When it comes to asthma, it’s not easy fighting the myths of Facebook, Google, or e-mail campaigns. And why are we so resistant to the diagnosis of asthma for our kids and ourselves? For asthma, if you don’t make the correct diagnosis, you’ll never implement the proper treatment. By that I mean, you’re not likely to use prevention, but instead will wait for an asthma attack and then rush in to treat the symptoms. Health care providers are responsible for this phenomenon just as much as patients. Go to any emergency room or urgent care with an asthma attack and you’re likely to receive steroids, antibiotics and the admonition to “see your primary care doctor”. The problem is that patients feel better after steroids and guess what? they never seek medical attention for the prevention of #asthma. After practicing asthma medicine for over 25 years, consider the following reasons for why our asthma treatment often fails to meet the “standard of care” according to published #asthma research:
Asthma attacks don’t happen all at once. If I can get through an asthma attack in September, what’s the big deal of one course of steroids per year? This paroxysmal nature of asthma makes proper treatment very difficult because we tend to have a very short memory about our last asthma attack.
As a general rule, we all resist preventive care. Do you miss a regular dental floss or exercise session? As difficult as it seems to continue with good preventive care, think how much more difficult it is to take an inhaler everyday to prevent asthma! Antibiotics are so successful after 10-14 days that we can stop therapy and recover back to our original health. Asthma isn’t the same disease process and many times one attack leads to never ending asthma.
Can I get over asthma? The short answer is usually not. Asthma is a disease of inflammation which means the airways over react to allergy, infections, or irritation. In short, this means lungs with asthma are forever inundated with “triggers” that cause wheezing, coughing, and typical asthma symptoms. If you don’t use preventive inhalers for the next attack, you can be assured it will come.
I for one am tired how my health score is tied to my existence as a person rather than who I really am. “How to keep up your credit score, what income bracket I’m in, what’s my IQ” are nagging reminders that I may not be anything more than just a number and not a unique person on this planet. Health care is fast approaching this same pigeonhole similar to banks and retailers, but it’s not all bad. Ever heard of personalized medicine?
#Personalized medicine has some pretty awesome benefits on the horizon, but “what’s the catch?” My cholesterol has to be below 120, cigarettes at zero, and my daily cups of coffee can’t be over 5 if I have any hope of living past 80;you just can’t get away from numbers.
According to Wikipedia, Personalized medicine, also termed precision medicine, is a medical procedure that separates patients into different groups—with medical decisions, practices, interventions and/or products being tailored to the individual patient based on their predicted response or risk of disease. So if numbers and health are an integral part of the future of health care, is there such a thing as an allergy or asthma number? Wouldn’t it be nice to find out which asthma inhaler is best for you based on “personalized medicine?” Or what if you suffer from chronic hives and can’t find the cause? Personalized medicine involves many more diseases that just asthma and allergy–just look at the link below, but I have a list as well. Continue reading Something about numbers→
Ever notice how everyone has #allergies these days? I kid you not, almost everyday, a patient will tell me that #Tulsa (where I practice) has more allergies than any other place in the country. The irony of it all, is so did patients in Kansas, and patients say the same thing in Virginia and Texas. You get my point–we all love to be known as the Allergy Capital of the World!Maybe it’s because allergies make us feel so miserable, and we love to hear stories about how to deal with the nemesis. Or maybe we want some “inside information” to share with our friends & family who also suffer from allergy. Whatever the reason for our obsession with allergy, you can’t argue with the fact that good allergy advise is not only helpful for better quality of life, but it’s crucial in making sure that allergy sufferers avoid heeding the WRONG advice for treating #hay fever. This is the passion I experienced in order to complete a fellowship training in allergy– I wanted to be able to interact with patients about their #allergic symptoms on their journey to good health. But wait, why practice a specialty that has so much incorrect information on-line and no doubt, “everyone’s an expert in allergy” when you could be doing real medicine to treat someone’s heart attack? Here are four reasons I still practice allergy for your consideration:Continue reading Four reasons I still practice Allergy in the Information Age→
I know you’ve been there before….waiting in the doctor’s office for your appointment and some smartly dressed man or woman barely has to say hello to the receptionist and walks right by your seat, straight to the doctor’s office. “Hey, that’s not fair,” you say to yourself as you dig your nose into that outdated magazine trying to mask the irritation. “My time is just as valuable as theirs is, put me to the front of the line!” As a patient, my frustration with the #health care system only percolates at the injustice. Isn’t the cost of #medication so high in America because of all the drug companies? If there were no drug reps, wouldn’t my doctor have a better and certainly more unbiased selection of medications? Granted, the goal of any #pharmaceutical company (employer of drug reps) is to make profit, but they can’t do that unless a product (medication) works well and is taken as directed. In the end, drug companies want you to be adherent to medications prescribed so they’ll work, you get better, all of which is good for the bottom line. Almost sounds too good to be true when everybody wins, but hang on and I’ll show you how this is possible. Continue reading Drug Reps Will Give You Asthma→
At first glance, I thought to myself, do we really need another quick acting inhaler? As I thought about inhaler technique and how we use our Ventolin MDI’s, most of use suck on the end of the inhaler which is the wrong technique to use. (all of the medication deposits on the back of the throat) Why not use the appropriate inhaler that’s meant to actuate with your breath anyway? ie, sucking on the inhaler is what you’re supposed to do!
