of the human disease in that (1) airway hyperactivity should be demonstrable either before or following antigenic challenge, (2) pulmonary function changes elicited by challenge with allergen should be consistent with reversible airway obstructive disease, and (3) the presence of allergen-specific IgE should be documented by serological assays or appropriate in vivo methods.

Nondihydropyridine Calcium Blockers Verapamil and Diltiazem

It should be emphasized that there have not been studies comparing the efficacy of verapamil or diltiazem with that of a P-blocker. P-Blockers more consistently reduce both mortality and reinfarction and should be recommended for those patients who can tolerate such medication. Verapamil or diltiazem may be a reasonable alternative for those patients who cannot tolerate a P-blocker, but who can tolerate one of the calcium blockers, for example, patients with severe chronic obstructive pulmonary disease or asthma. It should be noted, however, that many patients who cannot tolerate a P-blocker, because of concern of excessive bradycardia or CHF, may experience similar complications from diltiazem or verapamil.

Susan E Frates MS RD and Heidi Schauster MS RD

Eating disorders are characterized by a disturbed relationship between nutritional intake and body image, often leading to subsequent medical problems. While eating disorders are found predominantly in the adolescent and young adult populations, they are increasingly being recognized in children and preadolescents. Eating disorders are the third most common chronic illness in adolescents following obesity and asthma.1 Anorexia nervosa is estimated to occur in 3 of adolescent women and bulimia nervosa in 1 to 49r.- Undiagnosed disordered eating appears to afflict many school-aged Americans. In 1995. over one-third of Boston high school students reported that they were trying to lose weight. Six to seven percent of these students reported having vomited or taken laxatives in the last 30 days to avoid absorbing calories.-1 Males are also currently emerging as a population at risk for disordered eating. The age of onset of eating disorders appears to be decreasing.

Case 24 Tracheal Tumor Due To Adenoid Cystic Carcinoma

Adenoid Cystic Carcinoma Pictures

All patients diagnosed with asthma should have a CXR. In addition to looking for pneumothorax and transient pulmonary infiltrates, one should pay attention to the tracheal air column. Any obstruction to the major airway can produce a wheeze. If the obstruction is high up, i.e. extrathoracic, the sound is described as stridor, i.e. during inspiration. This is in contradistinction to rhonchi which is classically expiratory and due to small airway obstruction. The CXR here shows a bulge in the lateral wall of the mid-trachea (Fig. 24.2) due to a tumor. Possibilities include squamous cell carcinoma, metastases, mucoepidermoid carcinoma, adenoid cystic carcinoma and carcinoid tumor. Flexible bronchoscopy in this patient showed a mid-tracheal tumor (Fig. 24.3) and biopsy showed adenoid cystic carcinoma (a low-grade malignancy).

Intracellular Events Also Regulate Mast Cell Degranulation

Effects Camp

Intracellular stores in the endoplasmic reticulum (see Figure 16-6). The Ca2+ increase eventually leads to the formation of arachidonic acid, which is converted into two classes of potent mediators prostaglandins and leukotrienes (see Figure 16-6). The increase of Ca2+ also promotes the assembly of microtubules and the contraction of microfilaments, both of which are necessary for the movement of granules to the plasma membrane. The importance of the Ca2+ increase in mast-cell degranulation is highlighted by the use of drugs, such as disodium cromoglycate (cromolyn sodium), that block this influx as a treatment for allergies.

Isolated angiitis of the central nervous systen is a recently recognized vasculitic disorder primarily involving the

Churg-Strauss syndrome is a rare disorder characterized by hypereosinophilia, systemic vasculitis, and necrotizing granulomatous inflammation that occurs in people with asthma and allergic rhinitis. Pulmonary infiltrates occur in up to 90 of patients, and a cutaneous eruption is seen in 70 . Cardiac manifestations (pericarditis, cardiomyopathy, and myocardial infarction) account for about half of deaths. Peripheral neuropathy is found in 70 of patients its occurrence in susceptible patients is highly suggestive of CSS. Renal disease, seldom seen, is generally mild. B. The differential diagnosis of CSS includes WG, microscopic polyangiitis, PAN, chronic eosinophilic pneumonia, and the idiopathic hypereosinophilic syndrome. Neither asthma nor a history of allergies is a prominent feature of WG, in which eosinophilia is rarely found. Renal involvement is less severe in CSS, and the histopathologic features of the granulomatous lesions of CSS and WG are very different. The absence of...

