Asthma and Lung Disease

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Asthma and Lung Disease

Asthma is a genetic disorder where patients produce excessive levels of Immunoglobin E antibodies, which produce an immune reaction when exposed to substances such as pollens or house dust mites, or to infections such as influenza. The immune reaction causes inflammation of the bronchi in the lungs sometimes causing chest infections, although asthma can still be present even when exposure to external allergens is removed. In severe cases, the immune reaction caused by the IgE antibodies can be fatal. Over a period asthma attacks and infections can cause progressive damage to the lungs, rendering them more susceptible to further infections.

Allergy Avoidance

It is well established that many patients are allergic to house dust. Fit special barrier covers to the mattress, duvet and pillows, and wash the outer covers regularly at high temperature (60°C) - Alprotec covers are very good quality (inexpensive Tyvek covers are also effective, but less hard wearing). It is also advisable to fit a micro filter on the vacuum cleaner in the housing between the exhaust grill and the dust bag - universal filters are available cheaply on eBay and can be cut to size. Radiators are a magnet for dust and should be cleaned out with a radiator brush before vacuuming. In the summer months it can be helpful to have an air filter in the bedroom at night - I run a Filtaire 300 at low speed overnight to reduce my rhinitis. Place the unit on a piece of hardboard to avoid it sucking dust from the carpet! (Avoid ionisers as they create ozone which is harmful.) I should add that no pets should be allowed in the house or handled outside and smoky atmospheres must be avoided at all times. Also avoid perfume, paint and other fumes. Certain alcoholic drinks contain sulphites which can make some asthma patients very ill and are exempt from food labelling regulations in the UK. Particularly bad in my experience are cider, perry and white wine (including sparkling wine). Red wine may not contain as much sulphite but seems to have an adverse effect on my immunity.

Incremental desensitising injections were once popular for inhalant allergens such as house dust and pollen. They are rarely given now on the NHS as they led to 26 deaths. I was very nearly one of these statistics and spent about a year in and out of hospitals with very severe asthma back in 1976. In 1986 the Committee on Safety in Medicine ruled that a resuscitation team must be available for 2 hours after each injection. This would not have helped in my case as the allergic reaction developed slowly over several weeks. Be warned. Neutralization Therapy (described in Asthma Epidemic) and Enzyme Potentiated Desensitization are different techniques that use far smaller doses and are quite safe, although of no effectiveness in my experience. EPD was developed by Dr Leonard McEwen although it is now prohibited by the US Food and Drug Administration (see http://www.fda.gov/ora/fiars/ora_import_ia5715.html) and appears to be a case of medical fraud. Since the FDA ban in 2002, Dr McEwen was sanctioned by the British General Medical Council in 2006 for soliciting donations from patients (see http://www.casewatch.org/foreign/mcewen.shtml). A double blind randomised controlled study published in the British Medical Journal (Volume 327, 2 August 2003) concluded that Enzyme Potentiated Desensitization allergen immunotherapy method had no treatment effect. Neutralisation Therapy (used by Dr John Mansfield at The Burghwood Clinic) is not available on the NHS either and has little evidence of any efficacy. West Midlands Regional Evaluation Panel Recommendation by the Department of Public Health and Epidemiology, University of Birmingham concluded: No evidence identified to suggest provocation-neutralisation testing is useful for diagnosis of food allergy: Insufficient evidence identified to recommend the use of neutralisation therapy for food allergy. While Dr John Mansfield charges patients £300 for a useless desensitization treatment this pales into insignificance compared with the £5,000 demand from Dr McEwen! Quackery is a very profitable business certainly judging by the size and location of The Burghwood Clinic and Dr McEwen's substantial property and grounds on the banks of Henley-on-Thames! Elimination diets are fine to see if symptoms improve. The quackery is the phoney desensitization which is what the unfortunate punters are charged for. The problem is that the British medical establishment is a closed society - they will never rat on their members and the penalties imposed are risible. However unseemly there may be some efficacy in quackery, provided that the correct medical treatment is followed as well. If the practitioner can engender the belief in the patient that the quack treatment is effective, it may improve their outlook on life and immunity to disease - but it's fraudulent nevertheless.

