June 30th, 2009
Some encouraging news is being reported regarding severe asthma in pediatric patients. Dr. Joseph Spahn, a professor at National Jewish Health in Denver (probably the finest asthma and allergy facility in the U.S. if not the world) and his team performed a study comparing their asthma referrals from 2004 to 2007 to the referrals from 1993 to 1997. The biggest difference between these two time periods is the medications used to control asthma. Newer steroid molecules, combination medications like Advair, leukotriene antagonists like Singulair and novel asthma therapies like Xolair were not available in the mid-90s. As these newer medications have become more widely utilized, there has been significant improvement in numerous measurements. Notably, the rate of chronic oral steroid use fell by almost half, from 51% to 28% and the rate of intubation, being placed on a ventilator, fell as well, from 21% to 13%. The newer cohort did all this with fewer steroid-induced adverse effects.
Dr. O
June 29th, 2009
Drainage is one of the tougher nasal symptoms to treat. It plays a big role in many of the complications of rhinitis, too, particularly sore throat, hoarseness and cough. Allergies can lead to drainage, but there are numerous other causes as well.
Did you know that everyone drains about a liter of fluid down the back of their throat every day? That’s a lot. So when people have problems with drainage, it’s not that they have more than the next person, it’s just that what they have is abnormal. It’s a quality issue, not a quantity issue. When nasal secretions are normal, they are thin and runny and we swallow them without noticing. It’s only when the secretions become thick and sticky that they start to be a problem by adhering to the back of the throat, the vocal cords, or the trachea.
What sort of things, then, change the secretions from thin and runny to thick and sticky? First, since this is an allergy blog, is allergies. Allergies cause inflammation in the nose and sinus passages and this inflammation causes thickening of the secretions. Second is infections. Acute infections, like the common cold, clearly cause a change in the secretions. The role of chronic sinusitis is less clear. Third is medications. Numerous medications can dry or thicken the secretions and cause drainage. Common offenders include diuretics, some blood pressure medications, older antihistamines, and decongestants. Fourth is dehydration. Not taking in enough water or drinking too much caffeine can lead to relative dehydration. Finally, aging generally increases the thickness of the nasal secretions.
So how do we treat drainage? Obviously if allergies are present, then we aggressively treat those. Apart from this, simple things like adequate hydration are important. The best treatment I’ve found is nasal saline lavage (see below). It simply removes the secretions before they get to be a problem. Guaifenesin (Mucinex) is supposed to thin the secretions. Some of my patients find it to be helpful, some not so much. It is over the counter and very safe. Finally a word about decongestants. They are commonly found in OTC allergy and cold remedies. Any medication that has a “-D” suffix probably has a decongestant in it. Decongestants are good for treating nasal congestion, but can actually make drainage worse. I touch on decongestants in an earlier post on OTC allergy meds
June 26th, 2009
Regular readers now know that when a person has allergies, the basic underlying problem is that the immune system incorrectly identifies normal parts of the environment as potentially harmful and it sets up a reaction to try and get rid of them. What the immune system is really recognizing is proteins found in these substances. We call these proteins antigens. So, in a whole pollen grain, there may be several small protein antigens that the body is sensitive to.
So, what does this have to do with fruits and oral itching and burning? Well, many fruits contain proteins that are structurally similar to protein antigens found in pollens, particularly birch tree pollen, but also other trees and ragweed. The list of fruits is long, but includes apple, pear, cantaloupe, banana and kiwi. So when a pollen allergic person eats a fruit with a structurally similar protein, they may experience intense itching and burning of the lips, mouth and throat. Occasionally, there is mild swelling as well.
This phenomenon is called Oral Allergy Syndrome. (Some academic allergists are trying to change the name to Pollen/Food Syndrome). The good thing about OAS is that reactions are usually just local and are more irritating than dangerous. A few studies suggest that treatment with immunotherapy can lessen or stop OAS reactions and my own experience backs this up.
It is important to differentiate between annoying OAS and potentially dangerous food allergy. Simple allergy tests can answer this question.
Dr. O
June 25th, 2009
Flushing out the nose with a large volume of salt water is a great treatment for allergy symptoms. It removes allergens and irritants from the nose and also helps remove thick, sticky secretions that may be clogging the nose or leading to drainage.
This method has been around for a long time. You may have heard of the neti pot method. It uses gravity to force the liquid through the nose. Modern technology has given us simple plastic squeeze bottles that can provide a bit more force and flow through the nose. You can find one at any pharmacy.
Be sure to not use plain tap water to irrigate the nose. It is too dilute and will irritate the lining of the nose. To make a proper saline solution, add a teaspoon of salt to 8 ounces of lukewarm tap water. If you like you can use a half-teaspoon of salt and a half-teaspoon of baking soda instead. Some people prefer one over the other, but either way is fine.
Next, tilt the head forward and slightly sideways and place the nozzle in the upper nostril. Do not plug up the other side of the nose, simply let the solution drain out of the lower nostril. Obviously, one would do this over the sink or in the shower. Flush til the secretions clear. Once or twice a day is usually sufficient.
If you have had sinus surgery, this method may not work so well. The solution can pool in the sinuses and run out at very inopportune moments. (I’m speaking from experience here.)
Also, despite warnings in the commercially available squeeze bottles, you do not need to buy a fancy expensive mix. Whatever you have in your pantry will work just fine, including iodinated salt.