Oyarzun M.j. Stevens P. And Clemens J.a Exp. Lung. Res. 15 90 1989.

Dysfunction of pulmonary surfactant in asthmatics after segmental allergen challenge. Am J Respir Crit Care Med 1999 159 1803. 18. Wright SM, et al. Altered airway surfactant phospholipids composition and reduced lung function in asthma. J Appl Physiol 2000 89 283. Cheng G, et al. Increased levels of surfactant protein A and D in bronchoalveo-lar lavage fluids in patients with bronchial asthma. Eur Respir J 2000 16 831. Wang JY, et al. Allergen-induced bronchial inflammation is associated with decreased levels of surfactant proteins A and D in a murine model of asthma. Clin Exp Allergy 2001 31 652. Haczku A, et al. The late asthmatic response is linked with increased surface tension and reduced surfactant protein B in mice. Am J Physiol Lung Cell Mol Physiol 2002 283 L755. Ackerman SJ, et al. Hydrolysis of surfactant phospholipids catalyzed by phos-pholipase A2 and eosinophil lysophospholipases causes surfactant dysfunction a mechanism for small airway closure...

Immune Effector Cells Lymphocytes

Bacteria Effector Into Cells

Using light microscopy, all lymphocytes have the same morphology and staining characteristics. However, functional studies reveal that there are many lymphocyte subpopulations. Lymphocytes are divided into T and B cells depending on whether the cells are induced to maturation in the thymus (T cells) or the bone marrow or organs analogous to the bursa of Fabricius (B cells) in chickens. From a disease perspective, T cells are involved in inflammatory responses to intracellular bacteria, immunoregulation, and the lysis of tumor cells. Conversely, B cells produce protein antibodies directed toward bacteria and other extracellular pathogens. With the advent of flow cytometric analyses and fluorescence-labeled monoclonal antibodies reacting with cluster of differentiation (CD) markers on lymphocytes, it is possible to further dissect subpopulations of T and B cells. Pan T and B cell markers have been identified. In humans and rodents, all T cells express CD3 markers and all B cells express...

Immediate Hypersensitivity

Wheel And Flare Allergy Skin Test

Immediate hypersensitivity can produce allergic rhinitis (chronic runny or stuffy nose) conjunctivitis (red eyes) allergic asthma atopic dermatitis (urticaria, or hives) and other symptoms. These symptoms result from the immune response to the allergen. In people who are not allergic, the allergen stimulates one type of helper T lymphocyte, the TH1 cells, to secrete interferon-y and inter-leukin-2. In people who are allergic, dendritic cells stimulate the other type of helper T lymphocytes, the TH2 cells, to secrete other lymphokines, including interleukin-4 and interleukin-13. These, in Hay fever, asthma, and most other allergic conditions The symptoms of hay fever (itching, sneezing, tearing, runny nose) are produced largely by histamine and can be treated effectively by antihistamine drugs that block the Hj-histamine receptor. In asthma, the difficulty in breathing is caused by inflammation and smooth muscle constriction in the bronchioles as a result of chemicals released by mast...

