The Encyclopedia of Asthma and Respiratory Disorders (Facts on File Library of Health and Living)

THE ENCYCLOPEDIA OF

ASTHMA AND RESPIRATORY DISORDERS

THE ENCYCLOPEDIA OF

ASTHMA AND RESPIRATORY DISORDERS Tova Navarra, B.A., R.N. Foreword by Charles K. Dadzie, M.D., F.A.A.P., F.C.C.P., Director of Pediatric Pulmonology and Critical Care Medicine, Jersey Shore Medical Center, Meridian Health System; Clinical Assistant Professor, Pediatrics, U.M.D.N.J., Robert Wood Johnson Medical School

The Encyclopedia of Asthma and Respiratory Disorders Copyright © 2003 by Tova Navarra All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage or retrieval systems, without permission in writing from the publisher. For information contact: Facts On File, Inc. 132 West 31st Street New York NY 10001 Library of Congress Cataloging-in-Publication Data The encyclopedia of asthma and respiratory disorders / Tova Navarra ; foreword by Charles K. Dadzie p. cm. Includes bibliographical references and index. ISBN 0-8160-4467-8 1. Respiratory organs—Diseases—Encyclopedias. 2. Asthma—Encyclopedias. I. Title. RC732 .N37 2002 616.2’38’003—dc21 2002002445

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To Vincent Paul Fleming, my first grandchild, whose every breath reinforces and imbues my life with all manner of inspiration.

CONTENTS Foreword

Preface

Acknowledgments

xiii

Introduction

Entries A–Z

Appendixes

215

Bibliography

377

Index

381

FOREWORD pig in her bedroom. Sometimes she even let the guinea pig on the bed. When I did a radioallergosorbent test (RAST) on her, I found her to be a Class 6 for allergy to guinea pigs! I believed she should get rid of the pet, but it’s very hard to tell a kid to do that. So she takes Serevent and other medications that help ward off asthma attacks. Parents of children who have been diagnosed with asthma, as well as those parents who have been questioning the validity of giving their children drugs to control asthma, will find this book extremely informative and useful. This book will help in understanding some of the basic concepts and definitions of asthma that have boggled their minds for a while. Tova Navarra has a knack for making complex concepts and definitions easy to comprehend. This quality is easily appreciated in perusing her previous publications The Encyclopedia of Allergies, Second Edition and The Encyclopedia of Vitamins, Minerals and Supplements. She has written this book, The Encyclopedia of Asthma and Respiratory Disorders, with both professional and lay public in mind because they can all benefit from reading it. No one with interest in asthma should be without this book. Tova Navarra, an erudite clinical professional, has done it again!

sthma is a very common problem worldwide with incidence in the United States on the rise, especially among children. I remember a 12-year-old patient of mine some years ago whose pulmonary status was that of severe obstruction. I first saw him when he was in the intensive care unit, but he refused to come for continuous care. He took his medications at home. He was a tough kid—one of the toughest I’d ever encountered—and he was angry and did not accept that he had life-threatening asthma. I warned his parents, and I sat down with him to tell him with proper treatment he could be like any other kid. He said, “I’m not like any other kid, and I won’t go to the emergency room.” Unwilling to seek preventive measures, the boy died. A preventable death. Another patient of mine, about nine years old, thought he had only mild asthma. I’ll never forget him, because he wanted to go to a slumber party with his friends, much to the dismay of his mother, who was accused of being overprotective. He needed treatment episodically, and his mother agreed to let him go to the party as long as he took his inhaler with him, which he did. The group then went to a recreational facility similar to Great Adventure, where the boy must have felt sick but was hiding it because he didn’t want to have to leave the party. He collapsed. By the time people got him to the ER, he was brain dead. Again, preventable. A somewhat happier story involves a 13-yearold girl I was treating with continuous nebulization for frequent asthma attacks. She kept a pet guinea

—Charles K. Dadzie, M.D., F.A.A.P., F.C.C.P., Director of Pediatric Pulmonology and Critical Care Medicine, Jersey Shore Medical Center, Meridian Health System; Clinical Assistant Professor, Pediatrics, U.M.D.N.J., Robert Wood Johnson Medical School

PREFACE 548,000 people in the United States and 20 million worldwide. Today, flu and pneumonia combined are the sixth leading cause of death in America, which warrants many physicians’ urging their patients to get a “flu and/or pneu” shot each year well before the difficult cold weather is able to stress the human system a bit more than warmer temperatures do. It seems, too, that when hay fever lets up, the common cold rushes in. The “heat” is on to protect our respiratory systems in an age that claims to be more aware and knowledgeable about prevention, but, unfortunately, prevention remains the most elusive of common medical and hygienic practices. Organizations such as the American Lung Association and others seek to answer as many questions as they can as a way to educate the general population, sponsor research toward cures and treatments, and keep tabs on the trends and statistics related to respiratory disorders, lest we become complacent and thereby vulnerable to whatever new or old strain of microorganism may be waiting in the wings. This book’s “reason to breathe” is to promote prevention and add comprehensively and accessibly to the literature on diseases that affect our airways, which more often than not we take for granted.

reath is life, and breathing disorders threaten life. Lung disease is the third leading cause of death in America. Over the last decade, the death rate from lung disease has been growing faster than the death rate from almost any other leading killer. Approximately 30 million people in the United States suffer from some form of chronic breathing disorder, which generates a cost of $85 billion in health care a year. It is important to realize that 5 percent of all adults and 10 percent of children in the United States suffer from asthma, according to the American Medical Association. Asthma is the most common diagnosis among children’s diseases, and it seems to be on the rise because of increased air pollution and, possibly, increased stress factors. More than 5,000 people die from asthma each year, a good portion of them children and blacks. In addition to asthma, other enemies of breath are still lurking among millions of people all over the world. Tuberculosis has made a comeback with resistant strains of the Mycobacterium. Lung cancer and emphysema haven’t ceased to haunt persistent smokers as well as strike nonsmokers for some known and some unknown reasons. Influenza, bronchitis, and pneumonia continue to loom large every winter, particularly for infants, the infirm, and the elderly. In 1918, a flu epidemic killed

—Tova Navarra, B.A., R.N.

ACKNOWLEDGMENTS

henever I face the daunting task of writing a book that must be scientific, accurate, comprehensive, and accessible, I realize the importance of those who encourage me and provide valuable assistance. For their generous help with this volume, I heartily thank my daughter and journalist/lyricist, Yolanda Fleming, the late Myron A. Lipkowitz, R.P., M.D., my former coauthor, and Martin Corbo, who provided important reference materials. I offer a very special thankyou to Jim Reme. Many thanks to Dr. Charles Dadzie for praising my work so highly and adding his distinguished name to this book. In addition, Facts On File’s James Chambers and his staff are excellent, diligent editors with whom I am honored to work, and my agent Faith Hamlin deserves high praise for making a “perfect match.” Thanks also go to Frederic C. Pachman, director of the medical library at Monmouth Medical Center in

Long Branch, New Jersey. I am also infinitely grateful to Victor Zak, Paul Boyd, Bunny Schuler, Mona Wichman, Dorothy Fox, Johnny and Mitzi Navarra, Guy, Amanda, and Wesley Fleming, Jacquie, Tony, and Matthew Munoz, Lilo Meany, Sallie and Stan Tillman, Jordan Stinemeyer, Trista Clayton, Richard Conley, Dr. Andrea Campbell, and Betty Sorrentino, who lighten and brighten my days, do me endless favors, and tolerate a lot of whining. Finally, I feel moved to acknowledge a CD entitled One Single Breath, produced in 2000 by my daughter and son-in-law (Yolanda and Guy Fleming) as I began to write this book. The music is meditative and nothing short of awe-inspiring. The group itself, called One Single Breath, hopes to promote and raise money through its music for a charitable organization that focuses on asthma and breathing disorders.

xiii

INTRODUCTION Losing my breath again, never wanted to, what am I to do, can’t help it.

of breathing by conducting an exercise in which people were instructed to breathe in rhythm with each other. If nothing else, the exercise induced a keener awareness of taking in and letting out that all-important air, and brought to mind the 1974 pop song performed by the Hollies whose refrain ends with the line, “All I need is the air that I breathe and to love you.” Inspiration also means, perhaps more literally than we think, having ideas, decisions, or other concepts “breathed” into our minds from “nowhere,” usually toward a creative goal. “Breathtaking” is often the adjective that applies well to the panoramas of the Rocky Mountains, Michelangelo’s David, and other wondrous accomplishments. To be deprived of breath seems the ultimate enemy. Impaired breathing of any sort, frequently explained within the categories of various respiratory disorders, may be as symbolic as it is physical and is employed heavily as an artistic motif. In emergency medicine, one relates immediately to the choking victim’s hand at his throat—an image instinctively meant to alarm others—indicating that he can’t breathe. Similarly in literature and other arts, the plight of society’s victims may well be intensified by a respiratory disorder. Mildred in Somerset Maugham’s Of Human Bondage and Thomas Mann’s protagonist in The Magic Mountain suffered from tuberculosis. The leading female characters of the 1937 film Camille, Kathryn Hulme’s The Nun’s Story, and Puccini’s opera La Boheme also had TB. In the television series

—from “Falling in Love Again,” the signature song in the film The Blue Angel

Inspiration. From the Latin inspirare, to breathe in, we inherit a word that has dual meaning. First and foremost, it gives verbal acknowledgment to the most fundamental of all human activities: to take in the air our bodies crave in order to live. It tops the medical list of priorities commonly known as “ABC,” a mnemonic for assessing the status of emergency patients’ airway, breathing, and circulation. Breathing ranks supreme in religious teachings as well. In The Upanishads: Breath of the Eternal, part of the oldest Hindu scriptures, it is written: “O Prana, lord of creation, thou movest in the womb, and art born again. To thee, who, as breath, dwellest in the body, all creatures bring offerings.” Pranayama refers to yoga exercises during which one concentrates intensely on breathing patterns. The Incan word for God is expressed as “ha” in a forceful puff of air without the need for any more than a whisper-like sound—as much a reverence for the Greater Power as for the very ability to breathe. The exchange of oxygen for the exhaled carbon dioxide, then, goes far beyond the human requirement for the preferred gas, as author Dannion Brinkley put it, to symbiotic breathing described as “in for me, out for the universe.” He pointed even more emphatically to the significance

xvi The Encyclopedia of Asthma and Respiratory Disorders I, Claudius, the demented Caligula solved his intolerance of a young boy’s chronic cough by having him beheaded. On the lighter side, the hapless Adelaide in Broadway’s Guys and Dolls sneezed endlessly and worried about catching “la grippe” because her fiance, Nathan Detroit, kept eluding a wedding day. One may speculate whether the character called Wheezer in The Little Rascals had asthma or some breathing or allergy problem. In one episode, he suffers a coughing fit when he is near ducks. Many a dark-humored line in television sitcoms refers to an asthmatic child’s missing inhaler. Monmouth University photographer Jim Reme remembers his Little League coaching days during which one of his players had asthma. Before each game, the boy would give Jim custody of his inhaler and forget to retrieve it afterward. Late into the night, Jim would receive a call from the boy’s mother asking for the inhaler’s safe return. Real-life stories offer as much drama and impact as fictional ones. In December 1988, artist Linda Troeller exhibited 20 photocollages entitled TB-AIDS Diary at the City Without Walls Gallery in Newark, New Jersey. The images drew biting parallels between the disease that attacked her mother and countless others in the 1930s and the disease of the 1980s that initially burst into the male hom*osexual community. In both cases, the artist said, the diseases are deadly and infectious, and the victims have been stigmatized by people around them out of ignorance and fear. Dr. Richard Conviser, then health policy analyst of the State Department of Health in Trenton, New Jersey, praised Troeller’s exhibit, which won the PhotoMetro portfolio award in 1987 and other recognitions. On the everyday scene, one woman recounted to a group of friends that after she had legally parked in a spot designated for those with handicapped symbols on their cars and walked to a store, a man confronted her and said angrily, “You don’t look handicapped to me!” “Sir,” she replied, “I have a breathing disorder.” Asthma—the disorder synonymous with a chronic delicacy of constitution and the bane of famous individuals including French novelist Marcel Proust—beleaguers one of William Golding’s

protagonists in Lord of the Flies. In the book’s first chapter, Piggy, as he is called, admitted his physical ineptitude to the robust leader, a boy named Ralph: “‘My auntie told me not to run,’ he explained, ‘on account of my asthma.’ ‘Ass-mar?’ ‘That’s right. Can’t catch me breath. I was the only boy in our school what had asthma,’ said the fat boy with a touch of pride. ‘And I’ve been wearing specs since I was three.’”

The impact of asthma is clear, particularly for children who are set apart by it. Representative Nita M. Lowey of New York referred to the number of children suffering from asthma as “nothing short of a crisis,” following news reports in May 2000 that about 130,000 children in New York City are afflicted and that asthma is the leading cause of absenteeism from school. The recent film As Good as It Gets, which earned actors Jack Nicholson and Helen Hunt Academy Awards, focuses on a woman’s son who has severe asthma, and because she has limited resources and keeps taking him to the emergency room for treatment, the child receives no continuous medical care or follow-up until the protagonist appears and offers to pay for the doctors. This is not unlike situations that actually happen, and, unfortunately, all too often. On a larger scale in real life, as historian Paul Boyd wrote, there is the “well-documented phenomenon called ‘the toxic ghetto.’ The term reflects the fact that where there’s a dirty manufacturing plant, a smokestack industry, a landfill or a dump looking for a site, disproportionately, the selection falls on poor neighborhoods. The result is that bad-ecology illnesses are poverty illnesses in toxic ghettos, probably with asthma as one of the top outcomes.” The Centers for Disease Control and Prevention (CDC) reported in a 1998 survey that black children were 31 percent more likely than white children to have had an episode of asthma or an asthma attack during the previous year. Lara Akinbami, of the CDC’s National Center for Health Statistics, said, “In 1998, 68 out of 1,000 black children had asthma versus only 52 out of 1,000 white children. Black children are much more likely to be hospitalized or die from asthma.” So the

Introduction xvii racial gap expands for young people with a chronic respiratory disease. In addition, more inner-city children fall victim to asthma triggered by co*ckroach and mouse allergens than by cats, dogs, and house-dust mites, according to a federally funded report. Researchers at Johns Hopkins University found that in eight urban areas studied, 95 percent of the tested homes harbored mouse allergens, and 18 percent of the children who live in them are allergic to mice and tend to have severe asthma. In 1996, information from the National Cooperative Inner-City Asthma Study conducted in Baltimore, Washington, the Bronx and Brooklyn in New York City, St. Louis, Chicago, Cleveland, and Detroit brought forth the discovery that, of the 1,528 children ages 4 to 9 in the study, all had asthma and lived in communities in which 30 percent or more household incomes dipped below the 1990 poverty level. Hence, “inner-city asthma” has become a bona fide diagnosis attributable to insects, rodents, and the rank of the underprivileged. Urban areas in which there is a significant amount of industry—and the bad air that accompanies it—thunder into the picture as well. The New York Times reported on February 28, 2001, that the U.S. Supreme Court unanimously decided “in setting national air quality standards, the Environmental Protection Agency must consider only the requirements of public health and safety and may not engage in the cost-benefit analysis that a coalition of industry groups sought to import into the (Clean Air Act) statute. . . . The decision today dealt with new standards for two pollutants—groundlevel ozone, which causes smog, and fine airborne particles, commonly known as soot—that the Environmental Protection Agency issued in 1997.” At last, facing the grim toll taken by asthma, bronchitis, and other respiratory disorders caused and/or aggravated by air pollution, the federal government has rejected an industry attack in one of the most important environmental rulings in years. The Asthma in America: Executive Summary, conducted by Schulman, Ronca & Bucuvalas, a national research firm specializing in health issues, took the asthma connection a few steps further into the realm of what might be called the “secondary smoke” of the condition: “Nearly half of the

American public (48 percent) have had asthma themselves, or in their household, or in their immediate family. Another three out of 10 (29 percent) know friends, coworkers, or someone else personally who has asthma. Hence, nearly four out of five Americans (77 percent) are affected.” It stands to reason that if the person next to you, familiar or unfamiliar, suddenly starts gasping for air, your psyche will be moved. “‘I didn’t want to wake up this morning,’ said Northwestern coach Randy Walker, still fighting back tears and trying to control his emotions yesterday afternoon. . . .” in the Asbury Park Press’s August 5, 2001, story about a college football player. “The breathing problems that forced Rashidi Wheeler out of a conditioning drill didn’t seem to be any different from the 30 other asthma attacks he’d had while playing football the past three years. But the Northwestern safety was never able to catch his breath Friday afternoon and later died. Bronchial asthma was the preliminary cause of death, the Cook County coroner’s office ruled yesterday.” Boyd also points out that asthma has been dubbed “The Breath Robber You Can Stop.” Numerous self-help books for adults and children with asthma pepper the shelves, including Go Blow Your Nose, Robert! by Nancy Sander, president of the Allergy and Asthma Network/Mothers of Asthmatics, Inc., based in Fairfax, Virginia. In addition, the pervasive disorder prompted a movement called “asthma-friendliness” in schools, and asthma camps provide a tremendous service for children who may not otherwise be able to enjoy summer outdoor sports and activities. Modern literature and scientific advances stand as the fine result of an entire time-line of effort and study so people can “breathe easier,” as the saying goes. As early as the second century A.D., Aretaeus of Cappadocia described “bronchial asthma,” a term widely used for hundreds of years. In 1565, Leonardo Botallo described an asthma-like condition he called the “Rose Cold.” J. B. van Helmont in 1607 wrote of “spasmodic attacks of difficult breathing” with symptom-free periods between attacks. In 1713, Ramazzini recognized a hypersensitivity-pneumonitis-like lung disease in grain workers. The English physician John Bostock in 1819 was one of the first to describe multiple cases

xviii The Encyclopedia of Asthma and Respiratory Disorders suggestive of hay fever, which was called “Bostock’s summer catarrh.” Eleven years later John Elliotson noted a patient’s observation that pollen might be responsible for his symptoms. In 1890 Robert Koch discovered and extracted the tubercle bacillus, Mycobacterium tuberculosis, that causes tuberculosis. A worldwide malady transmitted by the inhalation of minute droplets from the cough or sneeze of an infected person, tuberculosis is still one of the chief causes of death in Third World countries. Even animals, such as cattle and other domestic animals, are susceptible to certain forms of TB. During the early 20th century, poor hygienic standards and periods of war and catastrophe resulted in high death rates from tuberculosis, but the drugs rifampin, isoniazid, para-aminosalicylic acid, and streptomycin eventually came about to fight it. Before the drugs were developed, sanatoriums operated to foster good nutrition, hygiene, fresh air, and exercise for the prevention and treatment of the disease. Potions falling under the moniker of folk medicine had their day, too. Until 1905 when coca leaf extracts were eliminated from Coca-Cola’s original formula, which contained “a little something to put color in your cheeks,” as Dr. Sigmund Freud put it, heroin was a popular over-the-counter cough suppressant. No doubt it was so effective that some patients saw to it they never coughed again. Recently, tuberculosis made a gruesome comeback in Japan, particularly in the elderly who had at one time been exposed to the infection but did not previously exhibit symptoms. A New York City television newscast of February 11, 2001, reported that Japanese officials were embarrassed that a disease for which there has been effective early detection and treatment for decades re-exploded among the frailest of their population. Tuberculosis has also presented as a complication in AIDS patients, in which the victim’s immune system cannot effectively ward off the invader, and in emigrants from certain countries who arrive in the United States with the infection, who do not understand contagion, and may refuse to comply with hospital treatment that seems to them like a punishing incarceration. Professionals as well shared in some of the misunderstandings that unwittingly allow disease to

flourish. After Dr. Alexander Fleming of St. Mary’s Hospital Medical School in London brought forth penicillin in 1928, it languished unused for nearly 10 years. By 1943, people had to pay $20 per 100,000-unit dose of the drug that proved effective against pneumonia and a host of other diseases. About 30 years passed after Austrian chemist Paul Gelmo discovered the white crystalline sulfanilamide in 1908, derivatives of which were eventually recognized as enemies of Staphylococcus and Streptococcus infections, pneumonia, meningitis, dysentery, and leprosy. The history of pathology always includes an evolution of sorts, for as one “devil” is recognized and perhaps conquered, another appears. In the late 19th century, Henry Salter concluded a correlation between asthma and hay fever and animal exposure. Sir Henry Dale discovered histamine in 1910 while working on rye poisoning by ergot. He noted the shock-like drop in blood pressure histamine caused by its effect on smooth muscle. Three years later, W. P. Dunbar reproduced the symptoms of hay fever using pollen extracts. Also in the 1900s Charles F. Cole established a test for histamines, and in the 1920s, Kern, Cooke, and Storm van Leeuwen demonstrated that many asthmatics had positive skin-test reactions to house dust. Storm van Leeuwen also removed asthma patients from their homes to demonstrate that changing one’s environment could improve asthma. Medical studies progressed. In 1942, the French produced the first antihistamine safe for human use—phenbenzamine (Antergan), closely followed by pyrilamine maleate (Neo-Antergan). In the United States, researchers developed diphenhydramine (Benadryl) and tripelennamine (Pyribenzamine). In 1950 corticosteroids were first used to treat asthma. The history of medicine continued to make stride after stride in the effort to treat or eradicate both major and minor infections and to understand the body’s immune system and why it suffered repeated attacks of determined microorganisms. Enter the “super bug” of the 21st century. “Shortly after the introduction of penicillin-G in the 1940s, it was recognized that certain strains of staphylococci have a potent enzyme called ßlactamase which inactivates penicillin,” writes

Introduction xix Jacqueline Fuccello-Breuer, R.N., in the February 5, 2001, issue of the New York-New Jersey Nursing Spectrum. “In patients with such staphylococcal infections, penicillin-G has no therapeutic effect. Since then some organisms have not only developed resistance to one antibiotic, but have developed resistance to many. Pharmaceutical companies in the 1970s and into the late 1980s developed newer and stronger antimicrobial agents—three generations of cephalosporins and the fluoroquinolones. These antibiotics were considered sophisticated enough to control bacterial infections; and drug development efforts were redirected to cardiovascular, metabolic, and psychoactive drugs.” Fuccello-Breuer goes on to describe the toll of “super bugs” as a major new health problem and how we’ve set the stage for their success: “Ninetyfive percent of physicians in office practice issue one or more prescriptions to a patient diagnosed with the ‘common cold.’ Similarly, a hospital study revealed that there was no evidence of infection in as many as 70 percent of patients who received antimicrobial therapy.” In the category of “super bugs” also stands the problem of vermin- and insect-related incidences of asthma, particularly in New York City, where the respiratory environment is compromised. In the article “Asthma: A Public Health Partnership Tackles a Neighborhood Terror” (Columbia University Magazine, Winter 2001), author Dodi Schultz says the Columbia Center for Children’s Environmental Health (CCCEH) was established in 1998 “with the far-reaching mission of preventing environmentally related disease in children. It receives support from the National Institute of Environmental Health Sciences (NIEHS), the Environmental Protection Agency (EPA), and several foundations. Its ‘patients’ are the children of northern Manhattan and the South Bronx. Its special areas of concern are three: low birthweights coupled with impaired growth and development; unusually high, and inexplicably rising, local rates of childhood cancer; and—the primary child-health concern as perceived by both researchers and residents themselves, based on community surveys—the devastating impact of asthma. Asthma levels in the Columbia study area are startling: In the South

Bronx, 17 percent of all children—two of every dozen kids—are asthmatic.” The study expects to involve 600 African-American and Latino women and their children through prenatal clinics. CCCEH director Frederica Perera said this is a pioneering study to examine prenatal and perinatal influences on the children’s medical status through analysis of the home environment, and blood and other body-substance analysis. Reported exposure to tobacco smoke, for example, may be assessed through cotinine levels (cotinine in the urine is considered a biomarker for exposure to nicotine). The study also plans to include environmental factors such as pollutants—ozone, oxides of sulfur and nitrogen, particulates (ash and soot), etc.— because they affect the quality of breathable air. “Particulate matter—known in the trade simply as PM—broadly includes all small airborne solids, ranging in size from visible smokestack effluent to the tiniest microscopic bits,” according to Schultz. “It’s the latter category that worries pulmonary specialists and public-health researchers, in particular those particles known as PM2.5; that designation denotes those with a diameter of 2.5 microns or less. Larger particles, as irritating as they are, are relatively harmless, since they’re trapped, coughed up, or blown out of the nose. The smaller particles, though, easily penetrate the bronchial tubes and even the lung’s small passageways. Researchers have repeatedly found these particulates statistically associated with markedly higher risks of disease and death.” Diesel and other exhaust fumes from vehicles are another concern to be addressed by the Columbia study, along with dust mites, co*ckroaches, pets, and other aspects of what has been dubbed “the toxic home.” The leading investigator on the CCCEH asthma project is Jean Ford, M.D., chief of pulmonary medicine at Harlem Hospital. He also heads the Harlem Asthma Research Team (HART), which operates (in affiliation with Columbia) under a grant from the National Institutes of Health. Ford is also a member of the National Heart, Lung, and Blood Institute’s expert panel on asthma management, and sits on the board of West Harlem Environmental Action (WE ACT), an activist group dedicated to environmental justice.

xx The Encyclopedia of Asthma and Respiratory Disorders While New York City, with the highest asthma mortality rates in the country, combats asthma and respiratory disorders, the diseases exist all over the globe. Schultz goes on to report that “scientists are more and more inclined to believe that, while who you are (family, race) may play a part, what you do and where you live may play far more significant roles. Speculations have postulated roles for factors ranging from day care and too many (or too few) childhood infections to junk food and use of computers. But we are, after all, talking about the lungs. The most significant factor of all may be the air you breathe, both indoors and out. The ethnic groups with the highest incidence are chiefly city dwellers. Even within broad ethnic groups, noted differences—again, particularly in acute-attack data—may be suggestive. Asthma mortality rates, for example, are markedly higher among Hispanics from the Caribbean; the rate among Puerto Ricans is approximately four and one half times that of Mexican Americans.” New drugs are being investigated to help fight all the entities that terrorize the respiratory system, but risk is always at hand in well-meaning research. A June 15, 2001, article in The New York Times reports that a 24-year-old healthy volunteer in a Johns Hopkins University breathing study died June 2 after inhaling hexamethonium, a drug used to determine how the lung protects the airways from narrowing, which plays a crucial role in asthma. The drug had been used in several studies of lung physiology at leading academic medical centers without any unexpected ill effects, said Johns Hopkins, but volunteer Ellen Roche died from progressive lung and kidney failure brought on by hexamethonium inhalation. The day after the chemical was administered to her, Ms. Roche

developed a cough, fever, runny nose, and fatigue. Before her death, the article says, “a CAT scan revealed that her lungs had the appearance of ground glass, indicating severe damage, and two days later she was put on a ventilator.” The study has been suspended, and the case is now under federal investigation. One may conclude that breathing, which ought to be easy, is all too frequently impaired either voluntarily or involuntarily. Alexander Lowen, M.D., said, “Most people are poor breathers. Their breathing is shallow, and they have a tendency to hold their breath in any situation of stress. Even in such simple stress situations as driving a car, typing a letter, or waiting for an interview, people tend to limit their breathing. The result is an increase of their tension.” Furthermore, Paul Bragg said, “Shallow breathers poison themselves,” and Hans Weller, M.D., said, “Nearly every physical problem is accompanied by a disturbance of breathing. But which comes first?” Andrew Weil, M.D., agrees that “improper breathing is a common cause of ill health.” According to the teachings of Tibetan mystics, “mastery over breath conquers all passion, anger and carnal desires, acquires serenity, prepares the mind for meditation and awakens spiritual energy.” Thich Nhat Hanh adds, “Without full awareness of breathing, there can be no development of meditative stability and understanding.” Given that we take between 17,000 and 20,000 breaths each day, it seems reasonable to believe that breathing truly does create a bridge between body and spirit. We all are breathing beings. It is our responsibility to honor and respect each breath and the intriguing physical system that facilitates it.

ENTRIES A–Z

A acquired natural, or “active,” immunity results when B cells and T cells of the immune system are “programmed” at the time of first exposure to an invading microorganism. In response to a foreign antigen, B cells and T cells manufacture antibodies that remember and attack the invader if it is encountered in the future. Mounting an immune response depends on one’s inherited disposition to do so to a particular antigen. Vaccinations (immunizations), as well as invading infections, can stimulate acquired active immunity. This immunity then prevents a manifestation of a particular disease, or, in the event immunity develops in response to having an active disease, or from contracting the disease again. Active immunity differs from passive immunity in that preformed antibodies injected into the body allow a more immediate protection. The advantage of active immunity is its longer lasting, perhaps lifelong, protection. A disadvantage is the delay between administration of a vaccine and its effectiveness. Active immunity is the basis for the immunizations known as “baby shots” because infants are usually immunized shortly after birth against a variety of diseases. Vaccines contain killed, modified, or parts of microorganisms in sufficient amounts to trigger an antibody response without causing the actual disease. In rare cases, a subclinical infection, a weakened manifestation of a disease, is produced by the vaccine. Some live-virus vaccines have been sufficiently diluted to render them safe for immunization. The medical breakthrough of genetic engineering has allowed the manufacture of safer vaccines. The duration of immunity depends on the type of antigen, quantity encountered, and its means of entering the body, but active immunity generally

acapnia

The absence of carbon dioxide. From the Greek word akapnos, meaning smokeless, acapnia indicates a level of carbon dioxide lower than the normal amount found in blood and bodily tissues, such as the level resulting from voluntary overbreathing or hyperventilation. Symptoms of acapnia include depressed respiration, giddiness, paresthesia, cramps, involuntary contractions of the fingers and, on occasion, seizures.

Accolate The trade name for the drug zafirlukast, which is used to treat bronchoconstriction. See also ZAFIRLUKAST. acidosis, respiratory

An excess of acidity in body fluids. Also known as hypercapnic acidosis, respiratory acidosis may be the result of diabetes, renal disease, or an excessive loss of bicarbonate (or alkalinity). The body requires an acid-base balance for optimal functioning. Therefore, when the hydrogen ion concentration increases, the pH decreases and causes an imbalance, or acidosis. Carbon dioxide acidosis is another form of excessive acidity caused by carbon dioxide retention, particularly as a result of drowning or a situation in which there is decreased respiration.

acquired immune deficiency syndrome (AIDS), respiratory complications of See AIDS. active immunity

Protection from disease via the body’s production of antibodies in response to a foreign, potentially pathogenic, organism. In the fifth century B.C., Greek physicians observed that persons who had recovered from the plague were immune to subsequent attacks of the plague. This

2 acupressure lasts from many months to a lifetime. Active immunity requires an inductive (latent) period between immunization and the development of protective antibodies. This process could take from several days to several months and may require “booster” doses of the vaccine. Some immunizations that produce active immunity are tetanus, diphtheria, pertussis, poliomyelitis, measles, mumps, Rubella or German measles, Haemophilus influenzae type b, viral influenza (flu), pneumonia, and hepatitis vaccines. These immunizations are given according to a schedule recommended by the Centers for Disease Control and Prevention. See also ALLERGY SHOTS; INFLUENZA; IMMUNITY, PASSIVE; AND VACCINE.

acupressure

Similar to acupuncture, a technique involving use of the fingers to press on the appropriate body meridians to unblock stagnant energy at painful sites. See also ACUPUNCTURE.

In an article in the National Auxiliary Publication Service (NAPS) (from the American Society for Information Science), Bryan Frank, M.D., president of the American Academy of Medical Acupuncture (AAMA), said, “Treating allergies with medical acupuncture stimulates the immune system to help the body more efficiently heal itself, diminishing the frequency and severity of allergic reactions.” A medical acupuncture session includes an extensive medical history and physical examination, possibly a prescription for medication, and the stimulation of points on the body that correspond to the symptoms experienced by each individual patient, which “customizes” the treatment. The AAMA encourages allergy sufferers to consider acupuncture treatments in conjunction with allopathic treatments. The AAMA’s patient referral service may be accessed by calling (800) 521-2262 or visiting www.medicalacupuncture.org.

acute mountain sickness

See

ALTITUDE SICKNESS;

PULMONARY EDEMA.

acupuncture

An ancient Chinese technique for reducing pain and/or promoting restoration which calls for the insertion of extremely fine needles into the skin over points related to other parts and functions of the body. A point near the wrist, for example, is associated with respiration. Acupuncture is said to be effective in treating sinusitis, asthma, pains and addictions (including depression), and many other digestive, nervous, musculoskeletal, and respiratory conditions. Traditional Chinese medicine refers to the qi or chi (pronounced chee), the life force or a flow of healthy energy along specific channels or meridians. Disease is thought to be caused by the blockage in one or more of these meridians, and the goal of acupuncture is to relieve the blockages at any of the 14 major “acupuncture points” or meridians. Each meridian contains numerous points and serves as a site for the insertion of the needles. Studies suggest that acupuncture stimulates the release of the body’s natural, opiate-like substances called endorphins. Endorphins act as painkillers, sometimes as effective as morphine or anesthesia, and are thought also to contribute to the feeling of well-being.

addiction A physical and often psychological dependence on a substance such as a narcotic, alcohol, or tobacco that affects the central nervous system. Repeated use and abuse of these substances may lead to substantial debilitation of one’s health and well-being, and increased dependence may lead to overdose and death. When an addict does not get the substance his body craves or when use of the substance is discontinued, withdrawal symptoms (also known as delirium tremens, or DTs) occur. Individuals who smoke, for example, develop a dependence on nicotine, which frequently leads to mouth, throat, lung, and other serious illnesses. Treatments abound for addictions of all types and include behavior modification, in which an individual is counseled psychologically as well as weaned off a particular substance by using increments of smaller and smaller doses until the dependence is gone. See also LUNG CANCER; SMOKING, PASSIVE; SMOKE POISONING. adenoids

Lymphatic tissue, the same as the pharyngeal tonsils, named from the Greek word for

aeroallergens 3 “glandular.” This tissue forms lymph fluid that contains nutrients and lymphocytes (white blood cells that help form antibodies), which fight infections by attacking pathogenic bacteria. Lymph is found throughout the body. The adenoids located on the wall of the nasopharyngeal area, often become overactive and swollen, resulting in nasal stuffiness. They can be removed by surgical adenoidectomy, or, when removed with the tonsils, a tonsillectomy, known as a “T and A” procedure. This is not routinely recommended as it was years ago, probably because it may be more advantageous to keep organs serving the immune system intact and also to avoid the risks of anesthesia. See also ADENOTONSILLECTOMY.

adenotonsillectomy A surgical procedure in which the tonsils and adenoids are removed. See also ADENOIDS. adult respiratory distress syndrome (ARDS)

A lung disease that causes difficulty in breathing, rapid breathing, rapid heartbeat, excessive sweating, pink, frothy sputum, rhonchi, and changes in the level of consciousness. Affecting approximately 150,000 people each year, with a statistic that half of these will die despite treatment, ARDS is attributed to abnormal permeability of either the pulmonary capillaries or the alveolar epithelium. Most patients diagnosed with ARDS have suffered a severe infection, trauma, or other illness, and the disease often strikes young patients who were previously healthy. Treatment includes assisted ventilation, the administration of oxygen, antibiotics effective against the infecting microorganism, tests for continuous positive airway pressure and positive end-respiratory pressure, adequate nutrition (parenteral [injected] nutrition if required), prevention of side effects of the patient’s immobility, and emotional support for anxiety of both the patient and his family.

adverse drug reactions

Hypersensitivity to medication that causes various symptoms, ranging from unpleasant to life-threatening, and may preclude a medication’s use as treatment. New medical guide-

lines have been established on drug hypersensitivity by a national task force of allergists/ immunologists and were published in the American College of Allergy, Asthma and Immunology’s (ACAAI) December 1999 Annals of Allergy, Asthma and Immunology. The guidelines, titled “Disease Management of Drug Hypersensitivity: A Practice Parameter,” are one of a series that includes asthma, allergy diagnostic testing, immunodeficiency, rhinitis, atopic dermatitis, anaphylaxis, immunotherapy, insect stings, and sinusitis. They are designed to help prevent medical errors. Risk factors for drug hypersensitivity include the chemical properties and molecular weight of a drug; dosage; route of administration; duration of treatment; repetitive exposure to the drug; concurrent illnesses; and a patient’s age, gender, atopy, and genetics. The new guidelines include components for clinical evaluation and diagnosis of drug hypersensitivity, including history, physical examination, and clinical tests. Parameters stipulate that prevention of allergic reactions may be accomplished by attention to: 1. 2. 3. 4.

A careful history to determine host risk factors; Avoidance of cross-reactive drugs; Use of predictive skin tests when available; Proper and prudent prescribing of drugs (especially antibiotics) frequently associated with adverse reactions, and 5. Use of oral medication in preference to parenteral (injected) drugs when possible.

aeration

The process of exchanging carbon dioxide for oxygen in the blood of the lungs. Aeration also refers to “airing” something out and to putting gases into a fluid.

aeroallergens Substances that, when transported through the air, are capable of causing an allergic reaction when inhaled by an allergic individual. Airborne allergens include pollen grains, fungal spores, and the so-called inhalant allergens such as house dust (which is actually a mixture of many allergens), dead dust mite bodies and pellets of their fecal waste, human and animal danders, and flakes of dead skin. Animal proteins from saliva

4 aerobic and urine become aeroallergens as they are absorbed into the environment. Cooking odors of highly allergenic foods and allergenic industrial chemicals behave in a similar manner. Most airborne allergens range in size from 2 to 60 microns (1 micron = 1/25,000 inch), but some are even smaller. Finer aerosolized particles may pass into the distant terminal bronchioles, but ragweed-sized pollen grains do not usually reach that far. Since most pollens do not reach the areas where bronchoconstriction is greatest, it is thought that reflex mechanisms occur when the allergen comes in contact with mucosal surfaces within its reach in the upper air passages. For some reason so far undiscovered, this triggers a spasm of the bronchial tubes and an asthma attack.

aerobic The characteristic of an organism or microorganism able to thrive in the presence of oxygen. Aerobic exercise, therefore, means physical activity that specifically uses and metabolizes oxygen to produce energy (as opposed to anaerobic exercise, which does not require inspired oxygen for energy and is limited to short bursts of strenuous activity; an anaerobe is a microorganism that can thrive in an oxygen-free atmosphere). Aerobic training fosters aerobic conditioning, generally with exercise three to five times a week for 20 to 30 minutes per session and at a level intense enough to produce a heart rate of 220 minus the age of the individual. Aerobic training is typically incorporated into cardiac and other rehabilitation programs. AeroBid

The trade name (also Nasalide) for the corticosteroid drug flunisolide, which is used to treat rhinitis, allergies, and nasal polyps. In metered doses obtained via nasal spray, flunisolide suppresses the migration of polymorphonuclear leukocytes. Contraindications include administering the drug to children younger than six years and to anyone with hypersensitivity to flunisolide. Precautions include nonasthmatic bronchial disease, bacterial, viral, or fungal infections of the mouth, throat, and/or lungs, respiratory tuberculosis, any untreated infection, pregnancy, and glaucoma. Flu-

nisolide is available as a nasal solution of 25 micrograms (Nasalide) or 250 micrograms (AeroBid).

aeropathy A disorder or condition caused by a significant change in atmospheric pressure. See also CAISSON DISEASE; EDEMA, PULMONARY. aerophobia

Morbid fear of fresh air or a draft.

aerosol

A solution administered in the form of a mist from a spray bottle or can. Aerosol therapy refers to the inhalation of beneficial aerosolized solutions, such as corticosteroids or mucolytic agents, by patients with asthma, bronchitis, emphysema, and other respiratory disorders. Aerosol devices include pressurized canisters called metered-dose inhalers, hand-held nebulizers, machine-powered jet or ultrasonic nebulizers, or dry powder inhalers. There are several types of aerosol nasal sprays. Aerosols are also used in the cosmetic and other industries. See also INHALATION THERAPY.

aerotherapy

The treatment of disease by using air, particularly changes in composition and density of air, such as a decompression chamber and hyperbaric oxygen. See also HYPERBARIC OXYGEN THERAPY.

aerothorax agonist

See

PNEUMOTHORAX.

