Asthma:

Background – Asthma patients experience reversible obstruction of the airways that makes it difficult to breathe and causes additional symptoms, such as coughing, chest tightness/heaviness and wheezing. If affects over 300 million people globally. There are several types of asthma. They include allergic asthma, exercise induced asthma, occupational asthma, neutrophilic asthma, eosinophilic asthma, aspirin induced asthma, non-allergic asthma, cough variant asthma, asthma-COPD overlap syndrome (ACOS) and infectious asthma. Each type has differences, which may require different testing and therapy. Many asthma sufferers also have allergies and experience a type of asthma known as allergic asthma. Sometimes, otherwise healthy individuals will experience asthma during exercise, which is known as exercise-induced bronchoconstriction or, more commonly, as exercise-induced asthma. Those who work in environments that contain fumes, gases, and other substances that affect respiration can also experience what is known as occupational asthma. Finally, millions of children develop asthma in their earliest years of development and have what is referred to as childhood asthma. Asthma symptoms can occur daily, weekly or infrequently, and can range from mild to severe. Many of these symptoms can be very frightening to people with asthma as well as their families. It is extremely important to seek medical attention for this illness.

How it works/Pathophysiology – Exposure to triggers such as pollen or exercise produce an inflammatory cascade that causes airways in both lungs to constrict or tighten. This impedes the flow of air and causes wheezing, coughing, and or chest tightness/heaviness. 

Symptoms:

• Wheezing
• Shortness of breath
• Chronic coughing
• Inability to sleep due to wheezing and coughing
• Tightening or heaviness in the chest
• Poor exercise tolerance; fatigued easily with exertion

Self-Treatment Tips  – 

• Limit your exposure to seasonal allergens
• Keep up with your local pollen counts whenever you check the weather
• Limit outdoor activities during times of high pollen counts
• Breathing Exercises
• Exercise at least 4 times per week
• Wear protective wear such as face masks during times of high environmental particulate matter
• Limit exposures to known triggers
• Keep windows closed during high pollen and mold seasons
• Steam clean carpets or remove carpets
• Vacuum with a HEPA filter to reduce dust in your home
• Wash your bed linens and pillowcases in hot water and detergent frequently 
• Use HEPA Air Purifiers in the house (small size 200 sq ft, medium size 200-400 sq ft, large size 400-1500 sq ft) 

Diagnostic Testing – Spirometry consists of measuring lung volumes by having patients take deep breaths in and out that is detected by a sensor. The data is compared to normal values based on race, gender and ht/wt. The allergy provider reviews the data and will determine if there is airway obstruction and its severity. 

Fractionated Exhaled Nitric oxide testing consists of measuring the amount of exhaled nitric oxide. It is a surrogate marker for airway inflammation and can assist with diagnosing asthma, asthma control or assessing for asthma flares. It can also be used in leu of spirometry for patients who cannot perform the spirometry testing.

Aeroallergen Skin testing consist of pricking the arms and/or back with up to 48 of the most common aeroallergens in Texas. 20 minutes later, the wheel and flare of the prick site is measured, and the allergy provider will discuss the results and overall interpretation.  

In -Vitro Aeroallergen testing consist of whole blood draw at a local lab for which the whole blood is analyzed for the IgE antibody to 48 of the most common aeroallergens in TX. About 1.5 wks later, the allergy provider will discuss the results and overall interpretation. 

In -Vitro testing consist of whole blood draw at a local lab for which the whole blood is analyzed for the IgE antibody to 48 of the most common aeroallergens in TX. Also, a complete blood count is derived which can shed light on the type of asthma involved. About 1.5 wks later, the allergy provider will discuss the results and overall interpretation.

Therapies

Rescue Inhalers – Rescue Inhalers provide quick relief of sudden symptoms. Rescue medications start to alleviate the symptoms of asthma within a few minutes by relaxing the muscle spasms within the airways. The most prescribed medication for rescue of asthma symptoms is albuterol, or a related medication called levalbuterol. The rescue medications can be administered via an inhaler or aerosolized with a nebulizer. Typically, these medications can be given every 4 to 6 hours as needed. Trade names for rescue medications include ProAir HFA, Proventil HFA, Ventolin HFA and Xopenex HFA. For children, their rescue inhaler is often used with a device called a spacer. This device helps children inhale the medication into the lungs to alleviate symptoms of asthma.