Respiratory Syncytial Virus

Oxygen Tent For Infant 1960s

The commonest manifestation of RSV infection in all age groups is a febrile rhinitis and or pharyngitis with limited involvement of bronchi However, the consequences may be much more serious in certain babies between the second and sixth months of life. Almost 1 of all babies develop an RSV infection severe enough to require admission to hospital, and of these about 1 die, particularly those with congenital heart defects, bronchopulmonary dysplasia, very low birth weight, or immunodeficiency. Characteristically, an infant with rhinorrhea develops a pronounced cough and wheezing, progressing to dyspnea with a markedly elevated respiratory rate and hypoxemia (Fig. 28-7). Death may occur very rapidly and may account for a proportion of cases of the so-called sudden infant death syndrome (SIDS). RSV infections in children also frequently involve the middle ear, making this virus the most important causal agent of otitis media. Of the children who recover from a severe pulmonary infection...

The Physical Examination

Bronchiectasis And Lung Abscess

Central cyanosis of respiratory origin is most frequently seen in chronic obstructive pulmonary disease. In such cases peripheral vasodilatation due to carbon dioxide retention (type II respiratory failure) leads to warm blue hands, but the colour of the tongue is a more reliable indicator of central cyanosis. Central cyanosis may occur in many other diseases, including pneumonia, bronchial asthma, pulmonary infarction, allergic alveolitis and any disease causing pulmonary fibrosis but only when these conditions are severe or extensive. Peripheral cyanosis affecting the face and neck, and sometimes the upper limbs, is one of the features of superior venal caval obstruction (see below). Severe chronic hypoxia of either pulmonary or cardiac origin is often associated with polycythaemia and extreme degrees of cyanosis, partly central and partly peripheral. The cardiac causes of cyanosis are described on page 81.

The Role of Mast Cells

Potently inhibited histamine-induced secretion of interleukin (IL)-6, IL-8 and granulocyte-macrophage colony-stimulating factor, as well as the topical mast cell stabilizers, e.g. sodium cromoglycate, lodoxamide 13, 14 and nedocromil 15 , which reduce tear concentrations of tryptase. Topically applied antihistamines (e.g. levocabastine 16 ) and systemic histamine H1 receptor antagonists (e.g. astemizole, terfenadine and loratadine) are also effective in the treatment of SAC and PAC 17 .

Pathophysiology Of Emphysema

Flow Volume Loop With Air Trapping

In general, reductions in or limitations to expiratory airflow arise from one of two mechanisms increased airways resistance or decreased elastic recoil (decreased driving pressure). In obstructive airways diseases such as asthma and chronic bronchitis, there is clearly increased resistance to airflow that occurs because the airway lumen is narrowed by bronchospasm and inflammation. In emphysema, however, there is typically little ongoing airway inflammation or bronchospasm, and it is likely that the majority of the airflow limitation arises from diminished elastic recoil. However, air trapping caused by early closure of overly compliant lung units also contributes to limitation of airflow and may represent a component of increased resistance to flow in these patients. At the level of the small airways, the loss of elastic recoil leads to increased collapsibility characteristic of emphysema, and this can cause increased airflow resistance. This is a fundamentally different mechanism...

Restrictive and Obstructive Disorders

Human Abnormalities

Spirometry is useful in the diagnosis of lung diseases. On the basis of pulmonary function tests, lung disorders can be classified as restrictive or obstructive. In restrictive disorders, such as pulmonary fibrosis, the vital capacity is reduced to below normal. The rate at which the vital capacity can be forcibly exhaled, however, is normal. In disorders that are exclusively obstructive, by contrast, the vital capacity is normal because lung tissue is not damaged. In asthma for example, the vital capacity is normal, but expiration is more difficult and takes a longer time because bronchoconstriction increases the resistance to air flow. Obstructive disorders are therefore diagnosed by tests that measure the rate of expiration. One such test is the forced expiratory volume (FEV), in which the percentage of the vital capacity that can be exhaled in the first second (FEVi) is measured (fig. 16.17). An FEVi that is significantly less than 80 suggests the presence of obstructive pulmonary...

