Q.What is allergic rhinitis?
A.Bouts of sneezing, called allergic rhinitis in medical terminology, is one of the commonest forms of allergy. It may occur in children or in older people, but, mostly, it occurs among young adults. Males and females are equally affected by it. The symptoms may be mild or very severe and distressing.

Q.What is seasonal allergic rhinitis?
A.Sneezing, running of the nose and itching in the eyes occurring in a person in a particular season, year after year, are the characteristics of seasonal allergic rhinitis. In other months of the year, the person feels perfectly normal. The condition is also called hay fever, though it has no causal connection with hay and no fever occurs in this condition.

Q.What is the cause of seasonal allergic rhinitis?
A.The cause of seasonal allergic rhinitis is the exposure to pollens of the grasses, weeds and trees, that are present in the air in a particular season. The condition is also called pollinosis i.e., caused by exposure to pollens.

Q.What is perennial allergic rhinitis?
A.Some persons have sneezing and running nose almost all the year round. This conditions is also referred to as “perennial allergic rhinitis”. These symptoms occur more often in the early morning, but may last throughout the day and even the night. A majority of the patients complain of a blocked or stuffy nose and of post-nasal discharge as well.
Children develop a peculiar mannerism of wiping their nose. They elevate the tip of the nose with the palm of the hand and wriggle the nose and mouth from side to side; this gives them a temporary relief from the symptoms. Constant rubbing of the nose sometimes leads to the development of a crease across the nose, called the “allergic crease”.

Q.What is the cause of perennial allergic rhinitis?
A.The condition is caused by allergy to pollens that occur throughout the year, or to number of pollens that collectively occur throughout the year; moulds (fungi) present in the air all the year round may also be the causative factor. House dust may also cause perennial allergic rhinitis.

Q.Do seasonal or perennial allergic rhinitis patients develop asthma?
A.In some patients, symptoms of asthma also appear. These may start at the onset of the disease, or they may appear later. In certain cases, along with sneezing, there is cough only and no asthma. Symptoms of cough and asthma may continue even when attacks of sneezing cease.

Q.What complications can occur because of allergic rhinitis?
A.Allergic reaction in the nose and throat can lead to congestion and inflammation causing nasal polyps, tonsillitis, enlarged adenoids, sinusitis and the middle ear disease.
Nasal polyps look like bunches of grapes in the nose. They are due to the presence of fluid behind the nasal mucous membrane, causing it to hang down because of the weight of the fluid. They disturb breathing, making the person a mouth breather. The patient loses sense of smell because the smelling area in the nose is encroached upon by the polyps.
Tonsils and adenoids get usually enlarged and infected, causing fever and bad throat. Surgical removal of tonsils and adenoids is not the answer to the problem. Allergic rhinitis needs first to be treated and controlled.
Sinusitis is inflammation of the mucous lining of the sinuses. It causes fever, stuffy nose, sleep disturbances, posterior nasal discharge into the throat, which may be foul smelling.
Infection in the middle ear in children, in majority of the cases, is a complication of allergic rhinitis.

Q.How is the diagnosis of allergic rhinitis established?
A.Medical history of the patient reveals the diagnosis most of the time. The history of allergy in parents and siblings may be present.
Local examination of the nose and throat is necessary. This reveals swollengreyish-pale mucous membrane. Nasal polyps may also be seen. Laboratory examination of the nasal secretions reveals the presence of eosinophil cells. This establishes the diagnosis.
The substances to which a person is allergic can be established by doing the skin allergy tests. Positive reactions correlating with the history of the presence of symptoms in the same months or seasons in which those pollens are present in the air, establish the allergic agents.

Q.How is allergic rhinitis differentiated from viral common cold?
A.Common cold usually begins with malaise, aches and pains, diminished appetite and a slight rise of temperature. Running nose and sneezing occur either simultaneously or soon after. The nasal discharge is at first watery but later it becomes thick.
History of the disease, family history, examination of the nose, and nasal smear, help to differentiate between allergic rhinitis and common cold. A nasal smear does not show eosinophils in a viral infection, while it does so in a case of allergic rhinitis.

Q.How is relief from symptoms obtained in cases of allergic rhinitis?
A.Rest in bed, sipping warm drinks, if necessary, with a tablet of paracetamol (Crocin, Calpol) is helpful.Anti-histamine tablets provide relief, though most of them also cause drowsiness. Combinations of paracetamol and antihistamines are also available. Given at the beginning of an attack, they are effective in lessening itching, sneezing and running of the nose. Taking antihistamines with tea, or coffee lessens the feeling of drowsiness.
Nose drops containing ephedrine and antihistamines lessen stuffiness of the nose. Cauterization i.e., burning the mucous membrane of the nose so that it becomes insensitive to stimuli, is more harmful than good. Nasal surgery is rarely, if ever, indicated. Nasal sprays containing newer antihistamines and or newer steroids such as Fluticasone are helpful.

Q.Are newer anti-histamines better than the usual ones in cases of allergic rhinitis?
A.Yes. They are longer-acting and cause less drowsiness. They may be tried.

Q.Should corticosteroids be taken as tablets either alone or in combinations with antihistamines in case of allergic rhinitis?
A.Corticosteroids should preferably be avoided. If it is a matter of a week or a fortnight and allergic rhinitis is very troublesome, steroids can be given alongwith antihistamines. They should be given by sprays into the nose. Oral steroids should be avoided. As allergic rhinitis, especially the perennial one, is a long-standing problem, relief obtained from the use of steroids will become a habit and ultimately result in lot of injurious effects.

Q.What is the role of injection treatment (hyposensitization or immunotherapy) in cases of allergic rhinitis?
A.If after taking the history of the patient and doing the skin tests, the causative agent has been diagnosed, then hyposensitization should be tried. In case of seasonal allergic rhinitis when symptoms last only for a week, a fortnight or so, one has to see whether one should go through the skin test procedure and the subsequent hyposensitization or takeanti-histamines and the likes for the period the troublesome symptoms exist. But if the symptoms are troublesome or prolonged, hyposensitization should be considered.

Q.What measures can be taken by the allergic rhinitis patient so as to get minimum of symptoms?
A.1. To avoid needless outdoor activities in the season in which the symptoms occur or get aggravated.
2.To keep bedroom windows closed and to use air-conditioner, if possible, in the bed room.
3.To use HEPA (High Efficiency Particle Arrestor) air filter in the bedroom.
4.To use an effective face mask.

Q.How useful is the nasal filter in cases of allergic rhinitis?
A.Nasal filter, as it is available, has a soft plastic rim and a very fine synthetic fibre mesh. This filter with a proper shape of the rim and size, fits well into each of the nasal cavities.
As many of the allergic rhinitis patients have lot of excretions coming from the nose, the mesh gets choked up with the excretions and the patients have difficulty in breathing through the nose and they start breathing through the mouth. This destroys the purpose of putting in the nasal filter.

Q.Should a person with allergic rhinitis continue smoking, if he is already a smoker?
A.Allergic rhinitis patient is more liable to get complications of the disease such as sinusitis if he smokes. This is because the smoke is an irritant and an inflammatory agent. Infections and other complications set in more easily and quickly in smokers. Hence, an allergic rhinitis patient should stop smoking.

Q. Why are there so many types of anti-asthma drugs?
A. Asthma varies in frequency and severity. The causes are varied and many. In order to fulfill different needs, different drugs have been developed and are available.

Q. What are the major types of anti-asthma drugs?
A. While the pharmaceutical companies make hundreds of brand-name drugs, there are only a few major types of anti-asthma drugs that are now used. There are :

Bronchodilators:
a. Xanthines: Aminophylline

Deriphylline b. Beta-adrenergics: Salbutamol

Salmeterol

Terbutaline

Bambuterol

Formoterol.

Mast Cell Stabalizers:

Ketotifen.

Leukotreine antagonists:
Montelenkast

Q.What are xanthines and how do they act?
A.It has been known since ages that decoctions of some herbs are helpful in cases of asthma. These herbs include stramonium, labelia, dhatura. Scientific analysis of these herbs has revealed that they contain a variety of active principles that all come under the class xanthines.

Xanthines reverse the airway obstruction in cases of asthma, providing thereby a quick relief. It is for this reason that the xanthines are called bronchodilators.

Theophylline, deriphylline and aminophylline are the generic types of drugs that belong to the xanthine class. There are dozens of brand names for each of them. They are sometimes combined with other anti-asthma medications and given by mouth; in severe attacks, injectable are also given.