Controller Inhalers – Controller inhalers provide long-term control of asthma and prevent future symptoms. They work by reducing the remodeling effects on the lungs by inflammation. They can also provide short term therapy especially during flare. Your allergy provider will determine if the frequency and severity of your or your child’s symptoms require the use of a maintenance medication. All the controller medications work by reducing the inflammation in the airways. By reducing swelling, the lungs are stronger, and a patient is much less likely to have asthma symptoms.

Aeroallergy Immunotherapy (Allergy shots) – Allergy shots or AIT are subcutaneous injections of a small amounts of the specific aeroallergen(s) that you are allergic to. It is just enough to stimulate your immune system in order to desensitize your body over time, which causes your allergy sxs to diminish over time. It is up to 85% effective. Patients who are part of the effective group will first notice improvement within the first 4-8 months of therapy. It will continue to improve. Studies show that most patients will need to be on the maintenance phase of AIT for at least (3-5) years in order to obtain long lasting benefit. AIT is conducted in (2) phases. The buildup phase for routine AIT will require a shot 2 times a week for the first (8) weeks in most cases. The maintenance phase requires an AIT shot once every (2-4) weeks thereafter in most cases. The overall rate of adverse reactions for AIT in most large, validated studies is <1%.  For patients with lifestyle and schedule conflicts we also offer Cluster and Rush buildups, which enables faster time to the maintenance phase in 4 wks or less.  Patients must be observed in the clinic for at least (30) minutes after each shot. Allergy shots are administered on a “walk in” basis during normal business hours, so there is no need for an appointment.

Sublingual Aeroallergen Immunotherapy (Allergy tabs) – Treatment typically takes 3-5 years but can vary based on allergy type and patient adherence. The tablets are small amounts of the specific aeroallergen that you are allergic to. Currently, there are tablets FDA approved just for dust mites, grass (Timothy and 5-grasses), and ragweed. It is just enough to stimulate your immune system in order to desensitize your body over time, which causes your allergy sxs to diminish over time. It is around 70-75% effective. The side effect profile is less than AIT. Pt’s will take the first dose in the clinic and at home thereafter. The tablets for grass are started (12) wks before summer. The tablets are usually taken daily for at least (3) years to obtain a long-lasting effect.

Sublingual Aeroallergen Immunotherapy (Allergy drops) – Allergy drops work like allergy shots by gradually helping your body build tolerance to the antigens or substance(s) that cause your allergies. The difference is that the antigen is placed under your tongue in a pain-free, liquid drop customized to your aero allergy profile. It is also nearly as effective as the shots and are safer. This form of immunotherapy is self-administered by patients. It is convenient for patients who don’t like needles, have time to come into the allergy clinic for a shot and or like to manage their own care in the convenience of their home or while traveling. Allergy drops are also very affordable. Please see the pricing tab for more information.

Xolair (Omalizumab) – Xolair is a humanized monoclonal antibody that is administered by subcutaneous injection every 2 wks. It works by preventing the “allergy” inflammatory by binding free IgE antibodies (this is the antibody that triggers allergies) and by blocking certain receptors on inflammatory cells (i.e mast cells, basophils). This decreases the frequency and severity of asthma symptoms. It is indicated for allergic asthmatics who are not controlled with standard asthma medications.  Xolair is very effective and has a relatively small adverse effect profile. 

Dupixent (Dupilumab) – Dupixent is a human monoclonal antibody that works by blocking interleukin-4 (IL-4) and interleukin-13 (IL-13), two proteins that are responsible for allergic inflammation in asthma. Dupixent is given as a subcutaneous injection every 2 weeks. It is indicated for patients with eosinophilic asthma and or those who are uncontrolled. It is very effective and has a small adverse effect profile. 

Fasenra (Benralizumab) – Fasenra is a humanized monoclonal antibody that is administered by subcutaneous injection every 8 wks. It works by directly binding to eosinophils and eventually eradicating them. It is indicated for eosinophilic asthmatics.

Nucala (Mepolizumab) – Nucala is a humanized monoclonal antibody that is administered by subcutaneous injection every 4 wks. It is indicated for patients with eosinophilic asthma. It works by disrupting inflammatory signaling for eosinophils and eventually renders them ineffective. 