In addition to IgE mediated allergy, which can be demonstrated by skin prick tests or measured from a blood test, some patients can also be allergic to foods without producing a raised IgE response. The mechanism of this form of delayed allergy to foods is not understood or acknowledged by the medical establishment, who only recognise IgE mediated allergy. What got me onto food was reading The Complete Guide to Hayfever by Professor Jonathan Brostoff and Linda Gamlin and Asthma Epidemic by Dr John Mansfield (these titles are available from many public libraries). The most methodical way to identify food intolerance is by using an elimination diet - go on to a restricted diet for a period and then introduce one food at a time. Unfortunately the restricted diet in Hayfever includes soya to which I am highly allergic. Brostoff states that patients with asthma and nasal polyps are often allergic to yeast and dairy products and in my case this was true, but including soya in the restricted diet could cause a worsening of symptoms.

Elimination Diet

Asthma Epidemic contains a very methodical Elimination Diet. For 7 days only the following are allowed: lamb, venison, salmon, cod, trout, mackerel (not tinned or smoked), pears, avocados, parsnips, turnips, swedes, celery, chinese bean sprouts, sweet potatoes, marrow, courgette and marrow. Only bottled mineral water is allowed for liquid and sea salt may be used for flavouring. Bicarbonate of soda should be used as a substitute for toothpaste. Of course you will also need to avoid allergy causing chemical additives, yeast and foodstuffs which are found in some medicines. If you get no benefit from avoiding these items for a week you probably do not have food intolerance. If you do get an improvement in symptoms then each food has to be introduced in turn to discover the culprits. Reactions can take a few days to build up with some foods. In Asthma Epidemic most foods are introduced for only a single day but it can take 3 days before I get a reaction. If you suffer bad headaches from caffeine withdrawal you may be able to take caffeine tablets depending upon what foodstuffs are in them.

Only after lengthy experimentation I found the greatest improvement by avoiding all of the following:

Yeast - Avoiding bread improves my nasal symptoms. I was making my own bread with self raising flour for a while but found that the wheat worsened my asthma, although it made no difference to my rhinitis. If you take vitamin tablets make sure they are free of yeast and soya (cheaper brands often contain yeast).

Dairy Produce - avoid all dairy products initially (i.e. milk, butter, cream, cheese). I find that tinned evaporated and UHT (Ultra High Temperature) milk are no problem, since boiling destroys the allergy causing proteins. Pasteurised milk worsens my nasal symptoms.

Soya - I avoid soya entirely.

Peanuts - I have recently discovered a peanut allergy. After eating peanut butter and fresh peanuts for 3 days, I had a nasty asthmatic reaction requiring steroids, although no nasal symptoms.

Wheat & Rye - avoiding all wheat products including durum wheat semolina in pasta and rye (Ryvita) has certainly improved my asthma. Rice, oats and maize (in corn cakes) are no problem.

You will usually only benefit by removing all the problem foods, not just one or two. I find that the diet takes about 3 days to improve my symptoms - you should allow at least a week as responses vary. If I introduce a problem food it takes about 3 days for my symptoms to worsen. Recently I tried introducing soya milk to see whether I had lost my allergy. After 3 days I developed a middle ear infection without warning and had to take a week's course of prednisolone in addition to antibiotics to get the fluid to drain out. Keep careful notes and once you have proved a food is a problem it's best not to experiment with it if you are highly sensitive. I should add that I am not allergic to aspirin or ibuprofen (some polyp patients are). If the Elimination Diet does not reduce your symptoms then you may not be sensitive to foods.

Asthma Drugs

For mild cases of asthma a bronchodilator inhaler alone should be sufficient. Salbutamol is a short acting bronchodilator while salmeterol is a more powerful and longer acting one. What they don't tell you is that bronchodilators cause insomnia and the more powerful, the worse the insomnia. There is really no answer to this as even z-drugs, the most modern sleeping tablets, cause tolerance to develop and become ineffective if used regularly. (Zopiclone is probably the best sleeping tablet for occasional use - available from United Pharmacies (UK). It can be cut into smaller doses and taken in a capsule to avoid the unpleasant taste - the dose can be reduced if combined with alcohol.)

