Management of Asthma

Asthma is an inflammatory disorder of the airways, which causes attacks of wheezing, shortness of breath, chest tightness, and coughing.

Asthma is caused by inflammation in the airways. When an asthma attack occurs, the muscles surrounding the airways become tight and the lining of the air passages swells. This reduces the amount of air that can pass by.

In sensitive people, asthma symptoms can be triggered by breathing in allergy-causing substances (called allergens or triggers).

Common asthma triggers include:

·         Animals (pet hair or dander)

·         Dust

·         Changes in weather (most often cold weather)

·         Chemicals in the air or in food

·         Exercise

·         Mold

·         Pollen

·         Respiratory infections, such as the common cold

·         Strong emotions (stress)

·         Tobacco smoke

In the United States, asthma affects more than 22 million persons. It is one of the most common chronic diseases of childhood, affecting more than 6 million children. India accounts for one third of the world's 115 million asthma patients.

Management of Asthma

General Measures

·         The most effective treatment for asthma is identifying the triggers and avoiding exposure to those agents.

·         Desensitization to allergens has been shown to be a treatment option for certain patients.

·         Smoking cessation and avoidance of secondhand smoke is recommended for all asthmatics.

·         In patients with EIA, higher levels of ventilation and cold, dry air tend to exacerbate attacks. Therefore, it is advisable to avoid activities, which results in inhalation of large amounts of cold air such as skiing and running. Activities such as swimming in an indoor, heated pool with warm, humid air is less likely to provoke a response.

Self-Management of Asthma

Guided self-management of asthma is a treatment strategy in which patients are taught to act appropriately when the first signs of asthma exacerbations appear. Patient education can allow patients with asthma to begin guided self-management of the disease. Self-management of asthma prevents exacerbations, improves care and is cost-effective. Such practice will ensure a favorable clinical outcome and an enhanced quality of life.

The aim of asthma management is to achieve a symptom-free, normal life for the person with asthma and prevent the development of permanent lung damage and abnormal lung function. To do that, physicians and people with asthma must work in partnership. Good asthma management depends as much upon the person as it does on the treating doctor and other health professionals.

Asthma management education by doctors and others in asthma care means that people with asthma understand their condition and treatment and can successfully manage it themselves between doctor visits. To do this, an individual written asthma action plan is essential.

These details:

1.    What to do if symptoms return or increase?

2.    When and how much to increase medications?

3.    When to seek medical help?

Long-term control medications are taken daily to maintain control of persistent asthma. They primarily serve to control airway inflammation.

The quick-relief medications are taken to achieve prompt reversal of an acute asthma attack by relaxing bronchial smooth muscle.

Many asthma medications can be administered orally or by inhalation. Metered-dose inhalers (MDI’s) are the most widely used method, but dry powder inhalers are becoming popular. Metered-dose inhalers are changing from the type propelled by liquefied chlorofluorocarbons (CFCs) to a new, CFC-free delivery system. Nebulizer therapy is reserved for patients who are unable to use MDI’s because of difficulties with coordination.

Treatment of Asthma Treatment

Asthma cannot be cured, but it can be controlled with proper asthma management.

1.    The first step in asthma management is environmental control. Asthmatics cannot escape the environment, but through some changes, they can control its impact on their health.

Listed below are some ways to change the environment in order to lessen the chance of an asthma attack:

·         Clean the house at least once a week and wear a mask while doing it

·         Avoid pets with fur or feathers

·         Wash the bedding (sheets, pillow cases, mattress pads) weekly in hot water

·         Encase the mattress, pillows and box springs in dust-proof covers

·         Replace bedding made of down, kapok or foam rubber with synthetic materials

·         Consider replacing upholstered furniture with leather or vinyl

·         Consider replacing carpeting with hardwood floors or tile

·         Use the air conditioner

·         Keep the humidity in the house low

2.    The second step is to monitor lung function. Asthmatics use a peak flow meter to gauge their lung function. Lung function decreases before symptoms of an asthma attack - usually about two to three days prior. If the meter indicates the peak flow is down by 20 percent or more from your usual best effort, an asthma attack is on its way.

