Management of Asthma through integrative medicine apporach...

Overview 

Definition

 

Asthma is a chronic inflammation of the airways associated with excess swelling and mucus, resulting in obstructed airflow. The airways may be further blocked when an irritant, or trigger, causes bronchial spasms to occur. Asthma symptoms are characteristically worse during sleep and may be intensified by emotion.

 

Etiology 

• Hypersensitivity to aeroallergens (including dust mites; cockroaches; dog, cat, or other animal proteins; fungal spores; pollens; dust; and fumes) 
• Respiratory infections 
• Gastroesophageal reflux 
• Air pollutants, such as tobacco, aerosols, perfumes, fresh newsprint, diesel particles, sulfur dioxide, elevated ozone levels, and fumes from chemical-cleaning agents and gas stoves 
• Meteorological changes in temperature and humidity 
• Exercise 
• Emotional behaviors that alter breathing such as laughing, shouting, or crying 

Risk Factors 

• Family history of allergies or asthma 
• Genetic predisposition to immunoglobulin E (IgE) and genes located on chromosomes 5, 6, and 11 to 14 
• Exposure to aeroallergens and pollutants 
• Viral respiratory illness 
• Exposure to tobacco smoke 
• Exposure to irritants 
• Low socioeconomic status 
• African- and Hispanic-American race, for both prevalence and severity 
• Age and sex—older women and children 

Signs and Symptoms 

• Shortness of breath or dyspnea 
• Wheezing 
• Chest tightness or constriction 
• Cough (can be the only symptom) 
• Cyanosis 
• Flattened diaphragm and hyperinflated chest 

Differential Diagnosis 

• Mechanical obstruction of air passages 
• Functional disorders of the extrathoracic airway, especially of the larynx 
• Chronic obstructive pulmonary diseases (COPD), such as chronic bronchitis or emphysema 
• Cardiac asthma as a result of myxoma and left ventricle or mitral valve disease 
• Pulmonary embolism, although few have bronchoconstriction and wheezing 
• Eosinophilic lung diseases 
• Carcinoid tumors, especially with wheezing accompanied by flushing, facial rash, or diarrhea
• Congestive heart failure 
• Tuberculosis 
• Hyperventilation 

Diagnosis 

Physical Examination 

Physical signs of asthma may include tachypnea, tachycardia, exaggerated normal inspiratory fall of systolic blood pressure, hyperinflation of the chest, diaphoresis, prolonged expiration, musical-sonorous rhonchi, and wheezing during auscultation. 

Laboratory Tests

• CBC normal 
• Blood test to determine eosinophil levels for diagnosis 
• Blood leukocyte and red blood cell count (limited usefulness in diagnosis) 
• To distinguish from chronic bronchitis, sputum or "wet prep" test to reveal bronchial epithelium, eosinophils, Charcot-Leyden crystals, and Curschmann's spirals 

Pathology/Pathophysiology 

• Serum test that indicates elevated IgE antibody levels 
• Increased eosinophil level 
• Mucous plugs 
• Mucosal edema 

Imaging 

• Chest radiographs and computerized tomography to rule out abnormalities or other diseases 
• Sinus X rays for differential diagnosis 

Other Diagnostic Procedures 

• The diagnosis of asthma is best confirmed by the spirometric measurement of lung volume and flow rate improvement after the use of a bronchodilator. A decrease in forced expiratory volume in one second (FEV1) by 20% occurs after inhalation of methacholine (25 mg/ml) in 95% of asthmatics. 
• Bronchoprovocation tests for patients in remission and to determine the extent of aeroallergens and occupational exposure can be helpful but risky. 
• Sophisticated tests of lung mechanics are occasionally used. 
• For severe asthma, measurements of arterial blood tensions of oxygen and carbon dioxide as well as pH are indicated. 
• PPD yearly 
• Exercise tolerance tests 
• Electrocardiograms: may show sinus tachycardia as well as right axis shift and P pulmonale, which is indicative of negative tidal pleural pressure and increased right-side heart transmural pressure 

Treatment Options 

Treatment Strategy 

• Controlling environmental stimuli or triggers 
• Anti-inflammatory drugs to promote relaxation of the bronchial smooth muscle 
• Bronchodilator drugs to stimulate the beta2-adrenergic agonist receptors during an attack 
• Antibiotics, when precipitated by a bacterial infection 
• Combination of these treatments for severe attacks, in addition to oxygen and injected epinephrine in emergencies 