If you have asthma, certain things can cause you to have an asthma attack. These triggers include things like cigarette smoke, pollen or air pollution, cold air, mold, animals, and dust. To help control your asthma, stay clear of these triggers.
Also, learn how to spot the early signs of an asthma attack. When you know the signs, you can stay in control. Early signs can be different for each person, but here are common ones:
A long lasting cough
Chest tightness or discomfort
Becoming out of breath more easily than usual
Frequent clearing of the throat
A written asthma action plan spells out how to use your drugs. If you don’t have a written asthma action plan, ask your doctor for one.
Remember: If you don’t have a written asthma action plan, ask your doctor for one.
Sinus pressure can be a real problem during the cold, winter months. Do I take decongestants or antihistamines? Sudafed or Zyrtec? Are my allergies acting up?
Here are some pointers on dealing with sinus infectionsand sinus pressure with some really cool slides at the end:
Most allergens are gone in December-January, so the statement “my allergies are bothering me” is actually misplaced. You are meaning to say that sinus pressure is causing congestion and runny nose. Inflammation and swelling definitely exist in your sinuses, it’s just that your symptoms during the winter are not caused by allergy, but rather sinus infection.
Treatment of a sinus infection is “all or nothing”. In other words, if you only remove 50% of the infection, it is likely your symptoms will quickly recur. Your body requires a mucociliary blanket in the sinuses to gradually remove bacteria and excessive snot. This protective blanket is destroyed during any infection, and won’t grow back until the inflammation subsides. Often it takes 30 days of antibiotics and prednisone to restore the sinuses back to their original condition.
One of the pictures in your slide set (slide 3 of 15) shows what normal mucociliary blanket looks like under the microscope. If this giant vacuum sweeper was operating normally all of the time, you wouldn’t have to use all your medication.
Make sure you eliminate nasal congestion. For the short term, use Afrin or similar equivalent (OTC) if you limit to < 1 week per month. This allows the nasal airflow to drive away the excessive mucous in your nose which would otherwise become a great meal for hungry bacteria. Sick but true!
Find out if you have allergy! The winter season gives you a reprieve from outdoor allergens, but during the spring, summer, and fall, tree pollen, Bermuda grass, and ragweed are more than willing to invade your sinuses and cause irreparable damage to your mucous membranes and make you always sick.
Use your prescribed nasal spray EVERYDAY as prescribed by your doctor. I know, Americans hate to put anything in their nose (except your finger), but regular use of nasal steroids and antihistamines will reduce the swelling in your sinuses and guess what? You got it, fewer infections.
Get smart! Go through the slides below, and if you don’t learn anything new, I’ll buy your favorite drink at Starbucks.
Europe and the United States differ on many things including how we look at war and how often we pick our noses…yes it’s true about rhinotillexomania (nose picking). Perhaps this is why Europeans will reach for a nose spray FIRST to treat allergies and then go for antihistamines. Yes, there’s even a Dr Oz video on the subject: http://www.oprah.com/oprahshow/Dr-Oz-on-Health-and-Hygiene
So what is the point of all this nonsense? Treatment of asthma also differs between the United States and Europe.
The Misuse of Asthma Drugs
Gene L Colice Expert Rev Resp Med. 2013;7(3):307-320.