3.    The third step in managing asthma involves the use of medications. There are two major groups of medications used in controlling asthma - anti-inflammatory (corticosteroids) and bronchodilators.

Anti-inflammatory reduce the number of inflammatory cells in the airways and prevent blood vessels from leaking fluid into the airway tissues. By reducing inflammation, they reduce the spontaneous spasm of the airway muscle. Anti-inflammatory are used as a preventive measure to lessen the risk of acute asthma attacks. The corticosteroids are given in two ways - inhaled via a metered dose inhaler (MDI) or orally via pill/tablet or liquid form.

Bronchodilators work by increasing the diameter of the air passages and easing the flow of gases to and from the lungs.

Some people cannot control the symptoms by avoiding the triggers or using medication. For these people, immunotherapy (allergy shots) may help. Immunotherapy involves the injection of allergen extracts to "desensitize" the person. The treatment begins with injections of a solution of allergen given one to five times a week, with the strength gradually increasing.

Prevention of Asthma Treatment

·         Periodic assessments and ongoing monitoring of asthma are essential to determine if therapy is adequate. Patients need to understand how to use a peak flow meter and understand the symptoms and signs of an asthma exacerbation.

·         Regular follow-up visits (at least every six months) are important to maintain asthma control and to reassess medication requirements.

Management of Diabetes

Diabetes mellitus is a metabolic disease characterized by hyperglycemia (high blood sugar). Diabetes is a disease in which the body does not produce insulin or properly use. Insulin is a hormone produced in the pancreas, an organ near the stomach. Insulin is needed to turn sugar and other food into energy. Three major forms of diabetes: type 1, type 2 and gestational diabetes (occurring during pregnancy), which have similar signs, symptoms and consequences, but different causes and population distributions. Ultimately, all forms are due to pancreatic beta cells are unable to produce enough insulin to prevent hyperglycemia. Type 1 is usually due to self-destruction of pancreatic beta cells that produce insulin. Type 2 is characterized by tissue wide insulin resistance and varies widely, but sometimes progressing to loss of function of beta cells. Gestational diabetes is similar to type 2 diabetes, since it involves insulin resistance; hormones of pregnancy cause insulin resistance in those women genetically predisposed to develop this disease.

Diabetes is a chronic disease with no cure as of 2010 but a lot of research is underway. It is associated with an impaired glucose cycle, altering metabolism. Management of this disease may include carefully managing diet, exercising, taking oral diabetes medication, using some form of insulin, maintaining proper circulation in extremities and may be further complicated by other external factors such as stress, illness, menses, injection site scarring, and other physiological factors unique to individual patients.

As diabetes is a prime risk factor for cardiovascular disease, controlling other risk factors which may give rise to secondary conditions, as well as the diabetes itself, is one of the facets of diabetes management. Checking cholesterol, LDL, HDL and triglyceride levels may indicate hyperlipoproteinemia, which may warrant treatment with hypolipidemic drugs. Checking the blood pressure and keeping it within strict limits (using diet and antihypertensive treatment) protects against the retinal, renal and cardiovascular complications of diabetes. Regular follow-up by a podiatrist or other foot health specialists is encouraged to prevent the development of diabetic foot. Annual eye exams are suggested to monitor for progression of diabetic retinopathy.

Late in the nineteenth century, sugar in the urine (glycosuria) was associated with diabetes. Various doctors studied the connection. Frederick Madison Allen studied diabetes in 1909-12, and then published a large volume, Studies Concerning Glycosuria and Diabetes, (Boston, 1913). He invented a fasting treatment for diabetes called the Allen treatment for diabetes. His diet was an early attempt at managing diabetes.

Modern approaches to diabetes primarily rely upon dietary and lifestyle management, often combined with regular ongoing blood glucose level monitoring.