A drug that mimics the body’s own regulatory function. An agonist binds to a cell’s receptors and stimulates the receptors’ function. There are at least two different receptor systems, alpha and beta. Alpha-adrenergic receptors are associated primarily with excitatory functions, such as the constriction of smooth muscle in blood vessels, bronchi, and the urinary bladder. They also cause relaxation of smooth muscle in the intestines. Stimulation of these receptors may raise blood pressure and increase heart rate. Beta-adrenergic stimulation primarily affects the airways or air passages by allowing smooth-muscle relaxation. There are beta1 and beta2 receptors and drugs that have very broad actions affecting both beta1 and beta2

AIDS 5 receptors. More selective drugs react primarily or only with the beta2 receptors. These medicines have fewer side effects and are the most frequently prescribed for the treatment of asthma.

AIDS A life-threatening disease caused by the human immunodeficiency virus (HIV) and characterized by a breakdown of the body’s immune defenses. The disease was first recognized in 1981 in a group of hom*osexual males in California, who were diagnosed as having a rare form of pneumonia, Pneumocystis carinii, seen only in immunosuppressed individuals. Then a rare cancer, Kaposi’s sarcoma, which affects the skin and other parts of the body, was reported in alarming numbers in this same population. In 1984, French and American scientists identified HIV as the virus responsible for AIDS. Persons at the highest risk appear to be hom*osexual or bisexual men and their partners, intravenous drug abusers, patients who received blood transfusions from unscreened donors (before adequate screening was available), and children of infected women. Heterosexuals are becoming increasingly infected, although heterosexuality itself still poses a somewhat lower risk. AIDS is not present in all patients who are infected with HIV. One to 5 percent of people who have a positive blood test for HIV but have no symptoms may eventually develop AIDS. Less than 1 percent of those infected with HIV appear to be immune to developing AIDS, and the virus and antibodies to it disappear spontaneously. Once the diagnosis has been confirmed, it is considered a fatal illness. Death usually results from an opportunistic infection such as P. carinii (a protozoan one-celled organism) or tuberculosis. Opportunistic infections are caused by commonplace organisms that do not usually trouble people whose immune systems are healthy, but take advantage of the opportunity provided by an immunosuppressed, or debilitated, person. Some individuals infected with HIV may remain well. In others, minor illness suggestive of infectious mononucleosis may occur between three weeks and three months following exposure to HIV. Symptoms including fever, sore throat, malaise,

muscle and joint aches, swollen glands, fatigue, weight loss, diarrhea, rash, and thrombocytopenia (decreased blood platelet count) appear suddenly and last about two weeks. These symptoms persist in many individuals, and up to 25 percent of those with this persistent condition, known as AIDSrelated complex or ARC, may progress to AIDS within one year. Those with AIDS may have one or more of a variety of disorders, including anomalies of the nervous system; severe and unusual infections, such as P. carinii pneumonia, fungal, tuberculosis, herpes simplex, and zoster (shingles), and oral yeast infections (thrush); cancerous tumors, such as Kaposi’s sarcoma, non-Hodgkin’s lymphoma, or primary lymphoma of the brain. A positive HIV-antibody test result in a person with signs and symptoms of an opportunistic infection or tumor characteristic of the disease must be confirmed by the Western blot blood test. A negative test result may occur in someone recently exposed to HIV. If that person is at high risk for developing AIDS, a repeat test should be performed in six months or sooner. AIDS is a contagious disease. Any person infected with the HIV can transmit the infection, even if that person does not have AIDS or ARC. It is spread by sexual contact, by direct contact of the HIV with the bloodstream from re-use of contaminated needles or accidental needle-sticks, and from mother to her unborn child through the placenta. Adequate screening at blood banks has made the blood supply for transfusions in the United States virtually free of HIV. The transmission of this disease requires intimate contact, such as sexual intercourse, in which an exchange of infected body fluids takes place. Researchers currently believe that HIV is not transmitted through casual or social contact. There is no cure for HIV infection or AIDS, and mutant strains of HIV have already emerged. However, attempts to develop a vaccine are under way. Various antiviral agents, such as zidovudine (Retrovir), formerly called azidothymidine, or AZT, appear to inhibit the progression of the disease. There are serious side effects from these drugs, including anemia, granulocytopenia, dizziness, and severe headache. It is often difficult to differentiate between adverse drug reactions and effects of the illness. Antibiotics and antifungals

6 air have been known to be effective against some of the opportunistic infections. Chemotherapy with interferon has shown promise in early studies, and radiation is used against Kaposi’s sarcoma and other malignancies. The 1990 Behavioral Risk Factor Surveillance System, or BRFSS, a government-sponsored study, assessed public awareness of HIV/AIDS. In random telephone interviews, 81,556 adults in 44 states and the District of Columbia were surveyed. Results are listed in the table below. Have you heard of the AIDS virus HIV? Are you aware that drugs can lengthen life of persons with HIV? Are you aware that infected individuals can look normal? Do you think that persons giving blood can get AIDS? Do you think that AIDS can be transmitted by insect bites?

83.0%

Yes

46.6%

Yes

67.7%

Yes

72.2%

83.9%

Source: Journal of the American Medical Association, 1992.

air A mixture of gases consisting of approximately 78 percent nitrogen and 21 percent oxygen, water vapor, carbon dioxide, and traces of ammonia, argon, helium, neon, krypton, xenon, and other gases. Clean air is odorless, tasteless, invisible, and surrounds the entire Earth. Alveolar air refers to air in the alveoli, or air sacs, of the lungs. Complemental air refers to the volume of air available over and above the air taken in by the deepest possible inspiration. This is also known as the inspiratory reserve (supplemental) volume. The amount of air remaining in the lungs after one exhales fully is called residual air. After a normal, full exhalation, approximately 1,600 cubic centimeters of air are available in an adult. This is known as the expiratory reserve volume. In an adult male, an average of 500 cubic centimeters of air flows in and out with each normal respiration, and that volume is called tidal air. Air that fills the structures of the respiratory system’s passageways but is not available for exchange of gases with the blood is called dead space air. When a lung collapses with the thorax (chest cavity) open, the small amount of air trapped in the alveoli is referred to as minimal air.

air bronchogram sign In pulmonary edema and pneumonia, a radiograph or X ray of the lung that shows a bronchus filled with air as it passes through an area of increased anatomic density. A diagnostic technique, bronchography is accomplished by instilling a radiopaque substance into the trachea or bronchial tree so the lung may be viewed by X ray. air conditioning The use of a ventilation device that controls air temperature and humidity, particularly to lower the temperature and humidity during the warm seasons. Air conditioning may prove beneficial to individuals with respiratory disorders because cool air is easier to breathe and may help shrink swollen membranes of the airways. On the other hand, there are dangers that certain infectious lung diseases may be spread by contaminated spray water from commercial air-conditioning systems. Actinomycetes are one cause of hypersensitivity pneumonitis, an allergic disease. Legionnaire’s disease is an infectious pneumonia also spread by contaminated water in cooling systems. Air-filtration systems, such as the high-efficiency particulate air (HEPA) filters, are available to keep the air clean and free of contaminants. They also may actually worsen exposure to allergens by lifting them into the air where they can be inhaled, so it is best to seek the advice of a physician or other health care professional when air purification is considered. air curtain

A method of directing air currents around a patient in order to divert air that might otherwise irritate or contaminate the patient with dust-borne allergens and other undesirable microorganisms.

air flow, laminar A system of filtered air flow in areas such as operating theaters, nurseries, bacteriology work areas, and places designated for food preparation. The system helps prevent bacterial contamination of the air and collects chemical fumes that may be harmful. air hunger A common term for shortness of breath or dyspnea (difficulty breathing), especially rapid, labored breathing.

airways 7 air pollution

Any contamination of the air we breathe, including industrial waste, fumes and exhaust from vehicles, and the spraying of pesticides, insecticides, or other noxious substances. Air pollution is also known as smog.

air quality

The degree of purity or pollution in the atmosphere in which we breathe. According to the American Lung Association, its new report, State of the Air: 2000, provides easy-to-understand summaries of the quality of the air based on concrete data and sound science. Cities and counties are assigned grades “A” through “F” based on how often the air quality exceeds the “unhealthful” categories of the U.S. Environmental Protection Agency’s Air Quality Index. The report confirms that air pollution remains a major threat to Americans and contributes substantially to the nation’s ill-health burden. The report also says more than 132 million Americans live in areas that received an “F”—approximately 72 percent of the nation’s population who live in counties where there are ozone monitors. Of the 678 counties examined, nearly half (333) received an “F.” Furthermore, in “F”-rated areas, there are an estimated 16 million Americans older than 65, more than 7 million people with asthma (5 million adults and 2 million children), 29 million children younger than 14, and 7 million adults with chronic bronchitis. According to the report, “while emissions of some air pollutants have generally gone down and the nation’s overall air quality has improved over the past 30 years, much of that progress has been in eliminating obvious pollution and sources, bans on open burning, for example. Many of the pollutants that are literally invisible, such as ozone, have been reduced far less, and as understanding of the health effects of air pollution has advanced, it has become clear that much of the nation still faces major air pollution problems. State of the Air is the first annual ‘report card’ on America’s air quality. It focuses on the most widespread air pollutant, ozone, sometimes called smog . . . among the most dangerous of the common air pollutants. . . . Many major metropolitan areas in the United States are plagued by high levels of ozone. As of 1998, almost 100 million Americans still lived in areas classified

as not meeting the earlier one-hour national ozone standard.” The American Lung Association has also declared May “Clean Air Month,” which will involve national and local events designed to emphasize the link between environmental conditions and respiratory wellness: “The quality of the air we breathe, both indoors and out, has a great impact on lung health. Fragile lung tissue is easily damaged by pollutants in the air, resulting in increased risk of asthma and allergies, chronic bronchitis, lung cancer and other respiratory diseases.” (May 28, 2000) See also OZONE.

air travel (related to impaired pulmonary function) Individuals with pulmonary impairment may require supplemental oxygen (appropriate to their respiratory system’s functional capacity) when traveling by airplane, and those with blocked sinuses or eustachian tubes may be advised not to fly until the disorder has been resolved. Anyone with an infectious disease that can be transmitted to others by the airborne route is advised not to fly. air vesicle See also

airways

An alveolus of the lung. ALVEOLUS.

Passageways allowing air from the atmosphere to reach the lungs, beginning at the nostrils and mouth, and gradually branching into bronchi and bronchioles. They end at the alveolar sacs in the lungs, where oxygen is absorbed into the bloodstream. During an asthma attack, the airways narrow or become obstructed by either constriction or mucous plugs. At first, muscles in the walls of the bronchioles constrict or go into spasm, called bronchospasm. If this is not relieved immediately, spontaneously, or with medication, blood vessels in the airway dilate and fluid leaks into the tissues. Resulting swelling (edema) further narrows the airway. This is followed by an inflammatory response and secretion of mucus, restricting airflow even more. Wheezing may not be heard until there is at least a 50 percent narrowing of the airways. However,

8 albuterol in extremely severe obstruction, there may be no audible wheezing. This can be misleading in a lifethreatening situation. In an emergency room or doctor’s office, the degree of narrowing of the airways can be measured by a spirometer or a peak flow meter. Inexpensive peak flow meters are available so patients can measure their peak flow at home, school, or work. Peak flow meters also aid physicians in making treatment decisions. See also PEAK FLOW METER; SPIROMETER.

cating beverages, alcohol is also a common ingredient in cough syrups. It is thought to be a depressant to the cough center of the brain and may have some muscle-relaxing effect on the bronchial tubes. Two common adverse effects of alcohol (ethanol) are sedation and drying of the mucous membranes of the upper respiratory tract. Alcoholism may eventually result in respiratory arrest and death.

alkalosis, respiratory albuterol (Gen-Salbutamol, Novosalmol, Proventil, Proventil HFA, Proventil Repetabs, Salbutamol, Ventodisk, Ventolin, Ventolin Rotacaps, Volmax) A fast-acting bronchodilating drug used to open constricted airways in the treatment of asthma and in the prevention of exercise-induced asthma, bronchospasm, and the prevention of premature labor. It is in investigational use for hyperkalemia in dialysis patients. Albuterol is contraindicated for patients with severe cardiac disease and hypersensitivity to sympathomimetics. The most widely used of the beta-agonist drugs, its use is rarely limited by minor tremors or palpitations. Possible other side effects include headache, dizziness, restlessness, hallucinations, flushing, irritability, dry or irritated nose and throat, heartburn, nausea, vomiting, muscle cramps, hypotension, and paradoxic bronchospasm. Albuterol also interacts with other aerosol bronchodilators, tricyclic antidepressants, MAO inhibitor antidepressants, and other adrenergics, increasing their action. Other beta-blockers may inhibit the action of albuterol. The therapeutic response is absence of wheezing and difficulty breathing, and improved airway exchange and arterial blood gases (ABGs). Albuterol is available as an aerosolized metereddose inhaler (MDI), as a solution for use with an aerosol nebulizer, or as a tablet or syrup for oral use. For children or other persons who lack the coordination to use an MDI, the product Ventolin is available in a dried powder form dispensed in Rotacaps and inhaled by using a device known as a Rotahaler.

alcohol

A chemical used as a solvent, an antiseptic, an astringent, and a component in intoxi-

Excessive alkalinity (as opposed to acidity) in the body’s fluids because of an acid-base imbalance, either an increase in alkalines or decrease in acid. Altitude alkalosis is caused by decreased oxygen in the air at high altitudes, which then causes respiratory alkalosis. Symptoms include numbness and tingling, carpopedal spasm, tetany, lightheadedness, and paresthesias. Respiratory alkalosis may also be the result of anxiety, fever, hyperventilation due to hypoxia (lack of oxygen), salicylate intoxication, exercise, and excessive assist, such as in the use of a respirator, to breathing. Initial treatment for hyperventilation includes having the person calm down by breathing into a paper bag, thus rebreathing carbon dioxide. Also, the patient may find some relief by breathing with one nostril closed off and the mouth closed. Other treatments depend upon the severity of the patient’s symptoms and his or her medical history, including cardiac and neurologic status, vital signs, and arterial blood gases.

allergen

A particle, substance, or other agent that causes hypersensitivity in certain individuals who come in contact with it. See also AEROALLERGENS.

allergic rhinitis (pollinosis, hay fever) An inflammatory condition of the nasal passages, adjoining sinuses, ears, and/or throat that occurs when an allergic person inhales an allergen to which he or she is sensitive. Allergic rhinitis is an immune response that does not occur in a normal or nonallergic individual. Allergic rhinitis may occur periodically (seasonally) or continuously (perennially).

allergist 9 Cause During the allergic reaction of hay fever, mast cells in the lining of the nose rupture when exposed to an allergen in a susceptible person. The mast cells release chemicals, called mediators, that are responsible for allergic symptoms. Hay fever is an English name given because of symptoms caused by exposure to grass allergens coinciding with the bailing of hay. It usually refers to seasonal allergies, occurring with exposure to the airborne (windblown) pollens of trees, grasses, ragweed, and other weeds and outdoor mold spores. A person may suffer the symptoms during spring, fall, or both seasons. Perennial, or year-round, allergic rhinitis is usually due to exposure to indoor allergens called “inhalants.” Cats, dogs, rodents, house-dust mites, and indoor molds are examples of perennial allergens. Allergic rhinitis is often confused with colds, sinus infections, nasal polyps or other nasal obstructions, and nonallergic, vasomotor rhinitis. Vasomotor rhinitis is nasal congestion that cannot be attributed to another cause, such as allergy. A deviated septum, an abnormality of the cartilage separating the nostrils, is a frequent cause of stuffy noses and can occur in allergic as well as nonallergic individuals. Rarely, more serious conditions such as tumors or nonhealing granulomas may exist. These conditions should be considered in patients who fail to respond promptly to treatment and who have blood-stained nasal mucus. Overuse or abuse of over-the-counter nasal sprays can result in a common and troublesome disorder called rhinitis medicamentosus (rhinitis means an inflamed nose; medicamentosus means caused by medication). This condition is often confused with allergy and may occur in both allergic and nonallergic individuals. Signs and Symptoms These vary in severity from person to person. Symptoms include pruritus (itching), sneezing, rhinorrhea (runny and watery discharge from the nose), postnasal drip, and congestion of the nose, ears, and sinuses. A general state of fatigue and malaise (a feeling of being “unwell”) may exist dur-

ing allergy attacks. Loss of smell or taste occurs in severe cases. Persons with hay fever frequently suffer from allergic conjunctivitis (itchy, watery, and red eyes caused by allergy) and asthma. Physical Appearance Hay fever sufferers often have a characteristic appearance. A horizontal crease across the lower portion of the nose is called the “allergic crease,” caused by the “allergic salute,” a constant pushing up on the tip of the nose by the palm of the hand prompted by the discomfort of nasal stuffiness. Dark circles under the eyes are referred to as “allergic shiners.” These are probably caused by blockage of blood flow to the tiny veins in the area because of swelling. Blood trapped in the area under the eyes has a very low oxygen content, resulting in the dark blue-black discoloration. There will often be swelling and puffiness of the eyelids, redness of the eyes, and watery discharge from the eyes and nose. Individuals with persistent nasal obstruction often breathe through their mouth, which causes facial abnormalities, such as long faces, flattened cheekbones, pinched nostrils, and raised upper lips. Orthodontal problems arise more frequently in allergic persons because of narrower retracted jaws, overbites, and high arched palates. See also ASTHMA; HAY FEVER; POLLINOSIS; POLYP, NASAL; RHINITIS.

allergic salute

See

ALLERGIC RHINITIS.

allergic shiner

See

ALLERGIC RHINITIS.

allergist (allergist-immunologist)

A physician who diagnoses and treats allergic conditions and related disorders. Asthma, hay fever, eczema, and hives are among the illnesses most frequently treated by allergists. Most allergists complete a twoyear fellowship in allergy and immunology following a residency in internal medicine or pediatrics. They are then eligible to become board certified in their specialty by passing a comprehensive examination. See also IMMUNOLOGIST.

10 allergist-immunologist allergist-immunologist

See

ALLERGIST.

allergoids Allergy extracts modified by treatment with the chemical formalin. This modification results in lower incidence of reactions and shorter courses of immunotherapy (allergy shots). While ragweed allergoid has proven to be excellent, no other allergoids are available in the United States. Because most people need multiple extracts for their treatment, use of the singular allergoid may not be practical. allergy

An overreaction by the immune system to a substance called an allergen that does not cause a similar reaction in nonsensitized persons. An allergen is any protein or proteinlike substance recognized by the body as foreign and capable of provoking an allergic response. Austrian pediatrician Clemens P. Pirquet (1874–1929) first used the term allergy, derived from the Greek allos (“altered”) and ergia (“reactivity”), in 1906. He referred both to immunity, which is beneficial, and to harmful hypersensitivity of the immune system as allergy. Today, allergy refers only to the hypersensitivity or injurious effects of the immune system. Causes Most individuals inherit the tendency to be allergic from one or both parents. It is not known why some persons develop allergies and others do not. It is thought by some that exposure to viral infections, smoking, or hormones influence a person’s propensity for allergy. It is also unknown why some individuals will get hay fever and others asthma, or both. Types of Allergy There are four classifications of allergic or hypersensitivity reactions: type I, immediate or immunoglobulin E (IgE) mediated; type II, in which antibodies are directed against cells; type III, in which toxic effects result from antibody and antigen complexes; and type IV, cell-mediated or delayed reactions. Pollens, animal proteins (dander, saliva, urine, feathers), house-dust mites, molds, drugs, foods, and venoms from insects or reptiles are examples

of allergens that can cause immediate, or type I, reactions. After a first exposure, these apparently harmless allergens stimulate the immune system to form IgE antibodies. IgE antibodies are specific to each allergen and attach to the surface of mast cells in the tissues. Upon re-exposure, the recognized allergen combines with its antibodies, rupturing mast cells and releasing biochemical mediators that cause the symptoms of allergy. The most severe form of type I allergic reaction is anaphylaxis. Prevalence The most common allergies include allergic rhinitis (hay fever), asthma, eczema, and urticaria (hives). The National Institute of Allergy and Infectious Diseases estimates that 35 million Americans have allergies and about 10 million have asthma. Approximately 80 to 90 percent of adult allergies are caused by inhaled allergens from animals, pollens, molds, or house dust. Foods are responsible for about 20 percent of children’s allergies but much less so in adults. A small percentage of allergies is caused by contactants or insect stings. Treatment Three main phases of treatment are avoidance of allergen exposure, use of medication, and immunotherapy (or allergy shots). Avoidance of allergy triggers is the management of choice, but it may be difficult or even impossible to achieve. Drugs offer excellent relief from symptoms of allergies and asthma with minimal side effects. Antihistamines, adrenergic agonists or decongestants, beta-agonists and xanthine bronchodilators (theophylline), cromolyn and corticosteroids (derivatives of cortisone) are available in inhaled, oral, and injectable dosage forms. These drugs are among the most widely prescribed of all medicines. Immunotherapy, successfully used to treat allergic rhinitis (hay fever) for many years, is now also recognized as effective treatment for allergic asthmatic patients. Alternative treatments include homeopathy (natrium muriaticum, or other preparation); kinesiology (balancing, stress reduction counseling, bowel cleansing, etc.); aromatherapy (Roman chamomile, helichrysum, melissa, etc.); hyp-

allergy shots 11 notherapy (hypno-healing, neurolinguistic programming, etc.); naturopathy (dietetic management and fasting, applied nutrition, etc.); color therapy (use of blues, greens, and oranges); autogenic training (rebalancing body systems); acupuncture; Ayurvedic medicine (panchakarma and a specialized diet); Chinese and Western herbalism, and auricular therapy (to relieve hay fever symptoms). See also ALLERGEN; ALLERGY SHOTS; ANAPHYLAXIS; IMMUNOGLOBULINE; MAST CELLS.

Allergy and Asthma Network/Mothers of Asthmatics, Inc. A nationwide, community-based, nonprofit health organization dedicated to eliminating morbidity and mortality due to asthma and allergies through education, advocacy, community outreach, and research. The AAN-MA offers membership, publications (Allergy & Asthma Health is the organization’s quarterly magazine; The MA Report is an eight-page newsletter), news and information, job and volunteer opportunities, marketplace, physician roll-call, outreach programs, and other allergy and asthma-related activities. The AAN-MA may be contacted at: Allergy and Asthma Network/Mothers of Asthmatics, Inc. 2751 Prosperity Avenue Suite 150 Fairfax, Virginia 22031 (800) 878-4403 or (703) 641-9595 (703) 573-7794 (Fax) http://www.aanma.org.

allergy shots

Allergy immunization or vaccination. According to a July 29, 1999, report by the American College of Allergy, Asthma and Immunology (ACAAI), allergies affect about 38 percent of all Americans, nearly twice as many as allergy experts had believed, and millions of them suffer unnecessarily or rely on medications they don’t want to take because they are not aware of other effective treatment options, including allergy shots. A representative sample of 1,004 adults was surveyed by the ACAAI about their experiences with allergies. According to ACAAI literature, “Thirty-

eight percent reported having allergies, while 56 percent said they live in a household in which at least one member, including themselves, has allergies. The number of people affected surprised even allergy experts who thought the incidence of allergies was closer to 20 percent of the population. ‘This new data shows us that allergies are almost twice as common as we thought,’ said Ira Finegold, M.D., past-president of the ACAAI. ‘What’s of even greater concern is that the majority of people with allergies don’t know about treatment that can bring them relief. A lot of them are either suffering from the symptoms or from medication sideeffects.’ “Almost two-thirds of respondents who said they have allergies have never tried or considered allergy shots. . . . Allergy shots are a well-established treatment that naturally desensitizes the immune system. Small amounts of purified extracts of the substance causing allergic reactions are periodically injected and gradually increased until immunity is attained. They are effective against allergic diseases including allergic rhinitis (hay fever), insect sting allergy, and asthma. “The treatment has a long track record of effectiveness and safety, with the incidence of adverse reactions less than 2/10 of 1 percent. It can be given to children as young as 4 and is safe for pregnant women as long as treatment was begun before pregnancy. Though not well known, allergy shots are viewed positively by those who are familiar with them, especially by those who have had the treatment, according to the survey. The survey also found that 54 percent of respondents would be willing to try allergy shots if the treatment would free them from medication. “The ACAAI commissioned the national survey as part of a public education campaign to increase understanding of allergy immunization and encourage people who may be helped by this therapy to consider it. The randomized telephone survey was conducted by Opinion Research Corporation (ORC) . . . 502 men and 502 women— 18 years of age and older living in private households in the continental United States. The survey results are projectable to the U.S. population and have a margin of error of plus or minus 2 percent to 4 percent. . . . The only negative perception of

12 altitude sickness allergy shots by a substantial number surveyed was related to cost. More than half answered ‘yes’ when asked if they thought allergy shots are expensive. “The perception seems to be that vaccination is a great treatment for allergies but is not affordable,” Dr. Finegold said. “In fact, allergy shots often are covered by health plans and the treatment can eliminate the need to buy medications. Overall, it’s often less expensive and more effective than relying on medications every day and trying to isolate the allergy-sufferer from the environment. In many cases, the shots eventually can be discontinued, along with allergy medications, and the immunity maintained.” The ACAAI has also created a new consumer education quiz available on its web-site that tests individual knowledge of allergy and treatments, and provides detailed answers. The ACAAI’s free brochure, You Can Have A Life Without Allergies, is available by calling (800) 842-7777. The brochure explains how allergy shots work and fit into the general management of allergy and asthma. See also IMMUNOTHERAPY.

and arterial smooth muscle of the heart. In addition, Altounyan suffered from atopic dermatitis as a child and later from severe asthma. Using himself as the experimental subject, he investigated 670 synthetic compounds, and in 1967 he recognized the effectiveness of cromolyn.

aluminosis A chronic inflammation of the lungs as a result of inhaled alum particles. A strong astringent, alum is a double sulfate of aluminum and potassium and aluminum and ammonia. Aluminosis is seen mostly in alum workers. aluminum chloride

An astringent and antiseptic solution used as an antiperspirant. Aluminum chloride can be irritating and a cause of skin allergy. It also can be toxic if ingested.

Alupent

See

METAPROTERENOL.

alveobronchiolitis Inflammation of the bronchioles and pulmonary alveoli, also known as bronchopneumonia. See also BRONCHOPNEUMONIA.

altitude sickness

Symptoms including headache, euphoria, shortness of breath, malaise, decreased ability to concentrate, lack of judgment, lightheadedness, and fainting that develop when an individual is in an environment of decreased oxygen, such as high on a mountain. Altitude sickness may cause death in some cases. When lack of adequate oxygen causes euphoria, an individual may be unaware of a potentially dangerous problem. Adaptation to high altitudes is possible over a period of time, perhaps months, depending upon the individual.

Altounyan, Roger E. C.

An Armenian-English physician (1922–87), born in Aleppo, Syria. Altounyan developed disodium cromoglycate, or cromolyn, an anti-inflammatory allergy medication. He first experimented with khella, a substance from the dried fruit of an herb, Ammi visnaga, indigenous to Egypt and North Africa, because khella had already been widely used for treating spasms of the intestines, bronchial tubes, uterus,

alveolitis

An inflammation of the air cells, or alveoli, of the lungs. Allergic alveolitis is a lung disease caused by hypersensitivity to organic dusts that are inhaled, especially by individuals whose occupation involves exposure to various dusts or pollutants. See also BAGASSOSIS; FARMER’S LUNG; PNEUMONITIS.

alveolus

The air cell, one of many sacs or small hollows at the end of an alveolar duct in the lungs, where gases are exchanged in respiration.

amantadine (Symmetrel) An antiviral drug that is also used in the treatment of Parkinson’s disease. During “flu” epidemics, amantadine may lessen the severity of, shorten the course of, or prevent type A influenza, but it has no effect on influenza B or other viruses. Individuals at risk for severe complications of influenza, including some asthmatics, may benefit from immunization with influenza vaccine and daily doses of amanta-

American Board of Allergy and Immunology dine for several weeks until the vaccine becomes effective.

Ambu bag The trade name for a bag used to help direct air into the lungs by artificial ventilation. The bag is a reservoir for oxygen attached to a one-way flow valve and a face mask that is placed over the mouth and nose of a patient who is not breathing. This resuscitator, also known as a bag-valve-mask resuscitator, is operated manually. A manikin used in teaching cardiopulmonary resuscitation is called an Ambu simulator. American Academy of Allergy, Asthma and Immunology (AAAAI) A professional organization of allergists and immunologists that promotes the advancement of scientific study of allergy and immunology both academically and in the practice of medicine. It was established in 1943 with the merger of the American Association for the Study of Allergy and the Association for the Study of Asthma and Allied Conditions. The AAAAI publishes the Journal of Allergy and Clinical Immunology. From time to time the academy issues position statements to clarify confusing issues in the fields of allergy or immunology. An emphasis is placed on aiding the public in seeking competent medical care and avoiding unproven or dangerous techniques for the diagnosis or treatment of these disorders. The majority of fellows and members of the AAAAI are board certified in their specialty. Contact telephone number is (800) 822-ASMA.

American Board of Allergy and Immunology (ABAI) A conjoint board of the American Board of Internal Medicine and the American Board of Pediatrics, established in 1971 as a nonprofit organization. It is sponsored jointly by the American Board of Internal Medicine (ABIM), the American Board of Pediatrics (ABP), the American Academy of Allergy, Asthma and Immunology (AAAAI), the American College of Allergy, Asthma and Immunology (ACAAI), the American Academy of Pediatrics–Section on Allergy, and the American Medical Association–Section on Allergy. The board consists of an even number of directors. The direc-

tors are nominated by the Sections on Allergy of the American Academy of Pediatrics and the American Medical Association, the AAAAI, ACAAI, and the ABAI itself. The nominees are appointed by the ABIM and the ABP. Each board director is appointed for six years. Purposes of the ABAI The major purposes of this organization are (1) to establish qualifications and examine physician candidates for certification as specialists in allergy and immunology, (2) to serve the public, physicians, hospitals, and medical schools by providing the names of physicians certified as allergists and immunologists, (3) to improve the quality of care in allergy and immunology to the public and increase the availability of specialists to deliver such care, (4) to establish and improve standards for the teaching and practice of allergy and immunology, (5) to establish standards for training programs in allergy and immunology, and (6) to provide increased opportunities for physicians wishing to specialize in allergy and immunology. Certification The ABAI is interested in candidates who have embarked voluntarily on a graduate program of study with the express purpose of excelling in the practice of the specialty of allergy and immunology. In outlining its requirements, the ABAI hopes to help the candidates select superior educational programs that will develop their competency in allergy and immunology. The ABAI believes that all allergists and immunologists should have a fundamental knowledge of the biological science basic to this discipline. Such knowledge is essential to the continued professional progress of any qualified allergist and immunologist. The ABAI anticipates that adequate knowledge in basic science, as applied to this discipline, will be acquired by the candidates during a post–medical school training program. The ABAI wishes to emphasize that time and training are but a means to the end of acquiring a broad knowledge of allergy and immunology. The candidate must demonstrate competency to the ABAI in order to justify certification in this discipline. The responsibility of acquiring the knowledge rests with the candidate. The ABAI is

14 American College of Allergy, Asthma and Immunology responsible for the establishment and maintenance of the standards of knowledge required for certification. Each candidate for certification must satisfy the general and professional qualifications listed below. The candidate must qualify for examination by having passed the certification examination of the ABIM or the ABP. Certification requires three years of postgraduate general training in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), by presentation of evidence acceptable to the board of directors of at least two years of full-time residency/fellowship or other acceptable training in allergy and immunology programs accredited by the ACGME upon the recommendation of the Residency Review Committee for Allergy and Immunology. These programs are listed in the Directory of Graduate Medical Education Programs, published by the American Medical Association, a copy of which may be found in most medical school libraries. Executive Office American Board of Allergy and Immunology, A Conjoint Board of the American Board of Internal Medicine and the American Board of Pediatrics Chairman: Lawrence B. Schwartz, M.D., Ph.D. Co-chair: M. Louise Markert, M.D., Ph.D. Executive Secretary: John W. Yunginger, M.D. Administrative Director: Lynn Des Prez 510 Walnut Street, Suite 1701 Philadelphia, PA 19106-3699 (215) 592-9466

American College of Allergy, Asthma and Immunology (ACAAI) Formerly the American College of Allergy and Immunology (ACAI), a professional medical organization comprised of 4,000 qualified allergists-immunologists and related health care professionals, founded by physicians and scientists to promote and advance the knowledge of allergy and to assure a high quality of care for patients with allergic disorders. Based in Arlington Heights, Illinois, the college is dedicated to the clinical practice of allergy, asthma, and immunology through education and research. The ACAAI publishes the monthly scientific journal Annals of Allergy, Asthma and Immunology,

which is available on-line through December 2000 and thereafter by subscription. Annals on-line contains full-text articles, including figures and tables, and text is searchable by keyword, with hyperlinks to MEDLINE. Archives are being built to include full-text articles of back issues since January 1997. Abstracts will be available from earlier publications. Patient education “Advice From Your Allergist” articles are archived on-line on the following topics: rhinitis, insect sting allergies, urticaria, pregnancy with asthma and allergies, osteoporosis, long-acting bronchodilators, latex hypersensitivity, food allergies, headaches, house-dust allergies, and pet allergies. The website www.annallergy.org provides information about the journal, including instructions to authors, the Editorial Board, and subscription information. The journal received a top rating in a recent readership survey reported by Lippincott Williams & Wilkins and Dataview Research, Inc., scoring its usefulness and comparing it to other medical journals. Additional information on the diagnosis and treatment of asthma and allergic disease is available on the ACAAI public website (http://allergy.mcg.edu).

American Dietetic Association An organization based in Chicago, Illinois, from which nutritional and dietary information important to individuals with allergies or asthma can be obtained. A list of commonly allergenic foods, including cow’s milk, eggs, and wheat, is available. The association may be contacted at: American Dietetic Association 216 West Jackson Boulevard Chicago, IL 60606-6995 (312) 899-0040

aminophenols Chemical derivatives of phenol used in orange, red, and medium-brown hair dyes. Adverse reactions range from mild contact rashes to convulsions from severe absorption or asthma from inhalation. aminophylline

A bronchodilating drug made up of two components, theophylline and ethylenediamine. Available in both tablet and intravenous forms, aminophylline has been a standard treat-

anaphylaxis 15 ment for acute asthma attacks for many years. However, recently, its use has been related to a backup role with the increased use of the beta-agonist bronchodilators. The action of aminophylline is based on the theophylline portion, which is a methylxanthine derivative and has many adverse effects and drug interactions. See also THEOPHYLLINE.

ammonium carbonate

A neutralizing alkaline chemical used as an expectorant in cough syrups, in permanent wave solutions, and in fire extinguishers. It can cause contact rashes.

ammonium iodide

A chemical used as an expectorant in cough syrups. It is also used as a preservative and antiseptic by the cosmetic industry.

analgesia (respiratory implications) Drug therapy used to relieve pain. In the case of respiratory disorders, the use of narcotic painkillers such as codeine, morphine, oxycodone, hydromorphone, nalbuphine, pentazocine, and others is contraindicated in the event of acute bronchial asthma and upper airway obstruction. Side effects that may be caused by these drugs are respiratory depression and respiratory arrest, among other conditions. anaphylactic shock

See

anaphylactoid reaction

ANAPHYLAXIS.