Clinical Aspects Immunity

Hypersensitivity is a harmful overreaction of the immune system, commonly known as allergy. In cases of allergy, a person is more sensitive to a particular antigen than the average individual. Common allergens are pollen, animal dander, dust, and foods, but there are many more. A seasonal allergy to inhaled pollens is commonly called hay fever. Responses may include itching, redness or tearing of the eyes (conjunctivitis), skin rash, asthma, runny nose (rhinitis), sneezing, urticaria (hives), and angioedema, a reaction similar to hives but involving deeper layers of tissue.

Clinical Symptoms And Occurrence Of Complement Activationrelated Pseudoallergy

Common allergic symptoms Anaphylactic shock, angioedema, asthma attack, bronchospasm, chest pain, chill, choking, confusion, conjunctivitis, coughing, cyanosis, death, dermatitis, diaphoresis, dyspnoea, edema, erythema, feeling of imminent death, fever, flush, headache, hypertension, hypotension, hypoxemia, low back pain, lumbar pain, metabolic acidosis, nausea, pruritus, rash, rhinitis, skin eruptions, sneezing, tachypnea, tingling sensations, urticaria, and wheezing Unique symptoms

Nutrition Therapy Goals for Type 2 Diabetes

Growth and weight gain, activity pattern, psychosocial economic issues, smoking, medical history (celiac disease, nephropathy, hyperllpidemia, eating disorder, high blood pressure, asthma, attention deficit disorder, hypothyroidism, and other autoimmune diseases), insulin regimen, oral glucose-lowering medications, blood glucose monitoring schedule

Respiratory Syncytial Virus Infection Control Guidelines

Cohort studies also failed to demonstrate an improved clinical outcome with ribavirin therapy (60,61). The Committee on Infectious Diseases of the American Academy of Pediatrics has changed its recommendations on the use of ribavirin to may be considered in selected infants and young children at high risk for serious RSV disease (62) however most clinicians do not use aerosolized ribavirin because of the limited clinical benefit, cost, and difficulty in administration. Other agents such as bronchodilators CP-agonists and epinephrine) and antiinflammatory agents (cromolyn sodium and budes-onide) have demonstrated some clinical improvement, but further studies are required to confirm these findings (52,53,58).

Abnormalities in the shape of the chest

Rickets Chest

This is a common sequel of chronic respiratory disease, usually asthma, in childhood (Fig. 4.13). it consists of a localised prominence of the sternum and adjacent costal cartilages, often accompanied by indrawing of ihe ribs to form symmetrical horizontal grooves (Harrison's sulci) above the costal margins, which are themselves usually everted. These deformities are thought to result from lung hyperinflation with repeated strong contractions of the diaphragm while the bony thorax is still in a pliable state. Pectus carinatum deformity may also be caused by rickets or be present for no obvious reason. Subcutaneous emphysema (air in subcutaneous tissues) is recognised by the characteristic crackling sensation elicited by palpation of the air-containing tissues. It may cause diffuse swelling of the chest wall, neck and face. Subcutaneous emphysema is a common complication of intercostal tube drainage of a pneumothorax. In severe asthma, air may track...

Recurrent GERD Symptoms

Heller Myotomy Wrap

When recurrent or new symptoms of gastroe-sophageal reflux develop in the late postoperative period ( 3 months), the symptoms should be investigated. For individuals who develop symptoms identical to those in which they underwent surgery, a trial of PPIs is appropriate. In addition, a barium swallow will demonstrate any new anatomic abnormalities in 90 of patients with anatomic failure.6 If the barium swallow does not demonstrate any anatomic problems, it is unlikely that the PPIs will be of much benefit. In this case, it is likely that the recurrent symptom is the result of a problem distinct from GERD. Because so-called extrae-sophageal reflux symptoms (cough, asthma, hoarseness, chest pain, etc.) are so common, it may be difficult to determine which of these symptoms, if any, are related to reflux and which are related to other conditions such as extrinsic asthma, or postnasal drip. It may take the performance of a fundoplication to determine, once and for all, which...