Diet management allows control and awareness of the types of nutrients entering the digestive system, and hence allows indirectly, significant control over changes in blood glucose levels. Blood glucose monitoring allows verification of these, and closer control, especially important since some symptoms of diabetes are not easy for the patient to notice without actual measurement.

Other approaches include exercise and other lifestyle changes which impact the glucose cycle.

In addition, a strong partnership between the patient and the primary healthcare provider – general practitioner or internist – is an essential tool in the successful management of diabetes. Often the primary care doctor makes the initial diagnosis of diabetes and provides the basic tools to get the patient started on a management program. Regular appointments with the primary care physician and a certified diabetes educator are some of the best things a patient can do in the early weeks after a diagnosis of diabetes. Upon the diagnosis of diabetes, the primary care physician, specialist, or endocrinologist will conduct a full physical and medical examination. The management of diabetes is so important for diabetics to understand. For a newly diagnosed diabetic, any management plan can be overwhelming at first, but it is a vital means of controlling this disease as well as preventing complications.

The main items that need to be managed and checked are:

•                     Height and weight measurements

•                     Blood pressure measurements

•                     Thyroid examination

•                     Examination of hands, fingers, feet, and toes for circulatory abnormalities

•                     Blood tests for fasting blood sugar, and cholesterol

•                     Family history of diabetes, cardiovascular disease, and stroke

•                     Prior infections and medical conditions

•                     A list of current medications, including:

•                     Prescription medications

•                     Over-the-counter medications

•                     Vitamin, mineral or herbal supplements

•                     Smoking history, including encouragement to stop smoking (if applicable)

•                     Signs of complications with pregnancy or trying to get pregnant for women patients

•                     Eating and exercise habits

•                     Vision abnormalities, to check for eye health issues

•                     Urination abnormalities, which can indicate kidney disease

•                     Teeth and Mouth hygiene

•                     Regular visits to dentist, ophthalmologist, and primary doctor.

This is when diabetics need to make a life time commitment to doing what is necessary to control diabetes. All of these factors are interconnected. And in the case of Type 2 diabetes, it can be totally controlled in some cases with diet and exercise.

Optimal management of diabetes involves patients measuring and recording their own blood glucose levels. By keeping a diary of their own blood glucose measurements and noting the effect of food and exercise, patients can modify their lifestyle to better control their diabetes. For patients on insulin, patient involvement is important in achieving effective dosing and timing.

Glucose monitoring

The home monitoring of glucose levels needs to be done frequently using a glucometer. This is vital as this is the main way to know that your management plan is working.

Diet

For most Type 1 diabetics there will always be a need for insulin injections throughout their life. However, both Type 1 and Type 2 diabetics can see dramatic normalization of their blood sugars through controlling their diet, and some Type 2 diabetics can fully control the disease by dietary modification. As diabetes can lead to many other complications it is critical to maintain blood sugars as close to normal as possible and diet is the leading factor in this level of control.

Weight Control

Weight is a risk factor for Type 2 diabetes, so managing the weight is a critical factor for controlling blood glucose levels.

Exercise

Exercise is important in helping with weight control as well as helping any medication or insulin therapy to work more effectively.

Driving

Studies conducted in the United States and Europe showed that drivers with type 1 diabetes had twice as many collisions as their non-diabetic spouses, demonstrating the increased risk of driving collisions in the type 1 diabetes population. Diabetes can compromise driving safety in several ways. First, long-term complications of diabetes can interfere with the safe operation of a vehicle. For example, diabetic retinopathy (loss of peripheral vision or visual acuity), or peripheral neuropathy (loss of feeling in the feet) can impair a driver’s ability to read street signs, control the speed of the vehicle, apply appropriate pressure to the brakes, etc.

Second, hypoglycemia can affect a person’s thinking process, coordination, and state of consciousness. This disruption in brain functioning is called neuroglycopenia. Studies have demonstrated that the effects of neuroglycopenia impair driving ability.