A severe and potentially life-threatening, allergy-like reaction characterized by swelling and constriction of airways caused by the direct release of potent biochemical mediators from cells in the body tissues. As opposed to anaphylaxis, anaphylactoid reaction does not involve immunoglobulin E (IgE) antibodies. Since symptoms of anaphylactoid and true allergic, anaphylactic reactions are indistinguishable, the terms are used synonymously. Immediate anaphylactoid reactions can result from poisoning after eating fish containing large amounts of histamine. Tuna, mackerel, and mahi mahi are the most common sources. Fish inadequately refrigerated or contaminated by Proteus morganii or Klebsiella pneumoniae bacteria may also

contain dangerously high histamine levels. Allergylike symptoms—flushing, erythema, itchy eyes, nausea, diarrhea, and headache—may last up to 24 hours and are self-limiting (they eventually disappear on their own). Swiss cheese may cause a similar reaction. Tuberculosis patients taking the drug isoniazid (INH) are highly susceptible to these food reactions. See also ANAPHYLAXIS.

anaphylaxis (anaphylactic

shock) The most severe or extreme type of allergic reaction, which may be life-threatening, characterized by any or a combination of the following symptoms: itching of the throat or skin, hives, dizziness, tightness and swelling in the throat, difficulty breathing, weakness, sudden drop in blood pressure, or unconsciousness. Anaphylaxis ranges from mild itching to collapse and death and, therefore, constitutes a medical emergency. True anaphylaxis occurs after exposure to an allergen to which a person has been previously sensitized. Prevalence An estimated four deaths per 10 million people from anaphylaxis occur each year. There are insufficient data to determine increased risk for anaphylaxis, such as age, sex, or ethnic criteria. There does not appear to be a predilection to penicillin or insect-sting anaphylaxis in persons known to have other allergies. However, some studies suggest that allergic individuals do have a higher incidence of anaphylaxis. In the early 20th century, before the availability of antibiotics, horse-serum antitoxin was used to treat the often fatal diseases such as diphtheria, scarlet fever, tetanus, and tuberculosis. Prior to the penicillin era, horse serum was the most common cause of anaphylaxis. Penicillin may account for 75 percent of all fatal allergic reactions: an estimated 500 deaths annually in the United States. One fatality occurs for every 7.5 million injections of penicillin; death may also result from oral, inhaled, or topical contact with the drug. Hieroglyphics depict death from an insect sting 4,000 years ago. In 2640 B.C., the Egyptian pharaoh Menes reportedly died suddenly after

16 anaphylaxis being stung by a wasp. Up to 4 percent of the population suffers systemic reactions to stings of bees, wasps, hornets, yellow jackets, and fire ants. Aspirin and the frequently used arthritis drugs called nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen, may cause anaphylaxis in as many as 1 percent of individuals. Up to 10 percent of persons with asthma may exhibit anaphylaxis. Cause Despite recognition of fatal allergic reactions dating from biblical times, it was not until 1902 that French professors of medicine Charles Richet (1850–1935) and Paul Portier (1866–1962) linked a case of fatal anaphylaxis to a foreign protein injection that had been previously tolerated by a patient. Anaphylaxis occurs when potent biochemicals such as histamine (also called mediators) are released from mast and other special cells in the body tissues and act in a sequence of events affecting various organs. It is now known that there is more than one mechanism for this reaction. Type I allergy, also called hypersensitivity or IgEantibody–mediated allergic reaction, is the most common and best understood cause of anaphylaxis. Following initial exposure of a foreign protein or hapten, antibodies develop during a latent period. Anaphylaxis occurs upon re-exposure of this same foreign substance. A hapten, of which penicillin is an example, is a low-molecular-weight and nonallergenic substance until it combines with a larger “carrier” molecule to become allergenic. Hundreds of allergens in drugs (especially antibiotics), foods ( the most frequent offenders include eggs, cow’s milk, peanuts, fish and shellfish, and tree nuts), food preservatives (especially sulfites), and foreign proteins (including seminal fluid, insulin, and insect and snake venoms) are capable of inducing anaphylaxis in susceptible individuals. However, other reactions that do not involve antigen-antibody production but stimulate the release of chemical mediators, including histamine, can cause the same symptoms as anaphylaxis. For many years this was referred to as anaphylactoid (anaphylactic-like) reactions. Most allergists feel the term is outdated and refer to all similar reac-

tions as anaphylaxis. Substances capable of inducing these reactions include whole blood, radiocontrast (X ray) media, aspirin, food dyes, and drugs. Trauma, burns, or infections can also induce anaphylactoid reactions. Signs and Symptoms An initial sensation of warmth, itching, or tingling begins in the axilla or groin and gradually spreads throughout the body. Sneezing, intense itching, and constriction in the throat may progress to generalized hives and angioedema, or swelling of the face and tongue. Wheezing, shortness of breath, abdominal pain, nausea, vomiting, and diarrhea may follow. A drop in blood pressure, described by some as a feeling of “impending doom,” may signal collapse (or shock) and death. Any of these signs and symptoms can occur individually or concurrently. The longer the time interval (or latent period) between the initial exposure to an allergen and the onset of symptoms, the less likely it is that death will occur. Treatment Treatment must be initiated at the first signs or symptoms of impending anaphylaxis, since there is no way of anticipating how severe a reaction may become. Epinephrine (adrenaline) given subcutaneously (under the skin) is the drug of choice; if it is given immediately, it may be lifesaving. Antihistamines, bronchodilators, corticosteroids, and oxygen are also administered as needed, but they take much longer to become effective and may not be lifesaving. Arrange transportation of the patient to the nearest emergency room or other medical facility. A delay of even a few minutes can be fatal. A person may experience a recurrence of anaphylaxis as long as 24 hours after the initial reaction and should be monitored for at least 24 hours. Prevention Individuals known to be at risk through a history of a prior severe allergic reaction should carry an adrenaline kit at all times. Identify and avoid a food (rarely more than one) that is thought to be a cause of allergic reaction. Avoidance of a food because another family member has had a serious reaction

anesthesia for the allergic and asthmatic patient to it is not necessary. Skin testing for foods can be hazardous and should be avoided if anaphylaxis has occurred; radioallergosorbent test (RAST) blood food testing is safer but often misleading because of false-positive or -negative results. Specific preventive measures should be taken by persons with cold-induced urticaria (hives), exercise-induced anaphylaxis, and allergy to seminal fluid, venomous insects, drugs, and radiocontrast (X ray) dyes. See also ADVERSE DRUG REACTIONS.

anapnea

Breathing or regaining the breath.

anergy

The inability of certain individuals to react to a test for hypersensitivity to antigens. Normal individuals almost invariably have positive skin tests to mumps, Candida (a common yeast), and tetanus antigens because antibodies to these conditions are present in their blood. However, some skin tests prove negative despite the presence of the antibodies. Several factors influence the possibility of anergy, including the number and type of antigens (bacterial, fungal, or viral) used in the skin test, the characteristics of a positive reaction, and the presence of a mild upper respiratory infection. Anergy was first noticed when patients with measles lost the ability to react to skin-testing for tuberculosis for a short period of time. Anergy also pertains to one whose skin temporarily does not show a reaction to a tuberculin (e.g., Mantoux) test after receiving a live-attenuated measles, mumps, and rubella (MMR) vaccine. If a tuberculin test is required, it should be administered either before or simultaneously with the MMR vaccine or after three months from the date of the vaccination.

anesthesia for the allergic and asthmatic patient Alternatives to general anesthesia should be considered for all surgical candidates with allergies or asthma, because any hypersensitivity may be exacerbated by anesthesia drugs with potentially severe results. (The risk of adverse effects of anesthesia, although small, exists even for nonallergic or nonasthmatic normal individuals.) Spinal, epidural, or

local anesthesias are excellent choices for many surgical procedures. Anesthetics, Local Lotions, creams, ointments, and sprays applied topically in the treatment of local injuries, burns, and insect bites. Other local anesthetics, drugs designed to eliminate sensation only in certain areas of the body, may be injected before minor surgery or repair of skin lacerations, or to numb dental tissues before dental surgery. Snow may have been the first anesthetic agent used and was recognized for its numbing ability by Hippocrates. Cocaine was isolated in 1860 by Niemann from the Erythroxylon coca bush. However, the modern era of a local anesthesia was not entered until 1884, when Sigmund Freud and Karl Koller reported the cocaine’s ability to numb the eye for surgical procedures. Although these agents rarely cause true allergic reactions, they often cause vasovagal syncope (fainting spell brought on by a sudden drop in blood pressure), hyperventilation, palpitations, or anxiety reactions. These are non-immune (nonallergic) adverse reactions resulting from excessive doses or other pharmacologic drug reactions easily confused with allergy. Patients suspected of having a true type I (immediate) allergic reaction to one of these drugs can be tested by injecting them with minute doses, gradually increasing the dose according to standardized protocol. Drugs may cross-react if they belong to the para-aminobenzoic esters group, such as procaine (Novocain) and tetracaine (Pontocaine). Lidocaine (Xylocaine), bupivacaine, and others do not cross-react and can usually be substituted for the drug suspected of a reaction without the need for the tedious process of testing and desensitization. Parabens and other preservatives may be responsible for some adverse reactions rather than the anesthetic drug. Local anesthetics are available in individual, preservative-free dose ampules. Benzocaine, although commonly used topically for temporary relief of the conditions listed above, may cause a sensitivity reaction of its own and worsen rather than improve the condition for which it is employed. Many allergists and dermatologists warn

18 aneurysm against their use on the skin; however, drugs like lidocaine offer temporary relief for ulcers of the mouth, rectal lesions, including hemorrhoids, and painful mucous membranes. Benzocaine, cyclaine, and tetracaine are used to inhibit the cough reflex before invasive diagnostic tests such as bronchoscopy. Another local anesthetic, benzonatate (Tessalon), is available as a prescription cough suppressant. High-pressure dental equipment can cause air infiltration into local oral tissues, resulting in swelling and wheezing that may be confused with an allergic reaction. Local Anesthetic Drugs Ester Type (contain para-aminobenzoic esters and may cross-react): benoxinate (Dorsacaine) benzocaine1 butacaine (Butyn) butethamine (Monocaine) butylaminobenzoate (Butesin) chloroprocaine (Nesacaine)2 cocaine cyclomethycaine (Surfacaine) hexylcaine (Cyclaine)3 procaine (Novocain)4 proparacaine (Ophthaine) tetracaine (Pontocaine)3 Amide Type (do not contain para-aminobenzoic esters and do not cross-react): amethocaine1 amydricaine (Alypin) bupivacaine (Marcaine) dibucaine (Nupercaine)4 dimethisoquin (Quotane) diperodon (Diothene) dyclonine (Dyclone) etidocaine (Duranest) lidocaine (Xylocaine)5 mepivacaine (Carbocaine) oxethazaine (Oxaine) phenacaine (Holocaine) piperocaine (Metycaine) pramoxine (Tronothane) prilocaine (Citanest) pyrrocaine (Endocaine)

More likely to cause contact dermatitis. May be safest because of its short duration of action. 3 More likely to cause true anaphylaxis. 4 More likely to cause anaphylaxis or contact dermatitis. 5 Most widely used and often combined with epinephrine, which may be the cause of adverse effects. 1 2

See also SURGERY, RELATED TO ALLERGIC AND ASTHMATIC PERSONS.

aneurysm From the Greek word aneurysma, meaning a widening, a dilation occurring due to a weakness in the wall of a blood vessel. In the case of an aortic aneurysm, dyspnea, cough, sputum production, congestion, and other symptoms may appear, and there may be pressure on the trachea, esophagus, veins, or nerves. Aneurysms are often the result of trauma or bacterial and mycotic infection. angioedema, hereditary

A rare inherited disorder (genetically known as autosomal dominant) due to the deficiency or malfunction of a substance called C1-esterase inhibitor usually manifesting in late adolescence or early adulthood. Infected persons have less than 15 percent normal-functioning C1 inhibitor (an inhibitor is a chemical that stops enzyme activity), and family history is positive for this disorder in 85 to 90 percent of patients. Lack of C1 inhibitor results in an activation of the complement system (consisting of components related to how antibodies work in the blood) and the release of chemical mediators that produce the symptoms of angioedema. The condition is characterized by recurrent episodes of painful swelling of the skin and mucosa of the upper respiratory and gastrointestinal tracts, and the extremities. Hereditary angioedema can be triggered by minor trauma, sudden changes in temperature, infections, and emotional upset. An estimated 25 percent of untreated individuals die of laryngeal edema after dental or throat surgery. Other symptoms include abdominal pain from swelling of intra-abdominal organs, vomiting, diarrhea, and a drop in blood pressure. Unlike idiopathic, or nonhereditary, angioedema, urticaria (hives) and itching do not occur. Diagnosis is made by measuring C1 inhibitor levels, assays that assess

anthrax 19 functional abnormalities in the presence of normal or near-normal levels of the enzyme, and other complement levels. This life-threatening disease can be treated with synthetic anabolic steroids such as danocrine (Danazol). However, the drug cannot be used in children or adolescents until they have achieved their full growth. Short-term therapy in anticipation of dental or throat surgery includes fresh-frozen plasma given one day prior to surgery. Epsilon-aminocaproic acid and tranexamic acid are drugs sometimes used prior to surgery. Emergency intubation or tracheostomy may be required.

anoxia

Lack of oxygen, such as in high altitude anoxia. Anoxic anoxia is caused by a disorder in the lungs’ ability to fill with oxygen, which in turn may be caused by decreased oxygen supply, a respiratory obstruction, decreased pulmonary function, or insufficient respiratory movements.

antasthmatic

A substance or agent that prevents or relieves the symptoms of asthma.

anthracosilicosis

A type of pneumoconiosis characterized by an accumulation of silica and carbon deposits in the lungs as a result of inhaling coal dust. See also COAL WORKER’S PNEUMOCONIOSIS.

anthracosis

Carbon deposits in the lungs from inhaling smoke or coal dust. See also BLACK LUNG.

anthrax An infectious disease caused by Bacillus anthracis that usually attacks cattle, sheep, horses, and goats, but may also be transmitted to humans through contact with animal hair, hides, or waste materials. The disease may target the lungs or loose connective tissue, which may cause malignant edema, necrosis of mediastinal lymph nodes, and pleural effusion. Shock, coma, and respiratory arrest may also occur. Penicillin, tetracyclines, and erythromycin are among the drugs of choice for the treatment of anthrax. In the fall of 2001 on the heels of the terrorist attacks on the World Trade Center in New York

City, anthrax-tainted mail became a major concern for postal workers and the general population. Considered an act of chemical terrorism (also called bioterrorism) committed by yet unknown perpetrators, anthrax spores in a powdered form were found in envelopes and packages. When inhaled by the recipient, there was a possibility of contracting the disease. The first of several victims of inhalation anthrax was American Media photo editor Bob Stevens, of Florida, who died in September 2001. An initial difficulty in diagnosing the disease involved medical professionals who had rarely, if ever, treated cases of anthrax. Now the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, releases updated knowledge on the diagnosis and treatment of anthrax. Believed to have a survival rate ranging from 1 to 15 percent before the terrorism occurred, inhalation anthrax now presents itself with a 60 percent survival rate. Of the 10 individuals who were reported to have contracted the disease, six survived, most likely due to early recognition of symptoms and prompt antimicrobial administration. Some victims of anthrax, aged 43 to 73, complained of various flu-like symptoms, while others experienced non–flu-like drenching night sweats, nausea and vomiting, abdominal pain, and pleural effusion. Of the three types of anthrax—inhalation, cutaneous, and gastrointestinal—inhalation is the most dangerous and life-threatening, particularly because the symptoms, including fever, malaise, nonproductive cough, chest or abdominal pain, nausea, vomiting, and headache, may suddenly subside (called “the anthrax honeymoon”), and treatment may be delayed. However, untreated symptoms of anthrax may lead to acute dyspnea, a widening of the mediastinum (seen in chest X ray/radiograph), diaphoresis, cyanosis, stridor, shock, and death in up to three days. Some victims of anthrax may also develop meningitis. According to reports, all 10 victims showed abnormal chest X rays with pleural effusion, mediastinal widening, or infiltrates. The incubation period of anthrax may be as brief as two days after contamination to two months. The dearth of information on the incubation period, symptoms, cross-contamination, and methods of infection has prompted the CDC to recom-

20 antibiotic mend the use of ciprofloxacin (Cipro) or doxycycline for initial intravenous therapy plus other antimicrobial drugs until antimicrobial results are specified. Other antibiotics that may be used include ampicillin, chloramphenicol, clarithromycin, clindamycin, imipenem, penicillin, rifampin, and vancomycin, or combinations of various drugs. The use of cephalosporins and trimethoprim-sulfamethoxazole, and the use of penicillin G, ampicillin, or amoxicillin alone, are not recommended by the CDC. For those anthrax sufferers who are allergic or cannot take ciprofloxacin or doxycycline for some other reason, high-dose penicillin, such as amoxicillin or penicillin VK may be substituted, and steroids may be necessary if the patient is experiencing respiratory distress or has meningitis. Treatment for children with anthrax may be even more difficult to diagnose, and the CDC urges pediatric practitioners to be aware of symptoms that may warrant immediate treatment. Prophylactic antibiotics have been recommended for individuals who may have been exposed to aerosolized anthrax spores or to air space shared by a victim of inhalation anthrax. More information is available on the CDC website, www.cdc.gov/ncidod/EID/vol7no6/pdf/jernigan. pdf. See also ANTIBIOTIC; PLEURA; WOOLSORTER’S DISEASE.

antibiotic A natural or synthetic substance or agent that inhibits the growth of or destroys microorganisms. In 1939, the first antibiotic— meaning against life—was gramicidin, used by René Dubos to treat infected cattle. Penicillin’s clinical use came later. A bacteriocidal or bactericidal antibiotic agent kills microorganisms; a bacteriostatic antibiotic inhibits their growth. A broadspectrum antibiotic inhibits or kills a number of microorganisms. Some strains of bacteria were either never affected by antibiotics or have evolved to become resistant to them. This has become a recent problem most likely because the use of antibiotics became so commonplace as to be overprescribed, and because individuals stopped taking the medication sooner than prescribed (therapy usually spans seven to 10 days) when symptoms subsided or disappeared. Completion of antibiotic

therapy is of utmost importance, even after an illness or infection seems to have gone away. Also, many patients demand antibiotics for respiratory or other infections that may in actuality be caused by a virus, not a bacterium, in which case the antibiotic is ineffective and the body develops a tolerance for it that may thwart the effectiveness of an antibiotic prescribed for a future infection. Antibiotics that target certain viruses have been developed. See also PENICILLIN.

antibody A substance produced by B cells (lymphocytes derived from bone marrow) and designed to attack a specific foreign invader called an antigen. For example, a cold virus stimulates a B cell to produce an antibody against that specific virus. The immune process involving antibodies is referred to as humoral immunity. When a B cell encounters its triggering antigen, T cells and other accessory cells collaborate with it to cause the production of large plasma cells. Each plasma cell becomes a factory for producing antibodies. Antibodies are Y-shaped protein molecules known as immunoglobulins. Transported through the circulation to the site of inflammation or infection, antibodies neutralize or combine with and identify antigens for attack by other cells or chemical mediators. antibody deficiency disorder

Acquired or congenital inability to produce all or selective classes of immunoglobulins. Individuals with this disorder have frequent infections or difficulty overcoming them. Examples are X-linked or Bruton’s agammaglobulinemia (lack of gamma globulin antibodies in the blood) and common variable or acquired hypogammaglobulinemia (abnormally low level of gamma globulin in the blood). See also ACQUIRED IMMUNODEFICIENCY SYNDROME; IMMUNOGLOBULIN A; IMMUNOGLOBULIN D; IMMUNOGLOBULIN G; IMMUNOGLOBULIN M.

anticholinergics

Bronchodilating drugs that block the action of nerve reflexes that constrict muscles of the bronchial tubes in the lungs. Anticholinergics take 15 to 20 minutes to become effec-

antihistamine 21 tive, as opposed to faster-acting beta-agonists. Atropine and ipratropium (Atrovent) are examples; only Atrovent is available as a metered-dose inhaler. Adverse effects of anticholinergics, dry mouth and cough, are rarely encountered with ipratropium.

antigen (immunogen) Any substance that, when introduced into the body, is recognized by the immune system and is capable of triggering an immune response. The term immune is derived from the Latin immunis (free from taxes or free from burden). An antigen can be a bacterium, fungus, parasite, virus, or a part or substance produced by these organisms. Tissues or cells from another individual, except an identical twin, are recognized by the immune system as foreign and, therefore, antigenic. See also ALLERGEN; IMMUNE SYSTEM. antigens, cross-reaction among plant families Allergic reactions that occur from exposure to allergens common to more than one plant family. For example, ragweed, a member of the Ambrosiaceae family, has antigens that cross-react with members of the family Compositae. This crossreaction explains why ragweed-sensitive persons may react when drinking chamomile tea, because chamomile is derived from Compositae. Ragweedsensitive persons also may react to pyrethrum, an insecticide made from chrysanthemums, another member of the Compositae. Although hay fever sufferers sometimes experience itching and swelling of the palate after eating melons and bananas during the ragweed season, there is no cross-reactivity between ragweed antigen and the botanical families of melon and banana.

antihistamine Any drug that blocks the effects of histamine, a potent chemical substance produced in the body, and is responsible for the body’s allergic responses. For nearly 50 years, antihistamines have been used to prevent or relieve the symptoms of immediate, type I hypersensitivity, or anaphylactic allergic reactions. Characteristic symptoms include sneezing, rhinorrhea (watery nasal dis-

charge), congestion, itching, wheezing, and swelling of tissues. During an allergic reaction, allergens bind to histamine type 1 receptors on the surface of mast cells and basophils, and cause the cells to rupture and release stored histamine and other substances called chemical mediators. Antihistamines bind to these receptors to prevent allergens from binding, which in turn prevents cell rupture and release of the mediators. Histamine blockade of receptors is competitive, and an inadequate dose or a lapse in timing of a dose of antihistamine may result in poor therapeutic response. Histamine may also be released by other mechanisms during exposure to certain drugs, chemicals, dyes, foods, toxins, alkaloids, venoms, or physical stimuli. Certain foods also contain histamine. Histamine and other released chemical mediators are responsible for the symptoms that occur during anaphylaxis, which may be lifethreatening, and antihistamines alone may be inadequate in this situation. The beneficial effects of antihistamines, as well as any adverse ones, are related to their basic chemical structures. There are five classes of type 1 antihistamines. Some antihistamines such as azatadine have a dual action and also prevent the release of the chemical reactors, thus blocking to varying degrees the cascade of events of allergic reaction. Drugs available in the United States, such as azelastine (Astelin Nasal Spray) and ketotifen (Zaditor Ophthalmic Solution) have traditional receptor blocking abilities, but their greatest antiallergic benefits combat inflammatory late-phase reactions. Since their primary function is against late-phase reaction, azelastine and ketotifen are not really antihistamines by definition. Antihistamines are most effective in seasonal allergic rhinitis or hay fever, slightly less effective for perennial or chronic allergic rhinitis, and least likely to improve symptoms of the nonallergic vasomotor and infectious types of rhinitis. Antihistamines are frequently prescribed with nasal decongestants either separately or combined in one tablet, capsule, or liquid preparation. There is no evidence that antihistamines are of any benefit for the treatment of colds, despite their inclusion in many over-the-counter and prescription cold remedies. But an indirect benefit may be attributed to the sedative side effect of most

22 antihistamine antihistamines, especially when the inducement of drowsiness or sleep is desired. The intense pruritus (itching) that accompanies urticaria (hives) and the allergic skin conditions, eczema and contact dermatitis, are relieved to varying degrees by antihistamines. At night, the added benefit of sedation from the first-generation agents such as hydroxyzine (Atarax) may make them more effective. The nonsedating astemizole (Hismanal) is effective for suppressing hives and can be given in a single-daily dose for convenience. H1 and H2 antihistamines are sometimes combined in resistant cases of hives. Minor allergic reactions to insect stings, drugs, foods, and allergy immunotherapy (allergy shots) often respond to antihistamines. When anaphylaxis is impending or has occurred, epinephrine (Adrenalin Chloride) should be administered promptly. Diphenhydramine (Benadryl) or other antihistamines are useful only as a secondary treatment. Prescription and overthe-counter antihistaminic eyedrops relieve itching associated with seasonal allergic conjunctivitis. Antihistamines are sometimes given prophylactically before a blood transfusion in persons with a history of prior transfusion reaction. While antihistamine may reduce the itching and flushing that can occur during a transfusion, it does not prevent the serious reactions possible from receiving blood from an incompatible donor. Many persons experience adverse reactions to radiocontrast (X-ray dye). Such reactions are complex, and there is a higher incidence in allergic individuals. Antihistamines and corticosteroids should be given to anyone who has had a previous reaction. Sedating properties of antihistamines make them useful as relatively safe, nonprescription hypnotics. One must be warned, however, that overdoses of these drugs may be fatal. Also, tolerance develops quickly, limiting their usefulness for chronic insomnia. Hydroxyzine (Vistaril) and promethazine (Phenergan) are antihistamines often mixed with narcotics such as meperidine (Demerol) to potentiate their effectiveness and also to prevent nausea. Cyclizine (Marezine), meclizine (Antivert, Bonine), and dimenhydrinate (Dramamine) prevent motion sickness and counteract the disabling vertigo of Ménière’s syndrome. Side effects vary by incidence. Intensity corresponds to

the class to which a particular antihistamine belongs. The traditional antihistamines cause drowsiness in many individuals because the drug diffuses into the central nervous system from the general circulating blood. Drowsiness varies greatly among individuals, often improving after several days. Great care must be taken when driving or operating dangerous machinery because of impairment of reflexes. Drowsiness intensifies if other sedative drugs or alcohol are used concurrently. Antihistamines may also disturb coordination and cause dizziness, a feeling of lassitude, fatigue, tinnitus (ringing in the ears), diplopia (double vision), and the inability to concentrate. Instead of sedation from antihistamines, a few individuals, especially infants or toddlers, experience an unexpected excitatory or stimulant effect, at times to the point of insomnia. Seizures, or convulsions, are a potentially serious adverse effect of antihistamines in some individuals predisposed to them, most often children. Sedation is the most frequent side effect of first-generation antihistamines, also referred to as “classic” or traditional antihistamines, such as chlorpheniramine (Chlor-Trimeton) and diphenhydramine (Benadryl). Newer antihistamines such as terfenadine (Seldane), astemizole (Hismanal), and the drugs loratadine (Claritin) and cetirizine are generally nonsedating in most patients. For many years antihistamines were thought to be contraindicated or harmful to patients with asthma. In fact, most over-the-counter and prescription antihistamines come with a warning against their use by these patients. It was thought that their drying effects would aggravate asthma. Not only has this been disproved, but some antihistamines have mild bronchodilating effects and may actually be beneficial to some asthmatics. Rarely will an antihistamine worsen asthma. The topical use of antihistamines available as over-thecounter remedies for the relief of itching from prison ivy, insect stings, and sunburn should be avoided. These products are skin sensitizers in many persons and frequently cause an allergic contact dermatitis worse than the original condition for which they are recommended. Anticholinergic, or atropine-like, side effects range from minor dryness of the mucous mem-

antihistamine 23 branes of the nose, mouth, and throat to constipation, tachycardia (palpitations), excitability, restlessness, nervousness, insomnia, irritability, and tremors. Blurred vision could be a potentially serious problem in a person with untreated or inadequately controlled glaucoma. It is not uncommon for a middle-aged or elderly male to develop a sudden inability to pass urine (acute urinary retention) after taking an antihistamine. Infrequent gastrointestinal disturbances include anorexia (loss of appetite), nausea, vomiting, abdominal pain, constipation, or diarrhea. The most important advance since the availability of these important drugs in the 1940s has been the development of the “second-generation” H1-receptor antihistamines. These newer agents, including terfenadine and astemizole, are nonsedating in up to 99 percent of patients because they do not cross the blood-brain barrier in significant amounts. Some rare side effects of nonsedating antihistamines include increased appetite and weight gain in patients taking astemizole and hair loss in a few patients taking terfenadine. A more serious, but fortunately an extremely rare, problem with both astemizole and terfenadine has been the onset of cardiac arrhythmias (irregularities), including ventricular tachycardia and fibrillation, which can be lifethreatening. Arrythmias follow doses two or three times the recommended dose. Patients at increased risk have been those also taking the drugs ketoconazole (Nizoral), troleandomycin (TAO), or erythromycin, or those with liver diseases such as hepatitis or alcoholic cirrhosis and hypokalemia (a state of low potassium in the blood). Rare cases of blood disorders, such as agranulocytosis (a severe depression of the bone marrow’s production of granulocytic white blood cells), leukopenia (low leukocytic white blood cell count), thrombocytopenia (destruction or decreased production of platelets), and hemolytic anemia (destruction of the red blood cells), are usually reversible when the offending drug is discontinued. Considering the millions of doses of these drugs taken every day, the chances of suffering a serious side effect are slim. Despite antihistamines’ long record of safety, their easy availability makes them popular for suicide attempts. The margin of safety for antihista-

mines is considerably less for children. The first signs of overdose usually occur within two hours of ingestion: drowsiness, dizziness, unsteady gait, flushing, dilated pupils, and fever; however, children will often paradoxically appear hyperactive, with hallucinations, toxic psychosis (bizarre behavior), and tremors. In adults, seizures, respiratory failure, cardiac arrest, and death may result. There is no perfect antidote for antihistamine overdose. Efforts may include eliminating the drug by induced vomiting in a conscious patient or by pumping the stomach in a lethargic or comatose one. Activated charcoal and strong laxatives called cathartics are also given. The drug physostigmine is sometimes used, but not without risk. It should probably be used only in situations when high temperature or delirium does not respond to cooling by hypothermia blankets, fluids, and cold bathing. Antihistamines may mask the early signs of anaphylaxis and should not be used to prevent this reaction when administering immunotherapy (allergy shots). Although the use of drugs during pregnancy, especially during the period of organ development in the first trimester, should be limited, the use of an antihistamine may be unavoidable. Treatment should be based on the same principles for using any drug during pregnancy. Not only must the drug be necessary, but it also should have a long record of use during pregnancy without reported adverse outcomes to the pregnancy and its use must be monitored by a physician experienced in its use during pregnancy. Chlorpheniramine (Chlor-Trimeton) and tripelennamine (Pyribenzamine) are the preferred antihistamines in pregnancy. Antihistamines: Chemical Classification and Generic and Trade Names Amino alkyl ethers (Ethanolamines): clemastine fumarate (Tavist); diphenhydramine hydrochloride (Benadryl) Ethylenediamines: pyrilamine maleate (generic); tripelennamine citrate or hydrochloride (PBZ) Alkylamines (Propylamines): brompheniramine maleate (Dimetane); chlorpheniramine maleate (Chlor-Trimeton, Teldrin); dexchlorpheniramine maleate (Polaramine); tripolidine

24 anti-inflammatory hydrochloride (Actidil) [Other antihistamines of this class not generally used for allergic conditions are not listed.] Phenothiazines: methdilazine (Tacaryl); promethazine hydrochloride (Phenergan); trimeprazine tartrate (Temaril) Piperidines: azatadine maleate (Optamine); cyproheptadine hydrochloride (Periactin) Piperazines: hydroxyzine hydrochloride (Atarax, Vistaril); phenindamine tartrate (Nolahist) Nonsedating: acrivastine (Semprex); astemizole (Hismanal); azelastine (Astelin); cetirizine hydrochloride (Zyrtec); loratadine (Claritin); terfenadine (Seldane). See also

DECONGESTANT; HISTAMINE H2, RECEPTOR

AGONIST.

anti-inflammatory

An agent or substance that prevents or reduces inflammation, the body’s nonspecific immune response to an area that is injured or traumatized. Anti-inflammatory drugs may also relieve pain. Ibuprofen is a popular example of a nonsteroidal anti-inflammatory (trade names include Motrin, Advil, Nuprin, and Rufen). Aspirin (acetylsalicylic acid) is also a nonsteroidal antiinflammatory (also known as NSAIDs) with painkilling and fever-reducing properties. Some NSAIDs have been known to produce asthma in certain individuals, which contraindicates their use. Bronchospasm, nasal polyps, rhinitis, and hypersensitivity to the particular drug are also contraindications.

antimicrobial

An agent or substance that destroys or inhibits the development of microorganisms.

antiseptic An agent or substance that prevents or inhibits the growth of disease-causing microorganisms. antituberculotic Thwarting or stopping tuberculosis in the body. In the treatment of pulmonary tuberculosis, antituberculars are drugs that inhibit RNA or DNA fats and protein synthesis,

which reduces the ability of the tubercle bacillus to replicate.

antitussive

An agent or substance that reduces, relieves, or prevents coughing. A centrally acting antitussive acts on the medullary centers of the brain to suppress the cough reflex.

antiviral An agent or substance that inhibits or destroys viruses. anxiety

Feelings including fear and panic or nervousness that may lead to physiological symptoms or discomfort. Breathing difficulties and disorders may cause anxiety in some individuals. Because anxiety is a response to stress or conflict, a person with a respiratory disorder such as asthma or chronic obstructive pulmonary disease may experience symptoms of anxiety during an exacerbation of the disease or after the discontinuation of a medication. Many individuals, with or without respiratory disease, may experience anxiety as shortness of breath or a feeling of being asphyxiated, faintness, heart palpitations, trembling or shivering, increased sweating, a sensation of choking, fear of losing control or dying, chills, numbness, nausea, diarrhea, pains in the chest, and other manifestations. Very often the family of a person with a respiratory disorder such as asthma may suffer severe anxiety when the person experiences an asthma attack or any situation that causes difficulty breathing. Education, precautions, and strategies prepared ahead of time may decrease the fears of the caregivers. Those with anxiety disorders not usually induced by a medical problem, such as social phobia, obsessive-compulsive disorder, agoraphobia, posttraumatic stress disorder, panic attacks, or panic disorder, should seek treatment if they develop a respiratory or other medical problem, or if they have an anxiety disorder in addition to a respiratory problem. It is also recommended that physicians check for possible adverse effects of a medication if a patient exhibits symptoms of severe anxiety.

apneusis 25 Psychiatric patients with severe respiratory disorders should be monitored carefully so that they can receive the proper medication and comply with proper medical treatment.

apicolysis

A collapse of the apex of the lung induced by surgically creating an opening in the anterior chest wall. This procedure may be performed for a number of reasons based on a physician’s assessment of a patient’s condition. Symptoms of anxiety may require attention and emotional support. Both during and after the procedure, caregivers must monitor the patient carefully for signs of dyspnea, cyanosis, increased pulse and respiratory rate (which may indicate tension pneumothorax), and signs of mediastinal shift, including severe dyspnea, cyanosis, increased pulse and respirations, distended veins in the neck, and severe, uncontrollable cough.

apnea A temporary cessation of breathing, which may be caused by failure of the respiratory center of the brain to discharge breathing impulses. Apnea is a symptom of conditions including arteriosclerosis, meningitis, cardiac and renal diseases, or following trauma to the brain. Apneic oxygenation refers to providing oxygen to the upper airway of patients who are not breathing. Apnea monitoring is recommended especially for infants to prevent sudden infant death syndrome. Infants may be placed on an apnea alarm mattress designed to sound an alarm if the infant stops breathing. Sleep apnea, or a cessation of breathing occurring during sleep, may last approximately 10 seconds and recur 30 or more times in a seven-hour period of sleep. This disorder may be caused by an upper airway obstruction, respiratory muscle activity dysfunction, or a combination of factors. Treatment may include surgical correction of an obstruction, the correction of an underlying disease, weight loss, and the prescription of certain drugs. apneumatosis See also

Congenital atelectasis.

ATELECTASIS.

apneumia A birth defect in which the lungs are absent. Birth defects may result from chromosomal

or genetic abnormalities of one or both parents, and genetic testing may be recommended for those who wish to conceive but may have a family history of genetic problems. Physicians or genetic counselors usually prefer to know the history of at least three generations in a particular family, i.e., causes of death of all parents, siblings, children, aunts, uncles, and grandparents, history of distant relatives if pertinent (such as if they had a genetic disorder), ethnic and racial background, possible intermarriages of relatives, and exposure to drugs that have been known to cause fetal distress or defects. Various testing is also helpful in detecting hereditary disorders. Carrier screening for diseases caused by recessive genes and prenatal diagnosis are among the available methods. Infants born with a physical abnormality such as the absence of lungs are most likely victims of a chromosomal defect or defects in several genes (polygenic). Amniocentesis, ultrasound scanning, and various blood, placental, and fluid tests aid the physician in prenatal diagnosis. Some genetic disorders that are detectable before birth include cystic fibrosis, congenital adrenal hyperplasia, duch*enne’s muscular dystrophy, hemophilia A, alpha- and beta-thalassemia, Huntington’s disease, polycystic kidney disease, sickle cell anemia, and Tay-Sachs disease.

apneusis A respiratory abnormality marked by the difficult and prolonged effort to inhale. The condition is the result of surgical removal of the upper portion of the pons in the brain. This procedure may be treatment for a disorder of certain cranial nerves. The pons is fairly centralized in the brain, just above the medulla and in front of the cerebellum. The pons, which works with the medulla to control breathing, connects the spinal cord with the brain and connects other parts of the brain to each other. Located in some of the pons fibers are nuclei for the trigeminal nerves, which govern impulses for chewing and for sensations of the head and face; the abducens nerves, which regulate some movement of the eyeballs; facial nerves, which carry impulses for the production of saliva, the sense of taste, and facial expressions; and part of the vestibulocochlear nerves that are involved with the sense of balance.

26 apneustic center apneustic center

The area of the brain stem that regulates respiration.

the vagus is the 10th cranial (head) nerve, which has the widest distribution in the body of any of the other cranial nerves.

apple-packer’s epistaxis

Nosebleed caused by contact with dyes used in apple-packing trays. See also EPISTAXIS.

apple-picker’s disease Bronchitis caused by a fungicide used on apples. Bronchitis is an inflammation of the bronchial tubes that causes congestion, pain, and other respiratory symptoms. See also BRONCHITIS. apulmonism A birth defect in which there is an absence of all or portions of a lung. See also APNEUMIA. arch, pulmonary An extension of the fifth aortic arch on the left side of the body into the pulmonary artery. Aretaeus the Cappadocian (ca. A.D. 120–180) A Greek physician who wrote treatises on causes, symptoms, and treatments of acute and chronic diseases and is credited with the first valid description of asthma, Aretaeus noted in his writings that exercise or other physical work may induce difficulty breathing and that a “sense of suffocation” may occur when a patient reclines. (Aretaeus also refers to orthopnea, which in modern medicine means respiratory discomfort that can be relieved when an individual either stands or sits erect, with the help of props such as pillows. A person may experience relief, for example, by what is called “two-pillow orthopnea.”) Also in the writings of Aretaeus are descriptions of heaviness in the chest, occupational hazards, thickened mucus, coughing and hoarseness, a desire for cold air, expectoration of foamy sputum, and other manifestations of asthma. Aristocort

See

AZMACORT; TRIAMCINOLONE.

