+ Environmental Controls

The attempt to decrease the exposure to potential inhaled allergens in the homes of patients with asthma and/or allergies is frequently quite rewarding. Of necessity, particular emphasis is placed in the room where the patient sleeps. Our goal is to provide an environment in which a minimum of potential allergens are present.

1. Pillows should be made of dacron. If not, they must be encased in an impermeable encasing. Do not use kapok, feathers, down or foamy rubber pillows.
2. All mattresses and box springs must be covered with an impermeable casing. The zipper ends of the casing should be sealed with wide adhesive tape.
3. A thin synthetic or cotton mattress pad is acceptable.
4. If the room contains more than one bed it should be similarly prepared.
5. Bed sheets should be of smooth cotton or linen.
6. Blankets should be made of cotton or synthetic fibers.
7. Quilts are acceptable provided that they are only stuffed with synthetic material.
8. Carpeting in general is not recommended; because of the difficulty in keeping shag carpets clean, their use is particularly discouraged. A flat synthetic carpet is acceptable if easily cleaned. Rug underpads should not be used.
9. Window curtains should have a smooth surface and be washable.
10. Furniture should be made of wood, plastic, or metal. All upholstered furniture should be permanently removed.
11. The closet should contain only clothing and should be as free of dust as the rest of the room. Do not use the closet for storage.
12. Since forced air heating stirs up and recirculates dust and other potential allergens, the heating outlets should be closed off and sealed permanently.
13. Air conditioning is frequently quite helpful. If cooled air happens to precipitate asthma attacks or increase other symptoms, the cooling component can be turned off and the air conditioner can be used as a filter.
14. Toys which are stuffed with plant or animal products should be eliminated. Toys which are stuffed with synthetic material are acceptable.
15. Since plants alone or in an aquarium frequently harbor mold, they too should be eliminated from the bedroom.
16. The entire bedroom should be thoroughly cleaned at least one time per week and dusted daily.
17. Pets, i.e., dogs, cats, birds, guinea pigs, hamsters and gerbils frequently cause allergic symptoms. If one is not allergic to a pet and has an allergic predisposition, the chances are unfortunately quite high that he will develop sensitivity in the future. Thus, the pet may have to be removed from the house. After a pet is removed, the dander may be present for many months.
18. If one has allergies, one should stay out of unfinished or damp basements as well as attics.
19. When you travel, take your pillow with you.
20. Strong odors such as paint, turpentine, perfume or odors from cooking can frequently aggravate allergic symptoms and thus should be avoided.
21. People are rarely allergic to pine pollen. However, almost all Christmas trees have molds on them; thus, artificial trees are preferable.
22. Smoking should not be permitted at home or in the car.
23. Bounce™ (the fabric softener) has been shown to exacerbate asthma and other allergic conditions at times; thus, this in general should not be used.
24. Those with allergies should not be around if any remodeling or redecorating of the house is going to be done such as painting, tearing down a wall, or even putting up new wallpaper.

Please understand that frequently environmental controls are not an all or none phenomenon; a variety of potential allergens may have a synergistic effect, i.e. one alone may not cause an asthma attack, however, several added together may precipitate one; thus, we attempt to decrease the so-called "allergic load."

+ Allergy Injections

Another way of treating asthma is with allergy injections. The idea is to desensitize the patient to certain things in the environment such as trees, grass and ragweed pollen, molds, dust, and mites. This is attempted by giving weekly injections for several months.

Concentration of the allergen is gradually increased until the maintenance dose is reached, after which, injections are given approximately every three weeks. Usually the patient is retested after two years.

The majority of patients have a decrease in symptoms and thus do not need to take medications as frequently.

+ Medications

There is a wide variety of medications that can be individually tailored to take care of a patient's asthma. It has become quite clear that pharmacologic management — that is, the use of drugs — is the most important modality of treatment in managing the patient with asthma.

Steroids

Inhaled steroids such as Azmacort, Vanceril, Beclovent, Aerobid, and Flovent, are frequently used to control asthma even in milder asthmatics. The current thinking is that inflammation in the bronchial tubes plays a significant role in causing symptoms. The beauty of these drugs is that they are inhaled into the lung and work there with very little absorbed; thus it is a form of a steroid that can be used daily without the side effects of long-term daily oral steroids.

Rarely in medicine has a medication been abused and misunderstood. Steroids such as Prednisone and Medrol frequently work very well in a variety of illnesses. They also work quite well in asthma. The problem with steroids is that unfortunately, they have been abused by physicians as well as patients. Since the medications work so well, they would frequently be used for months or even years. If steroids are used daily in this way, many of the nasty side effects you have heard about can occur: This varies from weight gain to stunting of the growth, weakening of the bones, skin rashes, diabetes, cataracts, etc. Because of the way steroids have been abused, patients as well as physicians have gone to the other extreme and have frequently withheld this potentially lifesaving and very valuable medication (steroid phobia). The facts are that if used appropriately, steroids will rarely cause permanent side effects. If any side effects do occur, they are usually quite transient, that is, they go away. For example, with the onset of a severe attack where all the previous medications have not worked, a burst of Prednisone, that is, three, four, or five tablets for four or five days may prevent the attack from getting worse and keep the patient out of the hospital. After a short burst of Prednisone, it can either be stopped abruptly or tapered over several days. A recent breakthrough several years ago has shown the use of steroids in an every-other-day regimen works almost as well as daily steroids and was almost completely without the side effects of the daily steroids. Some patients, in fact, in spite of all other medications, do require every-other-day steroids to achieve a certain quality of life where they can participate in sports, keep out of the hospital most of the time, and stay in school or work regularly. On every-other-day steroids, there would be very little weight gain, children would grow normally and there was really no great concern for any serious side effects. The most common side effect from four to five days of Prednisone in children is the cheeks may look a little red and the appetite might increase a little. Both of these side effects are in general welcome by most parents.