There are three major problems with asthma care in the USA today and misuse of asthma drugs contributes to each.
First, multiple sources document that symptom control of most Americans with asthma in the general population does not meet standards established in the National Asthma Education and Prevention Program Expert Panel Report III (EPR3). In the CHOICE survey, 1000 patients with asthma randomly chosen across the USA were asked about their care and burden of disease. Almost half of these patients (49%) reported that they did not use asthma controller medications, although 79% had evidence of persistent disease. Of the 51% of the patients reporting the use of asthma controller medications in this survey, 85.7% had not well controlled or very poorly controlled disease. Numerous previous surveys of asthma patients in the USA and Europe, using either telephone interviews or questionnaires, have reported similarly high levels of uncontrolled disease. In the Exercise-Induced Bronchospasm Landmark Survey, 78.8% of the children with asthma and 83% of adults with asthma described respiratory symptoms with exercise. Children and adults with asthma commonly described being limited in their ability to perform sports and outdoor activities by their disease in this survey.
I know most patients would like to stop their asthma medications ASAP, but it comes at the cost of losing asthma control. I’ve previously discussed when to stop asthma medications…I’d like to know what you think? Are doctors prescribing unneccesary medications?
Second, in addition to difficulties with symptom control on a daily basis, patients with asthma in the USA frequently suffer exacerbations.
In the CHOICE survey, 5% of the patients reported being hospitalized and 14.4% described either an emergency department (ED) or urgent outpatient visit for an asthma exacerbation in the past year. Patients interviewed in this survey with more severe, persistent or uncontrolled asthma were more likely to have suffered asthma exacerbations. Previous surveys have reported similarly high rates of asthma exacerbations resulting in ED visits and hospitalizations. Data from the US CDC confirm that nationwide rates of ED visits and hospitalizations for asthma exacerbations remain unacceptably high.
So what are parents to do? The choice between giving your child steroids and having to rush to the emergency room for an asthma flare can be a “no win” proposition.
Third, asthma is an expensive disease.
The CDC has recently estimated that asthma costs the US economy approximately US$56 billion annually. On average, an asthma patient has been calculated to generate approximately US$2000–$4000 more in healthcare costs per year than a nonasthma control patient. Indirect costs due to work loss, school absenteeism, reduced productivity and so on, further contribute to the economic impact of asthma. Healthcare costs of asthma increase in patients with more severe disease. In patients with moderate and severe persistent asthma, exacerbations will further substantially increase healthcare costs.
I know the most common reason that patients stop their medication is simple: medications are too expensive. Here are some tips to reduce the cost of your prescribed medications for asthma:
Make sure the medications you are picking up at your pharmacy are needed year round. Some patients need asthma inhalers only during the cold winter months.
Monitor your symptoms with a peak flow meter and pay attention to how much exercise you can do, and how well you sleep. Both of these indicators will tell you several days in advance if your asthma is flaring.
Use coupons for your inhalers. In years past, pharmacy reps would leave samples for us to hand out to get patients started on asthma prevention. This is no longer the case because of health care reform. But….coupons are available for a similar value. Just don’t forget to take the coupon in to your pharmacist when you pick up your inhaler.
In summary, having reviewed the data, the EPR3 predisposes to under treatment of asthma. The tendency is for healthcare providers to underestimate asthma severity and to correspondingly undertreat the disease. In most asthma patients, the result will be persistent asthma symptoms. In important subsets of asthma patients, particularly smokers, the efficacy of ICS seems impaired. For a given categorization of asthma severity (even if accurately calculated by the healthcare provider), the corresponding recommended treatment with ICS in the EPR3 might be insufficient in smoking and obese asthma patients. Again, the consequence will be persistent asthma symptoms. Asthma tragedies occur all the time…let’s make sure it doesn’t happen to someone you know!
What’s medicine and what’s just candy! Read on to find out. My own personal thought is many patients with vocal cord dysfunction (VCD) respond to vocal hydration which can occur while sucking on a cough drop/candy. Maybe we’ve been treating VCD all along with HALLs! Stranger things have happened.
An apple a day might keep the doctor away, but what is modern hospital medicine really like? Follow Dr. Benjamin Kirkland - a Doctor working in Australia - through the pinnacles and pitfalls of everyday hospital medicine!