Tulsa is the #allergy capital of the nation. You wouldn’t believe how many times in a day I hear that! and it makes sense…countless numbers of patients return to Tulsa and find their #allergies are now out of control. But is this really true? Does anyone even keep track of which city in America has the highest pollen counts and can thus claim to be the most miserable #pollen city in America? Continue reading Tulsa is the Allergy Capital of the Nation
I love weather! Growing up on a farm in Kansas brought a variety of weather right to my front doorstep, and that must be one reason I became an allergist.
You have to be part botanist to do this job anyway, with monitoring pollen counts, making allergy recipes for allergy shots, and knowing what is pollinating at what time of the year. Oklahoma makes predicting weather patterns quite a challenge. One minute it’s 80 degrees outside and 24 hours later the temperature has dropped back to 50. We fluctuate from drought to 5 inches of rain in 1 week. How are you supposed to take care of your lawn, much less predict the pollen counts? Here’s some clues that might help you anticipate “bad pollen” days based on the weather patterns in Tulsa; and better yet, you might do better than the weatherman! Weather plays an important role in how much pollen is produced, its distribution and how much pollen is in the air at a given time. (for the full article on weather and pollen counts go to: http://www.weather.com/health/allergy/news/how-weather-impacts-spring-allergies) Allergy symptoms are often reduced on rainy or windless days because pollen does not circulate as much during these conditions. Pollen tends to travel more with warm, dry and windy weather, which can increase your allergy symptoms. Pollen counts vary by time of day, season and weather conditions. Rain, wind and temperature are all important factors to consider when determining if pollen counts will be high, moderate or low on a particular day. Overall, pollen counts tend to be higher in the morning, as well as on warm, dry and windy days. Conversely, lower pollen levels are also typically observed during a stretch of cold and wet days. The National Institue of Heath Medline Plus recommends saving outside activities for late afternoon or after a heavy rain when pollen levels are lower. First, if we’re measuring pollen, what is it we’re measuring? The American Academy of Allergy Asthma & Immunology defines pollen as tiny grains needed to fertilize many kinds of plants.
Pollen from plants with colorful flowers usually do not cause allergies. Plants that produce a powdery pollen can easily be spread by the wind and can cause allergy symptoms. Spring allergies are often caused by tree pollen, summer allergies by grasses, and fall allergy by weed pollen. Pollen is transported in the air and enters our respiratory system, triggering an allergic reaction technically called allergic rhinitis. According to the National Institute of Allergies and Infectious Diseases, a branch of the National Institute of Health, approximately 35 million Americans complain of upper respiratory symptoms related to pollen. So how does weather conditions impact spring, summer, and fall allergies? Continue reading Wacky Oklahoma Weather
If you’re anything like me, waking up on Thanksgiving morning brings to mind a flood of memories to truly appreciate. Maybe its the intoxicating smell of turkey (and the tryptophan will make you want a nap) mixed with pumpkin pie, or the anticipation of Christmas that entices us to slow down and reflect on what is truly important in our hectic lives. For me, of course, my delightful family is always a “sweet spot” when I come home from work each day.
Healthcare on the other hand, has come under criticism for many reasons, and my position is no exception. Despite all of the challenges facing health providers, I still love the challenge of caring for patients with respiratory illness! Despite all of the changes proposed by the “powers that be” to make health care better, the following principles remain:
- If you understand the WHY about your condition, you’ll be better prepared to implement the HOW do I feel better!
- Feeling better is a cooperative effort between patients, health care providers, support systems, the right diagnosis and the right treatment. Solutions are never usually simple, easy, or a quick fix.
- I’m reminded of a middle-aged woman who was frequently hospitalized for her asthma. She was frequently on steroids (oral) for wheezing and almost died several times. She made a decision to stop smoking, clean her environment, and took her medications on a regular basis. She also attended classes on asthma and taught herself about what made her asthma so severe in the first place. Was she successful? I never hear from her anymore if that tells you something about her progress.