If the symptoms cannot be adequately controlled with bronchodilators, then inhaled steroids are added. For convenience this can be in a combined inhaler such as Seretide (salmeterol/fluticasone), which incorporates a dose counter. Fluticasone is a modern inhaled steroid which has very low systemic absorption, although it causes me hoarseness and a dry mouth and throat, even though I drink water after use. The older beclometasone is less effective for asthma, but was easier on my throat and controlled my rhinitis far better, as some of it is absorbed in the body.

For maximum efficiency the inhaler should be taken through an effective spacer such as a Volumatic. This oversized piece of asthma paraphernalia needs regular cleaning, which requires an old toothbrush. Most inhalers are now CFC free and unfortunately the substitute propellant tends to gum up and block the exit hole! To overcome this the inhaler case should be removed each week, rinsed through and brushed clean with hot water and allowed to dry.

If the symptoms cannot be adequately controlled then the dose can be increased to 4 inhalations of 25 micrograms salmeterol and 250 micrograms fluticasone propionate daily (the 25/250 Seretide inhaler is purple). For short periods I am professionally advised that up to 8 doses per day can be used, although it may cause insomnia.

An additional drug that I find effective is the leukotriene antagonist Singulair (montelukast sodium) - Accolate (zafirlukast) is similar. (These drugs are only effective in some patients). More recently I have found that fish oil capsules noticeably improve my asthma and rhinitis during the summer months. Choose fish oil in preference to fish liver oil as you can absorb too much vitamin A from liver products.

If the symptoms still cannot be adequately controlled then a maintenance dose of prednisolone has to be added. I currently take 10 mg enteric coated prednisolone on alternate mornings. This causes less adrenal suppression than using 5 mg every day. Without this the thing gets out of control after about three weeks and I then have to use a course of steroids. If steroids are used frequently or long term, one should have a bone density scan to diagnose osteoporosis - I currently take Fosamax (alendronic acid) once a week to treat this.

If you are very wealthy you may be able to afford the anti-IgE drug, Xolair (omalizumab) which is given by injection. This is a monoclonal antibody which is produced from mice and which the NHS will only fund in very exceptional circumstances - a similar situation to many modern cancer drugs. Sadly there is no immediate prospect of monoclonal antibodies becoming affordable as they are proteins which cannot be synthesised and are very costly to produce.

There are many anecdotal reports of cannabis improving asthma, although smoking is deleterious to the lungs. I have tried small amounts with tobacco in a Volcano vaporizer and found rapid relief of symptoms and an improved peak flow reading, but no sustained improvement the following day. Although it temporarily improves symptoms it also causes me chills and insomnia, so I rarely indulge.

Chest Infections

Unfortunately asthma is an immune reaction which can cause damage to the lungs, rendering them more susceptible to infections. In addition oral steroids suppress immunity, so using them can cause a chest infection to develop, or worsen an existing infection.

I find that a week's course of oxytetracycline will usually clear a chest infection. Unfortunately it takes some days to work in which time the asthma can get far worse requiring additional steroids, due to the immune reaction to the infection.

By experimentation I have found that an oral dose of DMT fumarate (120 mg), after pre-dosing with moclobemide (150 mg), will shift a chest infection within a few hours, avoiding the need for antibiotics and additional steroids, if taken in the early stages of infection. Even if a course of antibiotics is required, I have found DMT to be effective in reducing feverishness and speeding recovery. I have also found DMT to be efficacious with influenza type infections. Obviously DMT is illegal at present and has to be produced from South American plants which may be outlawed, but is medically beneficial. I have no idea how DMT combats chest infections although it may cause some localised dehydration, as I pass a lot of urine despite drinking water and my skin feels drier the following day. In addition I also sometimes get foot cramps while using it, which can be a symptom of dehydration. See www.dmt.20m.com for details and please note the dangerous drug interactions with moclobemide.