Dr. O
June 23rd, 2009
I see lots of patients who have either had their air ducts cleaned or want to know if they should. I saw a big uptick in this about 5 years ago so I decided to do a little research on the matter. The best information I’ve found comes from the EPA. They have a great page devoted to the subject on their website. It is detailed and extensive. I recommend it highly. You can find it here.
The EPA site brings up a couple of important points. Most importantly, air duct cleaning has never been shown to prevent health problems. Furthermore, they state,
” Pollutants that enter the home both from outdoors and indoor activities such as cooking, cleaning, smoking, or just moving around can cause greater exposure to contaminants than dirty air ducts. Moreover, there is no evidence that a light amount of household dust or other particulate mater in air ducts poses any risk to your health.”
They recommend cleaning for three reasons: 1) Substantial visible mold growth, 2) Insect or vermin infestation(ew), or 3) Excessive dust and debris that is released into the home.
Since proper duct cleaning can run $500-$1000, you should be sure to do your homework before considering it.
Dr. O
June 23rd, 2009
A nubulizer is a device that takes a liquid solution and turns it into a fine mist that can be inhaled. I frequently hear patients refer to it as a “breathing machine” that gives a “breathing treatment”. Albuterol is the most common nebulized medication and is used to treat wheezing and chest tightness in asthmatics and emphysema patients. The primary advantage to nebulizers is that they are very easy to use. Place the medication in the machine, flip the switch, and breathe normally from the mouthpiece or mask til the medication is finished- around 10 minutes.
The alternative to nebulizers is the simple metered-dose inhaler, or MDI. MDIs are harder to coordinate than a nebulizer, but when they are used with a spacer device,
Aerochamber
as pictured on the right, coordination is much easier and the delivered dose is more consistent. Learning to use a spacer device takes under a minute.
There is a common misconception that nebulizer therapy is a stronger treatment than an MDI. This is simply not true. Multiple studies have shown that patients receiving albuterol from an MDI/spacer combination do just as well as, if not better than, patients receiving nebulized albuterol.
MDIs offer several advantages. First, they are much quicker to use. Two puffs from an MDI/spacer takes 30 seconds or so if done properly vs. 10 minutes or so for a nebulizer treatment. Second, MDIs cause fewer side effects. Nebulized albuterol causes much more heart rate increase and tremor than albuterol from an MDI/spacer. Third, MDIs are much cheaper to use. Not including the cost of the nebulizer and related supplies, nebulized albuterol costs $2-$2.50 per dose versus $.40-$.50 per dose for MDI delivered albuterol.
So, MDIs are cheaper, quicker, have fewer side effects and have equal effectiveness. Sounds like we have a winner.
Dr. O
June 17th, 2009
On June 12, 2009 the U.S. Food and Drug Administration announced their request for new warning labels that would apply to leukotriene inhibitors. This includes drugs such as montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo and Zyflo CR). The warnings included an increased risk of neuropsychiatric events.
If you take these medications you should consider whether you have experienced agitation, aggression, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor.
In my personal experience of treating patients with asthma and allergies, the only problem noted above that I have heard patients complain of is vivid or disturbing dreams related to Singulair. If you are on these medications and have noted any of the above symptoms, let your doctor know and discuss other options for control of your allergy and/or asthma symptoms.
Dr. Norvell
June 17th, 2009
Loss of sense of smell has been a recognized complication of intranasal Zinc application. Yesterday, the FDA finally came out with a warning regarding Zicam, a product which contains Zinc for intranasal application. I’ve reposted yesterday’s bulletin from the AAAAI to its members after the jump.
To me, this case illustrates a couple of important issues. First, you don’t get pharmaceutical effects without the potential for adverse reactions. Just because something is “natural” does not make it innately safer than compounds which are crated in a lab and extensively tested. Second, the lack of oversight of the supplement industry is appalling. As long as manufacturers call their product a dietary supplement and say “this product is not intended to diagnose, treat, or cure any disease” then they can say whatever they want without a shred of proof that their claims are true. If their products really work, they should be required to show proof of effectiveness and safety, just like the pharmaceutical industry.
Dr. O
“This morning, The Food and Drug Administration (FDA) held a news conference warning physicians and consumers about Zicam Cold Remedy intranasal products, indicating “these products may pose a serious risk to consumers who use them.” Specifically, the FDA has received more than 130 reports of anosmia (loss of sense of smell, which in some cases can be long-lasting or permanent), associated with use of these products. Some individuals also report loss of sense of taste.
Included in the warning are: Zicam Cold Remedy Nasal Gel, Zicam Cold Remedy Gel Swabs, and Zicam Cold Remedy Swabs, Kids Size. All are administered by direct application to the nasal cavity, and as described in the labeling, are intended for use in “adults and children 3 years of age and older (with adult supervision). These products are available without a prescription, and they contain zinc gluconate (identified as zincum gluconicum on their labels) as their active ingredient.
These OTC’s are marketed as homeopathic and therefore are not subject to FDA approval. However, given the risk, the FDA has issued a warning letter to Matrixx Initiatives, Inc, makers of the products. During the news teleconference, the FDA indicated they have asked Matrixx to work with the FDA in removal of the products from the market.”
June 16th, 2009
If you are taking prescription allergy or asthma medications, chances are the pharmaceutical manufacturer has a program which could significantly reduce your pharmacy co-payments. Visit the medication’s specific website to check. Many programs provide a card or coupons which give an immediate rebate at the point of purchase. Savings can be in the range of $25 per prescription filled or more.
June 12th, 2009
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Dr. O
