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Wheeze, wheeze


Although there are many causes of wheezing in the chest, bronchial asthma is one of the most common. And since the winter cold can bring this on, asthma is a relevant topic for this season.

Wheeze happens when the chest makes strange noises as we breathe in and out. The reason for asthmatic wheeze is that the airways in bronchial asthma narrows and the inhaled air passes the wall of the airway instead of flowing smoothly down the middle.

Narrowing of the airways is brought about when smooth muscles, which line the airways, constrict (broncho-constriction or broncho-spasm is the medical terminology). Broncho-constriction may be caused due to many reasons including cold, allergy, exercise, mental stress and so forth. Therapies have been designed to decrease or reverse this constriction.

One of the most commonly used medicines in bronchial asthma are beta agonist inhalers which help relax the smooth muscles of the airways and reverse the process of asthma. Asthalin (a common brand name of a beta agonist) inhalers are used commonly and are usually effective. However it is important that the patients learn to use the inhaler properly. Many people do not inhale the medicine but rather swallow the puff of medicine. The medicine goes into the alimentary tract when it was meant to be delivered into the respiratory tract. Or, improper coordination can lead to exhaling air out of the lungs while the puff of medicine is being delivered, which leads to the medicine being wasted into the atmosphere. Beta agonist pills are less expensive but may lead to unwanted side effects.

About 25 years ago, some smart pulmonary scientists determined that relaxing the smooth muscles was just one part in the treatment of bronchial asthma. A revolutionary treatment strategy using inhaled corticosteroids (beclate is a trade name) was put forward because it was clearly shown that persistent asthma had a sizable component of inflammation in addition to the smooth muscle broncho-constriction. Hence, anti-inflammatory medicines in the form of corticosteroids were deployed with startling improvement in asthma care.

It is now routine to add a steroid inhaler if the beta agonist alone is not effective in the treatment of bronchial asthma. Although cold and exercise may be triggers for an asthma attack, travel to high altitude regions amazingly does not seem to worsen existing asthma. This is probably due to lack of allergens at higher altitudes.

1. A Nepali
Inhaled corticosteroids (ICS) only help eosinophilic asthmatics. If the underlying inflammation is neutrophilic, there is no benefit from ICS, only potential side effects. About half of moderate to severe asthmatics have inflammation driven by eosinophils and, therefore, likely to benefit from ICS therapy. In the absence of good diagnostics, high counts of eosinophils in routine CBC with differential can be used to guide treatment decisions, and there is a large scientific literature on this. Many publications are open access and should be readily available to doctors in Nepal.

2. You stand correct A Nepali
A Nepali, please do not mislead and give false info you even know what you are talking about? "ICS is the cornerstone for ALL asthma treatments PERIOD" check any major publication. Be it eosinophilic or neutrophilic, atopic or intrinsic, if you do not add ICS in the asthma treatment regimen once you have tried a beta agonist, as an rescue inhaler, you sir will have your license revoked in most countries of the world! Even a quack will tell you that. I don't know about you, but we practice what is called "standard of care" and I back up Dr. Basnyat 100% on what he is trying to deliver from his article. I am curious to know what literature  you are  suggesting Mr. Nepali? If you care to see the latest CHEST guidelines --whom we pulmonologist follow-- you will realize that you spoke too soon. That's why I tell everybody --get your facts right first before commenting. Once again, Dr. Basnyat thank you for giving practical tips for the public, we support you. Keep up the great work!

3. another Nepali
Though there are some write ups suggesting differences of asthmatics with predominant eosinophilla and others without it, there is no guideline so far that advocates separation of these for the sake of managing them differently. I have failed to land upon this "large scientific literature" as A Nepali says which recommend this as a guideline. It should also be a good idea to check the sources of such articles for reliability before jumping to conclusions about already standardized treatment guidelines.  I am sure A Nepali would not disagree to this being a downside of publications being "open access and should be readily available".

4. Ramprasad
@ A Nepali ...higher counts of eosinophils in blood or higher counts in sputum, bronchial secretions??. and wouldn't neutrophilic asthma mean a more severe form of asthma..a condition which i am sure nepalese doctors are quite familiar with...and are eosinophilic and neutrophilic asthma mutually exclusive??

5. A Nepali

#4 Ramprasad, you are correct that the gold standard for classifying as eosinophilic is based oneosinophil counts in induced sputum. However, induced sputum technique is laborious and highly specialized, which makes it impractical. Thus, eosinophil counts in blood are used as a surrogate (there is reasonable correlation between sputum and blood eosinophils). Eosinophilic asthma is usually more severe than neutrophilic asthma and contributes to greater healthcare expenditure in the West. The two asthma phenotypes are mutually exclusive, but there is some overlap in a proportion of patients. Thus, there are 4 major phenotypes: eosinophilic, neutrophilic, paucigranular (ie, overlapped), and neither.

#2 pulmonologist: you obviously like to play safe and not remove your head out of the sand. Have you heard of stratified medicine, or segmented medicine, or personalized treatment, in which the objective is to match disease phenotype with targeted therapeutic to provide the highest benefit/risk ratio to individual patients? It will probably take you a decade to learn about this major emphasis in treatment that is taking place in the West, and you will likely never practice it during your lifetime, with the (know-it-all) attitude you have. I feel sorry for your patients.

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(11 JAN 2013 - 17 JAN 2013)