Drug Therapies 

• Nonsteroidal anti-inflammatory inhalers, such as cromolyn sodium (Intal); prevents mediator release from airway mast cells; dose-dependent on severity; may cause coughing 
• Corticosteroids, such as methylprednisolone (60 to 80 mg intravenous push each six to eight hours for 36 to 48 hours), for severe attacks; prevents migration and activation of inflammatory cells 
• Corticosteroid inhalers, such as beclomethasone dipropionate (Beclovent, Vanceril, or Asthmacort), 1 to 5 puffs two to four times a day; side effects include: cough, hoarseness, oral candidiasis (thrush); chronic adverse side effects rare 

Bronchodilators: 

• Beta2-adrenergic agonists, such as albuterol (more than 8 puffs three to four times a week warrants reassessment), administered by metered-dose inhalers (MDI) or by nebulizer in the hospital (every one to two hours); stimulate adrenaline or epinephrine receptors; side effects include: rapid or irregular heartbeat, insomnia, shakiness, nervousness 
• Anticholinergic agents, such as ipratropium bromide (Atrovent), inhibit the parasympathetic nervous system; by inhaler (dose varies); side effects include: dry mouth, cough, headaches, urinary retention, worsening of glaucoma 
• Methylxanthines, such as aminophylline and theophylline, are now used only intravenously for severe attacks and for nighttime asthma because of side effects, which include: nausea, vomiting, headaches, insomnia, tremor, seizures, abnormal heart rhythms, death 

Complementary and Alternative Therapies 

Discerning and eliminating triggers are key to treating asthma. Suspect food allergy if asthma develops in childhood, if there is a positive family history, if atopic dermatitis is present, or with poorly controlled asthma with elevated total serum IgE levels. Following nutritional guidelines and using herbal support as needed may be effective in reducing inflammation and hypersensitivity reactions. 

Hypersensitivity reactions may be associated with stress and anxiety. Mind-body techniques such as diaphragmatic breathing, meditation, tai chi, therapeutic yoga, and stress management may help reduce the frequency, duration, and severity of symptoms.

 

Nutrition 

Note: Lower doses are for children. 

• Eliminate all food allergens from the diet. The most common allergenic foods are dairy, soy, citrus, peanuts, wheat, fish, eggs, corn, food colorings, and additives. An elimination/challenge trial may be helpful in uncovering sensitivities, or an IgG ELISA food allergy test may be used. Remove suspected allergens from the diet for at least two weeks. Re-introduce foods at the rate of one food every three days. Watch for reactions which may include gastrointestinal upset, mood changes, headaches, and exacerbation of asthma. Warning: Do not challenge peanuts, or any other food, if there is a history of anaphylaxis. 
• Reduce pro-inflammatory foods in the diet including saturated fats (meats, especially poultry, and dairy), refined foods, and sugar. Patients sensitive to antibiotics should eat only organic meats to avoid antibiotic residues. 
• Increase intake of fresh vegetables, whole grains, legumes, onions, and garlic if not sensitive to those foods. 
• Vitamin C (250 to 1,000 mg bid to qid) inhibits histamine release and increases prostacyclin production which promotes vasodilation. Vitamin C from rose hips or palmitate is citrus-free and hypoallergenic. Vitamin C taken one hour before exposure to the allergen may reduce reactions. This also applies to exercise-induced asthma. 
• B6 (50 to 200 mg/day) may improve symptoms, particularly in children with a defect in tryptophan metabolism. Use caution with a high dose (usually above 500 mg per day in adults). If neuropathy develops, discontinue immediately. Pyridoxal-5-phosphate (P5P) is an activated form of B6 that may be more readily bio-utilized. 
• Magnesium (200 mg bid to tid) relaxes bronchioles. Magnesium may cause loose stools in sensitive patients. 
• Consider hydrochloric acid supplementation as a deficiency is believed to increase the number and severity of food sensitivities and impair micronutrient absorption. 
• B12 is linked to hypochlorhydria and a deficiency may increase reactivity to sulfites. Dr. Jonathan Wright's protocol for childhood asthma: Hydroxycobalamin 1 cc (1,000 mcg) IM every day for 30 days, then three times weekly for two weeks, two times weekly for two weeks, then once weekly (according to the response). Oral B12, 1 mg per day, has also been shown to be helpful. 
• N-acetylcysteine (50 to 200 mg TID) and selenium (50 to 200 mcg/day) increase glutathione peroxidase activity and protect lung tissue from oxidative damage. 

Herbs 

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted. 

Green tea (Camellia sinensis) is a powerful antioxidant and contains theophylline. Drink 1 to 2 cups/day. 