Q.How long does the effect of a theophylline tablet last?
A.The effectiveness of theophylline or other xanthines lasts from 4 to 8 hours. Therefore the drug has to be taken several times a day at regular intervals in order to control asthma. Since children metabolize or breakdown the drug faster than do adults, taking the medicine on time is important.

Special long-acting forms are available that may make it necessary to take the drug fewer times each day. Theophylline and other xanthines do not appear to lose their effectiveness with long term use.

Q.What are the side effects of theophylline or deriphylline?
A.They do not have serious long-term side effects. However, there can be acute side effects that are produced when the dosage is too high. These

involve the stomach and the nervous system. The effects on the stomach include nausea, vomiting, loss of appetite and stomach aches. The effects on the nervous system include irritability, dizziness and changes in personality. When any of these symptoms occur, side-effects from the xanthine drugs should be suspected.

Q.How can the side effects on stomach be minimized?
A.If irritation in the stomach or intestines occurs, it may be minimized by taking theophylline or other xanthine drugs with milk, or other foods.

Q.What are adrenergic drugs and how do they act?
A.These drugs act upon particular sites called receptors on nerve cells of the “adrenergic” nervous system (commonly know as sympathetic nervous system). There are three main types of receptor sites called alpha, beta-1, and beta-2. These receptor sites are located in the airways, but they are also found in other parts of the body as well including inside the heart muscle and muscles in the arms and legs.

Some adrenegic drugs act on all three types of receptor sites but others are more selective.

Q.Which are the most effective adrenergic drugs?
A.The most effective bronchodilator drugs are the ones that primarily influence the beta-2receptors present only in the bronchial airways. They cause fewer side effects. Since they dilate the airways, they are called bronchodilators. Examples are salbutamol, terbutaline. They are available in tablet form and as aerosols in metered-dose inhalers and nebulizers.

Q.What are adrenocorticoids and how do they act?
A.Adrenocorticoids, commonly called steroids, are related to cortisol, the hormone that is produced by the “cortex” or outer part of the adrenal gland. A number of closely-relatedsynthetic compounds are available and used. These include hydrocortisone, prednisone, prednisolone, betamethasone, triamcinolone and dexamethasone. They are known by a variety of brand names.

The steroids are strong anti-asthma drugs. They decrease inflammation of the airways and thereby reduce frequency and intensity of the attacks.

Q. What are the side-effects of steroids?
A.The side effects which arise with steroid treatment depend very much on the level of the dose and how long the steroid is taken. Major side effects take months to develop. Therefore, treatment for a few days or a few weeks to help a patient over an acute flare-upis a safe procedure that rarely causes problems.

Q.Can the side-effects be minimized?

A.If steroids are to be used on a regular basis, the chance of developing side effects increases, if the drug is taken several times a day. Side effects are less if the entire dose is taken once a day, preferably in the morning. The incidence of side effects can often be reduced still further if steroids are given every other day.

Q.What is the role of inhaled steroids in asthma?
A.In recent years, several types of steroids have become available in the form of an inhaler. These are sprayed in much smaller quantities and directly into the lungs where they exert most of their action. This means of delivery, puts the drugs exactly where it is going to work and avoids many of the side effects that occur when steroids are taken by mouth.

Q. How can some of the commonly used anti- asthma drugs be classified?

Q.What early changes develop in a patient before an asthma attack?
A.The following symptoms occur hours or days before audible wheezing or before an attack is fully in progress; these early symptoms vary a great deal among individuals.

Mood changes: Aggressive, overactive, grouchy, tired, easily upset.

Change in facial features: Dark circles under eyes, pale face, flared nostrils.

Verbal complaints: Fatigue, tight chest, chest fill- ing up, chest hurts, dry mouth.

Breathing changes: Coughing, taking deep breaths, breathing through mouth.

Other changes: Listlessness, voice change, swol- len face, quickening pulse.

Becoming aware of these symptoms helps pa- tients use self-management techniques as soon as possible. This early action may ward off a severe attack.

Q.What is peak-flow monitoring and how is it helpful?
A.The narrowing of the bronchi in a patient with asthma can be detected early enough by measuring a lung function called the peak-flow of the breath. The change in it occurs earlier than the symptoms of breathlessness or the detection of wheeze through the stethoscope.

Peak Expiratory Flow Monitor measures the force of one’s expiratory breath. The patient af- ter a full inspiration, exhales forcefully into the tube of the monitor which has an indicator and a scale printed on it. The force of expiration is in- dicated by the push of the indicator along the scale and is read as Peak Expiratory Flow Rate (PEFR). In asthma patients due to the narrowing of the airways, the force of expiration is de- creased.

Q.How is PEFR interpreted?
A.PEFR measurement is taken daily by the patient, and he knows what his best reading is when he has no symptoms. It there is a drop in the read- ing, the patient becomes cautious and takes ap- propriate measures to avoid an attack. PEFR thus predicts an attack and alerts the patient to its dan- ger. Measuring the peak-flow also provides the patient with information to share with the physi- cian, to enable decision-making concerning treat- ment plan.

Q.What are the early steps in a asthma attack management?
A.The time to treat an asthma attack or an episode is when the symptoms first appear. The steps to be taken at this stage are as follows:
1.Rest and relax.

2.Drink warm liquid.

3.Use medicines prescribed for attack.

Q.How do rest and relaxation work ?
A.At the first sign of breathing difficulty, the pa- tient should stop and rest. This means sitting down and resting for at least ten minutes. Rest- ing helps the lungs to rest and not to work as hard. Relaxing may be explained as letting go, getting as comfortable as possible and staying that way for a while.

Diaphragmatic breathing or “belly breathing” helps in relaxing as well as in making the whole lung work, rather than just the upper parts. Pa- tients who panic or have a hard time setting down, may need the help of a professionally trained per- son.

Q.How is belly breathing done and what is its use?
A.It is a way of breathing that uses the diaphragm to help lungs get the air in. It may be performed in the following manner:

Lie on the floor, bend your knees, keep your feet on the floor, and put one hand on your chest and the other hand on your stomach. Breathe in through your nose, and make your stomach get round like a ball. Your chest should not move. Blow all the air out through your mouth with your lips pursed, and use the hand on your stomach to help you push all the air out. Your stomach should be flat.

In belly breathing, when you breath in, the stomach goes up and when you breath out, the stomach goes down.

Practice belly breathing 10 times, making sure that your chest remains still. Try practising this twice a day. Breathing this way may make you feel better and less tired.

Q.How does drinking of warm liquids help?
A.Warm liquids relax the airways which lie just in front of the oesophagus in which the liquid flows. Liquid should be taken slowly rather than gulped down. Liquids also help to thin the mucus. They also replace the water that has been lost through hur- ried breathing.

Q.What is the role of the medicines prescribed early in an attack?
A.They should be used as prescribed by the doctor. They provide relief and help abort an attack.

Q.What is the modern approach to early drug treatment?
A.It is necessary that inflammation of lining of the airways of the lung is taken care of, along with removing narrowing and spasm (bronchoconstriction) of the lumen of the air- ways. If inflammation is not removed, some bron- chospasm will be perpetuated.

Asthalin and the like drugs (e.g., salbutamol, a beta 2 adrenergic) either as aerosol (in metered dose inhalers) or tablets, are able to remove the early bronchospasm. They, however, do not check or reduce the inflammation. Taking of steroid aerosols along with salbutamol aerosols, provide quick recovery even in the early stages of the onset of an attack of asthma.

Q.How does diet affect the course of asthma?
A.Proper diet taken at regular hours is very important for an asthma patient. This not only prevents an attack from occurring, but also lessens the se- verity of the attack that a patient is having.

Q.What sort of dinner should be taken by an asthma patient?
A.Asthma patients should not take any meal full- stomach. Fullness of the stomach after meals, particularly at night, causes discomfort in breath- ing or even precipitates breathlessness. One should take less quantity of food at a time, but many times a day.

Q.What other dietary precautions should the asthma patient observe?
A.Asthma patient should avoid:Fried and fatty foods.Spicy and sour preparations. Taking alcoholic drinks. Sweet dish at night.Going out in the cold at night after dinner.

Q.What sort of health rules are applicable to an asthma patient?
A.Health rules for asthma patients include: Getting up in the morning at a regular hour.
Taking morning walk or doing some physical ex- ercise.
Maintaining regularity in daily work routine.
Sleeping early at night at regular hours so as to get up early.
Taking medicine regularly as directed by the phy- sician.
Moderating or slowing down the pace of work

Q.What can an asthma patient expect from treatment?
A.With proper treatment, most people with asthma can expect to achieve:
A full night’s sleep with no awakenings due to coughing.
A clear chest in the morning.
The ability to go to work or school regularly. Full physical activity with a normal life style. No emergency room visits or hospitalisations. No significant side effects from medication.