Enjoy your holiday….and by the way if you get heartburn, I wrote last year about the inevitable! Click on the link below.
Over the last decade, the aims of asthma management have altered to focus on achieving and maintaining good asthma control and reducing future risks, such as decrease in lung function, asthma exacerbations, hospitalizations, death, and adverse effects from treatment. The benefits of good asthma control include a variety of asthma outcomes that are important to both patients and society.
- No restriction in lifestyle
- Better physical fitness and quality of life
- Reductions in patients’ perception of the asthma burden, health care resource use, and lower risk of exacerbations, hospitalizations, and death.
Inhaled corticosteroids (ICSs) or combination therapy with an ICS and a long-acting β2-agonist (LABA) have become established as cornerstones in guideline-recommended asthma treatment because these therapies have been the most successful in achieving asthma control and reducing future risks in the vast majority of patients with asthma.
Changes in the goals of asthma management, as well as treatment recommendations, have revolutionized management from both the patient’s perspective and a societal perspective. The main question that remains is whether the clinical benefits balance or outweigh the risks of the treatments?
When regular ICS treatment was introduced 4 decades ago, safety concerns were common, and initially, the treatment was reserved for patients with severe disease. The concerns were based on fears generated by the side effects of oral corticosteroids rather than data generated by using ICSs, but with increasing knowledge and experience, the concerns decreased, and ICSs became a first-line therapy for asthma because the benefits of the treatment clearly outweighed the risks. Fast foward to 2012 and our concern is overuse of combination therapy with LABAs/ICS as a risk factor for severe, albeit rare, severe asthma exacerbations.
In this issue of the Journal of Allergy and Clinical Immunology, Wells et al add to the paucity of real-world data by reporting the findings from a large, population-based, real-world observational study comparing the effects of ICSs and fixed-dose ICS/LABA combination therapy on severe asthma exacerbations in a racially diverse population of 1828 patients with a total of 3791 person years of follow-up. Data were obtained longitudinally from a managed care organization, and LABA exposure was estimated from pharmacy data. It was found that ICS/LABA combination therapy had an overall protective effect on asthma exacerbations that was as good as or better than that for ICSs alone. The protective effects of ICS/LABA combination therapy seemed particularly marked in patients older than 18 years, male subjects, patients with moderate and severe asthma at baseline, and reassuringly, African Americans (who have been suggested to be at greater risk).
Although the study is well executed, carefully analyzed, and uses sound methodology, it was not of a sufficient size to make any firm conclusions about severe but rare asthma-related events, such as intubations, death, or both. Yet it is an important contribution to the literature on the perceived risk of serious adverse effects of LABAs. It is reassuring that the results from a carefully executed observational study, mimicking real-world study conditions, are in such good agreement with the findings in the randomized, controlled efficacy trials comparing ICS use alone with a fixed LABA/ICS combination. In addition to significant improvements in asthma control, such studies consistently report reductions in asthma exacerbations, need for oral steroid bursts, and asthma-related emergency department visits compared with ICS treatment alone. Because such events normally precede more serious outcomes, such as intubations, death, or both, these findings make it unlikely (but do not prove) that treatment with fixed LABA/ICS combinations per se should be associated with an increased risk of these serious outcomes.
The US Food and Drug Administration has requested a series of very large postmarketing clinical trials to evaluate LABA/ICS combination safety, (see reference below) but the most serious asthma outcomes are so rare that even these studies might not be able to provide a definite conclusion. Moreover, the results from these studies will not be available until 2017 at the earliest. What should clinicians do in the meantime?
It would be a disservice to our patients if we, in the fear of doing harm to our patients, waited for the perfect. The study by Wells et al supports that a better option would be to follow the recommendations of the asthma guidelines, which unanimously have taken the stand that there is no convincing evidence that LABA/ICS combinations administered in a single inhaler are associated with serious adverse effects. Their benefits on asthma control and reduction of asthma exacerbations outweigh their risk, and we should be careful not to let the perfect become the enemy of the good.