Arnold’s nerve The auricular branch of the vagus nerve, which, when stimulated, causes coughing. Originating in the medulla oblongata of the brain,

arrest, respiratory

The cessation of normal breathing that results in a dangerously low level of oxygen in the blood or a severe increased level of carbon dioxide in the blood. This condition may stem from a number of conditions: chronic bronchitis; emphysema; bronchiectasis; cystic fibrosis; asthma; bronchiolitis; an airway obstruction, or an inhaled or aspirated foreign body, particle, or object; a chest wound; kyphoscoliosis; a drug reaction; acute respiratory distress syndrome; pulmonary fibrosis; fibrosing alveolitis; tumors; sarcoidosis; radiation; burns; myasthenia gravis; muscular dystrophy; polio; Guillain-Barré syndrome; polymyositis; cerebrovascular accident (stroke); amyotrophic lateral sclerosis (Lou Gehrig’s disease); an injury to the spinal cord; poor breathing ability due to obesity, sleep apnea, or drug intoxication. In the case of respiratory failure or arrest, oxygen administration and alleviating the cause or causes are the treatments of choice.

arrhinia

A birth defect in which there is the lack of a nose. See also APNEUMIA.

arterial blood gases (ABGs) A blood test that determines the body’s acid-base balance and the concentrations of the gases oxygen, carbon dioxide, and bicarbonate in the blood. Blood samples are taken from an artery. An ABG test aids in monitoring respiratory failure, because the heart and lungs work to distribute oxygen from inhalation throughout the body via the bloodstream and expel carbon dioxide by exhalation. The normal acid-base balance, also referred to as the pH, or acidity-alkalinity, is 7.39 to 7.41. Asthma, chronic bronchitis, emphysema, diabetes (specifically diabetic ketoacidosis), aspirin poisoning, chronic obstructive lung disease, and symptoms including repeated vomiting may throw ABGs out of the normal range. See also ASTHMA AND PREGNANCY.

asphyxia 27 artificial pneumothorax

The introduction of air into the pleural cavity by means of the administration of oxygen, nitrogen, or filtered atmospheric air.

the muscles), and is considered a natural antibiotic that, when taken prophylactically, boosts the immune system and fights infection.

aspergillosis, allergic bronchopulmonary (ABPA) artificial

respiration

See

CARDIOPULMONARY

RESUSCITATION.

asbestosis

A lung disease, a variant of pneumoconiosis, resulting from protracted inhalation of asbestos particles (fibrous particles of magnesium and calcium silicate). Asbestosis occurs among workers who mine, mill, or manufacture the substance and construction workers who are exposed to it through building or demolition. Scarring of the lung tissue caused by inhaling asbestos dust may be severely aggravated by smoking, chronic bronchitis, or other pre-existing respiratory disorders. Inhaled asbestos fibers cause fluid to accumulate in the pleural space (between the two layers of the pleura), or, in some cases, cause cancerous, incurable tumors in the pleura, called mesotheliomas. Only workers trained in the proper techniques for the removal of asbestos should attempt such a task. The incidence of asbestosis has decreased significantly from that of four or five decades ago because of new industrial precautions and preventive measures, but people who were exposed back then to any of the four types of asbestos fibers may begin to exhibit respiratory distress (especially those who smoke) or mesothelioma decades later. Treatment for asbestosis inhalation includes removing the victim from the contaminated environment, oxygen therapy, the draining of excess fluid from around the lungs, cessation of smoking, and, in some cases, lung transplantation. See also MESOTHELIOMA.

ascorbic acid

A naturally occurring nutrient, also called vitamin C, in citrus fruits and fresh vegetables. It can be synthesized as well, and is important in the maintenance of the body’s collagen, bone tissue, and dentin production. Vitamin C, an essential vitamin, prevents scurvy (a nutritional deficiency that results in hemorrhaging of gums and mucous membranes and painful indurations of

A pneumonia-like disease caused by an allergic reaction to the mold Aspergillus fumigatus. It usually occurs in adult asthmatics. Signs and Symptoms This disorder usually involves episodes of fever, shortness of breath, wheezing, and coughing up copious quantities of dark brown, and at times blood-streaked, sputum. Diagnosis Because the fungus is ubiquitous (found in healthy persons in small quantities that are harmless), the presence of positive sputum cultures is not sufficient to diagnose this disease. The diagnosis is made in persons meeting the following criteria: (1) episodes of asthma; (2) elevated eosinophils (a type of white blood cell) and total immunoglobulin E (IgE) antibodies in the blood; these values are slightly elevated in most allergic individuals but extremely elevated in persons with this disease; (3) pneumonia-like X-ray findings, which may be temporary; (4) bronchiectasis (destruction of the muscles in the bronchial walls with chronic cough and large amounts of sputum); (5) positive skin tests to the Aspergillus fungus; and (6) positive blood tests for antibodies against the Aspergillus allergen. Treatment Prednisone, a corticosteroid drug, is the treatment of choice. It is used daily, most often for several months, and improvement is usually seen within days. In some cases, recurrences require long-term prednisone use. Prognosis If untreated, aspergillosis will damage lung tissues and can be fatal. See also CORTICOSTEROIDS; PREDNISONE.

asphyxia A life-threatening inability to obtain oxygen, such as in choking, trauma, electric shock, drowning, chest compression, lack of oxygen in the

28 aspiration environment, hemorrhage, pharyngeal and retropharyngeal abscesses, paralysis of respiratory muscles, collapsed lung, child abuse, anesthesia, injury of respiratory nerves or centers, and other conditions. Artificial respiration (cardiopulmonary resuscitation) or other treatments may be indicated. Symptoms include difficulty breathing, cyanosis, rapid pulse, sensual and mental impairment, convulsions, and unconsciousness.

aspiration

The act of drawing air or other substance in or out, such as in suction. When an excess of fluid or air, or a foreign body is aspirated into the nose, throat, or lungs upon breathing in, it may be suctioned, or aspirated, out to relieve the undesirable condition. An aspirator is a device designed to evacuate the affected area.

aspirator

See

ASPIRATION.

aspirin triad A condition consisting of asthma complicated by nasal polyps and aspirin sensitivity. However, there are many people with asthma and nasal polyps who can tolerate aspirin, and others with asthma and aspirin sensitivity who do not have nasal polyps. As a rule, it is usually advisable for any person with asthma to use aspirin and related drugs with caution. Astelin Nasal Spray Brand name for azelastine, the only antihistamine approved for topical use in the United States. See also ANTIHISTAMINE. astemizole (Hismanal) A nonsedating (secondgeneration) antihistamine, prescribed for allergic rhinitis and hives, that may take several days to become effective. Astemizole remains in the body for a prolonged period and may suppress hypersensitivity skin-test results for as long as four weeks. It may not be used simultaneously with the antibiotic erythromycin or in persons with severe liver disease because of the possibility of episodes of cardiac arrhythmias. See also ANTIHISTAMINE.

asthma

A chronic lung disease characterized by recurrent attacks of breathlessness, airways (bronchial tubes) that become hyperactive and constrict when exposed to a variety of stimuli or “triggers,” obstruction of the bronchioles that is reversible (but not completely in some patients) either spontaneously or with treatment, and inflammation of the airways. Asthma derives from the Greek word for “panting.” According to the American Lung Association, more than $3.2 billion are spent annually for in-patient hospital services and a total of $11.3 billion per year: $7.5 billion in direct costs and $3.8 billion in indirect costs. The basic cause of asthma is not yet known. The airways of the asthmatic are hyperactive (twitchy) and overly responsive to environmental changes or stimuli called triggers. Triggers result in wheezing and coughing that some researchers think may be set off by an abnormal reaction to sensory nerves in the lungs. As the attack progresses, chemical mediators are released from cells lining the bronchioles, causing inflammation that leads to contraction of airway muscle, production of mucus, and swelling in the airways. Asthma can be classified as either extrinsic (triggered by outside influences such as allergy) or intrinsic (from within). Each asthmatic reacts to a different set of triggers. Identification of a person’s personal triggers is a major step toward learning to control asthma attacks. Although episodes can sometimes be triggered by strong emotions, asthma is not caused by emotional factors, such as a troubled parent-child relationship. However, researchers at the Children’s National Medical Center in Washington and the National Jewish Center for Immunology and Respiratory Medicine in Denver have found a relationship between family stress and the onset of asthma by age three in genetically predisposed children. Three factors—marital discord, prolonged maternal depression, and parental problems in day-to-day care of the child—significantly increased asthma predisposition in genetically at-risk children from 17 percent (if one or none of these stress factors was present) to 42 percent (if at least two of the risk factors were present). Asthma is a disease, not a psychogenic illness or a sign of emotional instability.

asthma 29 There are great variations in asthma severity from person to person and in the individual asthmatic from time to time. Symptoms range from mild to severe and can become life-threatening. The frequency of episodes ranges from one occurrence in a lifetime to daily attacks. The individual attack may be short-lived, lasting from a few minutes to a few hours, or continuous, with daily symptoms for days or weeks. A severe, constant state of asthma is referred to as “status asthmaticus.” The symptoms of asthma are a major cause of sleep disturbances and time lost from school and work. Although asthma cannot be cured, the symptoms can almost always be controlled with proper treatment. In one study of more than 300 asthma patients, researchers found that only 54 percent accurately estimated the severity of their asthma and 27 percent overestimated the severity. The 20 percent who underestimated the severity of their asthma were considered to be at a greater risk for suffering a life-threatening attack. Experts selected to serve on the National Asthma Education Program have developed guidelines for the treatment of asthma. The four basic steps are: 1. Education of the patient and family 2. Control of the environment 3. A comprehensive drug regimen that may include immunotherapy (allergy shots) 4. Objectively monitoring progress. The goals of therapy are to maintain normal or near-normal activity levels including exercise; maintain normal or near-normal lung function test results; prevent coughing, shortness of breath, waking up at night, and loss of time at school or work; prevent the need for emergency room visits or hospitalizations; and avoid medication side effects. The National Asthma Education Program emphasizes an understanding of asthma by each patient and family members. An educated patient is better able to anticipate and, thus, avoid situations that might trigger or worsen asthma. Other guidelines include identification of triggers at home, school, or work; development of effective and simple drug regimens for the patient

to follow; close monitoring of medication dosage adjustments; monitoring effectiveness of advised environmental control measures; monitoring symptoms objectively with doctor’s office spirometry and home peak flow meters, devices that accurately measure breathing status; identifying high-risk individuals and providing psychological support utilizing mental health and social services personnel; preparation, frequent review, and revision as necessary of a crisis management plan for the patient and his or her family; aggressive, prompt treatment of acute episodes; and primary care coordinated with a specialist in asthma. Recognizing Asthma Asthma may resemble, and can be confused with or might coexist with, other respiratory problems such as emphysema, bronchitis, and lower respiratory tract infection. At times, the only symptom of asthma is a persistent cough, usually at night. In some individuals, coughing and wheezing may occur only with exercise. In infants and children, symptoms suggestive of asthma must be differentiated from many other conditions that cause wheezing. The sudden onset of unremitting wheezing in an infant or small child may point to an obstruction of the large airways by a foreign body lodged in the trachea, bronchus, or esophagus until proven otherwise. Laryngo-tracheobronchomalacia is a congenital disorder involving the softening of cartilage that may be associated with asthma and increased incidence of respiratory infections during a child’s first two years. Croup, caused by a respiratory virus, or acute epiglottitis, a serious bacterial infection that can threaten life, can be confused with asthma because inspiratory wheezing is common to both. Cystic fibrosis (CF) may coexist with asthma and should be suspected in any infant with failure to thrive (poor growth) and recurrent respiratory infections. In older children and adolescents, CF should be suspected in asthmatic patients who have had recurrent pneumonia. Mitral valve prolapse, which occurs commonly in slender adolescents (females more than males) and causes chest pain during strenuous exercise, may be confused with exercise-induced asthma. It

30 asthma is characterized by a systolic click heard in the mitral area with a stethoscope; diagnosis is confirmed by an echocardiogram. Hyperventilation syndrome may be misdiagnosed or coexist with asthma, especially in adolescents. The patient typically appears anxious and breathless but without wheezing. A complaint of tingling of the fingers and toes is common. Treatment consists of reassurance and having the patient rebreathe into a paper bag to elevate carbon dioxide levels. Recurrences may require psychological counseling and, possibly, antianxiety drugs. In adults, asthma is often confused with the other common lung diseases, emphysema and chronic bronchitis, which to some degree act like asthma. The hallmark of the three lung diseases is airway obstruction. The principal difference in the conditions is the degree of reversibility of the airway obstruction. A patient with asthma should have normal airflow between attacks. Chronic bronchitis is characterized by obstruction to varying degrees but usually is not completely reversible with treatment. The obstruction found in patients with emphysema is irreversible by definition. However, most patients fall between these strict limits. Asthma may be hard to diagnose and is greatly underdiagnosed. To distinguish asthma from other lung diseases, doctors rely on a combination of the patient’s medical history (the patient’s recount of his or her symptoms and past disorders), a thorough physical examination, and certain tests: measurement of airflow into and out of the lungs, chest X rays, blood tests, and skin tests. Sometimes, challenges with methacholine (a drug that constricts the bronchi in persons with asthma) are indicated.

Asthma Screening The American College of Allergies, Asthma and Immunology’s (ACAAI’s) Nationwide Asthma Screening Program is an assessment tool used to identify individuals who may be at risk for asthma and its complications. Now in its fourth year, the program has screened more than 20,000 people and referred more than half of them to professionals for diagnosis. The screenings are conducted by allergists, physicians who are asthma specialists, free of charge at shopping malls, civic centers, health fairs, and other accessible locations throughout the country. During a screening, adults who are experiencing breathing problems complete a 20-question Life Quality Test developed by the ACAAI. A special test is available for the parents of children up to age eight, called the Kids’ Asthma Check. In addition, participants in the screenings take a special lung function test that involves blowing into a tube and meet with a physician to determine if they should seek a thorough examination and diagnosis. People who already know they have asthma may also speak with a specialist at the screenings. The following Kids’ Asthma Check questions for children ages one through eight require a yes or no answer: Symptoms and Signs of an Asthma Attack It is unusual to have a sudden life-threatening attack of asthma without warning signs. Usually the signs of an impending asthma attack manifest hours or even days before a full-blown attack develops. Every asthma patient should have an emergency strategy preplanned with his or her physician. The

QUESTIONNAIRE FOR ASTHMA IN CHILDREN 1. When walking or playing hard with friends, my child has trouble breathing or coughs. 2. When walking up hills or stairs, my child has trouble breathing or coughs. 3. When running or playing sports, my child has trouble breathing or coughs. 4. Sometimes my child wakes up at night with coughing or trouble breathing. 5. Sometimes my child has trouble taking a deep breath. 6. Sometimes my child makes wheezing sounds. 7. Sometimes my child complains of pain or tightness in the chest. 8. Sometimes my child coughs a lot. 9. Being outdoors or around dust or pets makes my child’s breathing worse. 10. It’s hard for my child to breathe in cold weather. 11. It’s hard for my child to breathe when people smoke or there are strong odors. 12. Colds make my child cough or wheeze.

YES

asthma 31 National Asthma Education Program recommends the use of peak flow meters to follow the progress of an asthma attack. There are inexpensive portable devices to measure the peak flow (airflow in the bronchial tubes). Use of a peak flow meter can be a valuable guide with which to follow a person’s progress. Worsening of asthma can usually be detected in time to take corrective measures. Because individuals vary, patients should know their own signs of an impending attack. The initial sign may be itching of the face or throat, a feeling of tightness in the chest, and mild wheezing. This is the time to act to prevent progressive or sudden worsening of the attack. Early intervention is the key to preventing the need for emergency treatment and asthma fatalities. Extrinsic asthma is a form of asthma caused by allergens found in the environment, such as seasonal or perennial allergens such as house-dust mites, but can be triggered by a perennial allergen. A greater percentage of children (up to 85 percent) than adults (about 50 percent) suffer from extrinsic asthma. Extrinsic asthmatics usually have positive skin or radioallergosorbent tests (RAST), but not every asthma patient suffers from allergies. Foods may be blamed as a cause of asthma. Foods were cited for allergic reactions by patients almost four times as often as allergic rhinitis. However, most experts feel the true incidence of foodinduced asthma is much less frequent. In double-blind food challenges (tests in which a suspected allergenic food or placebo is given to a patient and monitored for reaction), symptoms of asthma could be confirmed only in 25 to 33 percent of the children. Most cases of food hypersensitivity stem from milk allergy in early infancy. Many adverse food reactions are probably caused by food additives or preservatives such as sulfites, bisulfites, and metabisulfites. Intrinsic asthma may be caused by factors other than allergy. Intrinsic asthma occurs in less than 50 percent of adults and in about 15 percent of children with asthma. Some children from infancy experience wheezing triggered only by viral respiratory infections. Other children and adults suffer asthma triggered by irritants, emotional factors, and other nonallergenic stimuli. Many of those

with intrinsic asthma have nasal polyps and sensitivity to aspirin. Skin tests for allergy are usually negative in these persons, but it is possible to have both intrinsic and extrinsic asthma. Nocturnal Asthma Nocturnal asthma refers to the occurrence of symptoms of asthma during the night. Nearly 40 percent of asthmatics experience nightly symptoms; approximately 64 percent have episodes three nights a week, and about 75 percent at least one night per week. Asthma attacks seem to occur most often between 10 P.M. and 7 A.M., peaking at about 4 A.M. When several things simultaneously trigger asthma, results can be severe. The most devastating asthma attacks that lead to respiratory arrest and possibly death most often occur between midnight and 6 A.M. During sleep, mucus secretions accumulate in the bronchial tubes, and the backup, or reflux, of stomach acid may spill over into the lungs, causing irritation and inflammation of lung tissue. The circadian fall in the body’s production of cortisone and adrenaline and the rise of other chemicals, such as histamine, further worsen the situation during the night. In addition, the cell counts of neutrophils and eosinophils (cells that release mediators of inflammation) are higher in patients with nocturnal symptoms. Timing medications to coincide with peak effectiveness and times of greatest need can greatly reduce symptoms and allow patients to sleep through the night. Medications for Asthma Medications are prescribed when the symptoms of asthma cannot be prevented by controlling the environment or other triggers such as a viral respiratory infection. The medicines used depend on the frequency and severity of symptoms and may be therapeutic or preventive, or both. Bronchodilators are chosen for their ability to prevent or reverse airway obstruction. They include beta-adrenergic agonists such as albuterol, metaproterenol, and pirbuterol; methylxanthines such as theophylline; and the anticholinergics atropine and ipratropium. Anti-inflammatory agents interrupt the development of bronchial inflammation and also act to

32 asthma prevent asthma attacks. These drugs include corticosteroids (cortisone-like drugs), cromolyn, and others that are still investigational. Beta-agonists alone may be all the therapy necessary for mild, episodic asthma. Metered-dose inhalers (MDIs) on an as-needed, or “PRN,” basis are the first line of therapy. These drugs are also taken before exercise or sports to prevent symptoms. Their prolonged use at regular four- to sixhour intervals has been associated with some diminished occurrences of asthma, and the recommended three to four doses a day should rarely be exceeded. Overuse of beta-agonists has been associated with increased risk of death from asthma. Oral dosage forms of beta-agonists are also available as short-acting (six to eight hours duration of action) or sustained-release (lasting up to 12 hours) tablets. When both dosage forms of betaagonists are taken simultaneously, the MDI is reserved for acute episodes or prior to exercise. Theophylline is the most widely used methylxanthine. It is available in tablet, capsule, and liquid forms, which are short- or long-acting, and for many years was the prime drug for the treatment of asthma. A related drug, aminophylline, is available for intravenous use but is rarely used orally. Theophylline and aminophylline have come under scrutiny because of the frequency of adverse effects, especially in infants. The 1991 asthma expert panel report from the National Institutes of Health (see the 1997 report below) relegates the methylxanthine drugs to a secondary or tertiary role behind beta-agonists and the anti-inflammatory medications. The methylxanthines are thought to inhibit phosphodiesterases, enzymes implicated as a cause of asthma. These drugs dilate constricted bronchioles. Longacting forms are most useful in preventing nighttime awakening from asthma. In addition, they reduce respiratory muscle fatigue and have a mild degree of anti-inflammatory activity. Close monitoring of blood levels can usually avoid the most serious complications of these drugs. The inhaled anticholinergic ipratropium, an atropine-like drug, is a weak bronchodilator that also blocks reflex bronchoconstriction by inhaled irritants. Although it is less effective than other

bronchodilators, ipratropium lacks side effects and is useful in the few individuals who cannot tolerate other drugs. Corticosteroids are the most effective antiinflammatory drugs for the treatment of asthma. They can be given orally as tablets or liquids, by injection, or topically as aerosol MDIs. Despite the fear of adverse effects, systemic corticosteroids, when used appropriately early in an asthma attack, prevent progression and lessen the need for emergency room visits and hospitalizations, and they may be lifesaving. In severe asthmatics, they may be required daily or on alternate days. Inhaled corticosteroids are safe and effective as preventive therapy and are first-line therapy for anyone with frequent symptoms of asthma. In recommended doses, side effects are usually limited to local irritation of the pharynx, though this can be prevented by rinsing the mouth after each use or by using a spacer device. Spacers allow active medication to be inhaled, while irritating larger particles settle in the chamber of the spacer. In addition to reducing adverse effects, they allow poorly coordinated persons, often including young children, to use MDIs effectively. Cromolyn sodium is a preventive, anti-inflammatory drug causing no serious side effects, administered by MDI or nebulizer. It is most effective in children. Prevalence According to a March 1999 report by the U.S. Centers for Disease Control and Prevention, asthma now affects more than 14 million Americans, approximately double the rate of 20 years ago. The asthma rate for children age four and younger has increased 160 percent between 1980 and 1994. The incidence of asthma seems to be equally distributed among males and females, but blacks have a 4.4 percent rate of asthma, while whites have a 4.0 percent rate. Increases have been reported in all ages, races, and in both sexes. Individuals with asthma require more than 100 million days of restricted activity per year. African Americans are three times as likely to die from asthma as are whites of all ages; however, this incidence increases five times in individuals ages 15 to 44. The asthma death rate doubled for children ages five to 14.

asthma 33 According to the American Academy of Allergy, Asthma and Immunology, nearly one in 10 American children have asthma, and the reason for that is still unknown. One theory for the increase is the result of spending more time indoors where we are exposed to more potent allergens. Studies are now being conducted to better understand the inflammatory response to allergens and the fundamental regulators of the entire process. The studies are focused on identifying the basic abnormality that causes asthma and the genes that direct the allergic process, developing more advanced patient-education, medicine, and treatments, including asthma self-management techniques, and refining emergency measures for asthma attacks. In the December 1999 issue of the Annals of Allergy, Asthma and Immunology, asthma “far exceeds other causes of occupational pulmonary disease, with an estimated 5 percent of all adult asthma cases workplace-related, and some 250 causative agents implicated.” The American Lung Association says the rate of asthma in the United States will likely double by the year 2020. The association supports the findings and recommendations of the report released by the Pew Environmental Health Commission at the Johns Hopkins School of Public Health entitled “Attack Asthma: Why America Needs a Public Health Defense System to Battle Environmental Threats.” The report calls for the creation of a national asthma tracking system within five years, development of an action plan to coordinate the efforts of federal agencies responsible for responding to the nation’s asthma problem, expanded investment in asthma prevention research, and implementation of a comprehensive public education campaign for the public and health care providers. John M. Corruthers, Jr., president of the American Lung Association, said the association “will continue to work with the 17 million Americans who have asthma and establish a foundation for significantly reducing the number of people who develop asthma in the future.” Asthma-Related Death In the United States, minorities from inner-city neighborhoods have a much higher proportion of

deaths as a result of asthma than do urban whites. In Chicago in a five-year period, 90 percent of all asthma deaths were persons in minority groups, although minorities accounted for only 40 percent of the total population. In the past decade, the greatest increase in deaths occurred in those older than 65 years of age. Nonwhites are almost three times as likely to die from asthma as whites. However, despite recently increased asthma deaths, the number of such deaths in the United States—approximately 14 people per day (more than 5,000 per year), according to the Statistical Abstracts of the United States—is one of the lowest numbers of asthma deaths in the world. Factors that increase risk for a fatal attack of asthma include age over 65, ethnicity (nonwhite race), previous life-threatening asthma attack(s), hospital admission for asthma within the last year, psychological and psychosocial problems, lack of access to medical care, and abuse of asthma drugs. In the past decade (1990–2000), the greatest increase in asthma deaths is seen in older age groups. There has also been a significant trend in deaths among those from five to 34 years of age during the same period. African Americans have almost three times the rate of asthma deaths as Caucasians for all ages. However, in age group 15 to 44, the rate increases to five times the rate for Caucasians. Persons who have required intubation and a respirator for respiratory failure, or who have suffered respiratory acidosis in the past, are at increased risk to die from a similar episode. Persons hospitalized within the previous year for asthma were more likely to die from asthma, as well as those with more than two hospitalizations for severe asthma and patients on oral corticosteroid therapy. There is an association between children dying suddenly from asthma and prior expressions of hopelessness, despair, and a wish to die. Unemployment, alcohol abuse, recent family loss, recognizable depression, and schizophrenia increase the risk of sudden and unexpected death from asthma for adults. Many poor families in urban neighborhoods lack a regular family doctor or asthma specialist. Treatment is often delayed until the patient’s

34 Asthma and Allergy Poster Child diagnosis is status asthmaticus (severe unrelenting asthma). Patients usually seek emergency room medical care only during a crisis. In rural areas, a similar situation can arise because of the great distance to a medical facility or lack of a specialist. Lack of prevention and knowledge of asthma may prevail in any environment. A Canadian study, based on health insurance records of 12,300 asthma patients between 1978 and 1987, demonstrated twice the risk of a fatal or near-fatal asthma attack in patients overusing certain medications. The use of twice the maximum recommended dose of a beta2-agonist MDI was considered the causative factor in this increased risk. Risk Factors for Asthma-Related Death • Past history of sudden severe exacerbations. • Prior intubation for asthma. • Prior admission for asthma to an intensive care unit. • Two or more hospitalizations for asthma in the past year. • Three or more emergency care visits for asthma in the past year.

accessory muscles, paradoxical breathing, cyanosis, and a respiratory rate of greater than 60 are key signs of serious distress. • Objective measurements such as oxygen saturation of higher than 91 percent also indicate serious distress. • Response to beta2-agonist therapy can be variable and may not be a reliable predictor of satisfactory outcome. However, because infants are at greater risk for respiratory failure, a lack of response noted by either physical examination or objective measurements should be an indication for hospitalization. • Use of oral corticosteroids early in the episode is essential but should not substitute for careful assessment by a physician. • Most acute wheezing episodes result from viral infections and may be accompanied by fever. Antibiotics are generally not required. Sources: Kallebnach et al., 1993; Rodrigo and Rodrigo, 1993; Suissa et al. 1994; Greenberger et al., 1993; O’Hollaren et al., 1991.

See also ACIDOSIS, RESPIRATORY; APPENDIX I; ARTERIAL BLOOD GASES; ASTHMA AND PREGNANCY; ASTHMA CAMPS; BETA-ADRENERGIC AGONISTS; BRONCHITIS,

• Hospitalization or an emergency care visit for asthma within the past month.

CHRONIC;

• Use of more than 2 canisters per month of inhaled short-acting beta2-agonist.

EXERCISE-INDUCED ASTHMA; IMMUNOTHERAPY; IPRA-

• Current use of systemic corticosteroids or recent withdrawal from systemic corticosteroids. • Difficulty perceiving airflow obstruction or its severity. • Comorbidity, as from cardiovascular diseases or chronic obstructive pulmonary disease. • Serious psychiatric disease or psychological problems. • Low socioeconomic status and urban residence. • Illicit drug use. • Sensitivity to Alternaria. Special Considerations for Infants • Assessment depends on physical examination rather than objective measurements. Use of

CORTICOSTEROIDS;

CROMOLYN

SODIUM;

CROUP; CYSTIC FIBROSIS; EMPHYSEMA; EPIGLOTTITIS; TROPIUM; OCCUPATIONAL ASTHMA; PEAK FLOW METER; SPIROMETER; TRIGGER, ASTHMA; THEOPHYLLINE.

Asthma and Allergy Poster Child

From 1983 to 1993, the Asthma and Allergy Foundation of America (AAFA) sponsored a national, annual contest in which a child with a documented history of asthma and allergies, as well as other certain qualities, was selected to represent all children who wish to overcome their illness. Poster children were judged to be outgoing and articulate, and would participate in AAFA-sponsored events. Past national poster children are: Lanny Bert Powell (Greenville, S.C.), 1983; Reggie Smith (Baltimore, Md.), 1984; Ann Cordrey (Cincinnati, Ohio), 1985; Jamie Noland (Ft. Collins, Colo.), 1986; Scott Halverson (Omaha, Nebr.), 1987–88; Chele Williams (Newport News, Va.), 1989; Jennifer Carol Price (Midland, Tex.),

asthma and pregnancy 35 1990; Chris Dulman (Michigan), 1991–92; and Amanda Johnston (Portland, Oreg.), 1993. The AAFA may be contacted at: Asthma and Allergy Foundation of America 1125 15th Street NW, Suite 502 Washington, DC 20005 (800) 7-ASTHMA

asthma and pregnancy Asthma is present in at least 4 percent of all pregnancies and may occur in as many as 10 percent. Asthma may occur for the first time during pregnancy. Preexisting asthma may worsen or improve during pregnancy. About one-third of pregnant women with asthma worsen during pregnancy, one-third continue unchanged, and one-third improve. General Treatment Principles of Asthma During Pregnancy • Asthma is a chronic condition with acute exacerbation or attacks; close monitoring by both patient and doctor is necessary to detect subtle changes throughout pregnancy. • Prevention of attacks is of utmost importance. Identify and avoid triggers, and optimize measures to reduce the presence of indoor allergens, such as furry pets, dust mites, and molds. Especially avoid tobacco smoke. Use air-conditioning during pollen seasons to reduce exposure. Use preventive drugs daily exactly as prescribed. • Anticipate or intervene early during an attack. Use a peak flow meter to detect subtle changes in breathing and have a plan to act before attacks become severe or catastrophic. • Although using as few medications as possible is generally desirable during pregnancy, normal breathing and oxygen levels must be maintained in the mother to assure normal oxygen supply to the fetus. Inhaled drugs are preferred, but if they are not totally effective, systemic drugs should be used to achieve normal lung function. • Disorders that aggravate asthma, such as sinus infections, nasal allergies, and heartburn, should be treated promptly so they will not trigger asthma.

Adverse Effects Whether a pregnant woman’s asthma worsens, remains the same, or improves, uncontrolled asthma can produce serious complications for mother and fetus. Maternal complications from asthma include preeclampsia (a toxemia of pregnancy), gestational hypertension, hyperemesis gravidarum (severe nausea and vomiting during pregnancy), vagin*l hemorrhage, toxemia, and induced and complicated labor. Fetal complications include increased risk of fetal death, diminished growth, prematurity, low birth weight, and neonatal hypoxia. The more severe the asthma, the greater the risk, but even mildly uncontrolled asthma is a risk. When asthma is well controlled, even if medications are required, the outcome of pregnancy should be the same as those experienced by a nonasthmatic mother. PREFERRED DRUGS FOR THE TREATMENT OF ASTHMA DURING PREGNANCY Drug Type

Specific Drug

anti-inflammatory

beclomethasone (Beclovent, Vanceril) cromolyn sodium (Intal) prednisone

bronchodilator

inhaled beta2-agonist: albuterol (Proventil, Ventolin), metaproterenol (Alupent), pirbuterol (Maxair), terbutaline (Brethaire) theophylline (Constant-T, Quibron, SloBid, Slo-Phyllin, Theo-Dur, Theo-24, Theolair, Theovent, Uniphyl; serum levels must be monitored to avoid toxicity)

Effect on Fetal Oxygen Supply During pregnancy, changes occur in the mother’s body, unrelated to asthma, that cause a mild sensation of shortness of breath in many normal women. However, these “normal” changes affect neither the supply of oxygen to the fetus nor the results of breathing tests that are used to measure the severity of asthma in the mother. During an asthma attack, the mother’s body utilizes available oxygen, reducing the amount supplied through the placenta to the fetus. A small fall in oxygen concentration that would result in only

36 asthma and pregnancy minimal to moderate distress to the mother can be catastrophic to the baby. Goals of Therapy and Treatment Traditionally, asthma was viewed as an intermittent acute illness. Symptoms were due to constriction of the bronchioles, and the goal of drugs was to reverse this spasm. Since scientists have determined the importance of lung inflammation in asthma, the goal of treatment is not only to improve symptoms during an attack but also to prevent symptoms from recurring. Treatment of asthma during pregnancy follows the same principles as for the nonpregnant individual. Avoidance of asthma triggers may reduce the need for drugs. When drugs are needed, the preventive anti-inflammatory cromolyn and corticosteroid inhalers are especially useful, safe, and effective. Monitoring Mother’s Breathing Status For pregnant patients with asthma, objective measurement of lung function is essential. This can be done in the doctor’s office with spirometry or a peak flow meter. Inexpensive hand-held peak flow monitors can be used at home or in the workplace to detect changes that may indicate the onset of an asthma attack. The peak flow meter may detect changes before symptoms are apparent. Fetal Monitoring For pregnant women with asthma, fetal evaluation is based on objective measurements such as sonography (ultrasound), electronic fetal heart rate monitoring, and by subjective means, such as the mother’s assessment of fetal kicks (“kick count”). Sonography from 12 to 20 weeks provides a guide to fetal growth and should be followed frequently in cases where asthma is moderate or severe to detect growth retardation. Effects of Asthma Drugs In considering the possible effects of drugs and disease on pregnancy, it is important to keep in mind the incidence of adverse pregnancy outcomes in the general population. Congenital anomalies (birth defects) occur in 3–8 percent of all newborns, and of these only 1 percent or fewer are attributable to drug exposures.

Both animal and human data are studied to evaluate the safety of drugs. If studies in animals, where huge doses are used during testing, are reassuring, the potential for effects in humans is low. However, animal data do not always give complete information. It may not be possible to know whether the effects of a drug on the newborn were caused by the use of excessive doses by the mother, the disease process itself, or other multiple factors. Human studies rarely include large numbers of patients exposed to a particular drug. Therefore, drugs that have been used for many years without a significant number of reported adverse effects are considered most reliable. Immunotherapy Immunotherapy (allergy shots) may prevent asthma symptoms triggered by allergies, therefore reducing the need for drugs. Desensitization by injecting minute amounts of allergy extracts for cat dander, dust mites, molds, and pollens is generally safe and effective. The principal concern for giving immunotherapy during pregnancy is the same as in nonpregnant individuals, to avoid anaphylaxis (the most severe form of allergic reactions). Because a severe reaction may threaten the lives of both mother and fetus, injections of allergy extracts must be given cautiously and doses are usually not increased or sometimes slightly decreased during pregnancy. It is generally recommended that allergy immunotherapy not be initiated during pregnancy, because it takes several months for any benefit to be evident and doses must be given in increasing amounts during the early stages of treatment. Influenza (“Flu”) Vaccine Annual flu vaccine is recommended for all patients with moderate or severe asthma. Influenza vaccine is based on a killed virus, and there is no evidence of risk to mother or fetus. Physical Activity Physical activity should be encouraged and no different from that of a nonasthmatic pregnant woman. If necessary, pretreatment with a betaagonist metered-dose inhaler such as albuterol or cromolyn five to 60 minutes before exercise should be used.

asthma camps 37 PREFERRED DRUGS FOR THE TREATMENT OF ALLERGY OR RESPIRATORY INFECTIONS COMPLICATING ASTHMA DURING PREGNANCY Drug Type

Specific Drug

antibiotics

amoxicillin

antihistamine

chlorpheniramine (Chlor-Trimeton) tripelennamine (Pyribenzamine)

anti-inflammatory

cromolyn sodium (Nasalcrom nasal spray) beclomethasone (Beconase, Vanceril)

cough

dextromethorphan, guaifenesin (Robitussin)

decongestant

oxymetazoline (Afrin) nasal

spray or drops

pseudoephedrine (Sudafed) (must be used sparingly to avoid rebound worsening of nasal congestion)

Summary Pregnant women with asthma need specific treatment. Nondrug measures are preferred such as improving the environment to avoid known trigger-allergens or irritants such as tobacco smoke. Drugs with many years of safe use are the best choice. A panel of experts from the National Institutes of Health strongly recommends that asthma be as aggressively treated in pregnant women as in nonpregnant women. See also EXERCISE-INDUCED ASTHMA; PEAK FLOW; PEAK FLOW METER; RHINITIS MEDICAMENTOSA; SPIROMETER. [Adapted from the National Asthma Education Program’s report Management of Asthma During Pregnancy (NIH Publication No. 93-3279A, October 1992).]

asthma camps

These recreational facilities provide a safe, medically supervised, and enjoyable experience for children with asthma who would otherwise be unable to attend camps. According to the American Lung Association, there are currently more than 130 children’s asthma camps in the nation and the number is growing. The Consortium on Children’s Asthma Camps (CCAC) has established parameters for the operation of asthma camps. The Consortium was established in 1988 to coordinate camp activities of national organizations

involved in the care of children with asthma. According to CCAC, the purpose of the Consortium is to promote the quality of medical care delivered at existing asthma camps; to provide parameters for educational goals; to promote the development of new asthma camps, and to develop initiatives to target high-risk children and give them the opportunity to attend asthma camp. The Consortium is composed of representatives from the American Academy of Allergy, Asthma and Immunology, the American Lung Association, the American Thoracic Society, the American Academy of Pediatrics, and the Asthma and Allergy Foundation of America. The current chairman is Sherwin Gillman, a practicing allergist in Orange County, California.

The key objectives of asthma camps include: 1. improving a child’s ability to self-manage asthma through a creative yet systematic approach to asthma education; 2. introducing children with asthma to a full camp/outdoors experience; 3. gathering valuable information on the effectiveness of various means of asthma education; 4. teaching asthma management in a fun and engaging way, leading to improved patient compliance; 5. providing health care volunteers with an opportunity to utilize and hone their professional skills in a fun, unusual environment; 6. providing a forum for all relevant audiences for teaching and learning optimum asthma management practices. The Inner City Asthma Camp Initiative In 1993, the national Consortium on Children’s Asthma Camps launched Phase I of the Inner City Asthma Camp Initiative: to meet the growing needs of inner-city children with asthma. The goals of this phase of the initiative were to develop and implement educational programs to take place both before and after asthma camp, and to involve not only camp attendees but their families as well; to identify and recruit for these programs disadvantaged children, ages 9–12, who have asthma and live in

38 asthma-friendly schools urban areas, and to increase knowledge of, change attitudes about, and gain more control over asthma among inner-city children who have the disease and their parents, guardians, or adult caregivers. Five asthma camps participated independently in Phase I, which included a study to evaluate the effectiveness of asthma camps in teaching innercity children and their families about the disease and how to manage it better.

Results of the study determined that, after participating in camp and pre- and post-camp activities, children reported fewer symptoms of asthma, and their ability to manage asthma increased. They also indicated that the camp experience expanded their knowledge of asthma and improved family communication. Most of the children in the study said they enjoyed the camp experience and found it helpful. (A complete copy of the study Effectiveness of Asthma Camps for Inner City Families by Stephen C. Weisberg, M.D., David H. Olson, Ph.D., and Richard J. Sveum, M.D., is available from the Consortium.) Asthma Roadways, Phase II, of the initiative (July 1995–November 1999) elected the following goals: to reduce asthma-related hospitalizations; to reduce asthma-related emergency room visits; to decrease symptom days, and to improve the quality of life, related to asthma, in the target population. Asthma Roadways was designed to encourage children with asthma and their families to interact effectively, which, it is hoped, will help them gain control over asthma by setting individual and family goals; learn more about asthma and environmental controls; reduce family stress related to asthma; improve family communication about asthma and increase overall satisfaction of individuals within families. In 1999, the Consortium sought to create comprehensive and consistent national guidelines and standards for the set-up, operation, and evaluation of resident and day asthma camps. In March 1999 a website was launched with links to all sponsors. In addition to a database of all asthma camps in the country, the Parameters for Medical Policies and Procedures for Children with Asthma was published in 1996, and the book for children I’m Going to Asthma Camp was published in 1997. For more informa-

tion, visit http://www.lungusa.org/asthmacamps/ about.htm. Camp Broncho Junction Camp Broncho Junction, formerly in Red House, West Virginia, was a pioneering, 16-year effort. The founders, the late Dr. Merle S. Scherr and his late wife, Lois, conducted psychological evaluations of the campers in the areas of behavioral and sociopsychological adjustment and provided a sharp profile not only of the individual patients but also of the group as a whole. Clinical psychologists and psychiatrists, testing with the California Test of Personality, and counselors’ ratings implemented psychological evaluation through personal interviews. The results point toward a more realistic and positive integration of the children’s physical problems into their total lifestyle. When the children were separated into two groups, those with severe asthma and those with the least severe asthma, improvement was especially striking in the most severe group. Group therapy sessions with children and families and weekend therapy sessions also contributed to patient improvement.

asthma-friendly schools

The National Heart, Lung, and Blood Institute, the National Asthma Education and Prevention Program, and the School Asthma Education Subcommittee developed the following questions to determine what constitutes asthma-friendly schools. Children with asthma need proper support at school to keep their asthma under control and be fully active. Use the questions below to find out how well your school assists children with asthma: 1. Is your school free of tobacco smoke all of the time, including during school-sponsored events? 2. Does the school maintain good indoor air quality? Does it reduce or eliminate allergens and irritants that can make asthma worse? Allergens and irritants include pets with fur or feathers, mold, dust mites (for example, in carpets and upholstery), co*ckroaches, and strong odors or fumes from such products as pesticides, paint, perfumes, and cleaning chemicals.

Ayerza’s syndrome 39 3. Is there a school nurse in your school all day, every day? If not, is a nurse regularly available to the school to help write plans and give guidance for students with asthma about medicines, physical education, and field trips? 4. Can children take medicines at school as recommended by their doctor and parents? May children carry their own asthma medicines? 5. Does your school have an emergency plan for taking care of a child with a severe asthma episode (attack)? Is it made clear what to do? Who to call? When to call? 6. Does someone teach school staff about asthma, asthma management plans, and asthma medicines? Does someone teach all students about asthma and how to help a classmate who has it? 7. Do students have good options for fully and safely participating in physical education class and recess? (For example, do students have access to their medicine before exercise? Can they choose modified or alternative activities when medically necessary?)

sion of the bronchus by enlarged lymph nodes, tumors, or aneurysms. Atelectasis in varying degrees is present during asthma attacks, particularly in children. Symptoms range from none to breathlessness. The X-ray appearance of atelectasis may be confused with the markings, or infiltrates, in the lungs associated with pneumonia. See also PNEUMOTHORAX.

If the answer to any question is no, students may be facing obstacles to asthma control. Asthma that is out of control can hinder a student’s attendance, participation, and progress in school. School staff, health care professionals, and parents can work together to remove obstacles and to promote students’ health and education. Contact asthma organizations for information about asthma and helpful ideas for making school policies and practices more asthma-friendly. Federal and state laws are there to help children with asthma. Asthma can be controlled; expect nothing less.

Aufrecht’s sign

asthmatic bronchitis

autoimmune disease

See

ASTHMA.

atmiatrics (atmotherapy) with medicated vapors. atmotherapy

See

atomizer

NEBULIZER.

See

Therapeutic treatment

ATMIATRICS.

atresia, pulmonary A congenital condition in which the pulmonary valve between the pulmonary artery and the right ventricle of the heart is closed. Named for the German physician, Emanuel Aufrecht (1844–1933), who first defined it, a diminished breathing sound heard through a stethoscope that indicates stenosis (constriction) of the trachea or windpipe.

auscultation

The act of listening to bodily sounds, usually through a stethoscope in order to determine any abnormalities. Chest sounds are heard both anteriorly and posteriorly, and patients are typically requested to take deep breaths in and out, and cough. See ACQUIRED IMMUNE DEFI-

CIENCY SYNDROME.