Q.Are scientists doing research that could help people with asthma?
A.Researchers are working on several fronts to solve some of the many unanswered questions
about asthma. The areas being investigated are basic abnormality that causes asthma, develop- ing better drug treatments and emergency mea- sures, and educating people with asthma to help themselves. It has been well established that edu- cation programmes can greatly reduce asthma disability and hospitalisations.

Q.What are “asthma triggers”?
A.Asthma triggers are those substances or situations that set off an asthma attack. The triggers that have been recognised are:

Pollens of different grasses, weeds, shrubs, trees, fungi that grow in abundance in moist air and moderate temperature, both inside and outside the house.
House dust which contains in it the mites (Dermatophagoides pteronyssinus) that grow abundantly in the mattresses, rugs and other furniture in the bed rooms.
Pets like cats and dogs.
Insects in the house, particularly the cockroaches.
Some of the food articles.
Besides the above, mental and physical stress and strain can also precipitate an attack in predisposed people. Viral infections of the upper respiratory tract either precipitate or aggravate an attack of asthma. Some irritants of the respiratory tract such as environmental pollution, tobacco smoke or sudden changes in weather, can also lead to an attack of asthma. Even physical exercise can act as a trigger.

Q.How is a trigger recognized?
A.Through keen observation by the patient over a period of time. Detailed medical history, careful examination of environmental influences and allergy testing are the ways, available to the doctor for discovering triggering factors.

Q.Do the skin tests reveal all that a patient is allergic to?
A.No. Tests only give indications about the things for which the patient has been tested. There may be other things against which the test are not done.

Q.Is it one trigger or more than one, responsible for an asthma attack ?
A.Often a combination of triggers precipitates an attack. That is one reason that asthma seems so unpredictable. At one time in a stressful situation, no asthma is experienced. At another time when stress is experienced, the chest tightens and wheezing begins.

Heavy expossure to any one trigger can also precipitate an attack.

Q.If asthma triggers work so unpredictably, why bother?
A.The reason is to gain better control of the asthma. If the patient or the child and parents are aware of the common triggers and can find ways to minimize their effect, the total impact of asthma can be lessened. One goal of asthma management is to eliminate as many triggers as possible.

Q.How can an asthma patient avoid indoor triggers?
A.House dust, moulds and pet animals occur mostly in indoor environments. In order to avoid house dust and the mites that grow in it, the bed-room of the patient should be as sparingly furnished as possible. It should have no rugs or carpets. The curtains should be light, easily cleaned and washable. The bed should have the mattress cover, pillow cover and the quilt made of cotton- synthetic material which does not generate dust or collect it. Since the mites grow in moderate temperature and humid environment, the mattress should be taken out and spread in the hot sun the whole day so as to kill the mites. Mite-killing spray does a better job. While cleaning is being done in the room, the patient should go out of it or go out of the house.

The houses which are dark and humid, accelerate the growth of the fungi; such houses should be avoided by the patients. The pets, cats and dogs may be removed from the house and in no case should they enter the patient’s room.

Sleeping in an air-conditioned room wherein no outside air circulates, protects the patient from the pollens and other pollutants present in the outside air. HEPA (High Efficiency Particle Arrestor) air filter installed in the room, clears the air of all the particulate matter.

Q.How harmful is cigarette smoke to a child with asthma?
A.Cigarette smoke is very injurious to an asthmatic child. A parent or anybody else who smokes in a house where asthmatic child lives, does him the greatest harm.

Q.How can a patient with asthma avoid outdoor triggers?
A.Outdoor environments contain pollens, moulds and other pollutants. Travelling in the country-sidedirectly exposes the patient to these triggers. If a patient has to travel, the window-panes may be pulled up. If the car is air-conditioned, it protects the patient immensely. Specially designed face masks are helpful in case of those who drive two- wheelers. Working in the garden or even being in the garden, exposes the patient to lot of moulds which grow on and under the rotting leaves; this may be avoided in a season when the patient is known to get the symptoms, or a face mask worn when so exposed.

Q.How to deal with stress triggers?
A.Rather than avoiding stress, one should learn to live comfortably with stress. Learning to relax at will is a useful technique for people whose asthma is triggered in stressful situations. There are many different methods of doing this. Some people are able to control their stress by imagining a soothing and relaxing scene. Others can gain control over stress by doing calm and controlled breathing. Meditation, transcendental, yogic or any other is, very helpful.

Q.How to help a child in an emotional state from getting an attack ?
A.Try to analyze what is going on in the situation. What factors contribute to the situation? In what ways can the situations be dealt with differently? If the problem is recurring and causes disruption for the child and family, consider seeking professional help to learn new ways to cope with emotinally charged situations.

Do not let the possibility of an asthma attack restrict either the child’s fun or need for discipline. If the child knows that discipline will be disregarded when an attack is threatened, the child may learn to respond to discipline with an attack. If the child gets asthma each time she/he gets excited, try to help the child; moderate the excitement and teach the child to relax. Let the child learn her/ hhis own limits, and manage any attacks that do result. If self-management is to become a reality, the child must develop an inner sense of when to tone things down.

Q.How to protect an asthma patient from respirotory viral infectons?
A.The precautions that can be taken include following good, general health practices such as getting plenty of sleep, eating a balanced diet, getting regular physical activity, drinking plenty of fluids, avoiding situations where people may be sick, and promptly taking care of any colds or infections that do occur.

Q.Should an asthma patient participate in physical exertion activities ?

A.All asthma patients should participate in regular physical activity, in spite of the fact that exercise itself can induce an atack. One should start off at a comfortable level and work progressively toward more difficult levels of strength and endurance. When the patient is unwell or in a pollen season or in very cold weather, special precautions may be needed. With the proper medications and understanding of one’s own abilities, there is no reason why asthma should handicap a person’s physical involvement.

Several Olympic athletes have had asthma and have won world class competitions. The key to enjoyment and mastery over physical activities is by gradual learning of your limits and having good medical advice about medication and general asthma management.

Q.Any recommendations about exercise in children with asthma?
A.If the child feels an attack coming on after exercise in the school, she /he should be allowed to stop and rest and to follow other self- management steps. It is importanat for the teacher to understand that “short burst” sports are well tolerrated by children with asthma, while sustained exertion, such as running laps, is potentially dangerous.

Swimming is excellent physical exercise for people with asthma. Any physical activity that a person desires to try, should be tried with the normal precautions and provisions for attack management in case it is needed.

Q.What is food allergy?
A.It is the appearance of some unpleasant symptoms in a sensitive (allergic) person after taking a particular food. The same food ordinarily causes no such symptoms in the vast majority of people who take it.

Q.What are the symptoms noticed in food allergy?
A.The symptoms may pertain to the gastrointestinal tract, the skin, the lungs or the whole body. There may be itching rash around the mouth, swelling of the lips, sores inside the mouth, vomiting, gaseous distension, or diarrhoea. The commonest skin reaction is urticaria (hives) in which red, itchy swollen patches appear in the skin. They arise suddenly in clusters in one area and disappear quickly from there to reappear in another area. Lung reactions in the form of asthma are uncommon as part of the food allergy.

Sometimes, food allergy manifests in the form of severe anaphylactic reaction with breathlessness, cyanosis (bluishness) and unconsciousness. If quick relief is not provided, it can be fatal.

Q.How long after taking the offending food, do the symptoms of food allergy appear?
A.The symptoms of food allergy may appear soon after taking it or may appear several hours later; in the latter case, it becomes difficult to identify the offending article of diet.

The same food in one particular season may produce symptoms, while in others, it may not. This depends on the combination with other allergic factors.

Q.Which foods cause allergy reactions more commonly ?
A.Food which cause allergic reactions include fish, prawns, oysters, lobsters, eggs, chocolate, cow’s milk, peanuts, soyabeans, dry fruits, citrus, etc. The parts of food that cause allergic reaction, are usually proteins.

Q.What are the characteristics of fish allergy?
A.Fish and other sea foods are amongst the most potent allergic agents. Those who develop reactions on eating fish should avoid other sea foods as well. Even the smell of fish can produce urticaria in some people who are strongly allergic to it.

Q.What are the characteristics of egg allergy?
A.White of an egg is pure albumin (protein), and a potent source of allergy. Taking a raw egg by a person allergic to it, can cause a severe reaction. Even the smell of egg’s content can cause allergic reactions in highly sensitive people.