Localized Anaphylaxis Atopy

In localized anaphylaxis, the reaction is limited to a specific target tissue or organ, often involving epithelial surfaces at the site of allergen entry. The tendency to manifest localized anaphylactic reactions is inherited and is called atopy. Atopic allergies, which afflict at least 20 of the population in developed countries, include a wide range of IgE-mediated disorders, including allergic rhinitis (hay fever), asthma, atopic dermatitis (eczema), and food allergies. ASTHMA Another common manifestation of localized ana-phylaxis is asthma. In some cases, airborne or blood-borne allergens, such as pollens, dust, fumes, insect products, or viral antigens, trigger an asthmatic attack (allergic asthma) in other cases, an asthmatic attack can be induced by exercise or cold, apparently independently of allergen stimulation (intrinsic asthma). Like hay fever, asthma is triggered by degranulation of mast cells with release of mediators, but instead of occurring in the nasal mucosa, the...

Promoting an Optimal Response to Therapy

Nursing care of the patient receiving a bronchodilating drug or an antiasthma drug requires careful monitoring of the patient and proper administration of the various drugs. These drugs may be given orally, parenterally, or topically by inhalation or nebulization (see Chap. 2). In general, the nurse gives the drugs around the clock to maintain therapeutic blood levels. If the drug is to be administered once a day, the nurse should give it in the morning. Dosages are individualized for each patient, which allows the smallest effective dose to be given. The nurse can give oral preparations with food or milk if gastric upset occurs. The nurse may administer epinephrine subcuta-neously for an acute bronchospasm. Therapeutic effects occur within 5 minutes after administration and last as long as 4 hours. Salmeterol is a long-acting inhaled bronchodilator and is not used to treat acute asthma symptoms. It does not replace the fast-acting inhalers for sudden symptoms. Salmeterol should not...

Paroxysmal nocturnal dyspnoea

PND is acute, severe, brcathlessness that wakes the patient from steep. The patient has to sit upright gasping in bed or sitting on the edge of the bed. The patient may even get out of bed, occasionally throwing open the windows in an attempt to relieve the distress. The intensity of the symptom is often described as akin to suffocation. Characteristically, the patient has a cough producing frothy sputum which may be streaked with blood. The mechanism is explained in Figure 3.2, which also lists the causes. Paroxysmal nocturnal dyspnoea has to be distinguished from nocturnal asthma (Ch. 4, p. 39).

Quality Institute of the Cleveland Clinic Health System

The Cleveland Clinic Health System is a consortium of health care institutions led by the Cleveland Clinic that was created between 1996 and 1998. The Quality Institute was established to coordinate system-wide quality improvement activities and promote evidence-based care within a culture of safety (13). The institute's staff serves as consultants to the individual hospitals and facilitates communication and the exchange of information leadership. The institute's leadership includes the physician and administrative leaders known as the Medical Operations Council, which identifies and prioritizes quality improvement initiatives based on volume, impact on quality, and potential for improvement, and then allocates resources as needed. Patient care initiatives include the evaluation of clinical processes such as treatment of breast and colorectal cancer, diabetes, stroke, heart failure myocardial infarction, pediatric asthma and chronic obstructive pulmonary disease. Patient safety...

Hypnotizabilityand Clinical Populations

Although some investigators have reported a relationship between high hypnotiz-ability and good outcome with hypnotic treatment the results have not been uniform among all disorders. Hypnotizability has been related positively to the degree of improvement in chronic pain problems, psychosomatic conditions such as asthma, and various dermatological conditions (Hilgard, 1975) and dental phobic disorders (Gerschman, Burrows & Reade, 1987).

