Asthma is a condition due to
airway inflammation often associated with an allergic component. It is
characterized by symptoms that can include chest tightness, cough, shortness of
breath and wheezing, which may be intermittent or persistent. Proper diagnosis
requires a thorough history, physical examination, appropriate lung function
testing and allergy testing.
Acute, or severe asthma, can
present as a rapid or gradual increase in symptoms resulting in an acute attack
or exacerbation. Chronic asthma, or persistent asthma, may present with
intermittent symptoms or even nocturnal awakening.
Control of asthma is defined
as an absence or decrease in asthmatic symptoms and improvement in the quality
of life. A 5-question survey known as the ACT defines uncontrolled asthma on
the basis of a score of less than 19 out of a possible 25.
The key to controlling asthma
is through the regular use of asthma controller medications such as inhaled
corticosteroids, antileukotrienes, or combination inhalers containing inhaled
corticosteroids and long-acting bronchodilators. These drugs treat the
underlying cause of asthma, namely airway inflammation. They are most often
delivered by inhalers with the exception of the antileukotrienes, which are
taken orally. Short-acting bronchodilators such as albuterol, are considered
relievers and are meant to be used on an as-needed basis or before
exercise. The need for a reliever inhaler more than 2 days a week or 2
nights a month is a sign of poorly controlled asthma.
Recent studies have
demonstrated adherence to asthma medications averages only 50%. In other words,
one-half of patients do not take their controller medicine regularly. This is
extremely important, as improved adherence is associated with less asthma attacks
and an improved quality of life and more symptom-free days. Thus non-adherence
is associated with a lack of asthma control, poor health outcomes and increased
The reasons for the lack of
regular use of asthma control drugs are varied. The cost, co-pays and coverage
for these drugs varies widely and high costs can be a barrier for many people.
Some patients are worried about ‘being dependent’ on daily medications while
many people simply find it hard to remember to take medication once or twice a
day. Additionally, correct inhaler technique is vital to ensure that the
medicine, when taken, is effective.
relationship is vital in improving adherence. Understanding, trust and mutual
respect are absolutely necessary between a patient and physician. For example,
patients should understand the difference between an oral steroid like
prednisone and an inhaled corticosteroid in terms of their safety and
efficacy. Patients should feel confident in why they are taking certain medications
and in how they are taking it. Regular follow up visits are vital. Asthma can
have fluctuations that require adjusting therapy up or down depending on the
situation. Thus prescribing or changing an asthma regime requires feedback to
insure safety, efficacy and compliance. Adjustments in dosing, if needed,
can be made on subsequent visits, usually 4-6 weeks apart, or as long as 90
Newly developed electronic
monitoring devices have the potential to be a very important asset to remind
and reinforce with patients when to take their medication. Such devices may
even provide vocal reminders that the medicines are due. Documenting the
regular use of these medications is of great use to physicians as well as to
In addition to devices that remind
us to take medication, the future of asthma therapy will no doubt include lung
function peak flow monitoring via the smart phone. This will allow both
patients and physicians to get a much fuller picture of an individual’s asthma
and allow far greater individualized care.
Managing asthma successfully
hinges upon using controller medications, such as inhaled steroid, regularly.
Regular use improves symptoms and quality of life and reduces the risk of
asthma exacerbations. For many, however, adherence can be challenging.
Effecting behavior change is quite difficult and time consuming. It requires
reinforcement and even such devices as peak expiratory flow meters to be used
by the patient at home. Technology should lead the way in helping patients and physicians
alike improve asthma control. In recent years we have all seen tremendous
advances in technology that have not only made our lives better, but improved
the quality of our lives. Such an outcome would be welcome in the care of our
asthmatic patients. As Leaders in Allergy and Asthma Care, Allergy Partners is
actively working to bring this technology to our patients.