Q.What are the characteristics of cow’s milk allergy?
A.It is seen more often in infants; 1 in 200 infants are said to be allergic to cow’s milk.

The symptoms produced are varied: from being unwell after taking cow’s milk to sores around the mouth, vomiting, diarrhoea, urticaria, eczema rash on the face or difficulty in breathing.

Q.What are the characteristics of wheat allergy?
A.An infant may develop a rash, abdominal colic or diarrhoea when it is given a cereal for the first time.
An older child or an adult may have asthma or a patch of eczema which is found to be improved by not taking wheat in any form.

Q.Are all reactions to food in infants and children allergic in nature.
A.That may not be so. Rash around the mouth in some children may be due to acid in foods like fruit juice. It is non-allergic in nature and usually a temporary problem.
Other reactions may be due to the presence of various preservatives in the commercial foods.

As the child grows older, even the foods which previously caused allergic reactions may be tolerated, perhaps, because of the maturing immune system.

Q.What is cross allergy to food?
A.All foods belong either to vegetable source or animal source and in either case they are grouped in families. Peas, soya beans, kidney beans, peanuts, etc. are all members of the pea (legume) family, just as garlic, onion, asparagus, belong to lily family. Similarly, many of the sea foods belong to one family.

Allergy to one member of a family may result in the person being allergic to other members of the same family. This is called cross allergy. Knowledge about this,fore-warns a person as to which foods to avoid.

Q.Is a person allergic to egg, allergic to chicken as well?
A.Usually not, Albumin, the pure protein in the egg, does not exist in the chicken.

Q.Is a person allergic to cow’s milk also allergic to beef?
A.Cooking usually reduces the ability of proteins in the food to cause allergic reactions. But some reactions may still occur. Boiled milk and cooked eggs still cause some reactions.

Q.How can one diagnose the allergy-causingfood?
A.Diagnosis as to which food is causing allergic symptoms is, many a time, like investigating a murder case with hardly any obvious clues. The difficulty is compounded when the offending food is either milk, egg or wheat, each of which is a common ingredient of many other foods, and its presence is not generally suspected by the patient. A thorough history of the patient is of the greatest help.

Skin tests in food allergy are not of much help. This is because the tests are done with foods extracted in the raw state but they are eaten in the cooked state. Many a time, there is no correlation between the skin tests and the trials with foods.

Blood tests are equally unreliable.

Food elimination tests are helpful. The patient is instructed to note in his diary, all the food he takes and the symptoms, if any, produced. By studying these daily notes for two to three weeks, one can often detect the onset of symptoms after taking a new food or after repeated use of a certain food. The elimination of these foods from the diet one by one results in disappearance of the symptoms, just as the intentional ingestion is followed by symptoms.

Even after carrying out all the investigations, sometimes one is not sure of the food causing allergic symptoms.

Q.How is a case of food allergy treated?
A.The best method of treating food allergy is to find out the incriminating food and to avoid it. While eliminating one food, it is necessary that a non-allergic substitute of equivalent food value, be added to maintain nutrition and avoid monotony. Along with this, the patient is advised to take as far as possible, cooked foods, which being denatured, cause less allergy.

Whenever possible, the infant should bebreast-fed. This reduces the chances of development of allergic symptoms. Giving of cow’s milk should be delayed upto the age of nine months to a year in a potentially allergic child. Milk prepared from the soyabeans is a good substitute. Soyabean milk should be given upto a year or so and then a re-trialmade with the offending milk. If only a few symptoms appear, then the cow’s milk may be gradually added in the diet. Soyabean milk is as nutritious as the mother’s milk; however, this needs to be supplemented with vitamins and minerals.

Injections of the incriminating foods are both dangerous and useless.

Those who are highly allergic to some foods, must carry epinephrine (adrenalin) and should be taught how to inject themselves with it, when necessary. Such people should also wear an identification bracelet which describes their allergy.

Q.What is food intolerance and how does it differ from food allergy?
A.Food intolerance reactions are caused by factors in the diet other than proteins. A common food intolerance reaction is the result of the body’s inability to properly digest milk sugar, lactose; this gives rise to diarrhoea and increasing weakness.

Food additives and preservatives are some of the other factors that cause reactions that are not really allergic but look like it. The food dye tartrazine has been shown to causeasthma-like symptoms in some persons. Sulphite preservatives such as sodium and potassium sulphite, bisulphite and metabisulphite are known to have the potential to cause a serious attack in some sulphite-sensitiveasthma patients. Sulphites are used in some restaurants as “stay fresh” agents, particularly as chemicals sprayed on salads to prevent wilting. They are also found in some processed foods and beverages like fresh shrimp, mushrooms, potato chips, dried fruits and wines.

Since reactions to these chemical can be very severe, people taking food outside their home frequently, should be aware of this problem.

Q.What is house dust ?
A.It is the dust produced indoors frombreak-down of animal and plant material used in the house. Such material includes cotton, wool, jute, hemp, animal hair, feathers, etc. used particularly for stuffing in mattresses, pillows, quilts, upholstered furniture and carpets. Skin scales from humans and a large variety of moulds (fungi) as well as dander and saliva from pets, add to the mixture of house dust.

Q.What is it in the house dust to which people become allergic?
A.It is the tiny mite of the species Dermatophagoides pteronyssinus which grows on the constituents of the house dust. It feeds on the shed-off human scales; that is why it is called dermato (skin), phagoides (eats).

Q.What does the house dust mite look like?
A.The mite has an unsegmented body supported by eight legs. It is less than one millimeter in size, and seen only through a microscope. It is so light in weight that it can float about in the air when the bed room is cleaned. Its diagram is given on the front page.

Q.Where in the house is the mite to be found most often ?
A.It lives primarily in mattresses and also in carpets and upholstered furniture. The food it eats, that is the human scales or the rubbings from the skin, is found abundantly in the mattresses because person spends at least one-third of the 24 hours over there. The temperature of the mattress, when the person is occupying it and giving its own body temperature, is optimum for the growth of the mite.

Q.Does the mite prefer any environment for its growth ?
A.The mite grows best in humid, temperate climate. Houses with dark and humid interior, have more mites in their house dust. On the other hand, high altitudes with a dry and cold climate are not suitable for their growth.

Q.What is it in the mite that the people become allergic to?
A.Excretory waste products produced by these mites, which consist mostly of a protein substance, are the main substance to which allergic people react. Each mite excretes about

20 of these pellets every day. These pellets, minute in size, continue to cause allergic symptoms even after the mite which has produced them, has died. Female mite can lay 25 to 50 eggs, with a new generation produced every three weeks.

Q.Is there a relationship between the number of mites in the house dust and the degree of allergy to them?

A.A direct relationship has been noticed between the number of mites in the house dust, the degree of allergy and the symptoms of asthma.

Q.Are the people allergic to mite, also allergic to the house dust?
A.Tests done with extracts made from thelaboratory-cultivated mite (D. Pteronysssinus), showed that all persons who gave positive reactions to the mites, reacted with house dust extract. “We have not yet seen a case in which a patient reacted to house dust and not to this particular species of mite or vice versa,” wrote Dr. Voorhorst, the researcher who discovered mite as the cause of house dust allergy.

Q.Do the asthma patients allergic to house dust have any characteristic features so as to become easily recognizable?
A.No. There are no characteristic features of house dust allergy. Patients allergic to house dust are more liable to have perennial symptoms, i.e. the year round, with some aggravation in the rainy season when the humidity and temperature is more congenial for the growth of the mites. But this happens in the case of allergy to many of the fungi also which collectively occur the year round.

Q.Is there any connection between increase of asthma attacks during Diwali season and the house dust?
A.Yes. During the Diwali season, more cases of asthma report with symptoms or in severe attacks. Diwali festival is known for cleaning up of houses and decorating them. Cleaning involves raising lot of dust. When an asthma patient is exposed to this house dust, he gets more symptoms of the disease or a severe attack.

On the day of Diwali, an asthma patient is exposed to polluted air of the burning crackers which acts as another factor aggravating the symptoms.

Q.Some asthma patients who go to the hill stations report lesser symptoms over there than they have in the same season in the plains. Why?
A.Temperature and humidity is low in the hill stations compared with the plains, in the season when people travel to hills. This low temperature and humidity does not allow the mites in the house dust to grow luxuriously. Less concentration of mites in the hill stations may be the cause of fewer symptoms in asthma patients who are allergic to house dust.

At higher altitudes where the mites don’t grow and there is very little vegetation and the pollen concentration in the air is nil or very low such as at Leh, in Ladakh, very few cases of bronchial asthma are seen, even though other chest diseases are seen in abundance.