Chowdhury BA, Seymour SM, Michele TM, Durmowicz AG, Liu D, Rosebraugh CJ. The risks and benefits of indacaterol—the FDA’s review. N Engl J Med. 2011;365:2247–2249
The practice of medicine is just that….I advise the recommended treatment based on the information available at the time. If I look back to the time during my fellowship in the early 90’s, much of what we thought was true and now 20 years later, been disproven. As an example, the following study from a respected medical journal cautions against the use of PPI medication for reflux in children. It’s worth your attention, but first some background information.
Children have a high prevalence of asthma and gastroesophageal reflux (GER). Children with asthma often report symptoms of GER and also have a high prevalence of asymptomatic GER. We call this “silent reflux”.
Some experts have suggested that untreated GER may cause persistent asthma control problems in children refractory to treatment with inhaled corticosteroids. However, whether treatment with proton pump inhibitors (PPIs) improves asthma control has not previously been determined. The objective of this study by Holbrook and colleagues was to determine whether lansoprazole is effective in reducing asthma symptoms in children without overt GER. (ie, Prevacid for “silent reflux”)
Study Synopsis and Perspective
Use of PPIs in children with poorly controlled asthma who were using inhaled corticosteroids and who had no symptoms of GER was not found to improve asthma control and was, in fact, associated with an increase in adverse effects, according to results of a study published in the January 25 issue of JAMA. (PPIs Produce Negative Outcomes in Children With Poor Asthma Control)
PPIs “are often prescribed for poorly controlled asthma regardless of reflux symptoms, and there have been large increases in the use of PPIs among children between 2000 and 2005…. Hence, it is of clinical importance to determine whether antireflux therapy, the most common of which are PPIs, improves control of asthma in children,” write Janet T. Holbrook, MPH, PhD, from the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues from the Writing Committee for the American Lung Association Asthma Clinical Research Centers.
The goal of this placebo-controlled, double-masked, randomized study was to determine whether the PPI lansoprazole was effective in controlling asthma symptoms in children with asthma, but no overt GER. The researchers also investigated whether pH testing would identify children with GER who responded to PPI therapy.
The children were randomly assigned to receive either lansoprazole (15 mg/day for those weighing <30 kg; 30 mg/day for those weighing ≥30 kg; n = 149) or a matching placebo (n = 157). The researchers found that the mean difference in the Asthma Control Questionnaire (ACQ) score between the 2 groups was 0.2 units (95% confidence interval [CI], 0.0 – 0.3 units), which was not statistically significant (P = .12).
There also was no significant difference in the forced expiratory volume in the first second (FEV1; 0.0 L; 95% CI, −0.1 to 0.1 L), and no change in the rate of episodes of poor asthma control (relative risk [RR], 1.2; 95% CI, 0.9 – 1.5) or asthma-related quality of life (−0.1; 95% CI, −0.3 to 0.1). In addition, children treated with lansoprazole developed more respiratory infections (RR, 1.3; 95% CI, 1.1 – 1.6; P = .02) than those in the placebo group.
A subgroup of children in the study (n = 115) underwent esophageal pH studies before randomization; the prevalence of GER among this group was found to be 43%. In those children with a positive pH study, there was no positive treatment effect with lansoprazole vs placebo for any asthma outcome.
The most common adverse event reported among both groups was asthma exacerbation.
- This is the exact opposite of what I would expect!
A higher prevalence of upper respiratory tract infections, sore throats, and episodes of bronchitis was noted among patients in the lansoprazole group. The study authors speculate that this may be a result of loss of host defense against bacterial colonization as a result of higher gastric pH levels.
“The results of this clinical trial are uniformly negative regarding the benefit of acid suppression therapy on symptom relief, lung function, airway reactivity, or quality of life,” write the authors. The results also “indicate that PPI therapy for poorly controlled asthma is not warranted.”
