Saturday, November 22, 2008

Visiting Dignitaries and Asthma...

Good Evening Everyone,

Medical clinics in Iraq are favorite spots for visitation by dignitaries. I suppose it always looks good to visit troops who are injured or ill. Over the last month, we have been flooded with visits from our higher military command. One of the reasons is that we have recently went through an Army change of command at the battalion level, secondly much of the duties on this post is being transferred to the Air Force. So, we have had visitation from both the Army and Air Force. Some times I feel like we are a museum and visitors are lining up to catch a glimpse of an Army clinic.
Today, we had a visit from Major General Thomas Loftus. He is the Deputy Surgeon General for the Air Force. He toured our base and stopped in to see our facility. I had the honor of showing him our operation and he seemed pleased by what he saw. I tried to pawn off the duty of touring him around to one of the other providers but alas, they left me hanging and they were no where to be found. So much for backing up your buddy.
Well today's medical topic is asthma. In the military, a person isn't suppose to be allowed to join any branch of the service with asthma. So, recruiters tell their recruits to not mention the fact that they have asthma or they will say that they don't have asthma but reactive airway disease. The result is that soldiers come over here, find themselves exposed to new and different environmental allergens and suddenly they have an asthma attack. So, I thought it would be appropriate to go over asthma tonight. I hope you find these medical lessons useful. I try to go over topics that are useful to parents as often times a parent will come to their doctor and leave without having their questions answered. So, I hope this will be helpful to you.
Twenty two million American’s, six million of which are children, have asthma.
Asthma is by definition, a reversible airway disease. In other words, it is a condition that presents with symptoms that can cause airway obstruction and then will resolve to some extent and the airways will reopen. This definition distinguishes asthma from other obstructive airway diseases like chronic obstructive pulmonary disease and emphysema, both of which are permanent conditions and non-resolving.
Asthma is an inflammatory disorder of the smaller airways of the lungs and presents with the triad of symptoms of inflammation, constriction, and excessive mucus productions.
The air that we breathe enters the lungs through the trachea and travels down and bifurcates into the right and left main stem bronchi. The main stem bronchi then divide down even further to smaller bronchioles and then air reaches the terminal end in the alveoli. The alveolar sacs are the location where oxygen and carbon dioxide are exchanged. The exchange of these two gases are critical to the oxygenation of our bodies tissues and maintaining the pH balance of our blood. Many people understand the importance of our body receiving oxygen but few understand the importance of getting rid of the carbon dioxide that builds up in our blood. If the lungs are unable to blow off the carbon dioxide then our blood becomes acidic, end organs like the kidneys and liver fail, and death can ultimately result.




The Asthmatic Response


Asthma is a disease that adversely affects the lungs ability to exchange oxygen for carbon dioxide. The obstruction of the airways that is caused by asthma is a result of the sudden onset of inflammation in the lung tissues of the smaller passages in the lungs. The bronchioles and the alveolar sacs become inflamed, narrowing the air passages and causing the classic wheezing sound that is associated with an asthma attack. Imagine blowing up a balloon and then squeezing the opening closed so that only a small amount of air is allowed to escape. There is usually a whistling sound when we do this. Well, this is the idea behind the wheezing sound made during an asthma attack.
In addition to the inflammation and constriction of the smaller airways, the lung will produce an excessive amount of mucus, which further obstructs air flow.
When a person has an asthma attack, inflammation, constriction, and excessive mucus production create an environment in the lungs where the air going into the lungs cannot reach the small blood vessels that are so desperately trying to bind oxygen and get rid of carbon dioxide. A patient will become short of breath and begin to posture for air. Breathing becomes labored and panic sets in which can exacerbate the symptoms. Eventually the patient can become cyanotic where the skin and mucus membranes will adopt a bluish color. This color change is due to lack of oxygen in the blood.
The triggers for asthma are varied. Often times people with asthma have allergies to dust, pollen, etc…and these antigens can trigger an attack. Other triggers include respiratory illnesses, cold weather, and exercise.
Treatment for asthma is also varied. Most practitioners agree that asthmatic patients will need to have a rescue inhaler in their possession at all times. The best known and most widely used rescue inhaler is albuterol. Albuterol helps improve the airway function by relaxing and dilating the muscles of the smaller airways. Pt. will usually have the side effect of slight shaking after using albuterol, but this usually resolves in a few minutes.
The goal of therapy for asthma is not to treat the acute attack but to prevent a future attack or at least lengthen the time between attacks and reduce the severity of each episode. This goal can be accomplished using some other long term medications. There are several classes of medication that can be used as long term agents. The first and perhaps most common are glucocorticoids like flunisolide, beclomethasone, fluticasone and triamcinalone. These medications are steroids and serve to prevent the immune response that causes inflammation in the lung passages. Then there are the Leukotriene modifiers like Montelukast and Zafirlukast that assist the body by preventing the inflammatory process in a different manner. Leukotrienes are lipid mediators that are responsible for the inflammatory effects in the lungs. The Leukotrienes inhibitors act by preventing the cascading effect of the Leukotrienes.
Another form of asthma medications are the mast cell stabilizers like Cromolyn and nedocomil. Mast cells are tissue cells that are filled with histamines. When these cells rupture or lyse then histamine is released. The body will respond to histamines with an inflammatory process. When this occurs in and around the smaller passages of the lungs, your body responds like it has had an allergic reaction. The fluid production and inflammation cause airway obstruction.
There are other forms of older medications that are still in use like Theophylline and newer medications like Spiriva as well as combination medications that mix a steroid with a shorter acting medication. The best known of these medications is Advair. Additionally, persons who have a history of allergies and who have asthma should be on an antihistamine like Claritan or Allegra.
Asthma is diagnosed by performing a pulmonary functions test (PFT). This procedure can usually be done in your local allergist office or pulmonary clinic. In addition to PFT’s a allergy skin test should be performed. Your doctor will want to order some laboratory testing and a chest x-ray prior to starting medications.
Asthma is a condition that can affect people of all ages, race, and gender. In the majority of cases an asthma exacerbation can be handled with the use of an inhaler and limiting of activities. In severe, cases a person who is experiencing an asthma attack should go immediately to the emergency room.
Asthma is a serious condition and compliance to your doctor’s medical regime is critical. If you have any questions about asthma, please call your provider’s office.

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