Q.Students going from homes to hostels, many a time, report lesser symptoms of asthma. Why?
A.They may be allergic to house dust. The house dust in the hostel rooms has been reported to have lesser number of mites because of austere nature of the furniture. Scanty furnishing also allow for better and easier daily cleaning of the hostel rooms.

Q.How is house dust allergy diagnosed ?
A.Taking a careful medical history which includes the nature and timing of symptoms, is very important. A specialist, generally, employs the skin test to detect the allergy. This test involves the injection of a tiny amount of house dust extract (allergen) to form a superficial bleb on the skin surface. The positive test consists of a raised itchy induration at the test site. Alternatively, an allergy test on the blood is done to identify allergic individuals.

Q.Are people allergic to house dust, allergic to other substances as well ?
A.Yes. Skin tests in asthma patients show that people allergic to house dust are, many a time, allergic also to other asthma triggers such as moulds and pollens.

All or most of the triggers need to be avoided to lessen the frequency and severity of the attacks of asthma. If most of the triggers can be taken care of, the symptoms of asthma can disappear altogether in spite of the tendency to allergy being there.

Q.What is the response of house dust allergic patients to injection treatment (immunotherapy) ?
A.The response is best when the patient is allergic only to house dust. When the allergy is to other triggers also, the response is good but variable.

Q.Does avoiding exposure to house dust help an asthma patient ?
A.Yes Taking steps to minimize dust mite exposure in the bed room, leads to lessening of symptoms. Emphasis is placed on the bedroom because it is the room with the greatest number of dust mites.

Q.How can one reduce exposure to house dust ?

A.The following measures are helpful in this regard.

1.Enclose mattress and pillows in zippered, dust- proof covers.

2.Remove all carpets. If it is not possible, anti- mite spray be applied periodically.

3.Avoid heavy curtains. Dry clean or wash them frequently.

4.Substitute wooden or plastic furniture for upholstered one.

5.Wash blankets in hot water every few weeks. Avoid woollen blankets.

6.Place the contents of the bedroom or at least the mattresses in the hot sun fortnightly.

7.HEPA air cleaners (high efficiency particle arrestors) can remove most of the air-bornedust particles.

8.Use dehumidifier in damp places. Mites grow best at 75-80 percent humidity and cannot live under 50 percent humidity. Use a humidity gauze to maintain humidity at 40-50 percent.

9.Wear a face mask when making the bed and doing house-cleaning.

Q.How does anti-mite spray or powder act ?
A.Two types of anti-mite substances are commonly used. One is a solution of tannic acid; this denatures the pellets excreted by the mites so that they do not act as allergens. Second is benzyl benzoate powder; it kills the mites. Studies have shown that tannic acid spray gives better results than benzyl benzoate powder.

Q. What are metered-dose inhalers?
A. These are devices that dispense medicines directly into the lungs, in the form of a mist or aerosol in a specific dosage. In an MDI, the medicine is suspended in a liquid and forced under pressure into a small canister fitted into a plastic case. When the canister is pressed, a measured dose of the medicine is released through the mouth-piece.

Q. What are its different parts?
A. These are shown in the diagram on the front page.

Q. What are the advantages of MDIs over the other modes of drug delivery in asthma patients?
A. 1. Inhaled drugs are delivered directly into the airways.
2. The drugs operate faster than when given orally.
3. Fewer side-effects occur as the dose is too small.
4. Inhaleddrugsalleviatethedistressexperienced by patients who do not like to receive injections.

Q. What are the steps for using an MDI?
A. 1. Remove the cap and hold the inhaler upright.
2. Shaketheinhaler.
3. Tilt the head slightly and breathe out completely.
4. Position the inhaler in one of the following ways:
(A) 2-4 cm away from the mouth,
(B) inside the mouth.
5. Press down on inhaler to release medication as you start to breathe in slowly.
6. Breathe in slowly for 3 to 5 seconds.
7. Hold breath for at least 10 seconds to allow medicine to reach deeply into lungs.
8. Repeat puffs as directed. Waiting 1 minute between puffs, would permit the second puff to penetrate the lungs better.

Q. Which technique, the open-mouth or the closed-mouth, is preferable?
A. Some doctors suggest that the technique of an inhaler held approximately 2 to 4 cm in front of an open mouth, is superior to an MDI held in and activated in a closed-mouth. The theoretical advantage of the open-mouth technique occurs because the particles become significantly smaller as they travel a distance from the activated canister orifice to the mouth. This enhances distal airway deposition. The disadvantage of the open- mouth technique is the problem of deposition on the lips, face and teeth. Your doctor can help you decide which method would be best for you.

Q. How can the patients to taught to correctly use their MDIs?
A. Asthma patients usually think they are using their inhalers correctly, but their doctors don’t agree with them. In one study, the doctors estimated that, on an average, only about half of their patients, used their inhalers correctly. The patient’s biggest challenge is to coordinate the procedure of pressing down on the inhaler and breathing in at the correct moment.

As a rule, patients should have their inhalers with them when they visit their doctor. The doctor can personally supervise its use and, if necessary, retrain the patient.

Q. Why is it so important to use MDI correctly?
A. MDI must be used correctly since only 10 percent of the inhaled dose penetrates the distal airways, even with optimal techniques.

For better penetration to distal airways, a slow deep inhalation to total lung capacity is desirable. It has been found that the particles are deposited uniformly throughout the lung with slow inhalation. The proportion of inhaled aerosol particles remaining in the lung also increases with the time of breath-holding upto 10 seconds.

Q. Which anti-asthma drugs are available in the form of MDI?
A. Many types of anti-asthma medication are available in the form of MDIs:
Salbutamol, Formoterol, Beclomethesone, Fluticasone, Budesonide, Cyclesonide, etc. to name a few. They come under different brand names. Combinations are also available.

Q. Which asthma patients need MDIs?
A. Patients with any type of asthma symptoms can make use of MDIs advantageously. Patients with mild symptoms may need only the MDI, while patients with moderate and severe symptoms would need it alongwith the help of other modes of drug delivery, such as tablets and / or injections.

Q. When should a salbutamol MDI be used?
A. Salbutamol dilates the airways. Whenever there is a feeling that the airways are constricted, salbutamol MDI can be used. It is better for an asthma patient to fix the time for taking salbutamol MDI, as for example, early morning when one gets up, and when going to bed at night.

Q. How many puffs of salbutamol a patient can take in 24 hours?
A. If the airway constriction is only mild, two puffs in the morning and two in the evening are enough.
If the airway constriction is moderate, the doctor generally prescribes salbutamol MDI along with other oral drugs so that the relief obtained is adequate and spread over all the hours of the day.
In moderate or severe asthma, if the symptoms are not relieved with 6 to 8 puffs of salbutamol in 24 hours, there is clear indication that advice of the doctor be obtained. Using more puffs of salbutamol, not only would not provide adequate relief, but the condition of the patient may deteriorate and prove dangerous.

Q. What should be the interval between the two puffs of salbutamol MDI?
A. An interval of 1 to 2 minutes should be there between the two puffs. The first puff takes that much time to dilate the airways. The second puff after this interval, penetrates the lungs further down and so it is more effective.

Q. If both salbutamol and steroid MDIs are prescribed, which one should be taken first?
A. Salbutamol should be taken first and after about 5 minutes of that, the steroid inhalation.
Salbutamol by dilating the bronchi, allows the steroid to penetrate the most peripheral parts of the lungs; this provides more relief.

Q. What does steroid MDI do when inhaled?
A. In an asthma patient, steroid inhalation relieves the inflamation in the lining of the airways. However, this is a gradual process, not a quick one. The patient feels relief in hours, not in minutes. But it is longer lasting and it prevents the permanent damage and the tendency to constrict the airways.

If a patient has difficulty in breathing and wants quick relief, he needs a bronchodilator like salbutamol and not a steroid.

Q. What complications can occur because of prolonged or excessive use of inhaled steroids?
A. Inhaled corticosteroids are generally very safe. In some patients, they can lead to formation of white patches inside the mouth. This is the growth of the fungus called thrush or candida.

Q. How can the above complication be avoided?
A. By using steroid inhaler after passing it through a spacing device such as Spacehaler.
Rinsing the mouth clean with water, after having taken steroid inhalations, is also very helpful.

Q. How many puffs of steroid inhalation are recommonded in 24 hours?
A. This depends on the severity of the disease and which type of steroid is being taken. But usually 2 puffs of 200 ugm (microgram) twice or thrice a day are recommended.