Tezspire (Tezepelumab-Ekko) – Tezspire is a human monoclonal antibody that works by blocking thymic stromal lymphopoietin (TSLP) which is an early phase signal that plays a big part inflammatory cell mobilization. Tezspire is given as a subcutaneous injection every 4 wks. It is indicated for any asthmatics who are uncontrolled with standard therapy.

Chronic Obstructive Pulmonary Disease (COPD):  

Background – COPD is a chronic obstructive lung disease that is most associated with significant smoking history. It can be due to direct or indirect (second hand) smoke exposure. COPD can also develop as a result of exposure to fumes from burnt fuel in poorly ventilated homes or chemicals such as fertilizers, paints/oils, and hair products. Patients with asthma are also at risk of developing COPD. Asthma patients who smoke are at an even higher risk of developing the condition. Patients with asthma and COPD have what is known as Asthma COPD Overlap Syndrome, or ACO. Most patients do not experience severe symptoms until after significant damage to the lungs has already occurred. Those with COPD may experience acute episodes of increased symptoms known as ‘exacerbations.’

How it works/Pathophysiology – Chronic exposure to cigarette smoke (directly or second hand), environmental pollution or occupational exposures to fumes, dust, and vapors lead to constant inflammation of the airways that waxes and wanes. Over time, the airways become thickened from the chronic inflammation. The airways become constricted and tight. This impedes the flow of air and causes wheezing, coughing, and or chest tightness. This can also lead to cardiac problems since the heart and lungs are physiologically connected.

Symptoms:

• Shortness of breath, most commonly during physical exertion
• Wheezing when breathing
• Chest tightness or heaviness
• A chronic cough that may produce clear, white, yellow or greenish sputum
• Recurring respiratory infections
• Depleted energy
• Unexpected weight loss
• Swelling in the ankles, feet or legs
• Poor exercise tolerance; fatigued easily with exertion

Self-Treatment Tips  –  

• Breathing Exercises; Diaphragmatic Breathing
• Exercise at least 4 times per week
• Wear protective wear such as face masks, eyewear, gaiter, and sleeves/pant
• Limit exposures to known triggers
• Steam clean carpets or remove carpets
• Vacuum with a HEPA filter to reduce dust in your home
• Wash your bed linens and pillowcases in hot water and detergent frequently 
• Use HEPA Air Purifiers in the house (small size 200 sq ft, medium size 200-400 sq ft, large size 400-1500 sq ft)

Diagnostic Testing – Spirometry consists of measuring lung volumes by having patients take deep breaths in and out that is detected by a sensor. The data is compared to normal values based on race, gender and ht/wt. The allergy provider reviews the data and will determine if there is airway obstruction and its severity. 

Fractionated Exhaled Nitric oxide testing consists of measuring the amount of exhaled nitric oxide. It is a surrogate marker for airway inflammation and can assist with diagnosing COPD or assessing for COPD flares and control. It can also be used in leu of spirometry for patients who cannot perform the spirometry testing.

In-Vitro testing consist of whole blood draw at a local lab for which the whole blood is analyzed for a complete blood count is derived which better characterize the asthma, screen for connective tissue diseases such as lupus or rheumatoid arthritis, arterial blood gas and screening for genetic conditions (i.e alpha 1 antitrypsin syndrome, cystic fibrosis etc.).  About 1.5 wks later, the allergy provider will discuss the results and overall interpretation.

Chest Imaging – Chest x-rays and CT scans of the lungs can screen for emphysema, lung cancer and or interstitial lung disease.  

Therapies:

Rescue Inhalers – Rescue Inhalers provide quick relief of sudden symptoms. Rescue medications start to alleviate the symptoms of COPD within a few minutes by relaxing the muscle spasms within the airways. The most prescribed medication for rescue of COPD symptoms is albuterol, or a related medication called levalbuterol. The rescue medications can be administered via an inhaler or aerosolized with a nebulizer. Typically, these medications can be given every 4 to 6 hours as needed. Trade names for rescue medications include ProAir HFA, Spiriva, Proventil HFA, Ventolin HFA and Xopenex HFA. 