Atarax The trade name for the antihistamine hydroxyzine hydrochloride, also known as Vistaril Parenteral. See also ANTIHISTAMINE.

autotuberculin Tuberculin, or the soluble cell substance prepared from the tubercle bacillus that causes tuberculosis, made by taking cultures of an individual’s own sputum.

atelectasis

A partial or total collapse of the lung that may be caused by mucous plugs, excessive secretions, foreign-body obstruction, or compres-

Ayerza’s syndrome Named for the Brazilian physician, Abel Ayerza (1861–1918), a condition of

40 Ayurvedic medicine pulmonary insufficiency marked by difficulty breathing, chronic cyanosis (blue coloration of skin and mucous membranes), erythrocytosis, spleen and liver enlargement, and bone marrow hyperplasia.

Ayurvedic medicine

The ancient Hindu medical system, named from the Sanskrit words ayu (lifespan) and veda (knowledge). Through yoga, herbal remedies, massage therapy, pulse diagnosis, and other factors, Ayurveda medicine

seeks to integrate mind and body for optimal wellness.

Azmacort Metered-dose asthma inhaler containing the cortisone-like anti-inflammatory drug triamcinolone. This unique inhaler comes with a white barrel-shaped device called a spacer. Spacers assure that even individuals with less than perfect coordination receive an adequate dose of the drug. See also CORTICOSTEROIDS; INHALED MEDICATIONS; INHALER; SPINHALER.

B Bacillus anthracis

See

Bacteria generally have flagella, or whiplike tails, for motility, and most form colonies that can flourish in soil, water, organic matter, humans, animals, and plants. In humans, undesirable bacteria usually succumb to antibiotic treatment. See also ANTIBIOTIC.

ANTHRAX.

bacteria Living microscopic organisms composed of a single cell and lacking chlorophyll. Structurally, a bacterium bears some resemblance to the human cell. Parts of one bacterium include the nuclear region (or chromosomes), or “central intelligence” in which DNA dictates the characteristics of the cell; ribosomes, which carry RNA and units of protein in the cell’s cytoplasm; and the cell membrane and the cell wall, which carry proteins, fats, and sugars. Bacterial infections, especially those affecting the respiratory and integumentary systems, may trigger or intensify conditions of allergy and asthma, or be mistaken for them. The three major categories of bacteria are spherical or ovoid, such as micrococci, diplococci, staphylococci, streptococci, and sarcinae; rod shaped, or bacilli, such as coccobacilli and streptobacilli; and spiral, or spirilla, such as spirochetes and vibrios. Because bacteria have no chlorophyll and do not photosynthesize the way plants do, they derive their nutrients from organic material, parasites, soil, or nonliving organic matter. Bacteria are considered pathogenic if they are capable of causing disease in their host, but many bacteria are nonpathogenic and perform beneficial functions in the human body and the environment, especially in the nitrogen cycle of the soil. Aerobes are bacteria that thrive on atmospheric oxygen; anaerobes can live without oxygen. Most bacteria reproduce asexually by binary fission, or splitting into two parts. Certain species of rod-shaped bacteria form spores, which are encapsulated bacterium cells in a resting or dormant stage. While in this stage, spores resist heat, cold, dehydration, disinfectants, and other attempts to destroy them.

bagassosis A form of hypersensitivity pneumonitis. This allergic pneumonia-like disease is caused by the inhalation of bagasse dust, the dusty fibrous waste of sugarcane after the sugar-containing sap has been removed. See also HYPERSENSITIVITY PNEUMONITIS. bag-valve-mask resuscitator

See

ARTIFICIAL RES-

PIRATION.

baker’s asthma An occupational lung disease caused by repeated exposure to flour, especially wheat, an airborne allergen. There is usually no related allergy to ingested bakery products. In one study, 10 percent of exposed bakers selected randomly developed asthma. The bakers were exposed an average of 17.4 years before symptoms developed. Immunotherapy (allergy shots) may be effective treatment for the inhaled food allergen causing baker’s asthma. This type of therapy is not recommended when the food allergen exposure is from oral ingestion. Baker’s rhinitis is an allergic condition of the upper respiratory tract caused by repeated exposure to flour, usually airborne wheat allergen. bambuterol A beta-agonist (bronchodilating) drug chemically related to terbutaline. Bambuterol has a direct action in lung tissue; little of the active

42 barosinusitis drug is absorbed into the bloodstream, therefore minimizing the possibility of side effects. It also has the advantage of requiring only one daily dose. See also BETA-ADRENERGIC AGONISTS.

barosinusitis A condition characterized by pain and inflammation in one or more of the nasal sinuses when they have ascended or descended in response to a change in environment, such as being in an airplane when a sinus outlet is blocked. barrel chest Enlarged chest diameter attributable to conditions including chronic obstructive pulmonary disease (COPD), chronic bronchitis, and emphysema. basic life support Part of cardiopulmonary resuscitation (CPR) and emergency cardiac care that attempts to prevent respiratory or circulatory arrest and provides means for external support of those functions. See also CARDIOPULMONARY RESUSCITATION; BAGMASK-VALVE RESUSCITATOR. beclomethasone (Beconase, Beconase AQ, Vancenase, Vancenase AQ, Beclovent, Vanceril) A corticosteroid drug used as a nasal spray for the prevention of allergic rhinitis and as a metereddose inhaler for the prevention of asthma. Beclomethasone’s anti-inflammatory action, considered safe for use during pregnancy, is also prescribed for the treatment of nonallergic nasal polyps and rhinitis medicamentosus. However, the drug is typically more effective for allergic rather than nonallergic disorders. Some authorities recommend cautious use in persons with active tuberculosis, bacterial, systemic fungal, or viral infections, recent nasal injury or surgery, nasal infection, or ocular herpes simplex. For hay fever, beclomethasone may take a week or more before reaching full effectiveness; in nonallergic conditions, it may take three weeks to prove either effective or noneffective. Severe asthma should be stabilized by using oral corticosteroids before a beclomethasone inhalant can elicit preventive, anti-inflammatory benefits. Most asthma authorities now advocate the use of

this and other anti-inflammatory metered-dose inhalers as first-line maintenance therapy in persons with mild to moderate asthma. See also AEROSOL; CORTICOSTEROIDS; CORTICOSTEROID NASAL SPRAYS.

Beclovent

See

BECLOMETHASONE.

bends Bubbles of nitrogen that get into the blood and tissues in the event of a rapid decrease in air pressure. The condition (common among deep-sea divers) causes pain in the limbs and abdomen. It occurs also when a person ascends too fast after a period of exposure to increased air pressure while under water. The treatment is to restore normal air pressure via a hyperbaric chamber so the patient may slowly regain normal pressure. See also CAISSON DISEASE; DECOMPRESSION ILLNESS. benign pneumoconiosis

Conditions such as siderosis (from the inhalation of iron oxide), baritosis (inhalation of barium), and stannosis (inhalation of tin particles) that show up in a chest X ray but actually do not cause symptoms or dysfunction of the lungs.

berylliosis

Poisoning typically affecting the lungs, caused by beryllium particles (beryllium is a metallic element) that may be inhaled or contracted under the skin. The particles result in fibrosis and granulomata. Beryllium is used today mainly in the aerospace industry, but it used to be mined for use in the electronics and chemical industries, particularly in the manufacture of fluorescent light bulbs. The lung inflammation from beryllium fumes or dust is different from other occupational lung diseases because it seems to affect only those with a hypersensitivity to beryllium, although symptoms may not appear for one or two decades after even a brief exposure to the substance. It has been reported, too, that people living near beryllium refineries have also developed berylliosis. Potentially fatal, acute berylliosis may manifest suddenly with coughing, dyspnea, weight loss, and eye and skin irritation. Chronic berylliosis is characterized

beta-adrenergic agonists 43 by abnormal tissue forming in the lungs and enlarged lymph nodes, and involves the individual’s history of exposure to beryllium and subsequent events in his or her medical history, such as changes in the chest X ray. The disease may be mistaken for other lung diseases, such as sarcoidosis, and may require other diagnostic testing. Treatment consists of corticosteroid medications and ventilator support, and proper and prompt treatment may lead to recovery in a week to 10 days. If lungs have been severely damaged over a long period of time or over the course of many flareups of the chronic form of the disease, there may be concurrent cardiac problems, including heart failure.

beta-adrenergic agonists

Drugs, also known as beta-agonists, that act as bronchodilators to relieve spasms of the bronchi during an asthma attack. These potent drugs act by stimulating the beta2receptors on smooth muscle in the bronchial tree. Alpha-adrenergic receptor stimulation causes a constriction of blood vessels and may raise blood pressure and heart rate. Beta-adrenergic stimulation primarily affects the airways or air passages. There are two types of receptors, beta1 and beta2. Drugs that act only on beta2-receptors have fewer side effects and are the most frequently used in treating patients with asthma. More than 5,000 years ago, the ancient Chinese treated asthma with ma huang, an herbal remedy that contains the beta-agonist ephedrine. Epinephrine (adrenaline) is a hormone that affects both alpha and beta receptors, and because of its rapid onset of action, it is a useful emergency drug. Within minutes after being injected into the subcutaneous tissues, it induces relief of severe bronchoconstriction and can usually prevent or reverse anaphylaxis if given promptly. Thus, epinephrine can be a truly lifesaving drug. Because of its alphaadrenergic properties, however, it tends to cause a jittery feeling and heart palpitations in many individuals. Albuterol, an example of a selective beta2 drug, with sufficiently rapid onset of action for all but the most extreme situations, has relatively few adverse stimulatory effects and is available in a wide variety of dosage forms.

A Canadian study of more than 12,000 patients over a 1-year period through 1977 raised some questions about the safety of beta-agonists. The Canadian data suggest that merely taking twice the usual dose of beta2 from an inhaler more than doubles the risk of death from an asthma attack. The drug fenoterol (Berotec) is twice as potent as any beta2 drug available in the United States. Asthma Medication Safe When Taken as Directed (Palatine, Illinois, Aug. 9, 1991) Drugs known as beta2-agonists are safe and effective for the treatment of asthma, and patients taking the medication should continue despite recent reports of potentially fatal side effects associated with overuse of the drugs, according to a national professional organization of physicians specializing in the treatment of asthma. The American College of Allergy, Asthma and Immunology said beta2-agonists are the drugs of choice for the treatment of acute, intermittent, and exercise-induced asthma and are safe if taken as prescribed. Beta2-agonists belong to a class of drugs called bronchodilators and are often administered through an inhaler. “We have been successfully and safely using beta2-agonists to treat asthma for more than 10 years,” said Dr. Edward O’Connell, president of the college. “As with any drug, there can be side effects if the patient exceeds the prescribed dosage, and we caution patients not to do this.” O’Connell also cautioned against discontinuing medication and said patients should discuss concerns about recent reports with their physicians. About 10 million Americans suffer from asthma, a disease that causes wheezing, coughing, and difficulty in breathing, and claims about 4,600 lives each year. Beta2-agonists relieve the symptoms of asthma attacks by relaxing and expanding the lung airways.

The FDA is considering a review of beta2-agonists because of reports that taking twice the prescribed dose might be fatal. “The danger for asthmatics is that if the prescribed dose of beta2agonists does not bring relief, the patient may try taking more of the drug,” O’Connell said. “Patients who are not getting relief from the prescribed dose of medication should never increase

44 beta-adrenergic receptors the dosage on their own,” O’Connell said. “They should talk with their doctors about supplementing with other drugs or switching to a different treatment plan. The essential thing is to develop a treatment plan only under the direction of the doctor.” The 3,600-member American College of Allergy, Asthma and Immunology is a national organization of physicians who specialize in the treatment of asthma and other allergic diseases. Board-certified allergists complete a three-year residency in either pediatrics or internal medicine and a twoyear fellowship study in allergy and immunology. —Press release from the American College of Allergy, Asthma and Immunology issued in August 1991. BETA-AGONISTS AVAILABLE IN THE UNITED STATES Dosage Forms Available

albuterol (Proventil, Ventolin) bitolterol (Tornalate) epinephrine (Adrenalin, Primatene) isoetharine (Bronkometer Bronkosol) isoproterenol (Isuprel)1 metaproterenol (Alupent, Metaprel) pirbuterol (Maxair) terbutaline2 (Brethaire, Brethine, Bricanyl)

1, 3, 4 3 2, 3, 4 3, 4 1, 2, 3, 4 1, 3, 4 3 1, 2, 3

orally=1; injectable=2; metered-dose inhaler (MDI)=3; nebulizer solution=4 (Not all brands are available in all dosage forms.) 1 Rarely used for the treatment of asthma because of adverse effects. 2 Terbutaline ampules for injection may be used as a nebulizer solution.

beta-adrenergic receptors

See

BETA-ADRENERGIC

AGONISTS.

beta-blocking agents

Drugs used to treat heart problems, high blood pressure, migraine headaches, and glaucoma. The most serious side effect of beta-blockers is constriction of the bronchial tubes, which can cause or worsen an asthma attack in an allergic or asthmatic person. Epinephrine (adrenalin chloride), the drug of choice for the treatment of severe allergic reactions or anaphylaxis, may be ineffective in persons taking beta-blocking drugs. Beta-blockers should be avoided by those with asthma or severe allergies.

WARNING: BETA-BLOCKING AGENTS MUST NEVER BE USED IN ANY PATIENT RECEIVING ALLERGY IMMUNOTHERAPY OR ALLERGY SHOTS and must be used very cautiously, if at all, in any allergic or asthmatic patient. Examples of beta-blocker medications (capsules, tablets, or eyedrops) are (brand names in parentheses): acebutolol (Sectral) atenolol (Tenormin) atenolol + chlorthalidone (Tenoretic) betaxolol hydrochloride (Betoptic) eyedrops carteolol (Cartrol) labetalol (Normodyne or Trandate) labetalol + hydrochlorothiazide (Nonnozide or Trandate HCT) levobunolol (Betagan) eyedrops metoprolol (Lopressor) metoprolol + hydrochlorothiazide (Lopressor HCT) nadolol (Corgard) nadolol + bendroflumethiazide (Corzide) penbutolol (Levatol) pindolol (Visken) propranolol (Inderal) propranolol + hydrochlorothiazide (Inderide) timolol (Blocadren) timolol (Timoptic) eyedrops timolol + hydrochlorothiazide (Timolide)

beta-receptors

See

BETA-ADRENERGIC AGONISTS.

biopsy The removal of a tiny portion of live tissue for medical analysis leading to a diagnosis. Tissue may be obtained by aspiration through a needle or other methods. bioterrorism

The use of toxic substances, particularly biological agents classified by the Centers for Disease Control and Prevention (CDC) that may be deliberately aerosolized and inhaled, constituting an act of war. Among the highest risks to national security according to transmissibility and threat to life are smallpox, anthrax, Yersinia pestis (which causes bubonic, septicemic, and pneumonic plague), botulism, tularemia, and viral hemorrhagic fevers. Other somewhat lower

Bostock, John 45 risks include Q fever, brucellosis, glanders (Burkholderia mallei), castor bean toxin (ricin toxin), Staphylococcus enterotoxin B, Nipah virus, and hantaviruses. Bioterrorism, with “weapons” including bacteria, viruses, and poisons, has an extensive history that dates back to the 12th century. According to a Nursing Spectrum article (December 17, 2001, Vol. 13, No. 25 NY/NJ) on biological weapons by Richard Stilp, R.N., M.A., C.H.S.P., corporate director of safety for Orlando Regional Healthcare, “In 1346, the Tatar army hurled the corpses of those soldiers who died of the plague over the Kaffa City walls, infecting residents who were defending the city. Some of those who left Kaffa may have started the Black Death pandemic that spread throughout Europe. Russian troops used this same tactic against Sweden in 1710. Biological warfare also occurred during the French and Indian War (1754–63) when an Englishman, Sir Jeffrey Amherst, gave smallpoxladen blankets to Native Americans who were loyal to the French. The Native Americans sustained epidemic casualties as a result.” The most recent instances of bioterrorism occurred concurrently with the terrorist attacks on the United States on September 11, 2001, with the destruction of the World Trade Center in New York City and damage to the Pentagon in Washington, D.C. As the news media reported the details of these events, letters containing powdery anthrax spores were sent through the mail to media and political offices. Stilp wrote that at least 17 countries have developed an anthrax weapon program in the knowledge that the spores can sustain their viability for more than 40 years. “In 1970, the World Health Organization (WHO) concluded that the release of 50 kilograms of aerosolized anthrax upwind of a population of 5 million could lead to an estimated 250,000 casualties and 100,000 deaths,” he explained. Preventive measures include the prophylactic administration of appropriate antibiotics if infection is suspected, the development of immunizations, and education of health care professionals as well as the lay public on the prevention, detection, and treatment of diseases transmitted through terrorism. See also ANTHRAX; BOTULISM; TULAREMIA.

bird breeder’s lung An adverse reaction in certain individuals caused by contact with birds, particularly their excrement, including pigeons and parakeets. Symptoms—chills, fever, shortness of breath, and coughing—may be acute or delayed and subside when contact is no longer occurring. black death black lung

See See

BUBONIC PLAGUE.

COAL WORKER’S PNEUMOCONIOSIS.

blast injury

An injury attributable to a sudden, severe change in air pressure. See also ALTITUDE SICKNESS.

block, air

Air that leaks from one of the passageways of the respiratory system and collects in connective lung tissue. This causes an obstruction of the normal air flow.

blowing exercise

Blowing into a tube attached to a bottle of water, which is attached to another bottle so the air pressure from one projects the water into the other. This exercise is designed to increase intrabronchial pressure and help expand the lung.

blue baby A newborn whose blood is not properly oxygenated, thus causing cyanosis, or bluish coloration of the skin and mucous membranes. In some cases, this condition may be a congenital anomaly in which the blood travels directly from the right to the left side of the heart without reaching the lungs. Bostock, John

British physician (1773–1846) credited with coining the term hay fever, which he believed was “produced by the effluvium from new hay.” In his writings “Case of a Periodical Affection of the Eyes and Chest” and “Of the Catarrhus Aestivus, or Summer Catarrh,” Bostock described in accurate detail common symptoms of hay fever as heat, fullness, redness, and itching in the eyes, sneezing with the discharge of mucus, difficulty in breathing, a quickened pulse, restlessness, perspiration, and loss of appetite.

46 botulism botulism

A life-threatening condition caused by a neurotoxin called botulinum, caused by the spore-forming bacillus Clostridium botulinum, that is usually associated with ingestion of improperly canned and, thus, contaminated food. However, botulinum may be intentionally aerosolized, which would pose a serious threat to the public. Symptoms include paralysis of respiratory muscles and upper and lower extremities, diplopia, dysphonia, dysphagia, and dysarthria. The Centers for Disease Control and Prevention (CDC) maintains a supply of an antitoxin to fight cases of botulism, and if detected early, most individuals afflicted with the toxin recover. See also BIOTERRORISM.

Bouchut’s respiration Exhalation longer than inhalation in children with asthma or bronchopneumonia, named for French physician Jean A. E. Bouchut (1818–91). Bovet, Daniele Swiss-born Italian scientist (1907–92), who discovered antibacterial sulfanomides and, with Ernest Fourneau in 1933, succeeded in synthesizing the first series of antihistamines. Bovet won the Nobel Prize in physiology or medicine in 1957. bradykinin

A potent chemical mediator whose vasodilating action plays a role in asthma, pulmonary edema, and anaphylaxis. This slow-moving kinin, a term for a group of polypeptides, influences contraction of smooth muscle, promotes hypotension, increases blood flow in small blood capillaries, and sparks the pain reflex.

bradypnea

Excessively slow respirations.

brass founder’s ague

Tremors resulting from the inhalation of toxic fumes or from zinc or brass poisoning. See also BRASS POISONING.

brass poisoning The adverse effect of inhaling the fumes of zinc and zinc oxide. Although rarely fatal, brass poisoning damages tissue in the respira-

tory system and may result in dryness and burning in the respiratory tract, cough, headache, and chills. Inhaling humidified air often relieves the symptoms.

breath, bad

Malodorous air expelled from the mouth. Also called halitosis, bad breath is usually caused by the ingestion of foods containing potent oils, such as onions and garlic, strong-smelling beverages, and other liquid substances, or the fermentation of food particles lodged between teeth. Proper toothbrushing, flossing, and regular dental hygiene prevent bad breath in most cases. Deodorant mouthwashes, gargles, sprays, mints, lozenges, and gum are available. Although not the cause of intestinal disorders, halitosis may indicate a systemic disease. For example, renal failure causes the breath to take on the characteristic smell of urine. An abscess on the lung creates bad breath. Liver disease may cause the breath to smell mousy. Severe diabetes may cause an acetone (nail polish remover) breath odor. People who think their breath smells bad when it does not may be suffering from psychogenic halitosis. Schizophrenics or people with paranoid or obsessive feelings of being dirty or smelly or the sense of “rotting inside” may believe they have offensive breath.

Breath Enhancer

A device to facilitate the use of aerosol metered-dose inhalers for poorly coordinated persons with asthma.

breath-holding attacks

Arrested breathing, cyanosis (turning blue), rigidity and extension of the arms and legs, and possible loss of consciousness that starts with a child’s crying and, subsequently, the child’s body goes limp, he or she resumes breathing and becomes alert. Breathholding attacks cease of their own accord before the child reaches school age. Voluntary or involuntary breath-holding on the part of a child may be part of a tantrum or tactic used to get parents’ attention and an attempt to manipulate their behavior and responses. Psychological counseling may be recommended for both the child and parents.

bronchial crises 47 breathing

The process of respiration, that is, the taking in (inhaling) of oxygen into the lungs and the expelling (exhaling) of carbon dioxide. The normal exchange of these gases is essential to life. Certain breathing patterns characterize a variety of conditions, including asthmatic breathing, or prolonged wheezing heard throughout the chest cavity; bronchial breathing, or harsh breathing sounds accompanied by a high-pitched expiration; CheyneStokes breathing, or periods of apnea followed by increased depth and frequency of respirations; cogwheel breathing, or a respiratory murmur often associated with bronchitis and incipient tuberculosis; continuous positive-pressure breathing, or a method of artificially assisting respiration; intermittent positive-pressure breathing, or a mechanism that administers air or oxygen for assisting respiration; Kussmaul breathing, or very deep, gasping seen in cases of severe diabetic acidosis and coma; and shallow breathing, which occurs in cases of acute lung disease when chest walls are thickened, when ribs are fractured thus inhibiting deep breathing, in pleurisy, emphysema, and other respiratory disorders. See also RESPIRATORY SYSTEM.

breathing exercises

A series of deep breathing techniques to build up lung capacity and to help an individual with respiratory disorders to relax and breathe as normally as possible. The Eastern practice of yoga includes breath control and rhythmic, deep breathing, which are geared to overall physical and mental improvement. Asthmatic children often respond to relaxation breathing techniques when they feel an asthma attack coming on, and in some cases, the fullblown attack can be avoided. Essentially, one is advised to inhale through the nose, filling the belly and then the chest with air, and to exhale through the mouth and contract the muscles in the abdomen. Breathing exercises may also be done with a spirometer, a plastic tube containing plastic balls. As one blows air into the mouthpiece of the tube, the balls rise. This encourages deep breathing, which helps clear the lungs and oxygenate the entire body. Physicians prescribe spirometry for patients with bronchitis, pneumonia, and other, especially chronic, lung diseases.

Brethaire

See

TERBUTALINE SULFATE.

Brethine

See

TERBUTALINE SULFATE.

Bricanyl

See

TERBUTALINE SULFATE.

Bromfed

See

BROMPHENIRAMINE.

brompheniramine (Bromfed, Dimetane, Dimetapp) A mildly sedating, commonly used antihistamine of the alkylamine class. Brompheniramine is available alone or in combination with a decongestant in prescription and over-the-counter allergy preparations. See also ANTIHISTAMINE.

bronchadenitis

Inflammation

bronchial

glands.

bronchi

The two large branches extending from the trachea, or windpipe, into the lungs, forming what is commonly known as the “bronchial tree.” Because each bronchus is an airway, a buildup of mucus, an infection, physical and chemical irritants, swelling of the bronchial mucosal lining, excess calculi, or a foreign body or obstruction can cause choking, bronchitis, bronchoedema, lung abscess, and pneumonia. A bronchoscope is an instrument through which the bronchi can be examined. Bronchopulmonary disorders are those that involve both bronchi and lungs, such as bronchial pneumonia. See also BRONCHIOLES; RALE.

bronchial asthma See also

A common term for asthma.

ASTHMA.

bronchial breathing Harsh breathing associated with high-pitched expiration (tubular breathing). bronchial challenge See also

A diagnostic breathing test.

SPIROMETER.

bronchial crises motor ataxia.

Paroxysms of coughing in loco-

48 bronchial glands bronchial glands Mucous or mixed glands in the bronchi or bronchioles. bronchial tree

See

BRONCHI.

bronchial washing Cleansing of one or both bronchi, or the process of irrigating the bronchi for the collection of cells for diagnostic testing. bronchiarctia

A narrowing or constriction of a

bronchial tube.

bronchiectasis

Dilation or irreversible widening of a bronchus or bronchi, usually chronic and involving a secondary infection, such as bronchopneumonia, chronic bronchitis, tuberculosis, and whooping cough or other damage to the bronchial wall. The bronchial wall has several varying layers corresponding to each segment of airway and is lined by an inner mucosa and submucosa that serve to protect airways from harmful particles and substances. Structural layers provide elastic, cartilage, and muscle fiber, while blood vessels and lymphoid tissue nourish and maintain the bronchial wall. When parts of the wall are inflamed or destroyed in bronchiectasis, mucus production increases and promotes bacterial growth, and the general protective structure breaks down. The damage may extend to the alveoli of the lungs and result in bronchopneumonia, scarring, and dysfunctional lung tissue. Inflammation and an increase in blood vessels in the bronchial wall may also result in coughing up blood and airway blockage that inhibits oxygen distribution. Bronchiectasis may be acquired or congenital, and on one or both sides of the chest. An underlying disease, such as allergic bronchopulmonary aspergillosis, may also be the cause. Frequent occurrences of pneumonia may be a sign of bronchiectasis. The most common cause is chronic or recurring infection; other conditions, including abnormal immune response, birth defects of the airways, and a predisposing factor such as bronchial obstruction, may lead to bronchiectasis as well. Symptoms include coughing, difficulty breathing, the production of foul secretion and sputum that

separates into three layers, the bottom layer containing pus cells, a greenish middle layer, and a layer of froth on top. Treatment includes antibiotics, postural drainage, and bronchodilating aerosols. Saccular bronchiectasis refers to dilated bronchi that are irregularly shaped or shaped somewhat like a sac. Varicose bronchiectasis refers to dilated bronchi that look like varicose, or herniated, veins, and an irregular dilation also found in cystic fibrosis. Preventive measures reduce the incidence of bronchiectasis: immunizations against measles and whooping cough; influenza and pneumococcal vaccines; early use of antibiotics in the case of pneumonia or tuberculosis; appropriate use of corticosteroid and other anti-inflammatory drugs if allergic bronchopulmonary aspergillosis and other disorders are present; avoidance of noxious fume, gas, dusts, and smoke; avoidance (in infants and children) of aspiration of foreign objects; avoidance of oversedation that leads to respiratory depression; prompt medical attention to neurological symptoms, including coughing or vomiting after eating, difficulty swallowing, and impaired consciousness; avoidance of using mouth or nose drops such as mineral oil at bedtime, and diagnosis by bronchoscopy and treatment of any obstruction in the bronchus before an extreme condition arises.

bronchiloquy

Strange vocal sounds as a result of a bronchus covered with consolidated lung tissue.

bronchiocele

A dilatation, swelling, or tumor located in a bronchus, one of the two large branches of the trachea or windpipe. This may indicate a number of bronchial disorders, including chronic bronchiectasis. See also BRONCHIECTASIS.

bronchiolectasis See also

Dilation of the bronchioles.

BRONCHIECTASIS.

bronchioles

The smaller subdivisions of the bronchial tree in the thorax, so named because the bronchi and bronchioles resemble a tree trunk and

bronchitis, chronic 49 its roots. The bronchioles bring air from the trachea, the upper part of the windpipe, to the lungs and participate in the exchange of gases (oxygen and carbon dioxide) in the breathing process. Bronchial glands are mucus-producing organs in the bronchi and bronchioles. (The Greek word for windpipe is bronchus.) Among disorders of the bronchioles are bronchitis, bronchiolitis, and bronchopneumonia. See also BRONCHIOLITIS; BRONCHITIS.

bronchiolitis An acute inflammatory disease of the bronchioles, or small airways, in infants in which excessive mucus production results in airway obstruction. This obstruction leads to tachypnea (rapid shallow breathing), with a respiratory rate of 50 to as high as 80 breaths per minute, hypoxemia (reduced oxygen content of the blood), and hyperinflation (overinflated lungs). Bronchiolitis occurs more often in winter and spring months, usually during the first six months of life. It predominantly affects males and may occur in epidemics. During outbreaks, respiratory syncytial virus and parainfluenza are most often the cause, but the bacterium Mycobacterium pneumoniae can cause bronchiolitis in older children and bronchioles may be contused with asthma. X rays, blood gas studies, and physical examination findings are virtually identical. Both illnesses are often caused by viral respiratory infections in infants, although allergy testing in the older child may help to confirm the diagnosis. Congestive heart failure can also be mistaken for both bronchiolitis and asthma in the infant. Treatment of acute bronchiolitis is based on improving hypoxemia, preventing dehydration, and administering bronchodilating drugs and corticosteroids. Antibiotics are probably of no value unless there is suspicion of a secondary bacterial infection. Recovery usually occurs within two weeks, but bronchiolitis can be fatal. Some believe that infants with bronchiolitis have a greater chance of developing asthma later on in life. However, it may be difficult to determine if the original diagnosis of bronchiolitis was correct or if the infant was actually having an initial attack of asthma. See also RESPIRATORY SYNCYTIAL VIRUS.

bronchiospasm

See

bronchiostenosis

BRONCHOSPASM.

Constriction or narrowing of a

bronchial tube.

bronchitis An infection or inflammatory disease in the bronchi and bronchioles caused by viral or bacterial germs, allergy, or irritating dust and fumes. It may be an acute infection or a chronic process. Typical symptoms may include coughing, wheezing, shortness of breath, chills, fever, fatigue, and excessive sputum. Infectious bronchitis, which occurs most often in winter months, may be caused by microorganisms such as Mycoplasma pneumoniae and Chlamydia, and recurring infections stemming from chronic sinusitis, bronchiectasis, allergies, and in children, enlarged tonsils and adenoids. Irritative bronchitis involves inhalation or exposure to various chemical dusts and fumes such as ammonia and strong organic solvents, air pollution such as ozone and nitrogen dioxide, or cigarette and other smoke. Treatment includes drinking adequate fluids, taking aspirin or acetaminophen to reduce fever, and, in certain cases in which a bacterial infection is evident, antibiotics, including tetracycline, ampicillin, trimethoprim-sulfamethoxazole, erythromycin (when Mycoplasma pneumoniae is suspected), and amoxicillin (for children). Sputum tests provide the information for proper diagnosis in the event of severe bronchitis. Chest X ray may be necessary to rule out the development from bronchitis to pneumonia. In mild cases, patients recover fully, although bronchitis may be life-threatening to the elderly and individuals with chronic heart or lung disease. See also BRONCHITIS, CHRONIC. bronchitis, chronic

A disorder characterized by excessive mucus production in the bronchial tree with a persistent productive cough. By definition it lasts at least three months of the year for at least two consecutive years. Chronic bronchitis may or may not be related to asthma. Persons with chronic asthmatic bronchitis have a long history of cough and mucus production and develop wheezing as the disease progresses.

50 bronchoalveolar lavage Chronic asthma with obstruction is characterized by a prolonged course of wheezing and late onset of a chronic productive cough. Chronic bronchitis is often confused with emphysema, an expansion of the air spaces in the lungs resulting in destruction of the alveoli, or air sacs. In chronic obstructive lung, or pulmonary, disease (COLD, COPD), the flow of air in and out of the lungs is blocked as a result of chronic bronchitis or emphysema, or both. In asthma without chronic obstruction, the blockage is present only during an attack. However, in chronic obstructive lung disease, some obstruction exists at all times. Approximately 20 percent of adult males have chronic bronchitis, although only a small number become disabled because of it. Chronic bronchitis is less common in females. Individuals who smoke, have allergies, or are frequently exposed to irritants or pollution in the environment may also suffer the disease. See also BRONCHITIS; EMPHYSEMA.

bronchoalveolar lavage The use of sterile saline solution to “wash” the lungs of secretions, cells, and protein from the lower respiratory tract. A fiberoptic bronchoscope introduces the fluid into the lung, and this treatment may be for diagnostic purposes or to treat patients with cystic fibrosis, pulmonary alveolar proteinosis, and severe asthma with bronchial obstruction due to a mucus plug. bronchoblennorrhea Chronic bronchitis characterized by large amounts of thin sputum. bronchocele

A dilation or swelling of a part of a

bronchus.

bronchoconstriction

See

bronchodilating drugs

BRONCHOSPASM.

Also known as bronchodilators, first-line medications that block the constriction of bronchial tubes during an asthma attack. Bronchodilators include beta-agonists, such as albuterol, and xanthine derivatives, such as theophylline. The exact mechanism by which these

drugs exert their beneficial effects is unknown. These drugs are available as metered-dose inhalers, solutions for injection or inhalation, or as oral tablets, capsules, and syrups. See also BETA-ADRENERGIC AGONISTS; THEOPHYLLINE.

bronchodilator

See

BRONCHODILATING DRUGS.

bronchoedema

Swelling of the mucosa of the bronchial tubes that constricts the airways and makes breathing difficult.

bronchofiberscope An instrument also known as a fiberoptic endoscope used to examine the bronchi. bronchography The introduction of a radiopaque substance into the trachea or bronchial tree for the diagnostic purposes of x-raying the lung or a portion of the lung. A bronchogram, or X ray of the lung, may be obtained during a bronchography. broncholithiasis

Calculi (stones) developed in the bronchi causing an obstruction or inflammation.

bronchomycosis An infection in the bronchi or bronchial tubes caused by a fungus, typically of the genus Candida. bronchopathy

Any disease involving the bronchi

or bronchioles.

bronchoplegia Muscle paralysis of the walls of the bronchial tubes. bronchopneumonia

Lung inflammation (pneumonia) complicated by the concurrent inflammation of the terminal bronchioles and alveoli. Caused by various pneumococci, Group A hemolytic streptococci, varieties of staphylococci, Klebsiella pneumoniae, Francisella tularensis, and various forms of other bacteria, viruses, rickettsiae, and fungi, bronchopneumonia is characterized by pro-

bronchospasm 51 ductive coughing (i.e., cough with expectoration of sputum), short and shallow respirations (50 to 75 breaths per minute), and sometimes cyanosis (blue coloration of the mucous membranes due to lack of oxygen). In children, the temperature may reach to 105 degrees Fahrenheit, and the fever may last two to three weeks. In the elderly, the fever (if any) may be 100 to 101 degrees Fahrenheit with only a slight cough and a small amount of sputum, but weakness, chest pain, chills, and sore throat may be evident. The treatment of choice includes antibiotic therapy, bed rest, increased fluids, a soft diet, painkilling medication, oxygen (for cyanosis), and treatment of shock symptoms if they present. Complications of bronchopneumonia include lung abscess, empyema, pericarditis, paralytic ileus, and atelectasis. See also PNEUMONIA.

bronchopulmonary aspergillosis, allergic (ABPA) Pneumonia-like disease caused by an allergic reaction to the mold Aspergillus fumigatus. It usually occurs in adult asthmatics. Signs and Symptoms This disorder usually involves episodes of fever, shortness of breath and wheezing, and coughing up copious quantities of dark brown, and at times blood-streaked, sputum. Diagnosis Because the fungus is ubiquitous (found in healthy persons in small quantities that are harmless), the presence of positive sputum cultures is not sufficient to diagnose this disease. The diagnosis is made in persons meeting the following criteria: (1) episodes of asthma; (2) elevated eosinophils (a type of white blood cell) and total immunoglobulin E (IgE) antibodies in the blood; these values are slightly elevated in most allergic individuals but extremely elevated in persons with this disease; (3) pneumonia-like X-ray findings, which may be temporary; (4) bronchiectasis (destruction of the muscles in the bronchial walls with chronic cough and large amounts of sputum); (5) positive skin tests to the Aspergillus fungus; and

(6) positive blood tests for antibodies against the Aspergillus allergen. Treatment Prednisone, a corticosteroid drug, is the treatment of choice. It is used daily, most often for several months, and improvement is usually seen within days. In some cases, recurrences require long-term prednisone use. Prognosis If untreated, aspergillosis will damage lung tissues and can be fatal.

bronchopulmonary dysplasia A chronic lung disease of premature infants that develops after a period of intensive respiratory therapy. Dysplasia refers to abnormal formation of tissue. bronchopulmonary lavage Irrigation of the bronchi and bronchioles to remove abnormal or excessive secretions. bronchorrhagia Hemorrhage (profuse bleeding) in the bronchial tube. bronchorrhea An abnormal secretion, which may be offensive to others, from the mucous membrane in the bronchi. bronchorrhoncus From the Greek word rhonchos, meaning “snore,” a rale heard in the bronchial passageway. bronchoscopy An examination of the bronchi through a device called a bronchoscope. The instrument is inserted into the trachea and down to the bronchi so the physician can diagnose a bronchial abnormality. bronchosinusitis

The simultaneous inflammation and infection of the bronchi and sinuses.

bronchospasm

Also called bronchiospasm, sudden narrowing or constriction of the bronchial tubes during an asthma attack or in persons with

52 bronchospirochetosis bronchitis. Bronchospasm is also referred to as bronchoconstriction. See also ASTHMA; BRONCHITIS.

bronchospirochetosis

A type of bronchitis caused by spirochetes, or microorganism of the order Spirochaetales. Bronchopulmonary spirochetosis is also known as hemorrhagic bronchitis.

bronchostaxis Profuse bleeding, or hemorrhage, from a bronchial wall. bronchostomy

From the Greek word stoma, or mouth, the surgical creation of an opening into a bronchus.

bronchotomy A surgical incision made into a bronchus, the larynx, or trachea, usually in order to open an airway. Bronkaid Mist

The trade name for epinephrine,

USP.

Bronkephrine The trade name for ethylnorepinephrine hydrochloride, USP. Bronkodyl

See

Bronkometer Bronkosol

THEOPHYLLINE.