Q. How to check whether the inhaler is full, half full or empty ?
A. 1. If the canister is new, it is full.
2. If the canister has been used repeatedly, it might be empty (check product label to see how many inhalations should be in each canister).
3. To check how much medicine is left in the canister, put the canister (not the mouth-piece) in a cup of water. If the canister floats sideways on the surface, it is empty, if it floats vertically, then it is full.

Q. What is a nebulizer ?
A. A nebulizer is a machine that takes an asthma medication and through its compressor, turns it into a fine misty aerosol. The medication thus dispersed is inhaled directly into the airways.

The diameter of the aerosol particles is a major factor that influences its site of deposition inside the lungs. Aerosol particles between 1 to 5 microns (a micron is a thousandth part of a millimeter) manage to reach even the distal parts of the airways where they are most effective.

Q. What are the different parts of a nebulizer?
A. These are shown in the diagram, on the front page.

Q. What is the procedure for using a nebulizer?
A. 1. Plug the power cord into the electrical outlet.
2. Open the nebulizer cup by turning the upper part counter-clockwise.
3. Pour into the cup, the quantity of drug as prescribed by the physician.
4. Close the nebulizer by turning the upper part clockwise.
5. Connect the cup to the unit’s air outlet by means of the tube.
6. Apply one of the required accessories; mouth- piece or mask, to the cup.
7. Position yourself comfortably in a sitting position in front of the nebulizer.
8. Start the unit by turning the switch on.
9. See that the medication in the nebulizer cup is forming the mist.
10. Put your lips securely around the mouth- piece, or position the mask around your face and inhale as slowly and deeply as possible. Concentrate on inhaling the medication as directed.
11. Hold your breath for one to two seconds and exhale slowly.
12. Continue to breath through the nebulizer until (a) you have used all the drug, or (b) have taken the treatment for the prescribed time.
13. Turn the machine off, and, if needed, cough several times to bring up any mucus or secretions.

Q. Since the aerosol from the nebulizer goes directly inside the lungs, is there a chance of occurrence of contamination of the aerosol, and consequently lung being infected?
A. There is definite risk if adequate precautions are not taken.

Q. What are the precautions that ought to be observed?
A. 1. Wash your hands thoroughly before opening the cup of nebulizer.
2. Unit dose vials should be carefully opened and the contents poured into a thoroughly clean and fresh nebulizer cup.
3. When measuring medications from multi-dose containers, use an eye dropper or syringe as instructed by the pharmaceutical company or doctor. Do not touch the dropper to any surface other than the medication inside the container. Promptly replace bottle caps tightly. Once opened, medication bottles should be stored in the refrigerator.

Q. How is the nebulizer washed and cleaned after each use?
A. 1. Disassemble the nebulizer unit immediately following each treatment.
2. Rinse the disassembled nebulizer cup, and mask or mouth-piece under a strong stream of warm water for thirty seconds.
3. Shake off excess moisture. Allow to air dry on a clean towel or paper towel.
4. Connect tubing to compressor and run several seconds to dry small parts.
5. Store all the parts properly in the space provided inside the nebulizer machine.

Q. How should one maintain the nebulizer unit?
A. Every week or so, immerse for 30 minutes the nebulizer cup, the face mask and mouth-piece in a disinfecting solution of 1 part distilled white vinegar to 2 parts water. Then rinse in warm running water for 1 minute, and dry on a clean towel. Change filters as needed.

Compressor tubing should be changed as and when necessary. Never use tubing that looks cloudy. Nebulizer cups, and masks or mouth pieces should be replaced when they become discolored. Always keep with you a spare nebulizer cup on hand.

Proper maintenance reduces the chances of bacterial contamination.

Q. Which asthma patients can derive the best advantage out of the nebulizers ?
A. The best candidates for the nebulizers are the elderly who have difficulty with hand-held metered-dose inhalers. The other group is of infants and young children who cannot grasp the concept of the MDIs even when the spacers are used.

Q. Which one serves the purpose better in children: the mask or a mouth-piece?
A. Mouth-piece. As it delivers more medicine effectively than a mask for most children above two years of age.

Q. When is the use of a nebulizer indicated?
A. When a patient has a moderate to severe attack of asthma. Nebulizers are particularly helpful in patients who get moderate to severe symptoms at night. Such patients can use a nebulizer before they go to sleep.

Q. What medication is used for nebulization?
A. Salbutamol, a bronchodilator, is most used for nebulization. Steroids are also used. Most asthma medications are now available in solution form for nebulization.

Q. How such salbutamol solution is needed for each nebulization?
A. 1/2 to 1 ml solution of salbutamol from the vial in 2 to 3 ml of saline solution, or the contents of an ampoule. In children, the dosage is less than in adults. The exact quantity depends on the severity of the attack of asthma.

Q. For how long is nebulization given?
A. The solution put into the working nebulizer cup usually finishes in 10 to 15 minutes. This much time is adequate for nebulization.

Q. How long does effect of nebulization with salbutamol last?
A. It should last for at least 4 hours. By that time other medicines given by mouth start being effective.

If the effect lasts less than 2 hours, then even though nebulization can be repeated, other drugs in the form of tablets or injections, particularly the steroids and deriphylline injections, are indicated.

Q. Can nebulization with salbutamol be combined with oxygen administration if indicated?
A. In very severe attacks of asthma wherein the patient has cyanosis (blue colour) due to deficiency of oxygen in the blood, nebulization is combined with administration of oxygen coming out either from a nearby oxygen cylinder or piped oxygen. Oxygen delivery of upto 5 liters per minute is necessary to produce sufficient force for production of the aerosol mist.

Q. Besides asthma, which other chest conditions benefit by nebulization?
A. Patients with chronic bronchitis having breathlessness, derive a lot of benefit by nebulization. Since in such patients, the symptoms are of a more permanent nature rather than spasmodic as in asthma, they can make regular use of nebulizers.

Q. In what situation can the use of a nebulizer prove more harmful than good ?
A. When the patient having a severe persistent attack decides to make use of the nebulizer repeatedly after short intervals.

At this stage, he needs the help of steroids either as injection or tablets along with nebulizer. If steroids are not taken at this stage, the patient can go into a dangerous stage.

Q. Can a patient use a nebulizer before going to bed at night and MDIs as and when indicated during the day?
A. Yes, it is all right to use them so. If the patient feels better by using the nebulizer both in the morning and at night, then in consultation with his specialist and after taking care of all the other anti-asthma drugs, she/he can do that also.

Q. What is a Peak-Flow Meter?
A. It is an instrument that measures Peak Expiratory Flow Rate (PEFR). PEFR is the amount of air a person can blow out during a forced expiration after taking in as full a breath as possible.

A peak flow meter for an asthma patient is like a thermometer for a patient with fever. You may feel “hot” or feverish sometimes, but when you take your temperature with a thermometer, it is normal. With asthma, sometimes you may feel “tight” or your chest may feel “heavy”, but you have normal lung function. The peak flow meter can help you to determine whether your sense of chest tightness is really an airway construction, just like the thermometer can help you to determine if your “hot” feeling is really a fever.

Its simplicity of use and light weight, enables it to be used at home, office or in a doctor’s clinic.

Q. What are its different parts?
A. The diagram on the front page depicts the parts.

Q. What are the steps for measuring PEFR?
A. 1. Place the indicator at the base of the numbered scale.
2. Stand up.
3. Take a deep breath.
4. Place the meter in the mouth and close lips around the mouth-piece.
5. Blow out as hard and fast as possible.
6. Write down the achieved measurement or value.
7. Record the highest of the three measurements achieved.

Q. What are the important points to be kept in mind while measuring PEFR ?
A. Be in the same position each time you perform the peak expiratory flow test. Standing is the best position.

Hold the peak flow meter lightly, and be sure your fingers do not interfere with either the movement of the marker or the movement of air through the base of the meter.

Gripping the instrument too tightly may lower your readings.

The effort required to make the measurement is a short maximal blast of air, similar to that required in the initial effort to blow up a balloon. Because PEFR is effort-dependent, patients may need to be coached initially to give their best effort.

Most adults, as well as children as young as 5 years of age, can usually perform PEFR measurement.

Q. Does the Peak Flow vary from person to person?
A. Yes, it does. It is lower in children than in adults. It is highest in early adult life, and decreases in old age. It is higher in tall people than in short people. Men have higher peak flows than women of the same height and age.

Q. What are the normal and the personal best values of peak flow? Which one of the two is important?
A. Normal values are the average of peak flow measurements obtained from a large group of healthy people.