Dental care

High blood glucose in diabetic people is a risk factor of developing gum and teeth problems, especially in after puberty and aging individuals. Diabetic patients have greater chances of developing oral health problems such as tooth decay, salivary gland dysfunction, fungal infections, inflammatory skin disease, periodontal disease or taste impairment and thrush of the mouth. The oral problems in persons suffering from diabetes can be prevented with a good control of the blood sugar levels, regular checkups and a very good oral hygiene. By maintaining a good oral status, diabetic persons prevent losing their teeth as a result of various periodontal conditions.

Medical Management of Diabetic Complications

Hypertension

Diabetic patients with hypertension should have their blood pressure (BP) lowered to targeted levels, since serious microvascular and macrovascular diabetic complications are strongly linked to hypertension. The optimal treatment goal for non-pregnant diabetics over age 18 is a systolic BP of < 130 and a diastolic < 80 mmHg.

Aspirin Therapy

Clinical trials have demonstrated that aspirin therapy is a cheap and effective intervention for preventing serious cardiovascular events such as myocardial infarctions and stroke among diabetics.

Clinical Precaution: Do not routinely use aspirin in inmates < 21 years of age, due to the increased risk of Reye’s syndrome.

Dyslipidemia

Type 1 and type 2 diabetes are considered coronary heart disease (CHD) risk equivalents, due to the strong association of diabetes and serious cardiovascular disease. Type 2 diabetes is associated with other CHD risk factors such as elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides. Lipid disorders should be managed aggressively in diabetic patients to reduce the risk of serious cardiovascular events.

Diabetic Nephropathy

Microalbuminuria (30–300 mg/24 hour), the earliest stage of kidney disease associated with diabetes, often progresses to clinical albuminuria (greater than 300 mg/24 hours) with a subsequent decline in renal function over a period of years. Hypertension usually develops during the onset of Microalbuminuria and, if left untreated, can hasten progression of renal disease.

Management of Heart Attacks

The heart is a muscle like any other in the body. Arteries supply it with oxygen-rich blood so that it can contract and push blood to the rest of the body. When there isn't enough oxygen flow to a muscle, its function begins to suffer. Block the oxygen supply completely, and the muscle starts to die. Heart muscle gets its blood supply from arteries that originate in the aorta just as it leaves the heart. The coronary arteries run along the surface of the heart and supply oxygen-rich blood to the heart muscle. The right coronary artery supplies the right ventricle of the heart and the inferior (lower) portion of the left ventricle. The left anterior descending coronary artery supplies the majority of the left ventricle, while the circumflex artery supplies the back of the left ventricle. The ventricles are the lower chambers of the heart; the right ventricle pumps blood to the lungs and left pumps it to the rest of the body.

During a heart attack, a clot forms in an artery that supplies blood to the heart and blocks blood flow to the area of heart muscle supplied by that artery. The portion of the heart muscle deprived of blood carrying the needed oxygen begins to become damaged. This is called a “myocardial infarction,” more commonly known as a heart attack. The amount of lasting damage to the heart muscle depends on a number of factors—the size of the clot, the location of the clot, and how long the clot blocks blood flow to the muscle. The longer the heart muscle is without blood and oxygen, the more extensive the damage to the muscle and the greater the size of the heart attack.

Heart Attack Symptoms and Signs

1.    Classic symptoms of a heart attack may include:

·         chest pain associated with shortness of breath,

·         profuse sweating, and

·         Nausea.

The chest pain may be described as tightness, fullness, a pressure, or an ache.

2.    Unfortunately, many people do not have these classic signs. Other signs and symptoms of heart attack may include:

·         indigestion,

·         jaw ache,

·         pain only in the shoulders or arms,

·         shortness of breath, or

·         Nausea and vomiting.

3.    This list is not complete, since many times people can experience a heart attack with minimal symptoms. In women and the elderly, heart attack symptoms can be atypical and sometimes so vague they are easily missed. The only complaint may be extreme weakness or fatigue.

