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Asthma/Allergic Asthma Vaccination

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QUESTION: Dear Sir,
My name is Shahid 29 years old, I live in the city of Jeddah, Saudi Arabia. the weather here is very hot in summer near to 50 and in winter its 25-40. I have an office job as Admin supervisor. I had nasal surgery two time in 2007 and 2009 because there was blockage they said meat has increased and bone is not straight and after surgery it again happened and I had to take second surgery and even after that I still feel nose blockage and phlegm falling everytime they say its allergy. Then gradually my lungs allergy became increasing day by day i noted that i have allergy from cold air or even the air below body temperature, i feel difficulty in taking breath from nose and breath at the same time, at night sound like whistle come from lungs and a lot of phlegm and mucus come with cough. we can not live here in Jeddah in 50 centigrade without air condition and fans. i try to keep myself away as much as possible but even my exposure to normal air cause me problem in breath. I had once an allergic test which name was IgE . Doctor told its normal and average reading should have been between 1 to 20 and if 20 to 100 then you have allergies but you know my reading for this test was 1045 i could not belive it.
I use Theophylline daily but some time i skip it and i have used Montelucast but not regular i use it when problem increase. Due to breath problem my blood pressure is always high.
I eat all kind of food each and everything.
Dear Doctor I want to ask, is it asthma ? and I want to ask you, is there any vaccination or injections to prevent this kind of allergy from cold environment.

ANSWER: Hello Shahid,
Have you been to a allergist or pulmonologist yet? It was good that your physician tested you for the IgE, but there should have been followup testing which would include skin & possible blood tests to make a determination of what specific allergens are affecting you, and also a lung function test called spirometry which directly checks your lung function. In fact, the spirometry is done where you breath in and out through a tube hooked up to a computer and your lung volume is determined, then you receive a breathing treatment with salmeterol, and then the spirometry is done again. If you show an improvement of greater than 12% or 200ml, the diagnosis of reactive airway disease is made (commonly called asthma), and then proper treatment is started.

I'm surprised that you have been on theophylline. It is a medication that is rarely used here anymore due to newer drugs which have much greater effect and fewer side effects. There are international guidelines that are followed to bring your condition under control and improve your quality of life. These are called the GINA Guidelines (Global Initiative for Asthma), and can be found at http://www.ginasthma.org  .

I personally would seek out a specialist for a full evaluation, and get on a proper course of treatment. While there is no cure, and in all likelihood you would have to be on a daily regimen, your quality of breathing and life would dramatically improve.

For the levels of IgE that you present, there is an injectable medication called Xolair (Omalizumab)that is very effective, but also very costly. I'm also not certain  if it is available in your country.

In my personal opinion, from what you have provided me, yes, I agree that it is probably asthma, but other conditions may have similar symptoms, which is why it is important to be evaluated by a lung/allergy specialist.

Hope this helps you. If you have further questions, or, after a final diagnosis is made and you wish to learn more, feel free to get back to me.

Sincerely,

Marc



---------- FOLLOW-UP ----------

QUESTION: Dear Doctor,

I am very much thankful for such nice advises and your answer is very helpful for me. I will get full examination by a pulmonologist. But I want to ask you,
IgE level represents what ?
is 1045 IgE level dangerous? and what kind of help the injection Xolair (Omalizumab)can give me ? and how often i have to use it. can you give me idea what is approximate cost of this medicine and how often i have to use it, and is my IgE level is the reason of Lung Infections and allergies ?
I am very thankful to you doctor, can you please suggest me medicine in place of Theophylline.

ANSWER: Hello Shahid,

  IgE is a chemical produced by certain cells in the lining of the lungs , intestine and in the skin. When a person has an immune system that has reactions to allergens (pollen, or animal dander, for instance), the allergen binds with the IgE causing a release of chemicals resulting in swelling, itching and rash. This inflammation in the lungs increases the risk of developing lung infections. High IgE levels are an indicator of that reactive system. High levels indicate a high response.
  Xolair is an chemical (IgG) which reduces IgE from attaching to the reactive cells, thus dramatically reducing the release of chemicals that cause all the problems. Over ~ 3 months of therapy, the IgE levels are dramatically reduced, with a greatly reduced need for other drug therapy. But, due to the high cost (~$5000/month), is usually saved for very severe cases, or those that do not respond to traditional drug therapy.Initial dosing is done every 2 weeks until IgE levels are reduced, then reduced to monthly.
  A critical aspect here is to truly identify what in your environment are your triggers, and to the greatest extent possible, removing them. For example, if you have a dog, it would be the best to give it away. If that is not reasonable for your family, the dog must not have any access to your bedroom. Once that is accomplished, the bedroom gets a very deep cleaning to rid all the potential dander. Did this at my home (my wife didn't believe me)and that night, she went to sleep without so much as a stuffy nose. The reason behind this is, during the night, your body's' defense system for inflammation goes down, and the presence of the dander or other triggers has a much greater impact, resulting in poor breathing and sleep. This defense system is at its peak in the early afternoon, and you probably notice that you have less difficulty during this time of day.
  The therapeutic approach for your level of problems would most likely be:
   1) combo drug of steroid + airway opening agent. In the US, that would be one of a few products, such as Advair, Dulera or Symbicort. These would be inhaled into the lungs.
   2) a nasal steroid to reduce sinus inflammation. This is important since, if the sinuses are inflamed, they can trigger the lungs to react.
   3) an antihistamine, to help reduce reactions to pollens, mold and dander.