See

ISOETHARINE.

bubonic plague (black death)

Named from the Greek word for gland, bubo, and the Latin plaga, meaning stroke or wound, bubonic plague is most famous for its epidemic proportions in Europe during the Middle Ages, hence the term “black death.” Plague is an acute, extremely contagious disease caused by Yersinia pestis, a microorganism found in infected rats, mice, squirrels, and prairie dogs. It is mainly transmitted to humans by way of a rat flea bite, and results in enlarged lymphatic glands, adenitis or pneumonia, and symptoms of severe poisoning. Symptoms include high fever, a staggering gait, restlessness, delirium or confusion, shock,

and coma. Even though it may be fatal, a mild form of plague is known as ambulatory; pneumonic plague refers to extensive lung involvement. In hemorrhagic plague, one of the severe forms of the disease, there is bleeding into the skin. Bubonic is the most common form of plague characterized by the formation of buboes, or swollen lymph nodes. Untreated bubonic plague causes death between the third and fifth day from the onset of symptoms in 60 percent of its victims. (Tuberculosis, caused by a Mycobacterium, is sometimes called “white plague.”) Plague infections occur most frequently in the United States in the Southwest, including Arizona, California, Colorado, and New Mexico. Recent outbreaks have been limited to an individual case or small clusters of people. In addition to infected flea bites, plague may be transmitted by the droplets of an infected person’s cough or sneeze. Pneumonic plague occurs when the lungs are infected by the plague bacteria. Symptoms High fever, chills, rapid heartbeat are signs of the plague, and in most cases, a severe headache, with a cough developing within a day or so from the time of exposure to the bacteria. The sputum becomes bloody and eventually turns uniformly foamy, resembling raspberry syrup. If untreated, a victim may die within two days of the onset of symptoms. Prevention Rodent control and use of insect repellent are key, especially to travelers to areas in which there are reported incidences of plague infection. Prompt treatment, i.e., within 24 hours, is also important when plague infection is suspected. Treatment includes streptomycin, tetracyclines, and chloramphenicol, and individuals with pneumonic plague must be isolated to prevent spreading the disease. A plague vaccine is available and is made by adding the preservative chemical formaldehyde to kill specific plague bacilli.

budesonide (Rhinocort,

Pulmocort) Corticosteroid available in the United States as a nasal spray for allergic rhinitis and in other countries as

byssinosis 53 a metered-dose inhaler for asthma. Budesonide has a greater potency than many similar drugs. See also CORTICOSTEROID METERED-DOSE INHALERS; CORTICOSTEROID NASAL SPRAYS.

butane

See

byssinosis

INHALANT ABUSE.

An allergic lung disease caused by occupational exposure to an unknown allergen in the dust from the processing of cotton, flax, hemp, or sisal. Symptoms of shortness of breath and wheezing gradually intensify upon increased expo-

sure and may lead to respiratory failure. Smoking increases the risk of permanent lung damage. Byssinosis is largely preventable by wearing a face mask and treating raw textiles before manufacturing. Because these measures are ignored in developing countries, the incidence of this disease is greater there than in the United States. Government compensation is available in the United States for those afflicted with byssinosis. Bronchodilating drugs, either aerosol inhalers or tablets, and removal of exposure to the harmful dusts are the treatment of choice. See also OCCUPATIONAL ASTHMA.

C cachexia The condition of being in bad health, malnourished and wasting that may occur in the course of chronic catastrophic disease, including advanced pulmonary tuberculosis. In addition to prescribed medical therapy, treatment consists of rest, good hygiene and nutrition, prevention of skin breakdown, pain, and fractures, maintenance of elimination, and emotional support.

cancer, lung A form of disease characterized by the uncontrolled growth of cells (derived from normal cells) and subsequent malignancy that is capable of killing the host by spreading from the original site to other parts of the body. Cancer is named from the Greek word karkinos, meaning crab. It is estimated that 200 different types of cancers exist, most of which, like the crab’s slow movement, have an insidious onset. See also LUNG CANCER.

caisson disease Pain in the joints, skin irritation, a burning sensation in the lungs, coughing, and various neurological disturbances caused by a sudden or rapid reduction in environmental air pressure. Caisson disease—named from the French word caisse, meaning “box”—is frequently seen in aviators and deep-sea divers. Also known as the bends or decompression illness, caisson disease is characterized by nitrogen bubbles forming in the tissue space and small blood vessels when a diver comes to the surface of the water after being 30 or more feet below in an environment of compressed air, or a pilot ascends rapidly from sea level to an elevation of 18,000 feet or higher. Treatment includes use of a hyperbaric chamber for recompression and then a gradual decompression. See also BENDS.

candidiasis An infection by the yeastlike fungus of the species Candida albicans affecting various parts of the skin or mucous membranes, including the bronchi and lungs. Oral nystatin, ketoconazole, or clotrimazole may be prescribed for localized infections, and systemic infections may be treated with amphotericin B and other medications. cannabis

The hemp plant, Cannabis sativa, from which the dried flowering tops are processed into a preparation that, when inhaled or ingested, may cause euphoria and, according to some reports, pain relief, antiemesis (particularly the important constituent called delta-9-tetrahydrocannabinol, or THC, in the treatment of cancer), and alleviation of the symptoms of glaucoma. Cannabis is also known as marijuana, which can be smoked. In addition to possibly exacerbating psychoses, such as schizophrenia, marijuana is a “gateway” drug known to cause psychological dependence, and the inducement of toxic delirium, among other ill effects. Cannabis that is smoked may lead to respiratory disorders. Although it has not been proven that heavy and chronic marijuana use causes lung cancer and other serious pulmonary impairments, marijuana contains some of the same harmful

canal, pharyngeal The tubular opening from the sphenoid bone to the palatine bone that contains the sphenopalatine vessels. canal of Lambert

The connecting points between bronchioles and alveoli in the lungs, which may help prevent collapse of the lung. See also ATELECTASIS.

carbon monoxide poisoning 55 components as tobacco smoke. Smoking marijuana is often concurrent with cigarette smoking, which increases the risk of respiratory disease. See also HASHISH; TOBACCO.

cannula, nasal Flexible tubing inserted into the nostrils that provides oxygen at 1 to 6 liters per minute. The tubes that go approximately 1 centimeter into each nostril are connected to a common tube and an oxygen source. capacity, vital The volume of air that can be forcibly exhaled from the lungs after a full inhalation. Caplan’s syndrome

Named for British physician Anthony Caplan (1907–76), a type of rheumatoid arthritis with severe fibrosis of the lung, found in coal miners and others with forms of pneumoconiosis. The syndrome is a rare disorder in which scar nodules develop in the coal miner’s lung as well as in the lungs of people who have been exposed to coal dust even if they do not suffer from black lung. See also COAL WORKER’S PNEUMOCONIOSIS.

capnography The record made of the level of carbon dioxide in the exhaled air of patients connected to a ventilating device. capreomycin sulfate (Capastat). See also

A tuberculostatic drug

TUBERCULOSIS.

carbinoxamine An antihistaminic drug, commonly combined with a decongestant, used to treat allergic rhinitis (hay fever) conditions. It is available in oral formulations as Rondec (Abbott) or as a generic brand. Carbinoxamine may cause drowsiness. See also ANTIHISTAMINE. carbon dioxide [CO2] A colorless, odorless gas exhaled during respiration that is the result of carbon oxidation that takes place in the tissues. Blood

levels of CO2 increase during hyperventilation, characterized by shortness of breath, tingling of extremities, and, at times, vomiting, elevated blood pressure, and disorientation. See also ARTERIAL BLOOD GASES; CARBON DIOXIDE INHALATION; CARBON DIOXIDE POISONING; HYPERVENTILATION.

carbon dioxide inhalation A 5 to 7.5 percent level of carbon dioxide and oxygen used for patients to inhale as a way to stimulate respiration (particularly in individuals with pulmonary disease) and as part of or sequel to the administration of artificial respiration. See also CARBON DIOXIDE. carbon dioxide poisoning The intake of excessively high levels of carbon dioxide, characterized by extremely deep breathing, a feeling of pressure in the head, acid taste in the mouth, ringing in the ears, a slight burning sensation in the nose, and possibly near respiratory arrest and unconsciousness. The treatment is administration of oxygen. See also CARBON DIOXIDE. carbon monoxide Known as CO, a colorless, tasteless, odorless, and insidiously poisonous gas produced as a result of imperfect combustion and oxidation. Engine exhaust gas is a common source of CO, and it is also found in coal mines (from the incomplete combustion of coal), sewers, cellars, and gasoline motors. Smoking tobacco, which impedes the level of oxygen in the bloodstream, increases the blood’s level of CO. In turn, night vision may be affected. Carbon monoxide detectors, similar to smoke detectors, have been developed for household use to prevent poisoning. See also CARBON MONOXIDE POISONING. carbon monoxide poisoning

The intake of excessively high levels of carbon monoxide in a brief period of time or the effect of inhaling small amounts over an extended period of time may cause poisoning. Inhaling fumes while in a closed car with the motor running, or using a gasoline

56 carbon tetrachloride poisoning motor in an enclosed area may cause the CO to combine with the hemoglobin and thereby cut off the body’s oxygen supply. Poisoning symptoms vary and may include a “cherry red” skin color, weakness of muscles, pounding heart, headache and throbbing in the temples, nausea, dilated pupils, ringing in the ears, and rapid pulse. Treatment of choice is the administration of 100 percent oxygen. Complications that may arise include cerebral edema, muscular spasms, blindness, paralysis, and other neurological disturbances. See also CARBON MONOXIDE.

carbon tetrachloride poisoning

The result of inhaling excessive levels of carbon tetrachloride (CCl4), a clear liquid with an odor similar to that of ether. Inhaling even a small quantity may cause death by damaging the liver and kidneys. Symptoms include eye, nose, and throat irritation, headache, nausea, visual disturbance, confusion, ventricular fibrillation, and depression of the central nervous system. Treatment includes the administration of oxygen, lavage with saline solution, and the removal of clothing contaminated with the chemical.

carcinogen

Any chemical or substance that induces the risk of developing cancer in animals or humans. Carcinogenesis refers to the origin of cancer.

carcinoma, alveolar cell

A malignant tumor that develops in the lung. A carcinoma specifically occurs in epithelial tissue and they frequently metastasize through the bloodstream or the lymph system. See also CANCER, LUNG.

carcinoma, bronchogenic A bronchogenic carcinoma is malignant and develops in the bronchi. See also CANCER, LUNG. carcinoma, oat cell A tumor that develops in the bronchus and contains tiny cells shaped like oats. See also CANCER, LUNG.

Cardarelli’s sign

Named for Italian physician Antonio Cardarelli (1831–1926), a throbbing movement of the trachea, or windpipe, to one side, which may accompany an aortic aneurysm.

cardiac asthma

Severe shortness of breath caused by fluid in the lungs that produces bronchospasm and wheezing. This condition results from an inability of the left chambers of the heart to pump adequately, that is, congestive heart failure. Cardiac asthma is accompanied by hyperventilation, a state of rapid breathing, and the person appears to be having an asthma attack. Primary treatment involves heart drugs such as diuretics, digitalis, and ACE inhibitors. Bronchodilators are sometimes helpful.

cardiopneumograph A device that records the motions of the heart and lungs for diagnostic purposes. cardiopulmonary arrest The sudden cessation of breathing and blood circulation, indicating the need for cardiopulmonary resuscitation and/or other methods that may revive the victim. See also CARDIOPULMONARY RESUSCITATION. cardiopulmonary resuscitation Commonly referred to as CPR, a method to try to restore breathing and heart function, i.e., to provide oxygen as quickly as possible to all the vital organs of a breathless victim. A CPR assessment is the first step to determine the victim’s state of consciousness; in three to five seconds, a caregiver must lift the jaw and remove any liquid or solid material in the mouth to make sure the airway is open. It is also best to remove the victim’s dentures at this time. (If the victim has sustained trauma of the head and neck, care must be taken not to move the victim unless it is absolutely necessary.) Next, the caregiver should observe the chest for breathing movements and listen for breaths. If there is no rise and fall of the chest or evidence of breathing, CPR may be started. To begin CPR, the caregiver kneels over the victim at the shoulder, tilts back the head and lifts the chin (unless spinal injury is suspected, in which case, one simply brings the jaw forward). Once the

cavity, pleural 57 airway is open, the caregiver gently pinches the victim’s nostrils closed, takes a deep breath and places the lips to form a seal over the victim’s mouth. (If the victim is an infant, the caregiver creates a seal over the nose and mouth.) The caregiver then gives two full breaths lasting one to one-anda-half seconds, watching carefully that the victim’s chest rises with each ventilation. A bag-valve-mask or other device may also be used to prevent the spread of disease between caregiver and recipient of CPR. The caregiver must also assess the victim’s circulation by taking the carotid-artery pulse (between the groove of the trachea and the strap muscles in the neck). If there is a pulse but no sign of breathing, continue mouth-to-mouth resuscitation by administering one breath every five seconds, or 12 breaths per minute. If there is still no pulse, the victim is suffering cardiac arrest and chest compressions over the lower part of the sternum (breastbone) should be started. With fingers either interlocked or extended and using the heel of the hands placed over the notch where the ribs meet the sternum in the middle of the chest, the caregiver should compress straight down on the sternum approximately an inch-anda-half to two inches on an adult victim, an inch to an inch-and-a-half on a child, and half an inch to an inch on an infant. After each rhythmic compression, the chest should return to its natural position. Eighty to 100 compressions per minute (at least 100 per minute for an infant) should be applied. CPR should not be interrupted for more than seven seconds. IT IS IMPORTANT FOR SOMEONE TO CALL 911 OR A LOCAL EMERGENCY NUMBER WHILE CPR IS BEING GIVEN SO EMERGENCY MEDICAL PERSONNEL CAN REACH THE VICTIM AND TAKE HIM OR HER TO THE HOSPITAL. When the victim begins to breathe on his own, stop chest compressions. Check with community health facilities and organizations for complete CPR instructions and emergency measures. Everyone capable of learning CPR should be certified.

carrier A person, animal, insect, substance, or other agent capable of spreading a disease organism without showing signs of having the disease itself. See also INFECTION CARRIERS.

case-control study A method of examining disease and disease processes by way of two groups, one of those who have a disease—referred to as cases—and one of those who do not—referred to as controls. Information is obtained from each group and analyzed. The method is useful in epidemiology. The first case-control study involved English chimney sweeps who developed cancer of the scrotum. Researchers hypothesized that the nature of their work had something to do with the incidence of scrotal cancer among their group as opposed to the rate of scrotal cancer in the general public. Epidemiologists also use the case-control study to determine other characteristics of disease processes, such as frequency of occurrence, risk factors, circ*mstances of exposure, and the differences between the cases and the controls. cast, bronchial

Hardened segments of bronchial secretions that accumulate and take on the shape of the bronchial tubes. Bronchial casts may be seen in the sputum of asthma or bronchitis patients. Cast material consists of substances thrown off during the course of pathological conditions (the products of effusion). The substances may also mold themselves to nasal, tracheal, esophageal, renal, urethral, intestinal, and vagin*l passages.

catarrh

Inflammation of mucous membranes characterized by a dry cough and severe coughing spells with little or no expectoration, especially in the aged with emphysema or asthma.

catheter, pulmonary artery

A tube that is passed into the pulmonary artery for the purpose of measuring pressures in the artery, wedge pressure in the pulmonary capillaries, and heart function.

cavernous rale

Hollow spaces in the respiratory tract that produce a bubbling sound. Cavernous respiration refers to a hollow sound heard when there is a lung cavity. See also RALE.

cavity, pleural

The space between the parietal pleura, serous membranes that extend from the

58 cell-mediated immunity roots of the lungs and cover the pericardium to the chest wall and backward to the spinal cord, and the visceral pleura, which invests the lungs and enters the interlobar fissures. The pleura pulmonalis refers to the membranes investing the lungs and fissures between the lobes. Pleurae secrete a lubricating substance that decreases friction between the structures of the lungs during respiratory movements. Pleural effusion refers to fluid escaping into the chest cavity between the visceral and the parietal pleura and may be seen in a chest X ray if the fluid measures more than 300 milliliters. Pleural fibrosis, which occurs with pulmonary tuberculosis, means the pleura thickens and obliterates the pleural cavity, making respiratory movements difficult. Pleuralgia is the medical term for pain occurring in the pleura or in the side. See also PLEURISY.

generation, cephalosporins are sometimes ineffective against some bacteria that produce a defensive enzyme, beta-lactamase, which inactivates the antibiotic before it can kill the bacteria. The newer second- and third-generation drugs in this group are more effective against these infections, including sinusitis and bronchitis. Trade names include Keflex, Duricef, Velosef, Ceclor, Ceftin, and Suprax. Many other cephalosporins are available in injectable forms for serious infections.

cerebral anoxia

A condition in which there is a severe lack of oxygen supply to the brain usually caused by cardiopulmonary arrest. Irreversible brain damage may result within a few minutes if the anoxia remains untreated. See also CARDIOPULMONARY RESUSCITATION.

chalcosis Poisoning caused by copper deposits in the lungs and tissues.

cell-mediated immunity

Immune protection provided by the direct action of immune cells such as macrophages. This differs from humoral (bodily fluids) immunity, which chiefly involves B cells and antibodies. The macrophage ingests the antigen, digests it, and then displays antigenic fragments on its own surface. The macrophage then binds to a group of genes called a major histocompatibility complex (MHC). This combined structure attracts a T cell’s attention. A T cell whose receptor fits this antigen-MHC complex binds to it and stimulates the macrophage to secrete interleukin-1. Interleukin-1 in turn activates other T cells and starts a series of biochemical processes that may result in certain subsets of T cells becoming cytotoxic, or killer, cells. The T killer cells track down viral-infected body cells. When the infection has been eradicated, suppressor T cells shut down the immune response.

chalicosis

A form of pneumoconiosis, or silicosis, a respiratory tract disorder associated with the inhalation of dust from stonecutting. See also PNEUMOCONIOSIS.

Charcot-Leyden crystals Six-sided, doublepointed crystals (solid formations made by salts, water, and other substances of the body) found on microscopic examination of sputum from asthma and bronchitis patients. The crystals are also found in the feces of patients with certain inflammatory conditions of the bowels, including ambiasis. Named for French neurologist Jean M. Charcot (1825–93) and German physician Ernst V. von Leyden (1832–1910), these colorless and sometimes needlelike protein crystals are produced by eosinophil cells. chemical warfare

cephalosporin

A group of antibiotics called cephalosporin C, derived from the fungus Cephalosporium, which are used to treat a wide range of infections that may be resistant to the penicillins. Cephalosporins kill bacteria by interfering with the development of the bacterial cell wall and production of proteins by the organism. Older, or first-

Another term for biological warfare referring to the tactics of combatants that include the release of toxic chemicals. The substances—gases, defoliants, herbicides, etc.—are capable of producing lung, nerve, skin, and eye irritation, blindness, paralysis, hallucinations, and deafness. See also BIOTERRORISM.

chloroformism 59 chest (thorax) The area between the frontal base of the neck and the diaphragm, named from the Greek word thorax, which means chest. The anterior surface of the chest is located above and over the clavicles, or collarbones, over and above the sternum, or breastbone, over the breast, or mammary, area, between the third and sixth ribs on either side, and the area above the lower border of the 12th rib on either side. The posterior (rear) surface includes the entire area of the scapulae, or shoulder blades, and the side regions include above the sixth rib and under the arms. In patients with advanced pulmonary emphysema, the chest becomes rounded out like a barrel and is called a barrel-shaped thorax. The bony thorax refers to the skeletal structure including the thoracic vertebrae, 12 pairs of ribs and the breastbone. In individuals with large pleural effusions, the chest becomes an obliquely oval shape and is known as Peyrot’s thorax. The long, flat chest of patients with constitutional visceroptosis (a dropped or downward displacement of one of the organs enveloped in a body cavity such as the thorax) is known as thorax paralyticus. The chest houses the lungs, heart, pleural cavity, pulmonary artery and veins, the thoracic aorta, vena cava, thymus gland, lymph nodes, trachea, bronchi, mediastinum, thoracic duct, and esophagus. chest expansion, normal The upward movement of the chest as air is taken into the lungs.

chiropractic A widely acclaimed discipline eschewing drugs and surgery and favoring handson manipulations, referred to as adjustments, of the spinal cord. Modern chiropractic follows tenets expressed in 1895 by Daniel David Palmer, of Iowa, based on the teachings of Hippocrates, who believed all illnesses had their sources in the spine. According to chiropractic, when vertebrae are subluxated, or dislocated or misaligned, the person experiences any number of ailments, including allergy, headaches, and back pain. Although there is a great deal of anecdotal testimony to their effectiveness, chiropractic techniques and theories have not been scientifically proven. Since symptoms of allergy and asthma often wax and wane, improvement following spinal manipulation may be falsely attributed to chiropractic. Because emotional stress triggers asthma (although it is not its cause), a placebo effect may result from chiropractic treatments. However, chiropractic as a system of health care thrives on the premise that the relationship between the spinal column and the nervous system is significant, and that normal transmission and expression of nerve energy are key elements in the healing and maintenance of the body. The main approach is that vertebral subluxation causes stress, which when removed will lead to the body’s capacity of setting intrinsic healing mechanisms in motion. The American Chiropractic Association is the major organization for chiropractic physicians. Chlamydia psittaci

Cheyne-Stokes respiration

See

BREATHING.

chill Shivers, coldness, pallor, body tremors, and chattering of teeth associated with infections or diseases, including pneumococcal pneumonia and malaria. Chills may be caused by a disturbance in the temperature-regulating center of the hypothalamus, the part of the brain that controls certain metabolic activities, such as water balance, sugar and fat metabolism, and inhibiting and releasing hormones. chin-lift airway technique MONARY RESUSCITATION.

See

CARDIOPUL-

A microorganism that causes a disease in birds and lower mammals that may be transmissible to humans. In an accidental human host, the illness takes on an influenza-like form or may be a severe type of pneumonia. See also PSITTACOSIS.

chloral hydrate poisoning

An adverse effect of excessive amounts of chloral hydrate, a sedative and hypnotic drug, that causes respiratory depression that may require assisted respiration.

chloroformism The potentially lethal inhalation of chloroform, an antiseptic and local anesthetic, as recreational drug abuse. A clear liquid with an etherlike odor, chloroform was used in the early

60 choana days of medicine as anesthesia by having the patient inhale it, usually by placing a piece of cloth or gauze soaked in the chemical over the person’s nose and mouth, a practice that is now obsolete. Developed in 1838, chloroform was chemically referred to as CHCl3 and was also used as a solvent and a veterinary antiseptic. Chloroform as a singular substance is not readily available today. Other substances, including nail polish remover, rubber cement, nitrite room deodorizers, gasoline, and paint thinner, are among the numerous abused inhalants in popular use today, particularly by teenagers. See also HUFFING; INHALANT ABUSE.

choana

From the Greek word meaning funnel, a funnel-shaped opening at the back of the nostrils (posterior nares) leading to the pharynx.

choke, choking The condition of impaired breathing and circulation of air to the brain attributable to a compression or obstruction in the trachea or larynx. A spasm in the larynx as a result of inhaling an irritating gas or anything that constricts the neck may also cause interference in the airway. If a person is choking on food or an object, the Heimlich maneuver may relieve complete airway obstruction. Signs of true choking include panic, inability to speak or make noise, cyanosis, and fainting. If the forced air pressure of the Heimlich maneuver does not work, a surgical intervention may be necessary to restore breathing. See also HEIMLICH MANEUVER. cholesterohydrothorax A pleural effusion in which the fluid contains cholesterol. See also CAVITY, PLEURAL. cholohemothorax

Abnormal presence of bile and blood in the thoracic cavity.

chorditis Inflammation of the vocal cord (also called the spermatic cord). Chorditis nordosa refers to tiny white nodules that form on one or both vocal cords and accompanying hoarseness. Usually this is a condition in singers or others who overuse

their voice. Resting the voice is the treatment of choice, but surgery to remove the nodules may be necessary in severe cases.

chronic obstructive pulmonary disease Known commonly by its acronym COPD, or COLD (chronic obstructive lung disease), a condition in which there is persistent blockage of airflow into or out of the lungs because of chronic bronchitis or emphysema or both, or chronic asthma or chronic bronchiolitis. In all forms of COPD, air gets trapped in the lungs, which then leads to a decrease in the number of capillaries in alveoli walls and the impairment of the exchange of oxygen and carbon dioxide between the alveoli and the bloodstream. Eventually carbon dioxide becomes elevated, and the oxygen level is dramatically reduced. A history of persistent dyspnea (difficulty breathing) on exertion, with or without a chronic cough, and less than one-half the normal breathing capacity are the main diagnostic criteria for COPD. In the United States, approximately 14 million people suffer from COPD, according to the Merck Manual of Medical Information, September 2000, and it is “secondary only to heart disease as a cause of disability that makes people stop working, and the fourth most common cause of death. More than 95 percent of all deaths from chronic obstructive pulmonary disease occur in people over age 55. It affects men more frequently than women and is more often fatal in men. It’s also fatal more often in whites than in nonwhites and in blue-collar workers than in white-collar workers.” Merck also says COPD may be an inherited tendency, and that smoking or working in an environment where there are chemical fumes or nonhazardous dust may increase the risk of COPD. Also, approximately 10 to 15 percent of smokers develop COPD. As they age, their lung function decreases more rapidly than that of nonsmokers. Symptoms of COPD include a “smoker’s cough,” bringing up mucus, common colds that frequently become chest colds (during which sputum may turn yellow or green because of pus), wheezing, and, as the disease progresses, shortness of breath when carrying out normal activities of daily living, possible severe weight loss, and swelling of the legs.

chylopneumothorax 61 In mild asthma, inflammation that thickens the bronchial walls, constriction of the muscles in the bronchial tubes, or obstruction by excessive mucus is present only during an attack. However, in the case of severe asthma, there is usually a degree of chronic obstruction that is reversible to varying degrees with treatment. Chronic bronchitis is often confused with emphysema, an expansion of the air spaces resulting in destruction of the alveoli, or air sacs in the lungs. Approximately 20 percent of adult males have chronic bronchitis, although only a small number are disabled because of it. It is less common in females and most common in smokers, but allergies and other irritants, pollution from the environment, and occupational exposure can be causes. Pure emphysema is rare and is not reversible with treatment. The degree of obstruction found in chronic bronchitis is often greater than that found in most asthmatics but less than that in emphysemics. In rare cases, a deficiency of the protein alpha1antitrypsin, produced naturally by the body and which prevents neutrophil elastase (an enzyme) from injuring the lung’s air sacs, or alveoli, may also be the cause of emphysema. Individuals who inherit the deficiency develop emphysema by early middle age, particularly in smokers. Young people who develop emphysema are tested for the deficiency by way of a blood test. The main treatment is cessation of smoking, use of bronchodilating drugs, avoiding exposure to airborne irritants, and avoiding dehydration. Antibiotics may be used in the presence of bacterial infection, and oxygen therapy and exercise programs may improve the quality of life for COPD patients. For those with the alpha1-antitrypsin deficiency, intravenous infusions of the protein may be required. Lung transplantation may also be an option in certain patients. People with COPD have an increased risk of developing lung cancer. See also BRONCHITIS; BRONCHODILATORS; CANCER, LUNG; EMPHYSEMA.

cases of severe asthma. Patients have fever, extremely elevated eosinophil counts in their blood, and vasculitis. In addition, they generally have a long history of allergies, usually allergic rhinitis (hay fever) that progresses to asthma. A vasculitis, an inflammatory condition of blood vessels, evolves that may affect almost any organ but most often targets the heart, lungs, skin, central nervous system, muscles and bones, kidneys, or gastrointestinal tract. The person may develop nasal polyps, which cause obstruction of the nasal passages and sinusitis. The most serious complications result from vasculitis. About one-third of patients have abnormal chest X rays that resemble those seen in cases of pneumonia. If the skin is involved, rashes, hives, bumplike lesions called nodules, or large areas of bruising may occur. Abdominal obstructions and perforations cause pain and diarrhea. Myocardial infarctions (heart attacks) or inflammation of the heart muscle can result in heart failure. Brain and nerve involvement often leads to strokes and is a major cause of serious disability or death. Kidney impairment leads to hypertension (high blood pressure). Symptoms of arthritis and muscle cramping may be present. Churg-Strauss syndrome may begin with a feeling of malaise but may progress quickly with severe weight loss. The American College of Rheumatology lists six criteria for diagnosing this condition:

Churg-Strauss syndrome (allergic angiitis and granulomatosis) A combination of symptoms first reported in 1951 in association with a cluster of 13

chylopneumothorax The condition of chyle and air in the pleural space. Chyle is a milky alkaline fluid, found in the intestine, consisting of absorbed

(1) asthma; (2) eosinophil count increasing to 10% of white blood cells; (3) a mononeuropathy or polyneuropathy (singular or multiple degeneration of nerves resulting in weakness); (4) pneumonialike fluid accumulation seen in chest X rays; (5) abnormality of the sinuses; and (6) characteristic blood vessel biopsy. The presence of four or more of these criteria highly suggests Churg-Strauss.

Cortisone is the treatment of choice, but other immunosuppressive drugs are sometimes used. Five-year survival was greater than 60 percent in 1977, the last year data are available.

62 chylothorax fats and the products of the digestive process. Chylothorax refers to chyle present in the pleural cavities.

chylothorax

See

CHYLOPNEUMOTHORAX.

cigarette smoke Fumes from a burning cigarette, which are not in themselves allergenic, although tobacco smoke is an irritant to persons with asthma and nasal or eye allergy. In the past some practitioners have skin-tested and given immunotherapy (allergy shots) to patients believed to be allergic to tobacco smoke, but there is no scientific rationale for this treatment. See also LUNG CANCER; PASSIVE SMOKING; TOBACCO. circulation, pulmonary Blood from the veins entering the right atrium of the heart that then passes through the tricuspid valve and into the heart’s right ventricle to the pulmonary artery. Each of the artery’s two branches then goes into a lung and its capillaries, where, by way of hemoglobin in the red corpuscles, the venous blood takes up oxygen from inspired air. The red arterial blood then goes back to the heart through the four pulmonary veins, two from each lung going into the heart’s left atrium. When the blood enters the atrium, it is fully oxygenated. Citelli’s syndrome

Named for Salvatore Citelli, an Italian laryngologist (1875–1947), a condition characterized by insomnia or drowsiness seen accompanying infected adenoids or sphenoid sinusitis in children.

clapping Also called cupping or tapping, percussion of the chest using a cupped hand as a method of loosening secretions in patients with respiratory disorders such as tuberculosis involving excessive mucus and congestion. Clara cells

Named for Max Clara, the Austrian anatomist born in 1899 who identified them, the cells in the epithelium of the bronchioles that provide secretions for the respiratory tract.

clean room

A room or environment in which the air—its temperature, pressure, humidity, and purity—is controlled. A filter may be used to remove 99.97 percent of all particles 0.3 microns (1 micron = 1/25,000 inch) and larger. Clean rooms are used in research and for individuals suffering from severe allergy or chronic infection due to immune system deficiency.

cleft palate A congenital anomaly in which there is a fissure, or elongated opening, in the roof of the mouth (palate) that creates a passageway between the mouth and the internal portions of the nose. clubbing Enlargement of the tips of the fingers or toes and loss of the normal angle at the nail bed, frequently caused by lung or other diseases or a hereditary factor. coal

worker’s pneumoconiosis Commonly known as black lung, a lung disease caused by the inhalation and accumulation of coal dust in the lungs. After the coal dust collects around the bronchioles, it spreads to other parts of the lung and eventually causes spots that may be detected on a chest X ray. A more serious form of the disease may occur in 1 to 2 percent of individuals who have simple black lung. Even long after exposure to coal dust has ended, lung tissue and blood vessels may suffer the effects of progressive massive fibrosis, or severe scarring. The scars measure at least a half-inch in diameter, and the fibrosis then causes coughing and debilitating shortness of breath, especially in coal miners who have been exposed to coal dust for more than 10 years. There is no cure for black lung, but drugs that help keep airways patent and free of secretions may be of help. Prevention is the key: adequate suppression of coal dust at the worksite; chest X ray every four to five years; transfer of workers at risk for progressive massive fibrosis to an area where coal dust levels are minimal; cessation of cigarette smoking; and avoidance of toxic exposure to industrial pollutants.

concha, nasal 63 cocaine hydrochloride poisoning, acute

The toxic effect of applying or inhaling cocaine hydrochloride, a topical anesthetic derived from the shrub Erythroxylon coca of Bolivia and Peru. Street names for the drug include crack, snow, gold dust, toot, co*ke, and lady. Symptoms after an initial stimulating effect are irregular respirations, tachycardia, hallucinations, vomiting, muscle spasms, chills or fever, restlessness, incoherence, dilation of pupils, seizures, coma, and death from respiratory arrest. Treatment includes intravenous diazepam (Valium), an emetic (or gastric lavage if the drug was ingested), succinylcholine chloride if convulsions interfere with breathing, oxygen, and artificial respiration. If a victim survives for three hours after the onset of symptoms, he or she is likely to recover.

coccidioidomycosis Also known as granuloma, valley fever, desert rheumatism, and coccidioidal, a disease affecting the respiratory organs in its acute (primary) form, caused by the fungus Coccidioides immitis. The progressive form of the disease may involve any part of the body and is considered grave and often fatal. The primary type does not require treatment. For patients with pulmonary disease, ketoconazole may be prescribed to inhibit the infection and suppress symptoms. However, amphotericin B is the only drug that is effective against the progressive form. See also GRANULOMATOSIS, WEGENER’S. codeine poisoning

An overdose of codeine, an alkaloid obtained from opium, that causes serious and potentially fatal depression of respiration and heart rate.

cogwheel respiration

See

BREATHING.

coin test

A diagnostic test for pneumothorax, or collapsed lung. A coin is placed on the chest over a suspected area of the lung and struck by another coin. If a metallic ringing sound is heard, a cavity containing air is underneath. Physicians now order X rays to confirm the diagnosis.

COLD disease.

The acronym for chronic obstructive lung

See also

CHRONIC

OBSTRUCTIVE

PULMONARY

DISEASE.

cold, common

A respiratory infection caused by a virus including sneezing, nasal discharge and congestion, sore throat, and coughing, all of which are often confused with or coexist with allergy symptoms. Viral colds can also trigger asthma; shortness of breath and wheezing may persist for a prolonged period following resolution of the viral infection. Some patients have asthma symptoms only when they “catch” a cold.

cold-induced rhinorrhea

A runny nose that occurs upon exposure to cold air. It is not an allergy and does not respond to antihistamines, but it may be prevented by using a mixture of atropine sulfate and saline solution as a nasal spray.

columna nasi tum. See also

Another term for the nasal sep-

NOSE.

coma

From the Greek koma, meaning deep sleep, an abnormal stupor from which the victim cannot be aroused. Occurring as a result of illness, acute infection or bacterial intoxication, inhalation of gases or fumes, or injury, coma may require basic life support as treatment. A patient’s airway must be kept patent, and all vital signs and bodily functions must be monitored. Adequate ventilation and oxygenation are also among the top priorities for a patient in a coma. There are several types of coma, including diabetic, hepatic, uremic, vigil, apoplectic, alcoholic, hypoglycemic, Kussmaul’s, and irreversible (brain death).

communicable disease

Any infection or malady that is transmissible from one body to another.

concha, nasal

Part of the anatomical structure of the nose, one of three bones shaped like scrolls, hence the name from the Greek word meaning shell, that project from the lateral wall of the nasal cavity. The superior, middle, and inferior conchae all protrude over an opening, or meatus.

64 congestion, pulmonary congestion, pulmonary An abnormal amount of blood in the pulmonary vascular bed, usually associated with heart failure. coniofibrosis Pneumoconiosis caused by the inhalation of asbestos, silica, or other dust, which produces fibrosis in the lung. coniosis Any illness, ailment, or anomaly caused by the inhalation of dust. coniosporosis

Asthma and pneumonitis caused by inhaling the spores of the fungus Cryptostroma corticale or Coniosporium corticale. Essentially a hypersensitivity reaction, coniosporosis occurs in workers who strip the bark of trees under which the fungi grow.

cor pulmonale

A dysfunction of the heart’s right ventricle caused by lung disease or disorders of the pulmonary vessels or chest wall. Long periods of time spent at high altitudes may also result in cor pulmonale.

corticosteroid metered-dose inhalers

Various asthma inhalers containing cortisone derivatives possessing anti-inflammatory properties useful in the prevention of asthma symptoms. See also CORTICOSTEROIDS.

corticosteroid nasal sprays (beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone, mometasone furoate, triamcinolone) Derivatives of the hormone cortisone that relieve symptoms of nasal congestion and excessive discharge from allergic rhinitis (hay fever). They may also give relief for vasomotor rhinitis (nonallergic nasal congestion) and may have a beneficial effect on small nasal polyps. Also called “steroid” nasal sprays, these medications may take one to two weeks to become effective and may be prematurely discarded by uninformed patients as ineffective. These are considered maintenance medications, and since their effectiveness does not accumulate, they must be used continuously. Because only a minimal quan-

tity of the active drug is absorbed from the nasal passages into the bloodstream, there is little chance for side effects. Use in children, however, must be closely monitored. See also CORTICOSTEROIDS.

corticosteroids

Naturally occurring (or synthetically manufactured) hormones produced by the adrenal glands, located next to the kidneys. Although corticosteroids do not initiate cellular or enzymatic activity, they are essential for many functions necessary for life, including the regulation of carbohydrate, protein, and fat metabolism, and salt and water balance. Natural and synthetic corticosteroids play a vital role in fighting allergic and inflammatory reactions. Although these drugs can be lifesaving, they also may produce very deleterious effects with large doses or prolonged therapy. Corticosteroids differ from dangerous anabolic steroids, which are often used illegally by athletes to enhance bodybuilding.

Antiallergy Effects The cortisone-like drugs have the ability to interfere with allergic antigen-antibody reactions. This most likely occurs by blocking the inflammatory tissue injury that results from the release of chemical mediators from mast and basophilic cells. Prostaglandin production is also suppressed by these drugs. In addition, these drugs suppress all types of delayed hypersensitivity or cell-mediated immune reactions. This is especially useful for preventing tissue transplant rejections from occurring. Metabolic Effects Hydrocortisone removes glycogen stores in the liver and raises blood sugar levels. In corticosteroid-treated patients, diabetes mellitus usually develops only in those with a latent diabetic tendency and rarely raises glucose to dangerous levels in normal patients. Hydrocortisone in physiologic or normal quantities is essential for normal muscle contraction. However, large doses or prolonged therapy causes a negative nitrogen balance by increasing amino acid production from protein, with depletion of body protein. This in turn causes severe muscle

corticosteroids 65 wasting, or atrophy, and weakness. A similar effect on bone results in osteoporosis with decreased bone matrix and removal of bone calcium. This process also interferes with normal growth in children. Aseptic necrosis is another serious adverse

effect of high-dose corticosteroid therapy. Hydrocortisone in high doses also causes a redistribution of the body’s fat stores with thinning of the extremities and increased disposition in the face and trunk. Thinning of subcutaneous tissue may occur

66 corticosteroids

corticosteroids 67 with resulting red or purple striae and ecchymosis, or bruises. Sodium and water retention also occurs, but potassium is lost. Blood pressure elevation may occur with high-dose therapy. Hormonal Changes When used for a prolonged time, corticosteroids may suppress the production of the pituitary hormone corticotropin (ACTH). ACTH secretion stimulates the adrenal glands for the natural production of cortisone. If the adrenal glands atrophy, they may fail to respond adequately to a crisis such as an acute illness, like an asthma attack or the stress of surgery, and if an extra dose of the drug is not administered, the patient may die. Some women develop hirsutism (excessive hair production), and acne is more common as a result of breakdown products of androgens, or male hormones, from prolonged use of corticosteroids, but rarely do these drugs affect menstrual function. Anti-inflammatory Effects One of the beneficial roles of anti-inflammatory drugs is to assuage reactions in asthma and arthritis; this same ability to suppress inflammation may have a deleterious effect on wounds by interfering with the healing process. The ability to suppress inflammation may be so great that the warning signs and symptoms of a major complication may be missed until there are serious consequences, such as a bleeding peptic ulcer or a severe infection. There may be an increased incidence of gastric or duodenal ulcers in corticosteroid-treated patients. Central Nervous System and Behavioral Changes Hydrocortisone stimulates the central nervous system and may cause seizures, especially in children with a seizure disorder. High-dose therapy may induce psychotic behavior, including hallucinations and delusions. Depression or alternately euphoria, insomnia, and agitation may result. Effects cannot be predicted by prior personality qualities. Rarely, increased intracranial pressure develops, resulting in a condition called “pseudotumor cerebri.”