4.    Pain may also radiate from the chest to the neck, jaw, shoulder, or back and be associated with shortness of breath, nausea, and sweating.

Heart Attack Causes

·         Over time, plaque can build up along the course of an artery and narrow the channel through which blood flows. Plaque is made up of cholesterol buildup and eventually may calcify or harden, with calcium deposits. If the artery becomes too narrow, it cannot supply enough blood to the heart muscle when it becomes stressed. Just like arm muscles that begin to ache or hurt when heavy things are lifted, or legs that ache when you run too fast; the heart muscle will ache if it doesn't get adequate blood supply. This ache or pain is called angina. It is important to know that angina can manifest in many different ways and does not always need to be experienced as chest pain. If the plaque ruptures, a small blood clot can form within the blood vessel, acting like a dam and acutely blocking the blood flow beyond the clot. When that part of the heart loses its blood supply completely, the muscle dies. This is called a heart attack, or an MI - a myocardial infarction.

·         Cocaine use: This drug can cause the coronary arteries to go into enough spasm to cause a heart attack. Because of the irritant effect on the heart's electrical system, cocaine can also cause fatal heart rhythms.

·         Prinzmetal angina or coronary artery vasospasm: Coronary arteries can go into spasm and cause angina without a specific cause, this is known as Prinzmetal angina. There can be EKG changes associated with this situation, and the diagnosis is made by heart catheterization showing normal coronary arteries that go into spasm when challenged with a medication injected in the cath lab. Approximately 2% to 3% of patients with heart disease have coronary artery vasospasm.

·         Anomalous coronary artery. In their normal position, the coronary arteries lie on the surface of the heart. On occasion, the course of part the artery can dive into the heart muscle itself. When the heart muscle contracts, it can temporarily kink the artery and cause angina. Again, diagnosis is made by heart catheterization.

·         Inadequate oxygenation. Just like any other muscle, heart muscle requires adequate oxygen supply for it to work. If there isn't adequate oxygen delivery, angina and heart attack can occur. There needs to be enough red blood cells circulating in the body and enough lung function to deliver oxygen from the air, so that heart cells can be supplied with the nutrients that they need. Profound anemia from bleeding or failure of the body to make enough red blood cells can precipitate angina symptoms. Lack of oxygen in the bloodstream can occur due to a variety of causes including respiratory failure, carbon monoxide poisoning or cyanide poisoning.

Heart Attack Risk Factors

Heart attack is most often caused by narrowing of the arteries by cholesterol plaque and their subsequent rupture. This is known as atherosclerotic heart disease (AHSD) or coronary artery disease (CAD).

The risk factors for ASHD are the same as those for stroke (cerebrovascular disease) or peripheral vascular disease. These risk factors include:

·         a family history or heredity,

·         cigarette smoking,

·         high blood pressure,

·         high cholesterol, and

·         Diabetes.

While heredity is beyond a person's control, all the other risk factors can be minimized to try to prevent coronary artery disease from developing. If atherosclerosis is already present, minimizing these risk factors can decrease further narrowing.

When to Seek Medical Care

Chest pain is almost always considered an emergency. Aside from heart attacks, pulmonary embolus (blood clot in the lung) and aortic dissection or tear can be fatal causes of chest pain.

Classic pain from a heart attack is described as chest pressure or tightness with radiation of the pain to the jaw and down the arm, accompanied by shortness of breath or sweating. But it is important to remember that heart problems may not always present as pain or with the classic symptoms. Indigestion, nausea, profound weakness, profuse sweating, or shortness of breath may be the main symptom of a heart attack.

Should any symptoms occur that you believe are related to your heart, activate the emergency medical system by calling 911 in USA, while in India, its 102, whereas in Europe its 112. First responders, emergency medical technicians, and paramedics can begin testing and treatment even before you arrive at the hospital.