In an accompanying editorial, Fernando Martinez, MD, from the Arizona Respiratory Center, University of Arizona, Tucson, notes that although it is not a statistically significant difference, the increase in activity-related bone fractures in the lansoprazole group also raises concerns. This potential complication has prompted an advisory from the US Food and Drug Administration about the risk for fractures in adults receiving chronic PPI therapy.
Overall, however, Dr. Martinez praises the work of Dr. Holbrook and colleagues and concludes that “[g]iven their potential adverse effects, these medications should thus be used with great restraint for treatment of GER/[gastroesophageal reflux disease] during childhood. The substantial increase in use of PPIs in children during the last decade is worrisome and unwarranted.”
Support for this study was provided by the American Lung Association Asthma Clinical Research Centers Infrastructure Award and National Institutes of Health/National Heart, Lung, and Blood Institute grants. Dr. Holbrook and colleagues have disclosed no relevant financial relationships. Dr. Martinez has served as a consultant to MedImmune and has presented at an Abbott-sponsored seminar.
- The Study of Acid Reflux in Children With Asthma was a randomized, masked, placebo-controlled, parallel clinical trial comparing lansoprazole vs placebo in children without overt GER but with poor asthma control despite treatment with inhaled corticosteroids.
- Lung function measures, such as FEV1, asthma-related quality of life, and episodes of poor asthma control, were secondary endpoints.
- In the subgroup with a positive pH study result, there was no apparent treatment effect for lansoprazole vs placebo for any asthma outcome, including asthma-related quality of life or lung function.
- Lansoprazole was also ineffective in subgroups defined by markers of asthma severity (either FEV1 at baseline or oral corticosteroid use in the past year).
- At least 1 serious adverse event occurred in 10 participants in the lansoprazole group and 9 in the placebo group.
- Asthma exacerbation was the most common serious adverse event in both groups (15 of 25 reports).
- The investigators concluded that in children with poorly controlled asthma without symptoms of GER who were using inhaled corticosteroids, the addition of lansoprazole did not reduce symptoms or improve lung function but was associated with increased adverse events.
- The findings do not support routine esophageal pH testing to identify children who respond to PPIs, nor do they support trials of PPIs for poorly controlled asthma.
- An accompanying editorial notes that the overuse of PPIs in childhood asthma is an example of “therapeutic creep,” or extending the use of a treatment with real or suggestive therapeutic effects in selected patients to other patients in whom the efficacy of that treatment has never been demonstrated.
- The editorial also notes that therapeutic creep increases the risk for potential adverse effects without any added advantage for patients and may have significantly added to the marked increase in asthma drug costs.
- Findings of a randomized, placebo-controlled trial suggest that PPI treatment of children with poorly controlled asthma but without symptomatic GER is not effective in reducing asthma symptoms or improving lung function.
- In this randomized, placebo-controlled trial, the addition of lansoprazole was associated with increased adverse events, particularly respiratory tract infections. There may be significant safety concerns for long-term PPI use in children, meriting further research
- I personally wonder if more aggressive use of Vitamin D replacement would be helpful for the increase in risk of fractures for the patients taking PPI medication. Yes indeed, further research is warranted.
Insurance is now a part of our lives, especially health care providers. Expensive medications such as omalizumab (Xolair™) are rarely approved for use unless patients and physicians complete an extensive application for benefits. Here is a list of medical articles that support the use of Omalizumab in the treatment of asthma:
1. Storms, W, et al. Omalizumab and asthma control in patients with moderate-to-severe allergic asthma: A 6-year pragmatic data review. Allergy and Asthma Proceedings 2012 33:172-177.
- Proven fewer symptoms of asthma
- Less need for rescue medication
- Burst of steroids decreased from 5.1 to 1.1 in the 12 months of the study
- ACT scores improved by 58% in the first year
- Fewer hospitalizations
What other medication do we have available that produces these results without the use of oral steroids? But don’t take it from me, see for yourself.