Remembering to take medications every day can be
difficult for many people. For asthma patients, forgetting to take daily
controller inhalers can lead to more asthma exacerbations. New technology,
however, may help asthmatics remember their medications and keep asthma under
On June 3rd, 2014, a New Zealand company, Nexus6,
announced it received marketing clearance for SmartTouch, an inhaler monitoring
device. In the recent December issue of the Journal of Allergy and
Clinical Immunology a study was published titled Inhaler
reminders improve adherence with controller treatment in primary care patients
with asthma by Foster et al. It used the SmartTouch
device to measure asthma medication adherence. The device, which can connect to
the internet via smart phones and other devices, records doses and provides
reminders for missed doses. At six months, adherence in the reminder group was
double (60%) that of the non-reminder group (29%) whose adherence data was
collected covertly. The reminder group also had a statistically significant
reduction in severe exacerbations (11% versus 28%) compared to the non-reminder
group. Such data will help health care providers distinguish patients that
are refractory to treatment versus treatment failures due to non-compliance.
A similar device appears on their website for nasal sprays.
Per the company website, the SmartinhalerAppTM is available on iPad, iPhone and
Android devices although it was not found in the iTunes App Store as of January
14. It appears the SmartTouch device is preparing for U.S. markets given the
product section of the company website has a color matching device
for most American branded inhaler products available.
The availability of a "Smart Inhaler" should
benefit both patients and physicians. We may eventually see devices that can
alert pharmacies when your inhaler is running low. The physician can be
alerted if rescue inhaler usage has exceeded the recommended amount. Can't
recall if you took your scheduled controller last night? Check the log.
No more over or under reporting of medication use based on what a patient
thinks the physician wants to hear. Patient reminders and accurate adherence
records will help improve asthma control as we continue to become further
Have you ever wondered what to make of those air quality
warnings you hear on the news? These warnings are intended to help you
take action to avoid harmful air, but it is not always clear what they really
mean and what actions are reasonable and necessary. Here is a brief
history of the system behind the Air Quality Index (AQI), and education
regarding how these warnings can help you breathe better.
The AQI was developed by the Environmental Protection Agency
in 1968. It measures the levels of 5 major air pollutants regulated by
the Clean Air Act: particle pollution, ground-level ozone, carbon monoxide,
sulfur dioxide, and nitrogen dioxide. Of these, ozone and particle
pollution pose the greatest risk to your health.
The AQI is a number from 0-500 for each of these pollutants,
and anything below 50 is considered good. From 50-100 only very sensitive
people will be affected. Above 100 more people will begin to experience
problems, especially people with allergies, asthma, COPD, heart disease, the
elderly, and children. Above 150 even healthy people might begin to have
Health effects of air pollution include irritation of the
nose, throat, and lungs, worsening asthma, increased susceptibility to
respiratory infections, and even long term damage to these areas if the
exposure is high and prolonged.
So what action should you take when the AQI is
elevated? The first step is to build awareness of how your own body
reacts to air pollution, by keeping track of air quality (www.airnow.gov or the AIRNow app), and seeing
what symptoms you experience. You may find you need to take precautions
in the Yellow or Orange range. Everybody should take precautions once
levels are in the Red range or worse. Precautions include avoiding
exercising outdoors when AQI is poor, and limiting your children’s outdoor
play. Go to the gym or walk at the mall instead of jogging
outdoors. Use the air conditioner in your home and auto to help filter
the air. If you have asthma or allergies you may need to take extra
precautions. Discuss this with your Allergy Partners physician and make a
plan to maintain optimal health.
dermatitis or atopic eczema is a chronic inflammatory skin condition that
causes itching of the skin and chronic or recurrent skin lesions. Atopic
dermatitis can significantly impair quality of life due to sleep disturbance,
skin changes and scarring, and skin infections. Treatment may require
topical or oral steroids which have potential side effects. Studies that have
evaluated allergen avoidance measures as a means to PREVENT atopic dermatitis
have not shown much benefit. However, new studies indicate that using
inexpensive moisturizing emollients at a very young age may prevent eczema and
perhaps even allergies in at risk children.
dermatitis is now felt to result from skin barrier defects. Many people with
eczema have defects in a protein called filaggrin in the top layers of skin.