Remember to take an aspirin immediately if you are concerned that you are having a heart attack. (Not for patient below 18 yrs of age)

If you have a history of chest pain for which your doctor has prescribed nitroglycerin, then take ONE dose right away. If your symptoms are not better 5 minutes after taking one dose, then you should call 102 immediately. In the past, you may have been told to take up to 3 doses of nitroglycerin before calling 102. However, the medical guidelines for the use of nitroglycerin have changed to help people who may be having a heart attack get to a hospital more quickly.

If you suspect you are having a heart attack, you should stop all physical activity immediately and lie or sit down. Alert anyone near you to call 102 for immediate medical attention and it is important to get to the nearest hospital emergency room as soon as possible. Immediate cardiopulmonary resuscitation (CPR) and direct-current shock (defibrillation) are essential for survival of sudden cardiac death.

Many people die before they seek medical care because they ignore their symptoms out of fear that something bad is happening, or by diagnosing themselves in error with indigestion, fatigue, or other illnesses. It is much better to seek medical care if you are unsure whether your symptoms are related to heart disease and find that all is well, than to die at home.

Heart Attack Diagnosis

Diagnosis and treatment tend to occur at the same time in patients who are experiencing chest pain. If there is concern that heart muscle is at risk, delays need to be minimized so that blood supply to that muscle can be restored.

Medical History

The diagnosis of angina is made by history of the patient. If the story that the patient tells is suggestive of cardiac ischemia, then the health care practitioner will continue on the path to determine whether a heart attack has occurred.

Important questions include:

1. When did the pain start?
2. What were you doing?
3. Did you have to stop?
4. Did the pain get better with rest?
5. Did the pain come back with activity?
6. Did the pain stay in your chest or did it move somewhere else, like the jaw, teeth, and arm or back?
7. Did you get short of breath?
8. Did you become nauseous?
9. Were you sweating profusely?

       The medical history also includes assessing risk factors for heart disease, including:

Smoking, hypertension or high blood pressure, high cholesterol, diabetes,

Questions may be asked about changes in exercise tolerance that might provide clues as to whether heart disease is present:

1. Have there been episodes of previous chest pain?
2. Is there shortness of breath on exertion?
3. Can you walk to get the mail?
4. Can you climb a flight of stairs?

The questions may try to distinguish between stable angina and unstable angina. Stable angina tends to be predictable. For example, it may occur after climbing a flight of stairs or walking a couple of blocks and then resolves quickly with rest. Unstable angina may occur without warning when the body is at rest and the heart is not stressed, for example while sitting or sleeping.

Since other diagnoses will be considered, some questions may be asked to identify potential symptoms of conditions such as reflux esophagitis (GERD), gastritis, trauma, pulmonary embolus (blood clot in the lung), or pneumonia.

Self-Care at Home

The first step to take when chest pain occurs is to call 911 in USA, while in India, its 102, whereas in Europe its 112. First responders, EMTs, and paramedics can begin treating a heart attack en-route to the hospital, alert the Emergency Department that the patient is on the way, and treat some of the complications of a heart attack should they occur.

       Step two is to take an aspirin. Aspirin makes platelets less sticky and can minimize blood clot formation and prevent further blockage of the artery. (Not for patient below 18 yrs of age)

       Step three is to rest. When the body does work, the heart has to pump blood to supply oxygen to the muscles and clear the waste products of metabolism. When heart function is limited because it doesn't have an adequate blood supply itself, asking it to do more work may cause more damage and risk further complications.

Heart Attack Prevention

While people cannot control their family history and genetics, they can minimize risk factors for heart disease by:

Quitting smoking; or smoking cessation,

            Controlling high blood pressure, cholesterol, diabetes;

Exercise regularly, weight loss, and

            Take a baby aspirin a day. (Not for patient below 18 yrs of age)

These are all lifelong challenges to prevent heart disease, stroke, and peripheral vascular disease.

Even with the best of preventive care, heart attacks happen. Develop an emergency plan so that if chest pain occurs make certain you, your family, and friends know how to activate the Emergency Medical Services in your area or call 102.