We haven’t had much of a winter in the Midwest, but the air is still dry enough to cause “winter” asthma. Today I would like to discuss how clinicians can provide evidence-based care for their patients with asthma by advising them on how to control asthma during the cold winter months. Today’s discussion is based on the National Asthma Education and Prevention Program’s Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma.
- Extreme temperature changes during the winter can wreak havoc on patients with asthma. Inhaling cold air, especially during physical exertion, can cause drying of the airway and bronchospasm in patients with asthma.
- This can result in dangerous episodes of coughing and shortness of breath. Often symptoms occur minutes after exposure.
Patients may recognize that coughing and shortness of breath are a result of exposure to cold air. However, they may not understand that there are ways for them to reduce these adverse reactions to the cold.
Educate your patients about ways to deal with their asthma in cold weather.
- Teach your patients to shield themselves from the cold air with a scarf, turtleneck, or jacket collar. Covering one’s mouth (and nose when possible) with a scarf will help to warm the inhaled air. Warming up before exercise and cooling down for at least 10 minutes after heavy exercise by walking or stretching can also help.
- Every use one of these for outdoor activity when it’s cold?
Most important, as their physician, explain the proper use of medication. All patients with persistent asthma (patients having any asthma-related nighttime awakenings or having daytime symptoms more than twice a week) should be on a controller medication, usually an inhaled corticosteroid. These should be taken daily, not just as needed.
The controller medication can be supplemented by the use of a short-acting beta-2 agonist inhaler before any outdoor activity in cold weather. It is better, however, to control the underlying airway inflammation and reactivity with a controller medication.
And remember: This is the time of year to give your patients a flu shot. It’s not too late even in March. People with asthma are more likely to have serious health problems from getting the flu, yet most people with asthma don’t receive a flu shot every year. Flu vaccine is the first and most important step they can take to protect themselves from the flu.
Finally, the goal of good asthma care is for your patients to be able to enjoy life with as few symptoms as possible. Partnering with your patients through scheduled follow-up care can achieve that goal. Schedule regular follow-up visits. Assess control at each visit, beginning with a standardized questionnaire. Review the patient’s written Asthma Action Plan at each visit. Ask about asthma triggers and help your patients reduce or eliminate them. Review medications and be sure your patients understand how and when to use them.
I have just returned from the Annual Meeting of the American College of Allergy, Asthma, and Immunology held in Boston from Nov 3-8. Sure the meeting was good, but the food was even better. Consider the oldest “active” restaurant in America, Union Oyster House–the stew was delightful and if you’re bored with allergies, peruse the menu on-line and dream of dining with JFK (he has a booth in his name there).
On to what’s new in allergy & asthma….
Smoking bans in Tulsa have stirred some vigorous debate this year (see link). Most importantly, do they work? Information presented last week would suggest a resounding YES! In the U.S. more than 200,000 asthma admissions per year are attributed to Environmental Tobacco Smoke (ETS). Smoking bans can prevent this complication! The Scottish health system has the database to measure the effects of a community-wide smoking ban and their intervention was associated with an 18% reduction in hospital admissions for asthma (NEJM 2010). Wow
If you have to smoke inside, HEPA filters reduced asthma visits in 6-12-year-old children by 18%.
I have a post on this blog describing VCD or paradoxical vocal cord motion. Our terminology is now changing and instead of VCD, I like the term” irritable larnyx syndrome (WILS).” The vocal cords are “housed” in the larynx and many structures and muscles have to work correctly in order for the vocal cords to allow air in and out of the lungs. This implies that multiple triggers will cause an attack and patients with difficult asthma may have a laryngeal dysfunction not just VCD. If you don’t believe me, look at this study. World-wide recognition (AJRCCM, a study from Australia).
Way too many choices in the treatment of asthma! Why would you consider Tiotropium or Spiriva for asthma?