For long-term lung support, combine equal parts of the following herbs in a tea and drink 3 to 4 cups/day. Licorice root (Glycyrrhiza glabra), coltsfoot (Tussilago farfara), wild cherry bark (Prunus serotina), elecampane (Inula helenium), plantain (Plantago major), and skullcap (Scutellaria lateriflora). Licorice root is contraindicated in hypertension. If given, blood pressure should be checked every six weeks. Coltsfoot contains pyrrolizidine alkaloids that can be hepatotoxic with prolonged use. Pyrrolizidine alkaloid-free coltsfoot products still have the desired therapeutic effect. The rest of the herbs in this section should be used only under the supervision of a physician. 

For a stronger formula to be used during periods of exacerbation, combine the following herbs in a tincture, 20 to 60 drops tid to qid. Ginkgo (Ginkgo biloba), thyme leaf (Thymus vulgaris), skunk cabbage (Symplocarpus factida), khella (Ammi visnaga), grindelia (Grindelia robusta), and valerian (Valeriana officinalis). Caution should be used when combining ginkgo with anticoagulant therapies. Ginkgo may reduce platelet aggregation. 

For acute antispasmodic action combine the following herbs in a tincture, 5 to 10 drops every 15 minutes up to eight doses. Indian tobacco (Lobelia inflata) two parts, thyme leaf (Thymus vulgaris) one part, ginger root (Zingiber officinale) one part, gelsemium (Gelsemium sempiverens) one part, ma huang (Ephedra sinica) 1/2 part, and belladonna (Atropa belladonna) 1/2 part. These herbs may produce toxic side effects and should be used under physician supervision and with caution. 

Essential oils that may be helpful are elecampane, frankincense, lavender, mint, and sage. Add 4 to 6 drops in a bath, atomizer, or humidifier.

 

Homeopathy 

An experienced homeopath should assess individual constitutional types and severity of the disease to select the correct remedy and potency. For acute prescribing use, 3 to 5 pellets of a 12X to 30C remedy, every one to four hours until acute symptoms resolve. 

• Arsenicum album for asthma with restlessness, anxiety, and fear of death Ipecac for constant constriction in the chest with an incessant cough that may lead to vomiting 
• Pulsatilla for asthma with pressure in the chest and air hunger. The patient may be thirstless and weepy 
• Sambucus for asthma that wakes the patient at night with the sensation of suffocation 

Physical Medicine/Hydrotherapy

Cold applications to the chest during an acute attack may lessen the severity. 

Contrast hydrotherapy may tone the lungs. Alternating hot and cold applications brings nutrients to the site and diffuses metabolic waste from inflammation. The overall effect is decreased inflammation, pain relief, and enhanced healing. If possible, immerse the part being treated (as with an extremity). Alternate three minutes hot with one minute cold. Repeat three times to complete one set. Do two to three sets/day. 

Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory. Apply oil directly to the skin, cover with a clean soft cloth (e.g., flannel) and plastic wrap. Place a heat source (hot water bottle or heating pad) over the pack and let sit for 30 to 60 minutes. For best results, use for three consecutive days. 

Acupuncture 

Acupuncture can be helpful for reducing the frequency and intensity of asthma attacks.

 

Massage 

Therapeutic massage may help reduce stress which exacerbates hypersensitivity reactions. 

Patient Monitoring

 

Patient education and compliance with inhaler and drug administration are designed to prevent asthma attacks. A peak-flow meter should be used at home; instruct patient to notify provider if it drops below 70% of baseline.

Other Considerations 

Prevention 

Conservative introduction of solid foods as child is weaning may help prevent hypersensitivity conditions. If there is a strong family history of allergies or atopic conditions and/or if the child's immunity has been compromised in infancy, delay the introduction of highly allergenic foods, such as grains and dairy, until one year or older. 

Prognosis

 

Good with attention to health and proper use of medications.

References

Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace Publishers; 1995:40-41. Hope BE, Massey DB, Fournier-Massey G. Hawaiian materia medica for asthma. Hawaii Med J. 1993;52:160-166. Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North Atlantic Books; 1992:21-27. Middleton E, ed. Allergy: Principles and Practice. 5th ed. St. Louis, Mo: Mosby-Year Book, Inc; 1998. Monteleone CA, Sherman AR. Nutrition and asthma. Arch Intern Med. 1997;157:23-24. Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed. Rocklin, Calif: Prima Publishing; 1998:150-155. Rakel RE, ed. Conn's Current Therapy. 50th ed. Philadelphia, Pa: WB Saunders Co; 1998. Regards INTEGRATIVE MEDICINE