This protein and lipid layers together help maintain a healthy skin barrier.
The outer layers of skin are important to retain skin moisture and act as an
effective barrier to environmental allergens and irritants. The question
is whether or not enhancement of the defective skin barrier could prevent or
delay the onset of atopic dermatitis. Emollients (hydrating agents) improve the
skin barrier by providing extra lipids to the skin.
studies have evaluated the benefit of early application of emollients to the
skin of infants at high risk for developing atopic dermatitis and have shown positive
results. In a pilot study done in the United States and in the United
Kingdom, daily application of an emollient to the entire body surface, except
the scalp, beginning by 3 weeks of age showed a reduction in the incidence of
atopic dermatitis at 6 months of age. The emollients used in the US included
sunflower seed oil with a high ratio of linoleic acid/oleic acid, Cetaphil
cream, and Aquaphor ointment. Most parents preferred using a cream and
there were no adverse effects noted from applying the moisturizers.
sensitization can occur through skin that is not intact and preventing the
development of atopic dermatitis may reduce allergic sensitization. For
example, studies have identified peanut allergen in dust in homes where peanuts
are consumed and skin exposure to this allergen is believed to sensitize some
infants and children with eczema to peanut. Thus, applying an emollient
cream such as Cetaphil on a daily basis beginning shortly after an infant is
born may prevent the development of atopic dermatitis and sensitization to
allergens through the skin.
dermatitis is established, use of emollients remains a mainstay of treatment.
In addition, evaluation by an allergist and allergy testing can help identify
environmental or dietary allergic sensitivity that may be triggering symptoms.
Your Allergy Partners physician will work with you to develop an individualized
treatment plan that includes avoidance of allergens and irritants and other
skin care recommendations.
shelves are stocked with herbs and supplements that claim to improve health.
Such complementary and alternative medicines (CAM) are part of a group of
diverse medical and healthcare systems, practices, and products that are not
generally considered part of the conventional medical practices.
Over 42 percent of people in the US (both
adults and children) have used CAM for their allergic disorders. Such
treatments are perceived to be natural and safe by patients, but reporting of
adverse effects is largely inadequate. But do CAM therapies really help with
allergies and asthma? Importantly, are CAM therapies safe?
Chinese Herbal Medicine has been used for
centuries in Asia. However, lack of standardization and controlled clinical
trials have hampered their use as conventional therapies in Western medicine.
There is potential for developing novel therapies for atopic diseases from
Chinese herbs. Several herbal formulas show early promise for the treatment of
asthma, food allergies, and allergic rhinitis in randomized trials. Work
remains to determine the active components of each herb and their mechanisms of
action. In addition, issues with consistency of herb quality and
standardization still need to be addressed.
Herbal therapies like Ayurvedic mixes, butterbur, and Tinofend have
demonstrated some efficacy but these treatments may have side effects.
These products are not systematically monitored for safety by drug regulatory
bodies. Herbal remedies, including teas, made from plants can cause allergic
reactions, such as hives, or can induce asthma symptoms. Pregnant and nursing
patients should be advised to avoid these herbal therapies.
Nasal sprays consisting of dilute
solutions of capsaicin or inert, micronized cellulose powder have shown
efficacy for allergic rhinitis. Nasal saline lavage, commonly with a nettie pot
can be effective in alleviating symptoms of nasal congestion and drainage.
A variety of other herbal preparations, homeopathic
products, and miscellaneous therapies have been suggested for the treatment of
allergic rhinitis or conjunctivitis. However, studies have either been of low
quality or failed to show benefit. Additionally, a number of herbs such
as chamomile and Echinacea can cause allergic reactions in people who are
allergic to ragweed pollen.
Vitamin D deficiency has been
increasingly recognized as a health issue, particularly in northern latitudes.
Low Vitamin D levels have been associated with increased rates of food allergy.