1. Tiotropium works as step-up therapy in adult asthma. Some patients just can’t tolerate albuterol or Xopenex™ because of tremor and other side effects. Now you have an alternative: There were similar improvements in lung function and symptom-free days with Spiriva as adding long acting bronchodilator (NEJM 2011).
2. Tiotropium does fit into the Asthma Guidelines (2007) and works better than increasing the dose of inhaled steroids (yea, less steroids) and is equal to salmeterol (Serevent).
3. This report is from England, so BEWARE! The Respimat inhaler isn’t used in the United States and should you read about this study, it doesn’t apply to patients in the US. (Recent BMJ meta-analysis showed increased cardiovascular mortality with that formulation in COPD) (BMJ, 2011).Anti IL-13 (lebrikuzumab)–Did you say leprechaun?
There is one take home message with the use of lebrikuzumab:
1. Personalized medicine is here! In this study, patients that improved with anti IL-13 also had elevated levels of periostin in blood tests. Periostin is a marker of airway remodelling and gives us a clue as to why and how IL-13 contributes to asthma. Lebrikizumab improved FEV1, but there was no improvement in symptoms or medication use (NEJM 2011).
This comes from the literature review at the College meeting—1 of every 6 children with asthma seen the ED are prescribed antibiotics. Don’t you think this is high for a “practice” that is supposed to be very selective in who gets antibiotics? Generally, antibiotics are not helpful in asthma anyway. More than 2 courses of antibiotics for cough in a 6-month time frame should warrant consideration of asthma as a cause (Pediatrics, 2011).
In a study in Arizona, Fernandez et al. showed skin testing to Alternaria to be surprisingly accurate. Ninety-six percent of patients with a positive skin test to this mold had a positive bronchial provocation test with Alternaria. In Arizona, Alternaria has surpassed dust mite as number one allergen in asthma (due to dry climate). I wonder what results would be in Oklahoma? Here’s what alternaria looks like:
Come on now, do allergy shots REALLY work? Shots with dust mite allowed for inhaled steroid reduction by 50% in children with asthma vs. 30% in controls. Not bad! Do I have to take my medication with shots? Adding dust mite shots to pharmacologic treatment was an effective and safe strategy to reduce corticosteroid doses while maintaining disease control in children with mite-induced allergic asthma (JACI 2011).
Which inhaled steroid to use? Does it matter? QVAR™ & Alvesco™ have said for quite some time that small particles penetrate the airways of an asthmatic better than the competition. They may be right– small particle size inhaled steroids may allow for equal efficacy (benefit) with 1/2 to 1/3 the dose of a larger size of same steroid. Marketing isn’t bad, sometimes it’s just delayed results.
SABA update: Levalbuterol (Xopenex™) may not have any real-life advantages over albuterol. Even in the Xopenex™ package insert, there is mention that there was no difference in heart rate or tremor. In patients who swear by Xopenex™, there’s no reason to change, just start out with cheaper albuterol.
Antihistamines for asthma?
Many patients take antihistamines every day like vitamins. They feel better if an antihistamine is “on-board.” Once again, learn from your patient….they will often give you clues to what medications work. Symptom scores in asthma patients show comparable improvement when given desloratadine (antihistamine) compared to montelukast. Use of antihistamine may prevent the development of asthma in some predisposed children. Well I’ll be….
Asthma in the elderly
The majority of asthma deaths are in patients older than 65.
Asthma in adults/elderly is still predominantly an atopic disease. This means, it’s still due to allergy. Don’t forget to test your older population. In a University of Michigan study, 77% of adult asthma patients were skin test positive.
Depression is definitely underdiagnosed in our loved ones who have retired (ie, grandma & grandpa). Why? They should have a carefree life during retirement, but they don’t. Depression is a significant factor for poor asthma quality of life in the elderly. You are 10x more likely to suffer from psychological dysfunction if you have more than 3 exacerbation of asthma in a single year.