The personal best value of peak flow is obtained in a patient after he or she has been adequately treated so as to show the highest attainable result by the person. It is generally the highest PEFR measurement achieved in the middle of a good day. A patient’s present value of peak flow compared to his personal best, gives the correct assessment of his asthma situation.

Q. What are the different variables that can effect the peak flow reading in a patient ?
A. There is a wide variation between morning and evening measurement of the PEFR, particularly at the start of treatment, before a good control is achieved. These variations occur because of the poor control of asthma, or due to the time at which the drug is given. It is recommended that home monitoring be done morning and evening at7a.m.and7p.m.

Different brands and models of peak flow meters often yield different values when used by the same person. Hence patients should always use the same model in the home or the doctor’s clinic.

Q. What is the significance of PEFR in asthma patients ?
A. The decreased rates of expiration of air as expressed in decreased PEFR in asthma patients, occur earlier than the production of the symptom of breathlessness or even the signs of wheeze and ronchi detected through the stethoscope. By the time, wheezing is detected through the stethoscope, the PEFR has already decreased by 20 percent or more. Poor perception of the severity of asthma, on the part of the patient and physician, has been cited as a major factor causing delay in treatment, and this may contribute to increased severity and mortality from asthma exacerbation.

Q. How does knowing PEFR help asthma patient?
A. 1. If the patient knows his best measurement of PEFR, drop in its value of upto 10 percent, indicates caution but no danger, as this much variation is not unexpected over a period of 24 hours.
A drop of 10 to 50 percent indicates that the patient is in danger of getting an attack.

If the drop is more than 50 percent, the patient is in an imminent danger of getting the attack. He must approach his physician who may examine him in the emergency department of the hospital. The correct knowledge of the reading of PEFR, predicts the condition of the patient and provides valuable time and opportunity to take all the necessary measures to prevent an attack of asthma.

2. A drop of PEFR also indicates that the patient has been exposed to allergenic environments. He must try to localize the cause and prevent recurrence of the situation.

3. In some cases, there may be difficulty in making a diagnosis of the disease. It has been shown that if within a day, there is variability of PEFR of upto 20 percent or an improvement of upto 20 percent after giving a bronchodilator, the patient is suffering from asthma.

4. PEFR reading also helps in monitoring the improvement in the patient after a particular mode of treatment.

Q. How dependable is the Peak Flow Meter for determining overall asthma control?
A. It is quite dependable. The peak flow meter removes much of the guesswork in asthma management. Parents who once struggled with decisions such as when to administer medications, when to keep a child home from school, and when to take the child home from school, and when to take the child to doctor, find they are able to make these decisions more easily, based on the objective data provided by the meter. Children and adults with asthma find it easier to understand the information provided by the peak flow meter.

Q. What is the importance of Peak Flow Monitoring at home?
A. There are two very important reasons for taking peak flow reading at home. First, asthma doesn’t behave the same way 24 hours a day. It tends to get spontaneously worse at night and get better during the day. Without peak flow meter at home, the physician can only guess how the patient was doing at home. Second, having a meter at home allows the patient to telephone the doctor during the night and get proper instructions for management of his case. Nine times out of ten, a physician experienced with home peak flow, can help get his patient out of trouble quickly and avoid uncalled for visit to an emergency room or hospital.

Q. Which asthma patients are recommended to do Peak Flow Monitoring at home?
A. The following patients should keep a peak flow monitor at home and use it:

1. Patients who experience severe attacks with little warning.
2. Patients who need to travel long distance to receive medical attention.
3. Patients who require high-dose inhaled corticosteroids or daily oral corticosteroids.
4. Patients with big ups and downs in peak flow, that is, greater than 20 percent of their best peak flow.
5. Patients whose medical history appears to provide an unsatisfactory guide to treatment.

Q. What is a Space Inhaler device?
A. It is a chamber that holds the aerosol produced by a metered dose inhaler (MDI) before it is inhaled into the lungs. This chamber performs two major functions: (1) The aerosol remains inside the device for some time, hence the larger particles emitted by the MDI settle down on the walls of the chamber and do not unnessarily go into the mouth or throat; (2) The distance between the MDI emission nozzle and the mouth of the patient is increased, whereby the finer particles of the mist form and penetrate into the distal airways.

Q. What are the different parts of the Space Inhaler device?
A. Many types of space inhaler devices are available. One type is in the form of a tube 10 cm long by 10.2 cm wide without a valve. Another is in the form of a collapsible bag with a capacity of 700 ml. And yet another type of chamber available in India is in the shape of a bottle with openings at both ends, in one of which the MDI is fixed and the other acts as a mouth-piece.

Another device said to be more scientifically designed, is the Spacehaler. Different parts of the Spacehaler are depicted on the front page.

Comparision of the spacer devices has shown that the larger pear-shaped spacers are significantly better than the smaller spacers, in achieving optimal results.

Q. Can any Space Inhaler device be fixed to any MDI?
A. Usually this is possible. But in some cases the nozzle of the spacer device is shaped in such a manner that it can fix only a particular brand of MDI. Hence while purchasing one, make sure that the MDI and the spacer device fit properly.

Q. How is the Space Inhaler used?
A. 1. Fix the MDI into the spacer device. Shake thoroughly so that the contents of the canister of MDI are properly mixed.
2. Hold spacer device with the mouth-piece pointing slightly upwards so that the valve is closed.
3. Press the canister to release the required dose into the chamber.
4. Breathe out slowly and completely.
5. Hold the mouth-piece between the lips.

Breathe in slowly and deeply through your mouth. Hold your breath for as long as possible or till you count upto 10. Breathe out through the mouth- piece. Breathe in again slowly and deeply through the mouth-piece to ensure that all the aerosol in the chamber has been inhaled.

Q. How is the Space Inhaler kept clean?
A. Dip the inhalation chamber in warm water using a mild detergent. The mouth-piece can be removed. Clean the plastic parts dry and reassemble the device when completly dry.
Space Inhaler must be regularly cleaned.

Q. Which asthma patients derive the maximum benefit from the use the Space Inhaler?
A. The elderly and or handicapped, and infant and children under the age of 5 years. These are the ages where the major problem of hand-mouth- lung discoordination exists. However, improper use of metered-dose inhaler devices is not limited to these specific groups. It has been shown that space inhalers improve bronchodilator response in patients unable to use metered-dose inhalers effectively.

Q. In what specific manner Space Inhaler helps children and older patients?
A. 1. It is easy to hold in the right position.
2. It allows the patient to inhale medicine without co-ordinating a puff with a breath.
3. It helps more medicine to get to the small airways where it works effectively.
4. It lessens the bad taste of the medicine.
5. It reduces possible bad effects of the medicine.

Q. Can Space Inhalers be used beneficially by asthma patients other than children and older people?
A. Patients who cannot master the proper technique of meter-dose inhaler use, should try using inhaler. For this reason, it is essential to determine each individual patient’s technique when prescribing a metered-dose inhaler.

Q. Is it not a wastage of the drug that a significant proportion of the aerosol particles from MDIs stick to the walls of the Space Inhaler?
A. The availability of aerosol particles in the respirable range (1-5 microns) is the crucial issue. Only such particles can enter the lungs and exert therapeutic action. Larger particles, in any case, are trapped in the throat on inhalation and cause side effects.

Aerosol particles deposited on the walls of the spacing device are the larger ones which anyway would not enter the lungs but would otherwise get deposited in the mouth and throat. The space inhaler actually increases the amount of aerosol particles in the respirable range available for penertration deep into the lungs.

With the space inhaler, the amount of drug delivered is said to be significantly increased. The therapeutic efficacy is therefore increased.

Q. How does it help a patient that the larger particles of the MDI mist are deposited on the Space Inhaler walls ?
A. Throat deposition of the drug is reduced by 9 percent with the space inhaler. This is the reason why it virtually eliminates the side effects of throat candidiasis, a fungus infection, and also hoarseness of voice.

Q. How many doses of MDI aerosol should be released inside the Space Inhaler ?
A. Upto four doses can be released and be inhaled.

Q. For how long should the patient inhale from the Space Inhaler, releasing aerosol from MDI in it ?
A. If a deep inspiration is possible, inhaling twice from the space inhaler would empty the chamber of the aerosol.

If a deep inspiration is not possible as by small children or due to tightness of chest, the patient may breathe in at his own rate for about half a minute.

Laser holography studies have determined that a large number of aerosol particles in the respirable range, remain suspended in the chamber for 30 seconds.

Q. Which drugs can be used through space inhaler?
A. All the drugs that come in the MDIs. These include salbutamol (Asthalin, SOS, Salbutamol), terbutalin (Bricany1), steroids (Beclate, Pulmicort), Fluticasone or a combination of them, cromolyn sodium (Fintal, Cromal-5).