It’s too early to say whether vitamin D can reverse food allergies. Future
research is needed to answer that question. However, research is beginning to
support the idea that vitamin D can protect against food allergies and vitamin
D is important for overall good health.
For most people, the best way to ensure you have enough vitamin D is a
combination between sensible sun exposure and adequate intake of foods
containing the vitamin. Your doctor can assess your vitamin D status with a simple
blood test and recommend a supplement if necessary
interventions such as Acupuncture and Acupressure (Stainless steel pellets in
adhesive discs are applied to specified points “acupoints” on the ear) show
modest benefit in the treatment of allergic rhinitis, although it is difficult
to estimate the size of the effect in most studies.
With all CAM interventions, it is vitally
important to discuss your use of these therapies with your doctor.
Additionally, CAM therapies should not be used in place of conventional
therapies without first talking to your doctor.
the calendar turns to the winter months, many allergy sufferers let out a sigh
of relief. No more pollen means no more sneezing and itching. But, for others
winter time means winter allergies. Winter allergies? Yes, winter allergies.
colder weather, we close up the house and get out our warm blankets and
comforters. Pets come indoors to snuggle. And for those allergic to pets and
dust mites, winter means more allergy symptoms.
mites are microscopic, eight legged creatures that feed on flakes of dead skin.
They absorb moisture from the air as opposed to drinking. Therefore, they like
to live where people are and where it is humid. Beds, bedding and carpets
provide dust mites the perfect place to live. And no matter how clean your
house is, you have dust mites.
to dust mites is one of the most common allergies. Up to 1 in 4 people are
allergic to dust mites and over 45% of homes have enough dust mite allergen to
trigger asthma and allergies. Symptoms of dust mite allergy tend to be a bit
different from pollen triggered allergies. As opposed to sudden fits of
sneezing, clear watery runny nose and itchy eyes, dust mite allergy tends to
cause more chronic nasal congestion that is worse first thing in the morning.
People allergic to dust mites are more prone to ear and sinus infections. Dust
mite allergy also worsens other underlying allergies.
what should you do? The first step is to find out if you are dust mite
allergic. Allergen skin testing under the direction of your Board Certified
Allergy Partners physician remains the best way to diagnose allergies. If you
are dust mite allergic, the following can help limit your exposure:
dust collectors such as stuffed animals in the bedroom
bedding in hot water (130 degrees)
carpets regularly with a HEPA filter vacuum
steam cleaning your carpets yearly
in high quality allergen encasements for your mattress and pillows to put a
barrier between you and the dust mites.
of dust mite allergy symptoms can include the use of over the counter and
prescription medicines. For those interested in preventing symptoms, allergen
immunotherapy (AKA allergy shots) can provide relief without having to take
daily medications. Your Allergy Partners physician will work with you to
determine the best options for you and your family.
learn more about allergies, asthma and our practice visit
The O2 Air Purifier attracts and eliminates not only allergens, but also mold,
bacteria, germs and odors.
Dr. Heather Gutekunst, Allergy Partners of Raleigh, hosted a great webinar last night on the symptoms and treatment options for Asthma. Her colleagues, Dr. Vaishali Mankad, Allergy Partners of Raleigh, and Dr. Ananth Thyagarajan, Allergy Partners of Richmond, joined in for a live Q&A session after the presentation. If you were not able to attend, please view the recording now on our YouTube Channel, www.youtube.com/MyAllergyPartners. You can also watch many other useful webinar and ‘how-to’ videos on various topics as it relates to allergies and asthma.
Ahh, cooler weather. Ahh Ragweed? Ahh
CHOO! Yes, Fall has its own pollen season, and the important pollen is ragweed,
which pollinates from August to October. The main two varieties in our area are
Giant ragweed and Short ragweed.