Just goes to show you that allergic respiratory disease is a very complicated condition and every year I’m challenged with new treatments! I can’t ask for anything more.
As physicians, we have the unpleasant task of learning the differential diagnosis for the diseases we treat. Patients don’t understand it, I have unpleasant memories of using it during rounds as an intern, but this exercise can be helpful for patient care and will keep us out of trouble! Not everything that wheezes is asthma–what are some danger signals that I
might want to modify my original diagnosis of asthma?
Asthma invariably causes symptoms during exercise. If your patient has no symptoms (pre-treatment) during exercise, rethink your asthma diagnosis. How about wheezing at night? Same story…no nocturnal symptoms, not likely to be asthma. Finally, response to therapy is a good clue if co-morbidity is contributing to persistent symptoms. For instance, I prescribe combination therapy (LABA/ICS), yet no improvement in wheezing. Only the most severe asthma patient will not respond to this treatment & I’d start down the path of an alternative diagnosis.
So what is the list for differential diagnosis of wheezing, coughing and suspected asthma? I’ll include links where I have some level of expertise :)
1. Left ventricular failure, mitral stenosis–I love cardiology consults! Pedal edema with dyspnea is a red flag even if they’re in your office for “asthma.”
2. Bronchiectasis, cystic fibrosis. Sweat chloride or genetic testing will suffice for CF, but bronchiectasis is often missed during the evaluation for asthma. High resolution CT of chest is the study of choice….
3. Paradoxical vocal cord motion–This one I have to tell you can stump providers even if asthma is present. The best link for this is American Academy of Allergy.
4. GERD or recurrent aspiration
5. Chronic obstructive pulmonary disease (COPD)–don’t forget about the use of Daliresp™ (500mcg/day)
6. α-1 antitrypsin deficiency–Yes this is rare, but treatment is available and diagnosis is as easy as three drops of blood on a postcard!
7. Interstitial lung disease or hypersensitivity pneumonitis–Again, high-resolution CT of chest is very helpful in this scenario…it’s worth fighting insurance to get the study approved.
8. Allergic Bronchopulmonary Aspergillosis (ABPA)–These are usually patients dependent on corticosteroids to breathe. Check total IgE & with ABPA, values are usually >1,000.
9. Pulmonary embolism–usually shows up in the ER, but you never know.
10. Laryngotracheomalacia–If you cough more when upset or crying with a “barky” cough, think tracheomalacia. Usually present before one year of age. Stridor may not always be present. This video is quite informative.
11. Airway neoplasm, foreign body. Found a peanut, found a peanut…..unilateral wheezing is always a concern here. Must keep a high index of suspicion even if there is no history of choking.
12. Rhinosinusitis–Even if it is asthma, sinusitis is ALWAYS a trigger for asthma flares. Don’t bother with plain sinus x-rays…false negative rate can be as high as 30-40%.
13. Churg-Strauss vasculitis or Hyper-Eosinophilic Syndrome–I won’t say more, just go to the link.
What in the world is Vocal Cord Dysfunction? Don’t believe your vocal cords can cause problems with your breathing–just look at this video!
Vocal Cord Dysfunction (VCD) occurs when the vocal cords (voice box) do not open correctly. This disorder is also referred to as paradoxical vocal fold movement or spasmodic dysphonia.
VCD is sometimes confused with asthma because some of the symptoms are similar.
In asthma, the airways (bronchial tubes) tighten, making breathing difficult. With VCD, the vocal cord muscles tighten, which also makes breathing difficult. Unlike asthma, skin testing is often negative with VCD.
To add to the confusion, many people with asthma also have VCD.
Although the two may have similar triggers and symptoms, the treatment approach for VCD is very different from treatments used to manage and control asthma. This makes proper diagnosis essential.
You will need specialized training and experience in the diagnosis, treatment and management of complex conditions such as asthma and VCD–please follow this link for more information (Vocal Cords)