It is important to understand that these meds have to be taken EVERY day. We call these CONTROLLER meds, because they bring the situation under control. You would still have a RESCUE inhaler, a short-acting (~4 hours)inhaler to bring your breathing relief during an attack. It can take up to a full 6 months for maximum benefit.

Proper technique is necessary to get the maximum benefit from these meds, and not only should you be shown how to properly use them, but they should have you demonstrate back that you understand the technique.

   There are 3 important parts to your ultimate success:
1) Getting to really know and identify your triggers, so you can avoid them, or pre-treat before you have to go somewhere that may be an issue, in order to minimize the reactions,
2)  Patient education, great patient info is found at http://www.aaaai.org   The more you know, the better for YOU to TAKE CONTROL!
3)  Understand the meds as to a) what they do, how they work, what side effects to watch for and how to properly take them.

When you master this, you are then in control of your quality of life.

Let me know how it goes with the pulmonologist.

Sincerely,

Marc

---------- FOLLOW-UP ----------

QUESTION: Hello Doctor,

my condition became worst just after few days when I asked you last question. I went to internist which gave me Prednisolon, Formoterol Inhaler, Theophylline Montilukast and Loretedine.

But still i was not feeling any improvement. I changed my doctor and went to another doctor who did my complete blood test, ultra sound, stool tests, and chest Xray and after examining all reports, he said that you don't have asthma and who ever told you this he is mis guiding you and your real problem is may be Heart, Because he mentioned that your heart size is increased in the Xray. Then i got Echo Cardiography and cardiologist told me that heart size is increased and Mitral valve are not functioning well due to increase in size and EF is 34. so you need surgery and he Referred me to Cardio Surgeon.. by the way i am taking medicine named, Aldactone, Lasix, Coversyl..... .. please see the following result of Echo Doppler test and please advise with your comments, do i need surgery??? or is it my real problem ?

ARD 30mm
LAD 47mm
IVST 9mm
PWT 9MM

LV EDD 61mm
LV ESD 51mm
E.F % 34%
F.S% 16%
MVA 4 Centi Meter Square

M.V FLOW 1mm Hg REGURGE SEVERE
A.V FLOW 2.3MM Hg REGURGE MILD
T.V FLOW  REGURGE SEVERE
P.V FLOW 1.3MM REGURGE MILD

COMMENTS

Dilated L.V internal dimension with severe impairment of systolic func.
E.F 34%
No SWMA

Answer
Shahid ,
If you look back to the first time) I contacted you, I said the symptoms may not be as necessarily be asthma, but it needs to be determined what exactly is taking place, which is why I suggested seeing a  specialist. I'm very happy that you followed  through with this, and it looks like your lung issues are secondary to your heart condition. What probably led to the initial  diagnosis of asthma was your age. This type of heart condition is something you'd more likely suspect in women, someone older, or with the family history of heart issues.  This is serious. It sounds like mitral valve prolapse and right-sided heart failure. My assumption is, you will have a valve replacement. My father-in-law had this done, and he has recovered a great deal of his heart function. Oh, and he is 90 years old. Surgery was 2 years ago.
   I understand your concern for the surgery, and I'd only suggest a second opinion of another highly regarded cardio specialist. If confirmed, have the surgery. Let me know the final diagnosis, and then I'll see if I can offer questions you may want to ask before the operation.

Best wishes for a return to good health.

Marc

Asthma

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Marc Rubin, RPh Asthma Educator

Expertise

I have worked directly with patients as well as caregivers for over 30 years. Have made presentations throughout Illinois educating school nurses as well as the teaching and coaching staff of public schools about asthma, and how they should respond to these students needs. Presented a public education program on asthma through the US Department of Public Health. Specialize in helping guide asthmatic patients to take control of their disease in order to live a near-normal, fully active life.

Experience

Practicing pharmacist for 40 years, specializing in asthma and COPD for 12 years. Developed nationwide education to nurses, teachers and athletic coaches regarding asthma and exercise induced bronchospasm. In addition, and closer to home. my daughter has asthma, and my son has exercise induced bronchospasm. In addition, I serve on the boards and committees of a number of asthma organizations: Sports, Exercise and Fitness Committee of AAAAI, Population Health Committee and Sports Medicine Committee of ACAAI, Sports Medicine Committee of the World Allergy Association. Board of Directors of the Chicago Asthma Consortium, Board of Directors of the Christopher D. Redding Youth Asthma Foundation, as well as the advisory board of a medical education company, Emmi Solutions. Directly involved in the creation of public education programs for asthma, COPD and diabetes.

Organizations
American Academy of Allergy, Asthma and Immunology / Sports Medicine Committee, American College of Allergy, Asthma and Immunology / Population Health Committee and Sports Medicine, American College of Chest Physicians, American Thoracic Society. World Allergy Association, Chicago Asthma Consortium / Professional Development Committee, Christopher D. Redding Youth Asthma Foundation, and Respiratory Health Association of Metropolitan Chicago: Development Committee for AE-C prep class, and presenter.

Publications
AAAAI PowerPoint on the new guidelines for EIB (Exercise Induced Bronchospasm), AAAAI Powerpoint on Asthma in School Setting for Teachers and Coaches, Annals of Allergy, Asthma and Immunology: Transition guide for teens with food allergies or asthma going out of the home to live independantly.

Education/Credentials
BScPharm, RPh, (NAECB Certified asthma educator in 2002), NIPCO Certified Respiratory Care Pharmacist

Past/Present Clients
Emmi Solutions, Chicago Next Level Health, Chicago

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