Tag Archives: Spirometry

What’s important about Asthma?

If you’re like me, your schedule can’t take another committment–how can you add one more task for asthma?  Don’t neglect treatment for your asthma as proper attention now will save you time & money in the end.  Anyone remember the Fram oil filter commercial….”you can pay me now or pay me later?”  We’ll help you focus on what needs to be done everyday and which tasks are to be used just when needed. 

But first, how does asthma really work and why do I have it?  Review this link for “real time” photos!

 What is my hope for you by using these techniques?

1.  More activity without wheezing, coughing, or becoming short of breath

2.  No unscheduled office visits or Urgent care/emergency room visits for asthma flares

3.  Preserve your lung function for your retirement…we all love being active with our grandkids!

4.  Get you on the cheapest medicines available to prevent asthma.

So what’s most important in treatment of your asthma to avoid the top box?

1.  Get a written Asthma Action Plan…if we don’t bring it up, ask.

2.  Review your inhaler use like you would an oil change–every 3 months.  Which medicines are “everyday” and which ones are just “as needed?”

3.  Peak flow meter.  Use for 1-2 weeks as a baseline and thereafter like a thermometer for your asthma. 

Need extra help:  Click on the link to the American Academy of Allergy (AAAAI)

The More You Know, the Less You Know

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.

JAMA. 2012;307:373-381, 406-407.

Study Highlights

  • 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.

Clinical Implications

  • 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. 

Full reference on the dangers of PPI medications

Breathing Retraining in Asthma Management–I told you so!

Many asthma patients or patients who can’t breathe are found to have problems with their breathing technique.  In medical terms, I use Vocal Cord Dysfunction, Spasmodic Dysphonia, Irritable Larnyx Syndrome just to name a few.  Some health care providers, including doctors, aren’t always familiar with the concept that vocal cord problems can cause difficulty breathing, but this 40+ page review should convince you otherwise. This is an informative video about problems that affect many asthma patients & isn’t directly related to the lungs at all–

Now I’m not condoning the use of “breathing exercises” to treat asthma, but remember that up to 40% of asthma patients have problems with their vocal cords.  What does this translate to:

  •  Underdiagnosis of vocal cord problems
  • Lack of follow-up when inhalers don’t completely resolve asthma symptoms

 Thanks to Dr Burgess & colleagues, I am beginning to see extensive medical reviews on breathing exercises for asthma that will most likely apply to vocal cord problems as well.  Burgess, et al.  Published in Expert Rev Resp Med. 2011;5(6):789-807)

In asthma management, complementary and alternative medicine is enjoying a growing popularity worldwide. This review synthesizes the literature on complementary and alternative medicine techniques that utilize breathing retraining as their primary component and compares evidence from controlled trials with before-and-after trials. Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library electronic databases were searched.  Breathing retraining, a popular form of complementary and alternative medicine (CAM), is the subject of this review.  You can read the entire article if you would like–don’t count on staying awake for the entire article! 

What do breathing modification techniques do for asthma:

  • Demonstrate a significant decrease in β2-agonist use
  • Improvement in quality of life
  • Decrease in inhaled corticosteroid use
  •  No between-group differences in forced expiratory volume  (FEV1) or provocation dose needed to cause a 20% fall in FEV1 for methacholine  (PD20)

 It is reasonable for clinicians to offer qualified support to patients with asthma undertaking these breathing retraining techniques.

What are these techniques?

  • Diaphragmatic breathing
  • Inspiratory/expiratory muscle trainer–see this very good video: 
  • The Buteyko technique
  • There was some evidence that beneficial effects declined with time if breathing techniques were not maintained.

Weiner et al., in three separate controlled trials, found that specific inspiratory muscle training using either an externally weighted device or a purpose-designed threshold inspiratory muscle trainer (HealthScan; NJ, USA) compared with ‘sham’ muscle training significantly increased inspiratory muscle strength as measured by maximal inspiratory mouth pressure at residual volume (PImax at residual volume). Whew what a mouthful!

The most recent of these studies that compared female to male asthmatics found that using the same training method to allow females to attain a PImax equal to that of males resulted in a significant and highly correlated decrease in both dyspnea score and medication use in the active intervention group only.  

Here’s a video on some very simple breathing exercises one can do for VCD:

VCD training

I am now beginning to use “The Breather” for both inspiratory/expiratory muscle training in patients with “Irritable Larnyx” syndrome who also have asthma.  Early success only means it warrants further examination of this technique by well-designed clinical studies–any volunteers? 

These techniques will not replace asthma medication or a carefully designed asthma plan, but their use should not be dismissed out of hand, especially in patients with throat problems along with their asthma.  Further well-designed trials of these techniques are needed to properly evaluate their place in asthma management.

Interesting case last week!

Here’s something you never want your doctor to say–interesting!  That usually means something is bad for you, but good for a teaching case.  Last week was no exception. 

 I won’t mention any names for privacy, but this teenage boy was having problems.  Everytime his lung capacity dropped below 60%, here came the steroids.  No cough, no wheeze, no attack….just steroids. What’s going on? Examination revealed the answer.  This patient has pectus excavatum (see below) that reduced his lung function because of a MECHANICAL problem, not asthma per se. 

One of many variations of pectus

The worse your deformity, the lower your lung function. The objectives and conclusion of this story are listed below.     J Pediatr. 2011 Aug;159(2):256-61.e2. Epub 2011 Mar 22.

Increasing severity of pectus excavatum is associated with reduced pulmonary function.

OBJECTIVE:

To determine whether pulmonary function decreases as a function of severity of pectus excavatum, and whether reduced function is restrictive or obstructive in nature in a large multicenter study.

CONCLUSIONS:

Among patients presenting for surgical repair of pectus excavatum, those with more severe deformities have a much higher likelihood of decreased pulmonary function with a restrictive pulmonary pattern.

Do you want pictures?  In English please!  The case report below means that if you have pectus excavatum, with any stress on the lungs (carrying weights, running, an infection) you are likely to experience a greater drop in your lung function than patients without the deformity. 

 J Med Case Reports. 2011 Dec 21;5(1):592.

Pectus on the right with lower lung function.

Objective effect manifestation of pectus excavatum on load-stressed pulmonary function testing: a case report.

CONCLUSION:

This report highlights the possible detrimental synergism of thoracic load stress and pectus excavatum on cardiopulmonary function. Thoracic load-stressed pulmonary function testing provides objective evidence in support of such a synergistic relationship.

Thus, our “mystery” patient is solved.  Because of the pectus deformity, he is more at risk for a low FEV1 with any cold or upper respiratory illness. And now you know the rest of the story….