Effects on the Eyes Topical corticosteroid eyedrops are frequently prescribed to treat allergic eye conditions, but they can cause a dangerous increase in intraocular pressure and other serious adverse effects that may lead to blindness. They should be prescribed only after evaluation by a physician well trained in their use. Uses Corticosteroids are mainstays for allergy and asthma treatment and are often lifesaving. In addition, they are effective therapy for arthritis, eye diseases, skin diseases, and many other diseases. Corticosteroids are available by injection, orally, and topically as creams, gels, ointments, lotions, solutions, aerosolized metered-dose inhalers, skin sprays, and nasal sprays. The potential for adverse effects is great with prolonged systematic use. Use of alternate-day dosing can greatly lessen this potential, but not completely. When allergy patients have been stabilized, they are usually candidates for aerosol corticosteroid therapy to prevent attacks by keeping inflammation under control. Corticosteroid nasal sprays play a similar preventive role for nasal allergies. Contraindications to the Use of Corticosteroids In early 1992, the Food and Drug Administration (FDA) warned about the use of corticosteroids in patients not immune to chicken pox (varicella) or other reduced-immunity illnesses. Several deaths have occurred in otherwise normal, asthmatic children who contracted chicken pox while being treated with corticosteroids. These drugs should be used only if no alternative exists. Corticosteroids absolutely must be avoided in the presence of herpes simplex infection of the eyes. They must be used cautiously in patients with coexisting diseases, including diabetes mellitus, hypertension, peptic ulcer disease, osteoporosis, diverticulitis, psychotic conditions, renal insufficiency, and congestive heart failure (except in certain inflammatory conditions such as rheumatic heart disease), and following some recent surgical intestinal procedures. Some references recommend against the use of corticosteroids during pregnancy; however, the use of prednisone should not be

68 coryza spasmodica withheld in patients with asthma and other serious diseases. Use of these drugs in patients with tuberculosis was once considered an absolute contraindication. However, in life-threatening situations they can be used in combination with antituberculosis drugs. WARNING: The risk of using corticosteroids must always be weighed against the risk of not using them.

coryza spasmodica CO2 therapy cough

See

HAY FEVER.

CARBON DIOXIDE INHALATION.

A reaction, or reflex, of the upper respiratory tract to correct an irritation or blockage of the airways. Dust or other particles, fumes, smoke, gases, and viral and bacterial infections cause the sudden, expulsive rumble characterizing a cough. Some coughs, such as whooping cough, create high-pitched sounds, whereas the inflammation of the upper respiratory tract, especially when children have croup, creates a narrowing of the airways and a barking cough. When an object becomes lodged in the larynx, or voice box, the cough mechanism is triggered to help expel the object and stop a person from choking. Coughing is also the body’s way of expelling mucus, phlegm, or other irritant, in which case it is called a productive cough. A dry, or unproductive, cough, which does not result in expulsion of a substance, may be caused by bronchospasm (a sudden narrowing of the bronchi), featured in asthma, allergic reactions, or infection. Causes of chronic coughing include smoking and/or lung disease, a foreign object trapped in a bronchus, and anxiety or nervousness. Other causes of cough include upper airway obstruction or irritation; infections; irritation or structural abnormalities; or other disorders of the epiglottis and larynx such as vocal cord paralysis, polyp, or tumor; tracheomalacia; external compression by lymph nodes, tumor, or vascular ring; intraluminal obstruction by foreign body, mucus plugs, inflammation or tumor; bronchospasm of asthma, chronic bronchitis, or emphysema; cysts; congenital malfor-

mation; inflammation from allergic diseases such as hypersensitivity pneumonitis; interstitial lung diseases; congenital heart disease; congestive heart failure; gastroesophageal reflux; hiatus hernia; edema; hysteria; paralysis; adverse effects of drugs such as the ACE inhibitor antihypertensives (benazepril, captopril, enalapril, fosinopril, lisinopril, quinapril, and ramipril) or drug toxicity; smoke from tobacco or fires; noxious fumes or gases; organic dusts containing allergens such as dust mites, animal allergens, industrial allergens, scents in perfumes and household or commercial cleaning agents; aerosol products; cold; humidity; and dryness. Types of coughs include 1) aneurysmal, described as brassy and clanging, as in individuals with an aneurysm; 2) asthmatic, i.e., more closely resembling difficulty breathing; 3) brassy, such as the cough in individuals who have pressure on the left recurrent laryngeal nerve; 4) bronchial, such as that which occurs in individuals with bronchiectasis or bronchitis and is accompanied by the production of sputum; 5) diphtherial, i.e., a brassy cough and labored breathing as a result of laryngeal diphtheria; 6) dry, in which there is no accompanying moisture; 7) effective or productive, which refers to the expectoration of exudates; 8) hacking, such as repeated coughing associated with pulmonary tuberculosis; 9) harsh, referring to the metallicsounding cough heard in patients with laryngitis; 10) moist, or a loose cough that produces mucus or exudates; 11) paroxysmal, i.e., in whooping cough and bronchiectasis patients; 12) pulmonary, i.e., hard, painful coughing such as patients with pneumonia experience; 13) reflex, which refers to a cough that is a result of irritation of Arnold’s nerve, the middle ear, pharynx, stomach, or intestine; 14) uterine, i.e., a reflex cough caused by an irritation of the uterus or other female organ; and 15) whooping, also known as pertussis, described as a paroxysmal cough with a whooping sound made upon inspiration. An antitussive refers to a drug that inhibits or suppresses a cough. See also COUGH, EAR; WHOOPING COUGH.

cough, ear A reflex cough resulting from an ear infection, irritation, or foreign body lodged against the tympanic membrane (eardrum).

cyclosporin 69 cracked pot sound The sound, similar to that of striking a cracked pot, during percussion to diagnose a pulmonary cavity. crackles

Rales or abnormal lung sounds including coarse crackles, which are longer, louder, and low-pitched, and fine crackles, which are soft, short, and high-pitched. See also RALE.

crepitation

A crackling sound, such as a rale heard in pneumonia patients, or the grating sound caused when the ends of broken bones rub against another bone or surface. See also RALE.

crepitus redux A rale or any abnormal sound heard through a stethoscope placed on the chest, that signals the recovery stage in pneumonia patients. See also RALE. cromolyn sodium (disodium cromoglycate, Intal, Nasalcrom, Opticrom) A drug that prevents the release of histamine and other chemical substances from mast cells in the eye, nose, and lungs, therefore preventing allergy symptoms and asthma. This drug is often discarded by patients who underestimate its benefit because it is very slow-acting and requires up to two months to exert its full effectiveness. However, cromolyn is a first-line treatment for respiratory allergies and asthma. It also has almost no side effects and is safe to use during pregnancy.

crossed finger airway technique A technique for removing debris or foreign material from the mouth of a person about to receive cardiopulmonary resuscitation. See also CARDIOPULMONARY RESUSCITATION. croup

A disease characterized by a metallic cough, often described as a “seal-like” bark, with hoarseness that occurs when breathing in. It is accompanied by thick mucus in the nose and throat, dyspnea, laryngeal spasm, and, at times, by

the formation of a membrane. Catarrhal croup refers to acute catarrhal laryngitis. Croup is most commonly caused by a viral infection during infancy or early childhood, and is generally a benign condition. However, when accompanied by high fever, it may be caused by a dangerous bacteria, Haemophilus influenzae. Unless antibiotics are started early, the bacterial form of croup may lead to the life-threatening complication known as acute epiglottis. The less severe forms of croup can be treated by breathing warm, humid air in a steamed-up shower or small bathroom.

crowing A harsh, crow-like sound produced when air is taken into the lungs. Curschmann’s spirals Named for German physician Heinrich Curschmann (1846–1910), coiled spirals of mucus seen frequently in the sputum of asthma patients. cyanosis Blue coloration of the mucous membranes caused by lack of oxygen supply. See also BLUE BABY. cyclic adenosine 3’, 5’-monophosphate (camp, cyclic AMP) A substance whose presence is essential for stabilization of mast cells in body tissues, which along with basophils are responsible for the symptoms of allergy. It is also deficient in asthmatics. Drugs such as epinephrine and theophylline increase camp-inhibiting mast cell degranulation and are useful for the treatment of asthma. cyclosporin An immunosuppressant drug used to prevent or suppress organ transplant rejection. Researchers at the National Heart and Lung Institute in the United States and the Royal Brompton Hospital in London are investigating cyclosporin as an alternative to dangerously high levels of corticosteroids required by the most severe asthma patients. Although some individuals in one study group had a significant improvement in lung function and less frequent acute episodes of asthma, cyclosporin can cause serious

70 cyst, alveolar kidney problems and is still considered experimental therapy.

cyst, alveolar

An air cyst or sac, formed when alveoli (air sacs) in the lungs dilate and rupture.

cystic fibrosis (CF) Among the most common fatal inherited diseases, an autosomal recessive genetic disorder. CF affects the exocrine secretory glands of the respiratory and digestive systems. Often called “sixty-five roses” by children afflicted with the disease, CF’s excessive production of thick, sticky mucus causes a chronic cough, wheezing, and plugging of the bronchial tubes. Trapped bacteria cause recurrent respiratory infections. Mucus also blocks the pancreatic secretion of digestive enzymes, causing malabsorption of nutrients and foul bulky stools, with failure to gain weight and thrive, a common finding in young children. This disorder is often confused with asthma, pneumonia, or other respiratory diseases when symptoms first appear, usually in infancy. Mild cases may escape recognition until adulthood. Gastrointestinal symptoms may be confused with

celiac disease or other disorders. Diagnosis is confirmed by a positive sweat chloride test. Since CF was first recognized as a disease in 1938, it has been estimated to occur in one in 2,000 to one in 1,600 live white births in the United States, but only one in 17,000 blacks. About one in every 20 persons carries the CF recessive gene. Genetic counseling is advisable when a previous pregnancy resulted in CF. Prenatal diagnosis and carrier state of parents can be established by DNA genetic markers. Until recently the prognosis for CF patients was poor, with very few patients surviving childhood. However, newer antibiotics and aggressive physical therapy to help drain the mucus from the airways by a technique called postural drainage, and the use of pancreatic enzymes and nutritional supplements, can greatly improve the outlook. Males generally outlive female patients, with half of patients living past age 21. Respiratory failure is the leading cause of death. The discovery of the CF gene on the long arm of chromosome 7 gives hope for the possibility of a cure for this disease utilizing gene therapy within a few years.

D Chronic Moderate Asthma In this category, asthma symptoms are not controlled by the occasional use of a beta2-agonist. There may also be a frequent need for beta2agonists, possibly more than twice a week. Symptoms in this group may be most apparent at night or, as in mild asthma, may be triggered by the environment or exercise. The lungs function at 60 to 80 percent of the predicted range for a person’s age, sex, and height, indicating a compromise in airway flow. The National Asthma Education Program’s Guidelines for the Diagnosis and Management of Asthma recommends the use of an anti-inflammatory agent in any person with moderate or severe asthma. Anti-inflammatory drugs include inhaled cromolyn sodium or inhaled corticosteroids. These safe and effective medications reduce the frequency and severity of asthma attacks and the need for oral corticosteroids. Nighttime awakening may necessitate the addition of long-acting bronchodilating drugs such as theophylline or albuterol. Occasional short bursts of oral corticosteroids are needed, but not on a daily or frequent basis. Individuals rarely require urgent emergency room visits.

death rattle

A rattling sound, or rale, produced in the throats of patients who are dying. The sound is caused by excess mucus and the absence of the cough reflex.

decompression illness

See

BENDS.

decongestant

A class of drug or other agent that acts against nasal or bronchial congestion. Also known as alpha-adrenergic agonists, decongestants may be used topically as nasal spray or drops, and orally in capsules, tablets, or syrups.

decortication, pulmonary The surgical removal of a segment of surface lung tissue or a pleura. Decortication is used as a treatment, though rarely, for severe pleural effusion when there is difficulty accomplishing the drainage of pus from the area. degree of asthma severity

The ranges or the levels of asthma from asymptomatic to fatal, with the majority of cases described as mild to moderate.

Chronic Mild Asthma Persons with chronic mild asthma have no abnormalities in baseline pulmonary lung tests, or spirometry, between asthma attacks. During attacks, airflow rates fall 20 percent below their predicted normal values. Asthma symptoms are usually triggered by exercise; exposure to irritants or allergens such as pollens, animals, or house-dust mites; or respiratory infections. Treatment prior to exposure is usually effective in preventing symptoms. Inhaled beta2-agonists are usually the only therapy necessary to control attacks, and they are used on an as-needed (PRN) basis only.

Chronic Severe Asthma Individuals whose asthma is not controlled by maximal drug doses and who may be at risk for life-threatening asthma attacks show a pulmonary function less than 60 percent of baseline. Airflow varies widely during attacks. These persons may require long-term use of daily or every-other-day oral corticosteroids. See also ASTHMA; CORTICOSTEROIDS.

demand valve manually cycled resuscitator

A type of resuscitator (trade names include Rober-

72 depressant, respiratory shaw valve and Elder valve) that uses high-low oxygen that is cycled by pushing a button and watching the chest of the patient rise.

depressant, respiratory

dexchlorpheniramine (Polaramine)

An antihistaminic drug used in the treatment of allergic disorders. This drug is moderately sedating and has few side effects.

A drug that lessens the frequency and depth of breathing.

dextromethorphan

depression A neurotic or psychotic disorder characterized by lethargy, loss of interest in socializing, sex, work and other activities of daily living, weeping and/or pervasive sadness, insomnia, inability to concentrate, and other symptoms. When asthma and depression occur simultaneously, both conditions can intensify, according to Nancy J. Rubin, Psy.D., of the University of Alabama School of Medicine in Tuscaloosa. Rubin reported in the American Medical Association’s Archives of Family Medicine that people with depressive disorders or symptoms tend to have physical, social, and role-functioning difficulties comparable to the difficulties of those who suffer from one or more of the eight major chronic illnesses, including lung disease. One association involves the effect of depression on the respiratory system. A depressed person enters a psychological state of nonaction, associated with decreased energy expenditure, decreased ventilation, low oxygen consumption, and skeletal relaxation. These conditions further complicate asthma, a disorder already characterized by compromised ventilation and borderline blood gas values. Another theory involves dysfunctional brain mechanisms associated with depression. One group of researchers speculates that neurotransmitter imbalances found in asthma and depression may combine to worsen both conditions. However, the correlation of brain dysfunctions and asthma is not fully understood. Formal assessment by a mental health professional of the patient with severe asthma is recommended as part of the standard medical assessment.

diaphragm From the Greek word diaphragma, or partition, the musculomembranous structure that separates the abdomen from the thoracic cavity. When a breath is taken in, the diaphragm contracts and moves downward to make room for the lungs to expand. Upon exhalation, it rises to its normal inverted-basin shape. Originating at the sixth ribs (anterior intercostals) and the 11th and 12th ribs posteriorly, the diaphragm is the major inspiratory muscle that helps draw air into the lungs, aids in defecation and childbirth by its capacity to increase intra-abdominal pressure during exhalation with the glottis closed, and its spasmodic activity during hiccoughs or sneezing.

dexamethasone (Decadron) tory derivative of cortisone. See also CORTICOSTEROIDS.

Non-narcotic synthetic derivative of levorphanol similar in structure and effectiveness to codeine as a cough suppressant. Dextromethorphan is found combined with antihistamines, decongestants, and expectorants in many prescription and over-the-counter allergy and cold remedies, including Benylin DM, Delsym, Mediquell, Pertussin, and Robitussin DM. This antitussive (cough-suppressing) drug is the safest available. It rarely causes minor adverse effects, such as mild nausea or dizziness, and is the cough suppressant of choice during pregnancy.

diffusion

The action of gaseous, liquid, or solid molecules of a substance to travel from an area of high concentration to an area of lower concentration.

Dilor

See

DYPHILLINE.

Dimetane

See

BROMPHENIRAMINE.

Dimetapp

See

BROMPHENIRAMINE.

An anti-inflamma-

diphenhydramine (Benadryl)

An antihistaminic drug used to treat the symptoms of allergic rhinitis

disinfectant 73 (hay fever) and urticaria (hives), including sneezing, runny rose, nasal congestion, itchy eyes and pruritus (itching). It is given by injection as a secondary treatment for severe allergic anaphylactic reactions (epinephrine, or adrenaline, must be used as the primary drug in this severe, shock-like, life-threatening condition), which may occur in persons allergic to bee stings or certain foods. Diphenhydramine is also useful as a cough suppressant, for the prevention and treatment of motion sickness, and for parkinsonism. It is widely available topically in creams or lotions for the relief of itching. However, many allergists and dermatologists advise against this use because of frequent adverse effects. The principal side effect is sedation, and it is often prescribed as a nonhabituating hypnotic in the treatment of insomnia.

diphtheria A contagious and sometimes lifethreatening infection by the bacterium Corynebacterium diptheriae spread by moist droplets coughed into the air by an infected person. The microorganism multiplies and causes inflammation in the mucous membranes of the mouth and throat, and certain types of the bacterium produce a toxin that may damage the heart and brain. Because of the effectiveness of the diphtheria-tetanus-pertussis (DTP) vaccine, diphtheria is rare in the United States and other developed countries, with fewer than five cases since 1980. Current instances of the disease have been reported in countries of the former Soviet Union, including Russia. Although anyone may be affected, the disease is mostly seen in children younger than 10. The Schick test, developed by the Hungarianborn pediatrician Bela Schick (1877–1967), determines the degree of an individual’s immunity to diphtheria. The test involves an intradermal injection of 0.1 milliliters of dilute diphtheria toxin, which is one-fiftieth of the minimum lethal dose (MLD) that would kill a small guinea pig within four days. A red, inflamed spot at the site of injection appearing after three or four days indicates a positive test. Little or no reaction to the injection constitutes a negative result and therefore an immunity. Symptoms include a mild sore throat and pain with swallowing, nausea, vomiting, chills, head-

ache, low-grade fever, swollen lymph nodes in the neck, runny nose, laryngitis, difficulty breathing, rapid heart rate, and prostration. In nasal diphtheria, a higher fever is usually present. Also, there may be inflamed adenoids, a blood-tinged discharge from the nose, and bad breath. Named from the Greek diphthera, or membrane, the disease is characterized by the false membrane on a mucous surface and at times affecting the skin. The pseudomembrane appears yellowish-white or gray and adheres to the tonsils or pharyngeal walls. If a child develops mild diphtheria, a pseudomembrane may never appear. Also, diphtheria carriers are able to spread the disease but manifest no symptoms themselves. Treatment involves hospitalization, usually in the intensive care unit (ICU) in order to monitor breathing and heart function, and the intravenous administration of the diphtheria antitoxin, which is made from horse serum. A patient may be allergic to the antitoxin, in which case he or she must be desensitized before receiving the drug. Penicillin, ampicillin, and erythromycin are also used to fight the bacterium. Three consecutive negative cultures after the completion of antibiotic therapy indicate that the bacterium has been eliminated. When the larynx is severely affected and an airway becomes obstructed, intubation or surgery (tracheotomy) may be necessary. Nerve damage may result if the condition is not treated promptly. Diphtheria victims may also develop skin lesions, especially where crowded conditions and poor hygiene prevail, myocarditis (inflammation of the heart muscle) and rarely, disturbances of the eye. Recovery from diphtheria may take many weeks.

diphtheria-pertussis-tetanus toxoid vaccine

See

DIPHTHERIA.

disinfectant

Any chemical that kills bacteria, especially vegetative microorganisms. Examples are chlorine, fluorine, iodine, silver nitrate, sulfurous acids, alkalies, formaldehyde, 70 percent alcohol, salts of heavy metals, cresols, phenol (carbolic acid), benzoic and salicylic acids and their sodium salts, thymol, potassium permanganate, boric acid, chloride of lime, and iodoform.

74 disodium cromoglycate disodium cromoglycate Dittrich’s plugs

which some individuals are predisposed through adverse reaction to routine immunizations and the removal of tonsils, and other nose and throat operations. Bronchopneumonia has been known to develop in rare cases of severe poliomyelitis.

diver’s paralysis

drip, postnasal A discharge flowing from the postnasal region (behind the nose) to the throat, caused by allergic or vasomotor (nonallergic) rhinitis or chronic sinusitis.

See

CROMOLYN SODIUM.

Small particles, named for German pathologist Franz Dittrich (1815–59), made of pus, detritus, bacteria, and fat globules in fetid sputum. See

BENDS.

doxapram hydrochloride (Dopram)

A drug that

stimulates respiration.

drainage, negative pressure

In the treatment of pneumothorax (collapsed lung), the use of a tube promoting negative air pressure (suction) so that excessive or abnormal fluids, blood, pus, or secretions may be drained. A drainage tube is a device that allows those substances to flow out of a wound or abscess.

droplet infection

The result of inhaling infected microorganisms, usually spread by an infected person’s cough or sneeze into the air. The common cold is typically transmitted by droplets.

drops, nose

Any medication or solution sprayed or dropped into the nostrils and nasal cavity.

drowning drainage, postural

The use of gravity to help remove secretions from the nose, bronchi, sinuses, and lungs by placing the patient in a position in which his head is lower than his feet. Tapping or cupping on the patient’s back may also aid in the procedure.

drainage tube

A hollow cylindrical device that may be inserted into the body in order to draw pus, blood, serum, or other fluid out of an area of a wound or infection in which fluid has accumulated. When drainage is required in the chest cavity, the tube is attached to a suctioning device. Typically, chest drainage may also involve the suctioning of air from the pleural space while preventing air from being sucked back in. Chest tubes are inserted into the pleural space for this procedure.

Drinker respirator

The apparatus, commonly known as the “iron lung,” that presses upon a patient’s thoracic area in order to produce alternating positive and negative air, as in the normal breathing process. The device was invented by Philip Drinker, born in 1894, an American engineer in industrial hygiene. The iron lung became widely used for the treatment of poliomyelitis, to

The cessation of breathing and heart function as a result of immersion in water or a spasm in the glottis that stops air or water from getting into the lungs (dry drowning). Near-drowning refers to recovery from severe oxygen deprivation and subsequent lung damage after being underwater for a long time. An individual who is submerged in cold water may survive because of the “diving reflex” such as that discovered in seagoing mammals. Very cold water slows the heart rate and redirects the blood from the extremities and intestines back to the heart and brain. It also cools the body tissues, which then do not require as much oxygen as warm ones do. Victims of near-drowning may, however, experience impaired breathing and abnormal volume and content of the bloodstream well after the actual crisis. Also, submersion in and inhalation of fresh water may have a damaging effect on the lungs, and salt water draws fluid from the bloodstream into the lungs. Treatment includes resuscitation techniques if the victim is not breathing and hospitalization to ensure the reoxygenation of the blood and maintenance of vital signs. Antispasmodic medication may be necessary to keep airways patent. Corticosteroids may be given to reduce lung inflammation, and antibiotics may be necessary in the case of

dyspnea 75 infection. Hyperbaric chamber therapy may be required. Even with modalities to prevent brain damage, some victims of near-drowning sustain permanent neurological impairment. See also CARDIOPULMONARY RESUSCITATION.

duct, thoracic Another term for the left lymphatic duct, or channel, that drains the left side of the body above the diaphragm and the entire body below the diaphragm. dyphylline (Dilor, Lufyllin)

A bronchodilator drug derived from xanthine and related to theophylline, used for the treatment of asthma.

dyspnea Difficulty breathing, also called air hunger, which may be painful and caused by a res-

piratory disorder or extremely strenuous exercise. Cyanosis, or blue coloration, indicates lack of sufficient oxygen in the blood in individuals experiencing dyspnea. Inspiratory dyspnea refers to difficulty breathing because of some blockage or interference with the individual’s ability to take in air. Expiratory dyspnea is usually seen in asthma and bronchitis patients, with wheezing and pain upon exhaling air. A shortness-of-breath attack that occurs at night and awakens an individual is known as paroxysmal nocturnal dyspnea and may be caused by heart failure and pulmonary pressure. In the past, this type of dyspnea was called cardiac asthma, which is erroneous.

E Eaton-Lambert syndrome Named for American physician Lee McKendree Eaton (1905–58) and American physiologist Edward Howard Lambert (b. 1915), a myasthenia syndrome characterized by muscle weakness, hyporeflexia, and autonomic dysfunction, frequently associated with oat cell carcinoma of the lung. See also CANCER, LUNG.

hormones through immunological and enzymatic activity.

Elixophyllin See also

A trade name for theophylline.

THEOPHYLLINE.

embolism, pulmonary

A type of artificial breathing technique in which electrodes providing intermittent electrical stimuli are applied over the phrenic nerves in the neck. This is used for patients with respiratory center injury.

A blood clot or obstruction of a blood vessel in the pulmonary artery or a branch of the artery, usually as a result of thrombosis, or blood clot, in a vein in the leg or pelvis. An embolus may also be an air bubble or consist of fat, amniotic fluid, bone marrow, or a tumor fragment. Anticoagulants such as heparin are used as prophylaxis before and after surgery and as treatment for thrombus formation. Acute dyspnea, chest pain, coughing, anxiety, and rapid breathing are often associated with pulmonary embolism. In addition to dextran (a plasma volume expander) and graduated compression elastic stockings, supplemental oxygen and mechanical ventilation may be required. An embolus may be diagnosed through chest X ray, electrocardiogram, a lung perfusion scan, lung ventilation scan, and pulmonary arteriography. Approximately 10 percent of patients with pulmonary embolism sustain a certain amount of lung-tissue death (also called pulmonary infarction), and large clots may cause sudden death. Treatment of a pulmonary embolism involves oxygen therapy and, if necessary, pain-killing medication, in addition to anticoagulants, thrombolytics (drugs such as streptokinase and urokinase that break up the clot), and surgery (pulmonary embolectomy).

ELISA (enzyme-linked immunoabsorbent assay)

emphysema

ECHO virus

A virus of the group of approximately 30 viruses whose acronym stands for Enteric Cytopathogenic Human Orphan, associated with acute respiratory infection, myocarditis, enteritis, pleurodynia, and nonbacterial viral meningitis.

edema, pulmonary

From the Greek oidema, or swelling, an accumulation of fluid in the lungs as a result of heart failure, in which more blood enters the pulmonary circulation than is released. In general, edema refers to any excessive amount of fluid in body tissues. Laryngeal edema typically occurs along with an anaphylactic allergic reaction that requires prompt treatment before it causes airway obstruction. Edema of the glottis refers to the cough, loss of voice, and feeling of suffocation when the submucosa of the larynx becomes infiltrated with excessive fluid.

electrophrenic respiration

A chronic lung disease named from the Greek word emphysan, meaning “to inflate,”

A method for detecting antigens, antibodies, and

endobronchitis 77 and characterized by difficulty in breathing, especially shortness of breath due to enlarged and damaged air sacs (alveoli) found at the ends of thin-walled air passages called bronchioles. Almost always, emphysema is caused by cigarette smoking; smoke as well as other pollutants stimulate the release of alveolar chemicals, which impede the oxygen and carbon dioxide exchange necessary for normal maintenance of the body’s metabolism. The lungs become progressively inefficient, which may result in pulmonary hypertension (increased blood pressure in the pulmonary artery), cor pulmonale (enlargement and/or failure of the heart’s right ventricle), edema (swelling due to excess fluid in the tissues), and chronic bronchitis (inflammation of the bronchial tubes). In mild cases this disorder may be confused with asthma. Symptoms of emphysema may not emerge until the disease is well under way. Initial signs include shortness of breath on exertion, such as climbing stairs, which gradually worsens until a person is short of breath even at rest. The chest may become barrel-shaped because air becomes trapped outside the lungs and pushes out the thorax. Coughing and wheezing may be present, too. When cor pulmonale develops, oxygen deficiencies cause edema of the legs, and a person looks blue or purplish. These persons are called “blue bloaters.” Individuals who breathe rapidly but retain normal coloring are referred to as “pink puffers.” In advanced emphysema, breathing becomes increasingly difficult. Chest X rays and pulmonary function tests determine the extent of the lung damage and breathing capacity. Emphysema is one of the causes of chronic obstructive pulmonary disease (COPD), which affects approximately 14 million people in the United States, second only to heart disease that results in disability. Treatment includes bronchodilating, diuretic, and corticosteroid drugs, nebulizers, and oxygen administration. In addition, patients are advised to avoid air pollutants, stop smoking, prevent respiratory infections with good pulmonary hygiene, lose weight if obese, improve nutritional status, and increase oral fluid intake. Smaller meals help reduce pressure on the diaphragm, which makes it easier to breathe. Breathing exercises also may

help to increase breathing efficiency and expiratory functional capacity, keep small airways patent, and educate the patient on the dangers of increased oxygen intake and other proper procedures in relation to ventilation therapy for hypoxic drive. See also CHRONIC OBSTRUCTIVE PULMONARY DISEASE.

employment opportunities for individuals with allergies and asthma Occupations or professions in which persons afflicted with allergic disorders or asthma can function in an environment free from occupational allergens or pollutants. An example of an inappropriate choice for an asthmatic person might be a zookeeper, pet shop employee, veterinarian, or farmer. See also OCCUPATIONAL ASTHMA.

empyema A type of pleural effusion, the presence of pus in the pleural space that occurs when pneumonia or a lung abscess spreads into the space. Other causes of empyema are an infection from a chest wound or surgery, esophageal rupture, or an abdominal abscess. Thoracic empyema, i.e., caused by the pus-forming pneumococci, may require surgical drainage. Pus in the pleural cavity, also called pyothorax, stems from a primary infection and may involve chills, fever, gray, sweaty skin, poor appetite, chest pain, cough, emaciation, and dyspnea. Treatment of the primary infection is key. Interlobular empyema refers to pus occurring between the lobes of the lung. E-Mycin

See

ERYTHROMYCIN.

encephalitis

An inflammation of the brain that may be a result of influenza or other diseases, including rabies, measles, smallpox, and viral infections. Treatment consists of therapy for the primary cause and physical and emotional support of the patient, such as monitoring vital signs, hydration, motor function, sleep patterns, and behavior.

endobronchitis bronchi. See also

Inflammation of the smaller

BRONCHITIS.

78 endotracheal tube endotracheal tube A tube with an inflated cuff surrounding it placed in the trachea, or windpipe, to prevent aspiration of a foreign substance or object into the bronchus and to keep the airway patent. endotracheitis

An inflammation of the mucosa

of the trachea.

ephedrine (Ephedrine, Ephedrine Sulfate, Neorespin) A sympathomimetic drug, similar to adrenaline but less powerful, that dilates bronchial muscles, contracts nasal mucosae, and elevates blood pressure. In the past, ephedrine was important in the treatment of asthma. An alkaloid originally derived from a species of Ephedra, a genus of shrubs, it was used in ancient Chinese medicine as an antipyretic (fever reducer) and diaphoretic (perspiration or sweat inducer). Later, its actions were rediscovered, and it was produced synthetically for oral or parenteral administration. Side effects may include tremors, anxiety, insomnia, headache, dizziness, confusion, hallucinations, convulsions, central nervous system depression, palpitations, dyspnea, nausea and vomiting, urinary retention, and chest pain. epidemic A massive outbreak of an infectious disease in a particular geographical area. epiglottitis

An inflammation of the epiglottis, a slender, leaf-shaped, cartilaginous structure with an outer mucous membrane at the opening of the larynx, or voice box. When a person swallows, the epiglottis covers the larynx to prevent food or liquid from entering the airway. The inflammation, commonly experienced as a sore throat, fever, and a barking cough, may lead to cyanosis (blue coloration of skin), drooling, and coma, and may be fatal. In extreme cases, a tracheostomy may be necessary to reopen the airway. Treatment includes antibiotic therapy.

epinephrine (Adrenalin Chloride, Asthma Haler, Asthma Nefrin, Bronitin Mist, Bronkaid Mist, Epinal, Epinephrine HCl, Epinephrine Pediatric, Epipen Jr., Epitrate, Eppy/N, Glaucon, Medihaler-Epi, Micro-

Nefrin, Nephron Inhalant, Primatene Mist, S-2 Inhalant, Sus-Phrine, Vaponefrin) Also called adrenaline, one of the two active hormones, along with norepinephrine, produced by the adrenal glands, which sit on top of the kidneys (hence the combination of the Greek words epi, meaning upon, and nephros, or kidney). Epinephrine has long been used as a vasoconstrictor, especially to prolong the action of local anesthesia, a cardiac stimulant, a topical application for the eye, a bronchiolar relaxant, and as a treatment for asthma attack.

epipharynx

The portion of the pharynx, or throat, that connects with the nose. Another term for epipharynx is rhinopharynx.

episodic asthma

Symptoms of asthma occurring only sporadically, such as during an acute upper respiratory infection, or cold, or upon exposure to a specific trigger. In the interim, there is no shortness of breath or wheezing, and lung function studies are normal.

epistaxis

A nosebleed, or hemorrhage from the nose, caused by trauman to membranes or structure of the nose or by skull fracture, various diseases, and high altitudes. It may also occur after surgery. Allergy and asthma patients may suffer nosebleeds as a result of violent, repeated sneezing, picking or blowing the nose, or dryness of the mucous membranes. Rhinitis and sinusitis may also cause epistaxis. To treat a nosebleed, have the patient sit upright and help him or her lean forward to spit out blood in order to prevent nausea and vomiting swallowed blood and to prevent aspiration of fluid into the trachea. Pinch the nostrils against the nasal septum for five to 10 minutes while the patient breathes through the mouth. Cold compresses applied over the nose and at the nape of the neck and applying pressure across or under the upper lip may be helpful. Other treatment includes local epinephrine use; if required, balloon tamponade, posterior packing of the nasal cavity, and cauterization of the bleeding vessel are also treatments. Increased humidity may help if dryness caused the nosebleed.

exercise-induced asthma 79 Epstein-Barr virus

Named for English pathologists M. A. Epstein (b. 1921), and Y. M. Barr (b. 1932), a type of herpesvirus thought to be the cause of infectious mononucleosis. Discovered in 1964, the virus is also associated with Burkitt’s lymphoma in South African children and nasopharyngeal carcinoma in Asian populations. The Epstein-Barr virus first affects cells in the nasal lining and spreads to the white blood cells called B lymphocytes that produce antibodies. Infectious mononucleosis has been known to be common among teenagers and young adults, who come in contact with the virus by kissing or intimate relations with an Epstein-Barr–infected individual, hence the term “the kissing disease.” Approximately 50 percent of all children in the United States have had an Epstein-Barr virus infection before the age of five, and the virus affects people of all ages. Symptoms of infectious mononucleosis include fever, sore throat, and enlarged lymph nodes. Also associated with the disease is a pronounced fatigue, which may last for weeks or months. The spleen and liver may become enlarged, a skin rash may develop, and serious complications such as encephalitis, seizures, meningitis, nerve and behavioral abnormalities may require further treatment. Sometimes an enlarged lymph node may press on the airway; lung congestion may also develop but may not cause symptoms. The Epstein-Barr virus has been suspected of causing chronic fatigue syndrome, a debilitating disorder that affects adults between 20 and 40 years of age, but it has not been proven. Treatment frequently includes antibiotic therapy and rest. In the case of a severe swelling of the airway, a corticosteroid may be prescribed.

esophageal obturator airway A tube that is inserted into the esophagus to block vomitus and keep the airway patent for optimal lung ventilation. ethmoiditis

An acute or chronic inflammation of ethmoid cells (the air cells or space in the ethmoid bone, which open into the nasal cavity) accompanied by headache, pain between the eyes, and a nasal discharge.

eupnea

Normal breathing.

exercise-induced asthma

The onset of coughing, wheezing, shortness of breath, and a feeling of tightness or pains in the chest following exercise. Exercise endurance is limited and should be anticipated in all asthma or respiratory disorder patients. Symptoms usually begin after three to five minutes of strenuous exercise. They may be minimal, occurring only with extremes of effort, or severe enough to require emergency treatment. The presence of cold weather, air pollution, hay fever-causing pollens, or a coexisting cold or sinus infection may lessen the degree of exercise needed to cause symptoms. Although the exact cause of exercise-induced asthma is unknown, it is thought by experts to be related to water loss from the bronchial tubes and increased concentration of the remaining fluid in the lining of the bronchi, provoking smooth muscles in the airways to constrict. Well-conditioned athletes may experience symptoms only at the extremes of their abilities; however, even Olympic medal-winning athletes often require asthma drugs to restore their breathing to normal. Diagnosis is suggested by a history of the symptoms. Exercise-induced asthma is confirmed by a decrease of at least 15 percent in lung function after an exercise challenge. Lung function can be documented by using either an inexpensive peak flow meter or a more sophisticated computerized spirometer. Swimming, downhill skiing, gymnastics, and karate are sports less likely to trigger asthma, but some well-known professional football and basketball players have asthma. The use of two or three puffs of a beta-agonist bronchodilator metered-dose inhaler (MDI), such as albuterol, pirbuterol, terbutaline, and metaproterenol, or two to four puffs of the anti-inflammatory drug cromolyn sodium 10 to 15 minutes before the start of exercise will prevent exerciseinduced asthma in the majority of patients. Alternative drugs include the MDI ipratropium, an anticholinergic (two to three puffs 20 to 30 minutes before exercise), or albuterol; metaproterenol syrup, astemizole, or terfenadine one hour before exercise may be effective. Albuterol and cromolyn are often combined for resistant individuals.

80 expectorant Allergy and lung specialists urge the participation of all students and adults in exercise programs. Students should be excused from gym classes only if they are having symptoms on the day of activity and should not be given blanket excuses. See also ASTHMA.

expectorant

A substance or agent that stimulates the ability to remove bronchopulmonary mucus from the lungs, bronchial tubes, and throat. Expectorants may be sedative or stimulating. Ammonium carbonate and ammonium chloride are rarely used today, but they were frequently found in cough medicines. Guaifenesin (Robitussin), iodinated glycerol (Organidin), and ipecac may be used alone or in combination with cough suppressants. Proof of their effectiveness has been questioned by some experts.

expectoration

The act of ridding the mouth of saliva or the throat of sputum, mucus, or exudates from the bronchi or lungs by spitting.

expiration

Breathing out, or expelling air from the lungs. A duration of expiration, or exhalation, longer than inspiration may indicate emphysema, asthma, or other respiratory pathology. In active expiration, one uses muscles including those of the abdominal wall. Passive expiration occurs without muscular effort, but rather with the elasticity of lung and chest tissues and the weight of the chest wall.

expiratory center

Part of the medulla’s respiratory center in the brain that controls expiratory movements.

exsufflation The expulsion of air from the lungs that is accomplished by natural force or mechanical exsufflator. extracorporeal membrane oxygenator Known as an ECMO, a device outside the body that oxygenates blood and returns it to the body, particularly in patients suffering acute respiratory failure.

F face (cyanotic; flushing)

faucitis

The visage of a person suffering from respiratory or other disorders, either cyanotic (blue) or flushing (pink or red). Cyanosis indicates deficient oxygenation of the blood, such as in the case of asthma, whooping cough, pulmonary tuberculosis, croup, tracheal obstruction, asphyxia, drug poisoning, emphysema, or cardiac maladies. Flushing, or hyperemia, is often attributable to pulmonary tuberculosis, alcoholism, febrile, and other diseases. A swelling of the face from edema is seen in cases of pneumothorax, mediastinal tumors, and aneurysm. See also EDEMA, PULMONARY.