Sympathomimetic Bronchodilators

These medications include another group of bronchodilators which attempt to keep the bronchial tubes open and dry up the secretions. There are two forms — inhaled medications and pills. The inhalers include Ventolin, Proventil, Alupent, Brethaire, Bronkometer, Tornalate and Maxair. A new long-acting inhaler is Serevent. This is used twice a day to prevent attacks. The pills include Alupent, terbutaline, Ventolin, Proventil, Proventil Repetabs, and Volmax. The inhalers must never be used more than five times in a 24 hour period without notifying his physician. If the patient is still having problems, we may have him obtain an aerosol machine at home. This is a machine that can blow medication directly into the lungs to keep the bronchial tubes open.

Theophylline

This is another type of bronchodilator that comes under a variety of names such as Theo-Dur, Slobid, Slo-Phyllin, Choledyl, and Theolair. Generally, we try to avoid the use of generic Theophylline preparations. Everyone metabolizes, that is, breaks down Theophylline at different rates. Theophylline levels, that is, the amount of Theophylline in the blood, can be measured several hours after the medication is taken to determine how much is actually in the blood and if the level is low and the patient is not doing well, then we can safely increase it.

Antihistamines

Patients with asthma frequently have hayfever and other nasal problems. Antihistamines are quite effective for nasal symptoms. It was formerly believed that because of the drying effects of antihistamines, they were not to be used in asthma; however, recent studies have shown that if there is a significant nasal problem, antihistamines will rarely worsen the asthmatic symptoms.

Antibiotics

Asthma symptoms frequently present as an infection or what seems to be an infection. In fact, an upper respiratory infection which is usually triggered by a virus can set off an asthma attack. When one listens to the chest, it is at times difficult to tell whether pneumonia is present. We see many patients who have repeated episodes of what sounds like pneumonia but in fact, are having episodes of asthma so that in general, we do not use antibiotics for the average asthma attack unless there is a strep throat, ear infection, or x-ray-documented pneumonia or sinus infection.

+ Emotions, Sports, School, and Aspirin

Emotions

Emotions do not cause asthma. However, a person has to have the asthmatic lung in order to have an asthma attack. That is, the manifestations of emotions can trigger an asthma attack, but if someone does not have the asthmatic lung, he can laugh, scream, cry, have a tantrum until he is blue in the face and he will never wheeze. However, when a person has the asthmatic lung or "twitchy lung," the slightest emotional turmoil can set off an episode of wheezing. This is not an emotional problem. The psychiatrists have probably done somewhat of a disservice by overemphasizing the emotional aspects of asthma and, at times, people have said that it is all emotional. This is just not true. I think, however, that we must be aware of the emotional contribution to an asthma attack and put it in perspective and consider it in the same category as pets, pollution, weather changes, and upper respiratory infections, all of which can trigger an attack so that in general, psychiatric problems are not any more common in asthma than other chronic illnesses.

I think one must still, however, be aware of what precipitates the patient's asthma attack. One frequently hears that one birthdays, Thanksgiving, Christmas, or Hanukkah, that a child with asthma is always sick. There may, in fact, be a variety of contributing factors. The child may be very excited at the party, people may be smoking, he may also have a cold. All these things together can contribute. If it is Christmas time, the scent from the tree or the molds on them can set off an attack. So if a person is not on daily medication, he might anticipate difficult times that have occurred historically and begin the asthma medication the night before the party.

Sports

Athletic activities are important for all people, particularly those with a chronic illness. Almost all asthmatics can participate in most sports if appropriately treated. For reasons which are unclear, swimming is the least asthmagenic, that is, the least asthma causing and is certainly recommended for all patients with asthma. Most other sports can be played except with an occasional exception. Appropriate medical treatment is available to prevent exercise-induced asthma, that is, asthma that results from exertion.

School

School is important for all children and many asthmatics, if not appropriately treated, will miss many weeks and even months of school. In the asthmatic who is properly treated, it is rare for him to miss more than a few days of school.

Aspirin

Aspirin should be avoided by all people with asthma since it can precipitate a severe asthma attack. Acetaminophen (i.e., Tylenol) should be used instead. There are over 400 preparations which contain aspirin, so it is important to read labels carefully.

Conclusion

In conclusion, I would like to emphasize that the quality of life of the asthmatic can be essentially the same as someone who does not have asthma, if one takes medications regularly, initiates appropriate environmental controls, and if indicated, begins allergy injections.