Novel Therapeutic Strategies

Mucociliary Transport Rhinitis

Another strategy is to block key molecules involved in inflammation. Trials of soluble IL-4 receptors in asthma have already taken place (Borish et al., 2001). It has been suggested that there is a balance in an individual's helper T-cell response between TH1 cells and Th2 cells (Berger, 2000). TH1 cells produce cytokines that produce the pro-inflammatory responses responsible for killing intracellular parasites and for perpetuating autoimmune responses. TH2 cells produce cytokines associated with the promotion of IgE and eosinophilic responses in atopy (Fig. 16.2). It has been suggested that in allergic rhinitis and seasonal asthma, an individual with a genetic predisposition toward a TH2-biased immune system could move away from this bias if exposed to certain environmental stimuli early in life (Openshaw and Walzl, 1999 Openshaw and Hewitt, 2000). Early exposure to microbial agents may be the appropriate stimulus causing the immune system in these individuals to move toward a...

Endoscopic Anti Reflux Procedures

We soon will have results of sham-controlled clinical trials evaluating all of the currently Food and Drug Administration cleared or approved endoscopic anti-reflux devices, and this will set the standard for the entire field as it relates to accurately measuring efficacy.14 There will be continued refinements in the techniques of use for all of these devices, and newer iterations of the devices will optimize the efficacy as well as safety of these procedures.15-17 It will be interesting to see results of the current endo-scopic anti-reflux procedures in patients with more severe reflux anatomy and physiology (those with larger hiatus hernias, more severe esophagitis, presence of Barrett's esophagus) as well as those with atypical GERD symptoms (i.e., cough, hoarseness, asthma).

Examples of Prostaglandin Actions

Some prostaglandins cause constriction whereas others cause dilation of blood vessels in the lungs and of bronchiolar smooth muscle. The leukotrienes are potent bronchoconstrictors, and these compounds, together with PGF2a, may cause respiratory distress and contribute to bronchoconstriction in asthma.

Recommended with Caution

Indications for NIV in the acute setting have been broadening over the past decade, based on accumulating evidence and experience. The best-established indications remain acute exacerbations of COPD and acute pulmonary edema, with non-invasive CPAP being the positive pressure mode supported by the strongest evidence for the latter diagnosis. However, NIV can be used for numerous other diagnoses, as long as selection guidelines are observed. Strong evidence supports the use of NIV for immunocompromised patients with acute respiratory failure, largely because of the risk of invasive ventilation in these patients. NIV can also be used to facilitate extubation with the aim of reducing the complications of prolonged intubation, and to avoid re-intubation in patients with post-extubation failure. Weaker evidence supports use in selected patients with acute exacerbations of asthma, cystic fibrosis, and deteriorating obstructive sleep apnea and obesity hypoventilation syndrome. Recent...

Mast Cells And Basophils

Mast Cells Fungi

Mast cells and basophils are responsible for the initiation of IgE-mediated hypersensitivity responses. Many fungal organisms produce allergens that result in allergic fungal diseases including rhinitis, fungal sinusitis, asthma, and allergic bronchopulmonary mycosis (ABPM). These diseases are associated with elevated serum and fungal specific IgE, and by implication, type-1 hypersensitivity (Horner et al. 1995 Bush et al. 2004 Khun and Swain 2003 Kurup 2000). Although it is presumed that IgE-mediated mast cell and basophil reactions are central to fungal allergy, the strict requirement for IgE-mediated reactions is still debated. There is even more limited information on the contribution of mast cells or basophils to host defense against fungal pathogens, though there is the potential to regulate immune responses. Overall, in the host response to fungi, mast cells and basophils make versatile contributions to allergy, inflammation and host defense (Figure 1).

Lung Volume Reduction For Emphysema

Brantigan Lung Volume Reduction

The operation consisted of reducing the volume of the lung to the capacity that fits the volume of the pleural space on full expiration. Resection was carried out with a clamp and suture method with reduction being accomplished as much by constriction of a running suture as by the volume of lung tissue removed (see Fig. 3). Anatomic resections were never performed for fear of removing normal lung tissue. An extensive lung denervation was also added to the lung volume reduction in order to relieve bronchospasm, decrease secretions, and increase pulmonary blood flow. Although Brantigan suggested that the operation be performed in a bilateral staged fashion, only half of the patients reported in his series had a bilateral operation.

Coping with Asthma

Coping with Asthma

If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.

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