Controller Inhalers – Controller inhalers provide long-term control of COPD and prevent future exacerbations. They work by reducing the remodeling effects on the lungs by inflammation. They can also provide short term therapy especially during flare. Your allergy provider will determine if the frequency and severity of your symptoms require the use of a maintenance medication. All the controller medications work by reducing the inflammation in the airways. By reducing swelling, the lungs are stronger, and a patient is much less likely to have asthma symptoms.

Antibiotics – Antiobiotics are usually employed in the setting of a COPD flare. Bacterial burden in the airways increase during a flare. Antibiotics assist in reducing the overall airway inflammation.

Oral Steroids – Oral steroids are also used during flares. They turn down the overall immune response, which decreases the airway inflammation.

Supplemental Oxygen – Supplemental oxygen are used for severe COPD patients who have inadequate oxygen levels at rest or during exertion. This is usually determined by conducting a walking test while on pulse oximetry. 

Pulmonary Rehab – This is reserved for severe uncontrolled COPD patients. It involves multiple pulmonary exercises and activities which increase lung capacity over time.

Xolair (Omalizumab) – Xolair is a humanized monoclonal antibody that is administered by subcutaneous injection every 2 wks. It works by preventing the “allergy” inflammatory by binding free IgE antibodies (this is the antibody that triggers allergies) and by blocking certain receptors on inflammatory cells (i.e mast cells, basophils). This decreases the frequency and severity of asthma symptoms. It is indicated for allergic asthmatics who are not controlled with standard asthma medications.  Xolair is very effective and has a relatively small adverse effect profile. This can be used in patients with asthma – COPD overlap syndrome who fit the above-mentioned criteria. 

Dupixent (Dupilumab) – Dupixent is a human monoclonal antibody that works by blocking interleukin-4 (IL-4) and interleukin-13 (IL-13), two proteins that are responsible for allergic inflammation in asthma. Dupixent is given as a subcutaneous injection every 2 weeks. It is indicated for patients with eosinophilic asthma and or ones who are uncontrolled. It is very effective and has a small adverse effect profile. This can be used in patients with asthma – COPD overlap syndrome who fit the above-mentioned criteria.

Fasenra (Benralizumab) – Fasenra is a humanized monoclonal antibody that is administered by subcutaneous injection every 8 wks. It works by directly binding to eosinophils and eventually eradicating them. It is indicated for eosinophilic asthmatics. This can be used in patients with asthma – COPD overlap syndrome who fit the above-mentioned criteria.

Nucala (Mepolizumab) – Nucala is a humanized monoclonal antibody that is administered by subcutaneous injection every 4 wks. It works by disrupting inflammatory signaling for eosinophils and eventually renders them ineffective. This can be used in patients with asthma – COPD overlap syndrome who fit the above-mentioned criteria.

Tezspire (Tezepelumab-Ekko) – Tezspire is a human monoclonal antibody that works by blocking thymic stromal lymphopoietin (TSLP) which is an early phase signal that plays a big part inflammatory cell mobilization. Tezspire is given as a subcutaneous injection every 4 wks. It is indicated for any asthmatics who are uncontrolled with standard therapy.  This can be used in patients with asthma – COPD overlap syndrome who fit the above-mentioned criteria.

Vocal Cord Dysfunction:

Vocal Cord Dysfunction (VCD) or Paradoxical Vocal Fold Motion (PVFM) occurs when the vocal cords do not open correctly. It is estimated that up to 2% of the general population have this syndrome. This syndrome is often times mistaken for asthma or laryngospasms. Much like with asthma, breathing in lung irritants, exercising, a cold or viral infection, or Gastroesophageal Reflux Disease (GERD) may trigger symptoms of VCD. But unlike asthma, VCD causes more difficulty breathing in than breathing out. The reverse is true for symptoms of asthma. Many people with asthma also have VCD. Although the two may have similar triggers and symptoms, the treatments for VCD and asthma are very different, which makes proper diagnosis vital.

VCD symptoms usually are:  

• Difficulty breathing
• Coughing
• Wheezing
• Throat tightness
• Hoarse voice
• Voice changes

With detailed history taking and measurement of lung volumes, this syndrome can be diagnosed. The treatment often will require vocal cord relaxation techniques and control/avoidance of known triggers.