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.
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?
Inspiratory/expiratory muscle trainer–see this very good video:
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:
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.
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).
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.
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)
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!