If one gets regular chest infections or has chronic low level infection, an inversion table can be helpful to shift the muck up. Also an annual flu vaccination is advisable for chronic asthma patients.

Skin Infections and Bruising

Unfortunately steroids cause skin thinning which can lead to acne type infections. Thin skin also cuts more easily and often becomes infected. I find that Quinoderm (10% benzoyl peroxide) is very effective, available behind the counter at Boots, although it is also very effective at bleaching clothes! Bruising is also a problem and can be treated with ice or cold water initially followed by regular applications of ibuprofen gel.

Fatigue

Chronic fatigue can be an issue if oral steroids have been used over a long period, which can cause the adrenal glands to become less active (secondary adrenal insufficiency). Even if oral steroids can be safely reduced or stopped, the adrenal glands may never recover fully due to atrophy. Another possible cause of fatigue is where there is some chronic infection present which causes white cell counts to be raised. Eosinophils may also be raised in asthma, which can damage the lining of the lung.

Insomnia

If a course of steroids if required for asthma, insomnia can become a major problem. As mentioned above, Zopiclone is probably the best sleeping tablet for occasional use - available from United Pharmacies (UK). It can be cut into smaller doses and taken in a capsule to avoid the unpleasant taste - the dose can be reduced if combined with alcohol.

Other Lung Diseases

Allergic Broncho-Pulmonary Aspergillosis (ABPA) is a condition where a patient develops an allergy to the spores of Aspergillus moulds. Predominantly it affects chronic asthma patients but also cystic fibrosis and bronchiectasis patients. Basically the damaged lung tissue becomes colonised by Aspergillus causing raised IgE antibodies and an immune reaction, which can lead to further lung damage. Oral steroids are an effective treatment, although long term use is obviously inadvisable. Antifungal drugs are also effective and should enable the oral steroid dosage to be reduced. However, over a period of years, Aspergillus fumigatus develops resistance to the most common antifungal drug Sporanox (itraconazole) and also becomes resistant to the newer azole drug Vfend (voriconazole). So the prognosis is not good. The only long term solution, apart from oral steroids, is the phenomenally expensive anti-IgE drug, Xolair (omalizumab), which is rarely prescribed.

Tuberculosis is a slow and potentially deadly disease. The current BCG vaccine only provides limited protection although an improved vaccine is in development. Although fairly uncommon its diagnosis is woefully inadequate in the UK. If you are suspected of having TB a sputum test will be sent for analysis and you may be sent for a chest x-ray. Unfortunately a negative sputum test does not mean that the disease is not present. If you are fortunate enough to be referred to a specialist, you should be given a skin test (Heaf/Tine/Mantoux). This will cause the skin to swell up if TB antibodies are present in the blood, indicating that TB is present, or that you have been exposed to it in the past. A specialist will decide whether TB is present, depending on the skin test result, your symptoms and chest x-ray, if the sputum test is negative. Treatment usually consists of a combination of TB antibiotics taken for a minimum period of six months. Early cessation of treatment can lead to drug resistant TB which can be fatal, as well as contagious. The great weakness of the present diagnostic system is that the skin test is not performed at the GP's surgery, so a negative sputum test may delay diagnosis and treatment for years, by which time the disease will have advanced. In this respect the French system of medicine is obviously superior, where patients have direct access to the hospital specialist.

Nutritional Supplements

Currently I take 6 x 1g fish oil capsules daily (each containing 180 mg EPA and 120 mg DHA) during the summer months. Also one yeast-free multi vitamin and mineral tablet, 2 x 150mg magnesium citrate tablets and one 30 mg zinc gluconate tablet daily (taken at a different time to the magnesium). Magnesium supplements improve asthma in some patients and certainly won't do any harm.

Finally may I please ask you not to email me for advice as I get too many to answer. I am not a doctor or an allergy expert - read the books above for further information. You should do the elimination diet for at least a week to see if you achieve any improvement and you must stick to it rigidly. We should also consider whether we are morally justified in inflicting our ailments on the next generation, since asthma and rhinitis are genetic disorders. It is my view that, except in mild cases, we should not.

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