Q. Are the results shown to be specifically better with steroids used through Space Inhaler ?
A. Studies with inhaled corticosteroids have noted that there is a marked increase in efficacy with the use of space inhaler over metered-dose inhaler alone.

Q. Can Space Inhaler be recommended in moderately severe or severe attacks of asthma in the above specified groups of children and older patients ?
A. Just as MDIs do not by themselves provide adequate relief in severe attacks, similarly use of space inhalers on MDIs would not provide adequate relief.

If the attack is severe, use of a nebulizer with salbutamol is recommended for bronchodilation. Besides, that, other anti-asthma drugs in the form of tablets or injections are prescribed by the physician.

Q. Are Space Inhalers recommended in other chest diseases causing breathlessness such as chronic bronchitis in older patients?
A. Yes. They will prove helpful in cases needing salbutamol MDI. Very old patients of this disease having hand-mouth coordination problems, will definitely benefit by the use of this device.

Q. What is urticaria?
A. Urticaria is the sudden occurrence in the skin of red itchy swollen patches. It appears in one area and disappers quickly in minutes or hours from there, only to reappear in another area. Urticaria may be localized at some part of the body or spread all over the body. It may occur as only a few spots or it may be confluent or joined together.

Q. Who are the people more likely to get urticaria?
A. Urticaria is a manifestation of allergy. People with a family history of allergy, are more likely to develop it at one time or another. But even those who have no family history of allergy also get it.

In the majority of the cases, it is a transient phenomenon occuring only once or twice. In some people, it comes up only in a particular season; in others, it persists for weeks, months and years, making life miserable.

Q. What are the causes of urticaria?
A. Some of the causes of urticaria are :
1. Physical agents such as cold, heat, sunlight and mechanical pressure.
2. Emotional causes such as laughter, anxiety and panic.
3. Food articles such as nuts, seeds, fish, milk, eggs, citrus fruits.
4.Drugs,outofwhichasprin isthecommonoffender. Others are antibiotics, laxatives, etc.
5. Inhalation of certain pollens or chemicals or fibres such as of nylon or wool.
6. Unknown causes which form the majority of the cases. Urticaria can be caused by allergic as well as non-allergic factors. Allergic mechanism involves the release of histamine in the tissues. There are other chemicals that are also released.

Q. What are the characteristics of urticaria caused by cold?
A. Cold weather, cold winds, bathing with cold water, holding cold drinks in the hands or drinking them, are known to give rise to urticaria in susceptible people. Swelling of the mucous membrane of the mouth, difficulty in swallowing, pain in abdomen, or difficulty in breathing due to swelling of the glottis, are some of the other symptons.

In order to make sure that the symptoms produced are a result of cold, it is necessary to perform a cold immersiontest.Immersionof handofapersonallergic tocoldinwaterat5o Cfor5to10minutesmaybe followed by a reddening and swelling of the hand and apperance of urticarial rash in other parts of the body.

This may happen immediately or after a few minutes. The temperature level at which symptoms appear varies considerably.

Treatment consists, primarily, in the avoidance of exposure to cold. Hyposensitization by exposing the hand or hands to water at progressively lower temperatures may be helpful. The hand is immersed in water at about 15o C for 2 to 5 minutes several times a day, and the temperature of water is gradually reduced on successive days to about 6o C, if the patient tolerates the lowered temperatures. The use of antihistamines is helpful at times, but occasionally it is ineffective.

Q. What are the characteristics of urticaria caused by heat?
A. Heat, exertion or excitment in the form of laughter or pain can bring on urticaria in some cases. Hot baths, exposure to the heat of the sun, eating hot foods, sitting in a warm room or strenuous exersice, can bring on an attack of urticaria.

Diagnosis is made on the basis of the case history, and confirmed by testing for heat exposure by having the patient put one leg in hot water. Attack of generalized urticaria will be induced over the entire body except for the immersed leg which merely becomes flushed.

In treating an acute reaction, any cooling agent such as cold water, cold air, or the application of alcohol to the skin will give some relief. An attempt can be made to increase tolerance by exposing the subject gradually to higher temperatures, beginning by placing the hand in water at about 37o C and increasing the temperature to 43o C, followed by a bath at 37o C. In general, the treatment of allergy to heat is not satisfactory.

Q What are the characteristics of urticaria caused by sunlight ?
A. In some rare cases, urticaria appears on exposure to sunlight.Thisisnotduetoheat,but duetothesunlight itself. Burning sensation is noted within 20 to 30 seconds after the exposure followed by redness and a weal. The reaction may reach a peak in 10 minutes and persist for 1 to 2 hours.

In some cases, reactions occur only after photosensitizing agents have been ingested, such as sulphonamides, or applied to the skin, such as the tar derivatives, contained in some cosmetic creams.

Diagnosis depends on the case history and the reproduction of symptoms by exposure to sunlight. Change of environment, wearing tinted glasses, staying indoors, avoiding known photosensitizing substances, coating the skin with agents capable of filtering out the injurious rays, have given good results in some cases. Treatment is generally unsatisfactory.

Q. Which drugs are known to cause urticaria?
A. Penicillin, aspirin, laxatives, sedatives, hormones and vaccine injections are commonly incriminated. Pencillin either by injection, oral or ointment is considered, by some, to be the commonest cause of urticaria now-a- days.

It is, however, not easy to find out the causative drug, asurticariallesionsoftenappeardaysandweeks after the taking of the drug.

Q. Which foods can cause urticaria?
A. Among the foods that cause urticaria in sensitive individuals, are those eaten raw such as bananas, oranges, strawberries, groundnut, tomatoes and wheat; other suspected foods are eggs, chocolate, fish, lobster, oyster and prawns.

Q. How is the cause of urticaria determined in a particular case?
A. A thorough searching history of the patient is the most important single factor that helps in pinpointing the cause. Physical examination is important particularly with regard to the appearance and distribution of the lesions.

In chronic urticaria, the food that a patient usually takes must be throughly checked. In the case of a patient who gets isolated bouts of urticaria, the causative food may be that which is eaten occasionally. Commonly known allergic articles of diet such as eggs, fish, milk, chocolate, dried fruits etc. be eliminated and the results noted. If there is an improvement in the symptoms, then all the eliminated foods should be re-administered, one by one, and the effect of each noted. There should be an interval of at least one week in between. Urticaria localized continuously or repeatedly at 7 certain areas suggests the possibility of a contact with an allergic substance. Pollens may be implicated when there is seasonal incidence.

Q. Are skin tests helpful in finding the cause of urticaria ?
A. Skin test in these patients with extracts of pollens, dust and foods commonly elicit some positive reactions, but their true significance can only be ascertained after correlating them with the case history and food trials.

Skin tests with the drugs are unreliable and may prove dangerous as well. In spite of best efforts, in a vast majority of cases, the causative agent cannot be found by any means.

Q. How is a case of urticaria treated ?
A. Treatment lies in avoiding the causative agent. If that is not possible, the following measures are adopted.

If an examination of the stool shows presence of a worm, its eradication may in some cases be helpful.

Sites of infection in the teeth, tonsils and other places should be treated appropriately.

Patients should be warned against taking any pain- relieving tablets, laxatives or sedatives.

Q. Is hyposensitization or immunotherapy (injections) of any value in the treatment of urticaria ?
A. Many a time it has not been found to be of much value. 8

Q. What measures are recommended for getting relief from symptoms?
A. For symptomatic relief, various antihistamine tablets are recommended. Hydroxyzine (Atarax) and cyproheptadine (Periactin) are especially effective for the treatment of urticaria caused by cold, heat and exitement.

Q. Are newer antihistamines better than the usual ones in cases of urticaria?
A. Yes. They are longer-acting and cause less drowsiness. They should be tried.

Q. Should corticosteroids be taken as tablets either alone or in combination with antihistamines in cases of urticaria ?
A. Corticosteroids should preferably be avoided. If it is a matter of a week or a fortnight and urticaria is very troublesome, steroids can be given along with anti- histamines. But because urticaria can be a long standing problem, relief obtained from the use of steroids will become a habit and ultimately result in lot of injurious effects on the body.

Q. How useful are herbal remedies for cases of urticaria?
A. Ayurveda and Unani physicians claim good results with their preparations, not only as temporary relief but also for the cure of disease as well. Homoeopathic remedies have also been claimed to provide good results. Those patients who do not find relief, preventive or curative, under modern medicine, and have a long-standing and troublesome disease, may try remedies under these systems of medicine, under the care of a reputed physician.