There are other weeds whose pollen may provoke allergic reactions, but
ragweed produces pollen in quantities which put these other weeds to shame. Other weeds which produce allergenic pollen
in our area during the fall are:
Of these, English plantain has the longest pollinating
season. None of those minor weeds above
can match Ragweed's production, but are still important contributors to fall
think that they are allergic to goldenrod, which they see growing in large
quantities in open fields in the fall. In fact, the pollens of most flowering
plants do not provoke allergy for
the simple reason that flowering plants have flowers in order to attract bees
which are required to transfer the heavy, sticky pollen from the male to the
female plant. Since the pollen requires bees for transfer, it isn't blown aloft
where it can be inhaled into the respiratory tract or get into the eyes of
allergy sufferers. Those plants which are wind pollinated generally have small
and unspectacular flowers or florets, and light, aerodynamically shaped pollen.
So when you sneeze next to a field bursting with yellow flowers, it's probably
the ragweed, not the goldenrod.
comes in several varieties, but the important ones in our area are giant
ragweed and short ragweed. In the delta region of the Mississippi river, vast
stands of giant ragweed may grow to reach as much as 15 feet in height! Let
that be a warning to those who are ragweed-sensitive not to visit that area of
the country during the fall pollinating season! Many people ask if there is a
better place to live if they have ragweed allergies. Last year, the Asthma and Allergy Foundation
of America compiled a list of the worst cities to live for those
with ragweed allergies. Top on the list was Louisville, KY. But don’t think about moving right away. In general, studies have shown that when
people move to another city, 50% have worse allergy symptoms and only 50% get
In the past,
many ragweed-sensitive subjects have taken late summer or fall vacations in the
upper peninsula of Michigan or the northern tip of Maine because these areas
have traditionally been free of ragweed. People hiking in carrying pollen and
seeds on their clothing have unfortunately introduced some ragweed.
who are sensitive to ragweed will complain of itching of the throat and/or
nasal congestion after eating cantaloupe, watermelon or bananas. This is due to
a cross-reacting protein present in these foods and the syndrome is called oral
A publication from the United States Department of Agriculture found data that
indicate a significant increase in the length of the ragweed pollen season by
as much as 13–27 days at latitudes above 44°N since 1995 compared to before
that time (this latitude crosses states in the northern part of the U.S.)
This is not good news for those people who suffer from ragweed allergy.
The pollen is highest during the morning hours, on windy days or shortly after
a rainstorm when the plant is drying out. However, rain “washes the pollen out
of the air,” so going out during the rain generally causes fewer symptoms.
symptoms of allergic rhinitis are sneezing, runny nose and nasal congestion.
Eye symptoms include itchy, watery, red and, at times, swollen eyes. The ears
and roof of the mouth may itch as well. In asthmatic patients, allergen
exposure can trigger cough, wheeze and shortness of breath. Importantly, up to
70% of asthmatics have underlying allergies. People with allergies are also more
prone to ear and sinus infections.
other allergic conditions, the mainstays of treatment include avoidance,
medications and allergy shots. Some basic avoidance tips
- Keep windows closed to
prevent pollens from drifting into your home.
- Keep air conditioning on as
that filters out 95% of the pollen.
- Minimize early morning
activity when pollen is generally at its maximum -- between 5:00 and 10:00
- Keep your car windows closed
- Stay indoors during high
pollen counts (which are available on our home page) and
on windy days when pollen may be present in higher amounts in the air.
- Machine dry bedding and
clothing. Pollen may collect in laundry if it is hung outside to dry.
- When you come home for the
day, change your clothes and take a shower to remove the pollen that is
attached to your clothes and hair. Also consider washing out your eyes
with contact lens saline solution or artificial tears and rinsing out your
nose with saline nasal spray to wash the pollen out of those areas.
you can also follow us on Facebook and Twitter for daily
pollen counts, office information, patient education and more. If you enjoyed
this post please “Like” us on Facebook and “Share” the article.
S. Turner, MD
Welcome to our blog site! Stay tuned to get the latest news. We
will share tips and techniques for living with and managing your Allergies &
Asthma. We look forward to sharing useful resources with our patients!