Inflammation of the fauces, or the constricted opening that leads from the mouth to the throat.

fexofenadine (Allegra)

Metabolite, or derivative, of the popular nonsedating antihistamine Seldane. Unlike Seldane, fexofenadine bypasses the liver and avoids the drug interactions that can cause potentially life-threatening heart irregularities. Allegra is effective for the treatment of sneezing, runny noise, itching, and other allergy symptoms.

fibrosis, pulmonary

Abnormal scar tissue that forms in the connective tissue of the lungs as a result of an inflammation, pneumonia, or pulmonary tuberculosis. The most common causes include the inhalation of dusts, such as silica, carbon, metal, asbestos, molds, and bird droppings; immune system disorders such as rheumatoid arthritis, scleroderma, systemic lupus erythematosus, and polymyositis; inhalation of gases, fumes, and vapors, especially chlorine and sulfur dioxide; therapeutic or industrial radiation, and drugs and poisons, including gold, methotrexate, sulfonamides, penicillamine, cyclophosphamide, busulfan, nitrofurantion, amiodarone, and paraquat. Idiopathic pulmonary fibrosis refers to an unknown cause of scarring in the lung, but symptoms and diagnosis may be determined by the extent of the lung damage, the disease process, and the manifestation of complications such as infection or heart failure. Coughing, loss of stamina, shortness of breath, weight loss, loss of appetite, fatigue, chest pain, cyanosis, and finger clubbing may develop. Chest X ray, arterial blood gas tests, and pulmonary function tests may confirm the condition of fibrosis. If the scarring is not too

failure, respiratory The inability of the lungs to function because of a disease of the lung tissue, or weakness or paralysis of the muscles of the respiratory system. falling drop

A clinking sound heard during auscultation with a stethoscope over large cavities in which there is air or fluid, such as in hydropneumothorax.

farmer’s lung A pneumonia-like allergic lung disease from exposure to bacteria-like microorganisms called actinomycetes. These organisms thrive in silos when the water content of the hay exceeds 28 percent. Emptying a silo often causes an attack. See also PNEUMONITIS. fascia, endothoracic

The fibrous membrane separating the pleura of the lung from the diaphragm and the inside of the chest, or thoracic, cavity.

82 fibrothorax extensive, a corticosteroid such as prednisone may be prescribed, along with oxygen therapy, medication to treat infection if necessary, and drugs for heart failure. In severe cases of fibrosis, lung transplantation may be an option. Variants of idiopathic pulmonary fibrosis include desquamative interstitial pneumonia and lymphoid interstitial pneumonia (which involves the lower lobes of the lung and may be secondary to HIV infection in children and adults). Both variants have been known to respond to corticosteroid therapy.

fibrothorax The development of scar tissue that causes the two pleural surfaces of the lung to stick to each other. fistula, pulmonary arteriovenous The congenital condition in which a fistula, or abnormal channel between an artery and a vein, forms in a pulmonary artery in the lung and then communicates with a pulmonary vein. The connection of the two vessels causes blood to bypass the oxygenation process. An arteriovenous fistula may also be acquired after birth, or as a result of an injury to an artery and vein in close proximity to one another. It may also be subsequent to kidney dialysis or other medical treatment in which a vein is pierced repeatedly and clotting and scar tissue develop. Small congenital fistulas can be excised surgically or destroyed by laser coagulation therapy; large acquired fistulas, which can cause heart failure if untreated, must be surgically corrected. flames, inhalation of Severe irritation of the nose, throat, windpipe, and lungs as a result of exposure to flames or smoke. Coughing, choking, difficulty breathing, facial and nasal burns, elevated carboxyhemoglobin, and shock are among the initial symptoms that may lead to adult respiratory distress syndrome (ARDS), pulmonary complications, upper airway obstruction, and carbon monoxide poisoning. flatness

Heard on auscultation with a stethoscope, the sound produced by the presence of fluid in the thoracic cavity.

flint disease

Also known as chalicosis, a type of pneumoconiosis resulting from the inhalation of dust from stone cutting. See also CHALICOSIS; PNEUMOCONIOSIS.

Flonase

Brand of fluticasone, a corticosteroid for topical use as a nasal spray for the prevention of nasal allergy symptoms.

Flovent Brand of fluticasone, a corticosteroid for topical use as a metered-dose inhaler for the prevention of asthma symptoms. It is available in three strengths. flow meter

A device that measures the flow of a liquid or gas, including the respiratory gases oxygen and carbon dioxide.

Floyer, Sir John

British physician (1649–1734) who designed a 60-second pulse watch that made it possible to study the pulse and respiratory rates as they are affected by sex, age, emotional state, temperature, climate, diet, drugs, and disease. Floyer also estimated blood volume according to an individual’s body weight. An asthmatic, Floyer wrote of his increased difficulty in breathing in the presence of tobacco smoke, dust, and other changes in the air as a sequel to ingesting certain foods, performing exercise, and experiencing emotional changes. Floyer is credited as the first to observe that asthma and predisposition to asthma are hereditary. In addition, he dissected a “brokenwinded mare,” and his findings provided the first description of a lung physically deteriorated by emphysema.

flunisolide (Aerobid, Nasalide) A corticosteroid for topical use as a nasal spray and metered-dose inhaler for prevention of nasal allergy symptoms and asthma. fluticasone (Flonase, Flovent) Corticosteroid for topical use as a nasal spray and metered-dose inhaler for the prevention of nasal allergy and asthma symptoms. flu vaccine

See

INFLUENZA.

fumes 83 forced expiratory time (FET) The amount of time one needs to strongly exhale a certain volume of air, called the forced expiratory volume (FEV). Spirometers are the devices that measure lung volumes and flow rates during forced breathing tests for the diagnosis of laryngeal or tracheal blockage, and other abnormalities. formaldehyde

A poisonous, foul-smelling, colorless gas that when dissolved in water is used as a preservative for animal tissues. Formaldehyde is found in abundance in our environment. Also a by-product of the combustion of gasoline and diesel, and from cigarette smoke, gas, wood stoves, and kerosene heaters in the home or workplace, this gas is an irritant to the respiratory system. Formaldehyde is also widely used in building materials, especially in mobile homes. Urea formaldehyde foam insulation was injected into the walls of homes until 1977, when it was replaced by safer materials. Plywood, molded plastics, and carpeting are additional sources of formaldehyde. It has been blamed as a cause of the strange symptoms referred to as “mobile home syndrome.” Although there is no evidence that formaldehyde causes allergy, it is a frequent cause of contact dermatitis.

4-Way Nasal Spray

A topical, vasoconstricting drug generically known as naphazoline hydrochloride. Other trade names are Privine HCL, Albalon Liquifilm, and Vasocon.

fraction of inspired oxygen

Abbreviated as FiO2, the percentage of oxygen in the air taken into the lungs. More than 50 percent oxygen indicates toxicity in air provided to patients through ventilation devices for extended periods of time.

Freeman, John

British physician (1877–1962) who investigated tests for immunity and contributed to the development of therapeutic immunization. He served as director of the clinic for allergic disorders and bacteriological services at St. Mary’s Hospital in London for many years. Freeman also published Hay Fever, a Key to the Allergic Disorders, which he dedicated to his colleague Leonard Noon, who died from tuberculosis.

fremitus Tremors or vibrations in the chest that can be felt by placing a hand on the chest. Tactile and vocal fremitus refers to vibrations felt through the chest wall of a person who is speaking, and tussive fremitus may be felt when a person coughs. This type of auscultation may help determine the symptoms of pleural effusions, emphysema, abnormal growths on the lung, and obstruction in a bronchus that may lead to collapse of the lung. friction rub, pleural The sound produced during respiration by inflamed pleural surfaces, frequently heard on auscultation of patients who have a newly developed pleurisy. Friedländer’s bacillus

Named for German physician Carl F. Friedländer (1847–87), the Klebsiella pneumoniae, a species of bacteria that causes pneumonia and is also known as a secondary invader in conditions including bronchitis and sinusitis.

fumes

Irritating vapors, such as smoke fumes and ammonia gas, that may cause sneezing, coughing, choking, tightness in the chest, and shortness of breath or trigger an attack in an asthmatic person.

G ganglia, thoracic The eleven or twelve sympathetic nervous tissue masses located in the thorax or chest.

gastrointestinal reflux and asthma A flow of acidic gastric juices from the stomach into the esophagus (also called heartburn or reflux esophagitis) because the muscle at the junction of the esophagus and stomach does not function well enough to keep the stomach contents from backing up into the esophagus or the throat. The juices may also flow into bronchial tubes and cause asthma symptoms or aggravate preexisting asthma. One of the adverse effects of theophylline, an effective, widely used drug for the treatment of asthma, is reflux esophagitis. Drugs used to treat reflux esophagitis include Tagamet and Zantac. However, Tagamet may increase blood levels of theophylline and therefore should be avoided in patients for whom theophylline products are prescribed.

gas, lung irritant

Chlorine, phosgene, and other gases that cause burning sensations in the eyes, nose, and throat and may trigger asthma or cause bronchitis and pneumonia.

gas, suffocating

Phosgene or diphosgene, or any gasses made with chlorine that cause severe irritation of the bronchi and lungs. Inhalation of these so-called war gases may result in pulmonary edema and other respiratory disorders.

gas exchange, impaired

See

ARTERIAL BLOOD

GASES.

gastropulmonary A term used to denote any condition or concern involving both the stomach and the lungs.

gasoline poisoning The toxic result of inhaling gasoline, a distillation of petroleum that may contain poisonous additives such as tetraethyl lead or tricresol phosphate. Some people are poisoned by gasoline during an attempt to siphon the substance from a gas tank by suctioning it through a tube. Putting the suctioning end of the tube in one’s mouth may lead to inhalation or swallowing the gas. Symptoms include headache, nervousness, dyspnea, cyanosis, pulmonary hemorrhage, and other disturbances. Treatment involves getting the victim into fresh air, administering oxygen and carbon dioxide, or cardiopulmonary resuscitation if necessary, removal of gasoline-soaked clothing, and cleaning of gas-contaminated skin. Every precaution should be taken to keep the victim away from sparks, open flames, or potential explosive substance or circ*mstance.

gating, respiratory

A radiological procedure that attempts to reduce image discrepancies that may be caused by involuntary movement, such as during a certain stage of the respiratory process. Respiratory gating refers specifically to images collected repeatedly during a patient’s respiration cycle.

general adaptation syndrome (G.A.S. syndrome) The body’s overall response to stress as described by Austrian-Canadian endocrinologist Hans Selye (1907–82). Selye noted that the response consists of three stages, the alarm reaction (also known as “fight or flight”); the resistance or adaptive stage; and the exhaustion stage. A consequence of the exhaustion stage may be the body’s inability to

granulomatosis, Wegener’s 85 fight disease, and certain types of asthma may manifest. See also ASTHMA.

glands, bronchial

Mixed glands, i.e., glands that produce both a clear, watery (serous) secretion and a viscous (mucous) secretion, located in the submucosa (connective tissue) of the bronchi and bronchial tubes.

glossitis From the Greek glossa, meaning tongue, an inflammation of the tongue causing symptoms that may include tenderness, pain, localized ulcers, swelling, burning, dark and furry patches, intensified sensitivity to certain foods, elevated temperature, edema, thickened saliva, and malaise. In the case of acute glossitis, edema in the tongue may lead to asphyxia, for which a tracheostomy may be necessary to create an airway. Glossitis is frequently treated with antiseptic mouthwashes, anesthetic oral solution, bland or liquid diet, and, if necessary, surgery. glossopharyngeal breathing

Taught to patients with inspiratory muscle weakness, a breathing technique in which one takes “gulps” of air and closes his or her mouth in order for the gulped air to reach the lungs. This technique increases the patient’s air intake.

glucocorticoids, inhaled

Named from the Greek gleukos, or sweet, and cortex, or shape, a class of adrenal cortical hormones that combat stress and promote protein and carbohydrate metabolism.

glue sniffing

The act of deliberately inhaling the fumes of glue or solvent chemicals such as benzene, toluene, and xylene for the effect of an altered state of consciousness. The practice can be fatal. See also INHALANT ABUSE.

hemosiderosis—characterized by bleeding into the lungs and eventually failure of the kidneys and respiratory system. The cause of Goodpasture’s syndrome, which typically affects young men, is unknown, but it has been established that in individuals with the syndrome, certain antibodies appearing in the filtering apparatus of the kidneys and of the lungs’ alveoli and capillaries are responsible for causing the deleterious inflammation and malfunction of those organs. Considered an allergic disorder, Goodpasture’s syndrome causes the presence of protein and blood in the urine, abnormal areas in both lungs, a specific pattern of antibodies in kidney tissue, anemia attributable to the rapid loss of blood, shortness of breath, and coughing up blood. Treatment includes high intravenous doses of corticosteroids and cyclophosphamide, removal, cleaning (of undesirable antibodies), and return of blood to the circulation, supplemental oxygen, blood transfusions, renal dialysis, and possibly kidney transplant. Early treatment is essential to prevent permanent damage to the kidneys and lungs.

goundou

An African word referring to the enlargement of nasal bones as a result of yaws or syphilis infection. Other colloquial descriptions of the condition include “big nose” or “dog nose.”

grain allergies

Symptoms of allergy caused by allergens found in flour, often leading to occupational asthma in up to 10 percent of bakers or those exposed to flour on a regular basis. See also OCCUPATIONAL ASTHMA.

Grancher’s disease Named for French physician Jacques J. Grancher (1843–1907), a disease known also as splenopneumonia. Splenization refers to any change in tissue, such as lung tissue, that creates a resemblance to tissue of the spleen. Grancher’s sign, heard on auscultation of the lungs, is the high-pitched murmur that occurs when a patient with Grancher’s disease exhales. See also PNEUMONIA.

Goodpasture’s syndrome

Named for American pathologist Ernest William Goodpasture (1886– 1960), a rare, often fatal disease—also known as progressive glomerulonephritis, hemoptysis, and

granulomatosis, Wegener’s

Named for F. Wegener, a German pathologist of the 20th century, a rare and potentially fatal disease that involves

86 grass pollen allergy inflammation of blood vessel walls of the sinuses, nasal passages, lungs and airways, kidneys, and skin. In some cases, only respiratory system structures are affected. The inflammation may be so severe that lung tissue is at risk of being destroyed. The vasculitis (swelling and inflammation of the vessel walls) is accompanied by granulomatous lesions throughout the respiratory tract and by glomerulonephritis, a kidney disorder. Granulomas are grain-like tumors that factor into the disease, affecting the skin and the other organs. Possibly attributable to allergic reactions but generally of unknown cause, Wegener’s syndrome may or may not be evidenced by symptoms including fever, fatigue, weight loss, shortness of breath, chest pain, coughing, purulent rhinitis, sinusitis, polyarthalgia, nasal septum ulcerations, and signs of renal dysfunction. After early diagnosis by chest X ray showing areas of the lung that appear to be cancerous, the syndrome is treatable with cyclophosphamide (an immunosuppressive drug) and corticosteroids, or, if there are intolerable side effects from the cyclophosphamide, with azathioprine. Untreated or not treated promptly, the disease may cause death within a year of detection.

grass pollen allergy Hay fever symptoms related to the seasonal exposure of more than 4,500 plant species of the family Gramineae in North America and approximately 9,000 grass species worldwide. Grasses cover roughly 20 percent of the world’s surface. These monocotyledonous, herblike, mostly anemophilous (having windborne pollen) plants reach their peak of pollination in temperate climates of North America from mid-May to mid-July. In tropical and subtropical regions, however, pollens may be present throughout the year. The grass flowers are open for only a few hours a day during the pollinating season. The pollen grains are viable for less than one day. A majority of hay fever sufferers experience symptoms when there is a concentration of pollen grains approaching 50 per cubic meter. The weather is largely responsible for pollen counts, with rain washing the air clean and higher winds blowing the pollens away. See also HAY FEVER.

green tobacco sickness

A nonallergenic, toxic disorder occurring in tobacco harvesters from absorption of dissolved nicotine from wet tobacco exposure. See also TABACOSIS.

grindelia

An American flowering, resinous herb known as gum weed whose dried leaves and stumps are used in making a remedy for bronchitis as well as a topical preparation for poison ivy rash.

grinders’ disease grippe

See

SILICOSIS.

INFLUENZA.

growing out of allergies and asthma Disappearance of childhood allergic symptoms and asthma upon reaching puberty. Generally the more severe the symptoms in childhood, the more likely the continuance during adolescence and adulthood. Usually the tendency for hyperreactivity of the airways remains for a lifetime, although often there are no symptoms. The tiny bronchioles of infancy widen profoundly with age, and therefore a greater triggering stimulus is required to cause wheezing or shortness of breath. British studies have established that most asthma begins during childhood. As many as 11 percent of all children experience asthma symptoms at least once. Eighty-five percent, or the vast majority, have mild asthma, and 50 percent stop wheezing once they achieve adulthood and almost all have milder attacks. Children, whose asthma develops after the age of six months and who do not have allergies, have the best chance to outgrow their asthma tendency by adulthood. guaifenesin (Robitussin)

An expectorant drug used singly to loosen thick mucus or to help expel mucus and in conjunction with cough suppressants.

Guillain-Barré syndrome

Named for French neurologists Georges Guillain (1876–1961) and J. A. Barré (1880–1967), a type of polyneuritis allegedly caused by an autoimmune attack of the

gustatory rhinitis 87 nerves’ myelin sheath. Severe weakness occurs in the muscles that support the respiratory system, and a respirator or tracheostomy may be necessary to sustain the life of the patient. The prognosis is good provided there is prompt and appropriate treatment, which includes corticosteroids, immunosuppressive drugs, physical therapy, plasma-

pheresis, infusion of autoimmune globulin, and other measures.

gustatory rhinitis

The nasal congestion and inflamed mucous membranes that follow smelling or tasting a substance to which an individual may or may not be allergic.

H Habitrol

See

hacking cough See also

ijuana cigarettes (joints). Despite its reputation for inducing euphoria and intensified perception, frequent smoking of marijuana can cause bronchitis, lung cancer, and any disorder caused by using cigarettes made from tobacco. Although marijuana has not been conclusively proven to be physically addictive, it may cause psychological dependence and lead the user toward addiction to other illegal drugs. See also CANNABIS; TOBACCO.

NICOTINE PATCHES.

A dry and recurrent cough.

COUGH.

Haemophilus influenzae

See

INFLUENZA.

Haemophilus influenza type b infections

See

INFLUENZA.

halitosis

See

BREATH, BAD.

hay fever A common name for allergic rhinitis or nasal allergy, also known as coryza spasmodica. The term originated in England when symptoms were observed as they occurred simultaneously with the harvesting of hay. However, exposure to hay does not usually produce the characteristic sneezing, runny and stuffy nose, or itchy, watery eyes, and does not cause fever. Seasonal hay fever occurs in the spring and fall with exposure to pollinating trees, grasses, and weeds in susceptible persons. Perennial hay fever affects some allergic individuals and occurs year-round from exposure to animal danders, house-dust mites, and molds. An estimated 22 million Americans suffer from seasonal allergies and spend approximately $225 million for 8.4 million doctor visits and testing, $300 million on prescription drugs, and $2 billion on over-the-counter medications. These individuals suffer six million days of bed rest, 28 million days of restricted activity, 3.5 million days out of work, and 2 million lost school days. A Type I hypersensitivity reaction also known as pollinosis and vasomotor rhinitis, this disease of the nasal mucosa and upper airways may also be caused by airborne fungus spores. Coughing and asthmatic symptoms may occur. In addition to

Hamman-Rich syndrome

Named for American pathologists Louis Hamman (1877–1946) and Arnold Rich (1893–1968), another term for idiopathic pulmonary fibrosis. See also FIBROSIS, PULMONARY.

Hamman’s disease Named for American pathologist Louis Hamman (1877–1946), another term for spontaneous mediastinal emphysema. See also EMPHYSEMA. Harrison’s groove Named for British physician Edwin Harrison (1779–1847), a groove or depressed area of the lower chest caused by the pulling of the diaphragm, usually seen in infants afflicted with an airway obstruction or rickets. hashish

The Arabic word for the extract of the female hemp plant, Cannabis sativa, to be smoked or chewed for its mind-altering effect. The gummy, concentrated resin extract is made from the plant’s flowers, stalks, and leaves. Also called “hash” and “charas,” the substance is often used to make mar-

hemithorax 89 treatment by antihistamine or corticosteroid medication in the form of nasal sprays, nose drops, pills, or liquid, the patient may benefit from air-filtration systems, air masks, nasal filters, removal of the irritating allergen, and, if required, hypersensitivity testing and desensitization. See also BOSTOCK, JOHN.

headache, histamine

Headache that appears to be a direct result of histamine given by injection or ingested through certain wines containing histamine. See also HISTAMINE.

heartburn

A burning pain typically arising between the esophagus and stomach and possibly radiating through the chest, neck, and throat often as the result of gastroesophageal reflux disease (GERD). Nearly one-third of the American population suffers from GERD, the backward flow of the stomach’s contents into the esophagus. The lower esophageal sphincter valve, the muscle at the base of the esophagus and stomach that is supposed to block food from getting back into the esophagus, may be weak in individuals with GERD, though anyone may experience occasional heartburn. Also, GERD patients may be breathing in gastric fluids that irritate the lungs, and in addition to heartburn, they may have asthma. Heartburn, indigestion, and regurgitation may trigger asthma. Heartburn is usually treated with antacids and lifestyle modifications, but there is a surgical option for those with severe heartburn called Nissen fundoplication, in which the upper portion of the stomach is wrapped around the esophagus to create a new sphincter valve and thus reduce reflux.

throat or windpipe. The three basic steps of the maneuver are: 1) standing behind the victim and putting your arms around his waist; 2) making a fist with one hand and putting it between the victim’s navel and rib cage while the other hand supports the intended thrust of the fist, and 3) pressing with the fist with a quick and forceful upward thrust, to create a burst of air pressure that will send the blockage out the victim’s mouth. This technique should be used only if a person is choking. The name “Heimlich sign” has been given to the natural instinct of a choking victim to grasp his throat with the thumb and index finger. In the event that the victim is alone, he may thrust the midsection of his body (between navel and rib cage) against a counter top, chair, table, or other strong, stable object to simulate the thrust a rescuer would provide. Most adults can effectively use the back of a chair to press against for self-administration of the Heimlich. The maneuver may also be performed if the victim is lying on his back. Instructions for the Heimlich maneuver are usually posted in restaurants and other public places and are available through most local first-aid squads.

Heiner’s syndrome A chronic lung disease, characterized by cold-like symptoms, caused by allergy to cow’s milk. Hypoventilation, that is, the reduction of the rate and depth of breathing, may occur in conjunction with other respiratory disorders, such as chronic obstructive lung disease, and with various obstructions in the respiratory tract. Less severe blockage may occur as an allergic reaction to cow’s milk. The condition usually improves with the elimination of cow’s milk protein from the diet. See also HYPOVENTILATION SYNDROME.

heart-lung machine

helium

Heimlich maneuver Named for American physician H. J. Heimlich, born in 1920, a lifesaving technique for expelling a foreign object from a person’s

hemithorax

Also known as a heart-lung bypass, a device designed to support the functions of both the heart and lungs when an individual’s body is unable to pump and deoxygenate blood in the normal exchange of blood gasses (oxygen and carbon dioxide).

A low-density gas often mixed with air or oxygen for the treatment of respiratory disorders including air pressure-related problems such as caisson disease. Helium and air administered to individuals subjected to high atmospheric pressure helps reduce the time they need to adjust to varying air pressure. See also BENDS. A term referring to half of the chest.

90 hemlock poisoning hemlock poisoning

Intoxication caused by the ingestion of the oil extracted from the unripe fruit of the hemlock, a species of evergreen plant, Conium maculatum. If respiratory failure occurs, the patient must be treated with artificial respiration and oxygen therapy.

hemopleura space. See also

The presence of blood in the pleural

HEMOTHORAX.

hemopneumothorax

The presence of blood and air in the pleural cavity.

hemoptysis From the Greek words haima, or blood, and ptyein, meaning to spit, the expectoration of blood from the mouth, larynx, trachea, bronchi, or lungs through a coughing attack. The sputum becomes salty-tasting, red, and frothy. Hemoptysis may be the result of hemorrhage, respiratory disease, or a lung infection caused by the parasitic fluke Paragonimus westermani. Treatment includes the application of ice packs over the chest, bedrest, sedatives, and other medication and procedures, depending upon diagnosis.

hernia, diaphragmatic

The protrusion or “dropping” of part of the diaphragm into the stomach through the esophageal hiatus. The hernia may be congenital, esophageal, or acquired (traumatic), the latter possibly caused by debilitating illness, weakness, tumors, physical exertion, or strenuous, chronic coughing. Hernia may also be characterized by an organ or part of an organ projecting into the diaphragm. Treatment may include surgery. See also HERNIA, PHRENIC.

hernia, phrenic The rupture or abnormal protrusion of an organ through the diaphragm into a pleural cavity. heroin toxicity

Poisoning from heroin, a morphine-derived narcotic drug, in which there is pulmonary edema and a decrease in respiration that may require artificial resuscitation and oxygen therapy. Treatment also may include the administration of a drug that stimulates the respiratory system, such as doxapram hydrochloride. Heroin toxicity is life-threatening.

hepatopulmonary

hiccough, hiccup A short cough or sound on inspiration caused by the sudden closure of the glottis after a spasm that lowers the diaphragm. Also known as singultus, hiccups may be the result of indigestion, respiratory irritation, growths within the pleural cavity, hysteria, cerebral lesions, or alcoholism. Prolonged hiccups often require treatment, including inhaling carbon dioxide (breathing into a paper bag), antiemetic drugs, nasopharyngeal stimulation with a rubber tube, or placing some granulated sugar in the hypopharynx. In severe cases, the phrenic nerve may need to be anesthetized.

Hering-Breuer reflex

hilitis Inflammation occurring at the root of the lungs at the fourth and fifth dorsal vertebrae level.

hemorrhage, lung The bright red, frothy blood coughed up as a result of a lung disease or other respiratory disorder. hemothorax The presence of blood in the pleural cavity caused by ruptured blood vessels as a result of pneumonia, pulmonary tuberculosis, traumatic injury, or malignancy. The term used in reference to both the liver and the lungs. Named for German physiologist Heinrich Ewald Hering (1866–1948) and Austrian physician Josef Breuer (1842–1925), the reflex inhibition of breathing in as a result of pressoreceptor-nerve stimulation when the lungs are inflated.

Hippocrates Greek physician who lived ca. 460–375 B.C., considered by many “the father of modern medicine.” Among his major tenets are that physicians should observe all, evaluate hon-

hoarseness 91 estly, assist nature, work for the good of the patient, treat the whole person and not simply the illness, and, above all, do no harm. Modern chiropractic also employs Hippocrates’ idea that all illness stems from anomalies of the spine. In Hippocrates’ writings, he described, for example, the symptoms of pulmonary edema: “Water accumulates; patient has fever and cough; the respiration is fast; the feet become edematous; the nails appear curved and the patient suffers as if he had pus inside, only less severe and more protracted. One can recognize that it is not pus but water. . . . If you put your ear against the chest you can hear it seethe inside like sour wine.” Hippocrates also wrote that some foods known to be safe and healthful for most people caused illness in some, possibly, he speculated, because of a “poison” in the food, such as cheese, to which some people were particularly sensitive.

histamine H2, receptor antagonist

A drug that blocks the effects of the chemical histamine by competing for receptor sites on the surface of cells in the stomach, thus preventing the secretion of gastric acid in the treatment of peptic ulcers. H2blocking drugs available in the United States include cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine (Pepcid). Traditional antihistaminic drugs, called H 1-receptor antagonists, differ from H2 agents by blocking the allergic symptoms caused by histamine primarily in the respiratory system and skin. H1 and H2 antihistamines are sometimes combined for the treatment of hives. H2-antagonist drugs rarely have adverse effects; however, cimetidine causes a rise in theophylline levels and should be used with caution in asthmatic patients taking both drugs. The other drugs in this class are probably free of this problem. See also ANTIHISTAMINE.

hippus, respiratory

The condition characterized by the pupils of the eye dilating during inspiration and contracting during expiration.

Hismanal

See

ASTEMIZOLE.

histaminase

An enzyme found throughout the body that counteracts histamine. See also HISTAMINE.

histamine

A natural substance liberally distributed throughout the body (especially in the skin, heart, lungs, gastrointestinal mucosa, the brain, and other organs) and a major substance released by mast cells of the tissues to initiate an allergic reaction. Inflammation, excess acid production in the stomach, constriction of the bronchi in the lungs, red flushing of the skin (as occurs with a burn), red rashes, decrease in blood pressure, and headache are among the symptoms characteristic of histamine release. Antihistamines are substances that counteract histamine. See also ANTIHISTAMINE.

histamine headache

term for antihistamine.

An alternate

HEADACHE, HISTAMINE.

histoplasmosis A fungal respiratory infection characterized by acute shortness of breath, coughing, fever, pains in the joints, potential adrenal gland failure, and other symptoms if the disease goes untreated or becomes chronic. Infection may be caused in susceptible or immunocompromised individuals who inhale the spores of the fungus Histoplasma capsulatum, found in soil (especially when contaminated by fecal material of birds or bats) in the southern and central United States, regions of South America, Africa, and Asia. In severe cases ulcers may appear in the gastrointestinal tract, and the spleen and liver may become enlarged. Other aspects of the disease may include weight loss, leukopenia, anemia, and adrenal necrosis. Histoplasmosis may be fatal. Treatment with antifungal medications is usually effective. Histoplasmosis is not an allergic disorder, but it may easily be mistaken for symptoms of allergy or asthma. hoarseness

histamine H1, receptor antagonist

See

A raspy or rough-sounding voice caused by an inflammation of the throat and vocal cords. Among the causes are allergy to certain

92 holistic medicine foods, chemical irritants, tobacco, and alcohol. Persistent hoarseness may be a sign of benign or malignant polyps in the throat.

when taken by individuals with emphysema. Home remedies do not substitute for professional care.

holistic medicine

hormone

A recognized discipline of Western medicine that incorporates some theories of Eastern medicine and the recognition of the patient as both a physiological and psychological being. Holistic practitioners believe that psychological factors affect well-being and disease processes. They employ various techniques, including relaxation, guided imagery and visualization, and hypnosis, along with conventional methods of treatment appropriate to the ailment, and they advocate the patient’s participation in his or her own healing. See also HIPPOCRATES.

A natural substance produced in an organ or gland that, when conveyed by the bloodstream, stimulates either increased or decreased functioning in various parts of the body. Among the most commonly known hormones are thyroid hormone, parathormone, cortisone, estrogen, testosterone, progesterone, human growth hormone, insulin and glucagons, adrenocortical hormone, ACTH (adrenocorticotropic hormone), and gastric hormone. Cortisone-like synthetic hormones, known as corticosteroids, are often used in the treatment of asthma because they act against inflammation. See also CORTICOSTEROIDS.

homeopathy

An alternative treatment system based on the theory that “like cures like,” that is, if a substance causes a symptom, it can conversely cure it when taken in a highly diluted form or in minute quantity. Remedies are made from plant, animal, and mineral sources and are available at health food stores and pharmacies. Homeopathy relates to desensitization techniques to treat allergic patients. Depending upon the patient’s complaints, homeopathic remedies are reported to have had positive effects against allergies, sore throats, arthritis, indigestion, colds and flu, chronic pain, and infections.

home remedies

Actions that individuals can take on their own to help combat allergies, asthma, and other ailments and augment treatments prescribed by the physician. According to some experts, one can seal bedding in plastic liners to keep mattresses free of dust and dust mites, get rid of carpeting, use fungicides in damp areas of the house, avoid fireplace fires, install air-conditioning, maintain a sensible diet and avoid foods that may be allergenic, and other such measures. Other home remedies involve herbalism, a practice that relies on the use of various herbs as combatants of disease. For example, a syrup made with rhubarb, water, and sugar and then diluted with four inches of water to one inch of syrup is said to have a soothing effect

house-dust mites Microscopic members of the class Arachnida, subclass Acari. Species known to be important as allergens are Dermatophagoides pteronyssinus (skin-eating, feather-loving), D. farinae, D. microceras, Euroglyphus maynei, and Blomia tropicalis. Many asthma experts consider dust mites to be the single most important allergen associated with asthma. Two principal groups of allergens of considerable importance are digestive enzymes, one group of them found in high concentrations in the fecal pellets, and a second group found in both fecal pellets and mite bodies. Two micrograms of Der p I (mite allergen) per gram of dust is considered a risk factor for sensitization and the development of asthma in susceptible individuals. A concentration of 10 micrograms of allergen per gram of dust is a risk factor for triggering acute asthma in these persons. Prevalence House-dust mite exposure is especially great in the Gulf Coast region and Pacific Northwest of the United States, the United Kingdom, northern Europe, Australia, New Zealand, Brazil, and Japan. Dust mites require high humidity, moderate temperatures, and a food source that includes human skin scales.

house-dust mites 93 In the United Kingdom, an estimated 80 percent of asthmatic children are sensitive to house-dust mites. When placed in a dust-mite-low environment, such as a hospital ward or a high-elevation, mountainous region, sensitive individuals invariably improve. Unfortunately, it takes several months for the condition to improve; as soon as allergic individuals were placed in their former environment, the asthma returned. Dust Mite Control Removal of the dust mite from the environment by either killing them with acaricides, benzyl benzoate or tannic acid, or changing environment is an effective measure. The relative humidity in bedrooms should be kept below 60 percent. Uncarpeted floors are best, but treatment of carpets with acaricides is recommended. Vacuum cleaners with double bags may be beneficial, but most vacuuming increases airborne levels of mites. HEPA filters on vacuum cleaners are of little or no value. Covering mattresses, box springs, and pillows, and hot washing of bedding can reduce mite allergen levels significantly. Dust mites were discovered in 1964. House-dust mites are microscopic (approximately one-third of a millimeter in length), sightless, eight-legged arthropods that are natural inhabitants of our indoor environment. These mites are not an indicator of uncleanliness and do not transmit human diseases. However, they are a major cause of asthma, allergic rhinitis (hay fever), and atopic dermatitis (eczema). The most important house-dust mite allergens result from proteins in the mite’s digestive tract excreted in the fecal waste rather than the mite itself. The tiny fecal particles break down to an extremely fine powder that sticks to surrounding absorbent materials. The allergen-containing powder becomes airborne when carpets are walked on, upholstery is disturbed by sitting or rising, shaking out blankets and quilts, or airing out rooms. The growth and reproduction of house-dust mites are dependent on a food supply, relative humidity, and temperature. They feed on human and animal dander (flakes, scales, or dandruff) and other materials such as fiber and feathers. The

average human sheds up to 1.5 grams of skin particles per day. The mites thrive at temperatures between 68 degrees and 84 degrees Fahrenheit and a relative humidity of 65 to 80 percent. Distribution Moist areas such as the South, the Gulf Coast region, and the Pacific Northwest present excellent breeding grounds for these microscopic organisms. House-dust mites mature and breed from May to October and may be responsible for triggering as many as 44 percent of acute asthma attacks in these areas. Since the dust mites do not thrive where relative humidity is above 90 percent or below 33 percent, they are rarely found in dry climates over 3,600 feet above sea level. There are 47 recognized species in 17 genera of the family Pyroglyphidae. Species common in temperate and tropical regions are Dermatophagoides, Euroglyphus, Hirstia, Malayoglyphus, Pyroglyphus, and Sturnophagoides. Dermatophagoides or Euroglyphus species can be found in most homes in North America, Western Europe, Japan, New Zealand, and Australia. House-Dust Mite Control The highest number of dust mites are found in bedding, upholstered furniture, and carpeting. They also inhabit pillows, quilts, children’s stuffed animals, and areas where pets sleep. They are rarely found in hospitals. It has been established that a level of 100 dust mites per gram of dust is a risk factor for sensitization and the development of asthma in susceptible persons. A level of 500 mites per gram of dust is considered a major risk factor for the development of acute asthma in a sensitized individual. Bedrooms are usually the chief target of avoidance measures for dust mites because of the allergic individual’s continuous exposure. Asthma has been demonstrated to improve in mite-free environments. The following measures have been found to reduce dust mite exposure by tenfold or more: (1) covering mattresses and other bedding with encasings designed to prevent dust mites from penetrating them; (2) hot washing of all bedding at least every 10 days; (3) removal of carpets and upholstered furniture; (4) reduction of humidity,

94 Huang-ti and (5) use of acaricides. Other measures include replacing cloth curtains with blinds, vacuuming and dusting with a moist cloth every week, organizing and rotating clothes in your closet and dresser by season, and storing out-of-season clothes in plastic tubs, according to Gerald Vanderpool, M.D., past president of the American Association of Certified Allergists. More information on allergen barrier encasings is available at www.allergydirect.com or by calling (877) 283-2323. Test kits are available to measure the quantity of dust mites in a particular room. After treatment to reduce the mite population, tests can be repeated to determine the success or failure of the measures taken. Immunotherapy When avoidance measures are unsuccessful or impossible to achieve, standardized allergen extracts for Dermatophagoides subspecies farinae and pteronyssinus are available in the United States for immunotherapy.

Huang-ti

Legendary ruler of China in the 25th century B.C., according to Chinese historians, known as the “Yellow Emperor” because he reigned under the influence of the earth, whose elemental color was believed to be yellow. Huangti (Huangdi) is considered the author of the oldest recorded canon of internal medicine called the Nei ching su wen. In this work, Huang-ti conducts a discussion between himself and his physician-minister Ch’i Po on the physical and mental aspects of health and disease. The Nei ching is valued today by many for its observations on “noisy breathing,” serving as the original description of asthma.

huffing Slang term used by youths to describe the inhalation of airplane glue, aerosol gas, solvents, gasoline fumes, and other noxious substances in order to achieve euphoria, or a “high.” Because the exact contents of these substances may be unknown by the user, they have the potential of causing a life-threatening allergic reaction or of masking symptoms of asthma. If inhalant abuse is suspected, a hotline has been established to help: (800) 788-2800. See also INHALANT ABUSE.

humidifiers Devices that increase the humidity in a building or room by blowing moisture into the air, including ultrasonics, cool-mist impeller types, evaporative units, and steam vaporizers. Humidifiers may be part of a centralized or portable heating/air-conditioning unit. These units have the potential to cause harm because they may promote the growth of molds and distribute them as an aerosol into the local environment. Even if the units are kept mold free, increasing the relative humidity of a room may stimulate growth of molds and dust mites. Steam vaporizers are considered by some experts to have the lowest potential of contamination of the humidifying units in light of the fact that the steam kills many offending microorganisms. (However, the danger of burns exists if this type of unit is knocked over or the steam comes into direct contact with skin.) The Environmental Protection Agency discovered that ultrasonic units, which claim to kill microorganisms by ultra-high-frequency sound waves, can nonetheless send out particles of dead bacteria and molds into the room air. Evaporative units on central heating systems, some with tanks in which water stays warm, have also been criticized as potential breeding harbors for bacteria. Commercial units may be sources of microorganisms, such as actinomycetes and fungi, that may cause the allergic lung disease hypersensitivity pneumonitis. Severe sinusitis has also been linked to contaminated humidifiers. One report describes “humidifier fever,” a syndrome characterized by flu-like symptoms including fever, chills, cough, headache, and malaise. It was first recognized when large numbers of office and factory employees became ill and the origin of their illness was central humidifying systems contaminated by microorganisms. After the systems were cleaned, affected individuals recovered. According to research scientists at the University of Michigan, all humidifiers are contaminated, leading to warnings of possible health hazards issued by the federal Consumer Products Safety Commission. Some research indicates that humidifying dry air is of little or no health benefit because oral and nasal passages are designed to stay moist under all environmental conditions.

hypersensitivity pneumonitis 95 humidity

The amount of moisture, or water vapor, in the air, ranging from 100 percent humidity (air completely saturated with moisture) to small percentages. An extremely humid atmosphere may seem oppressive to some individuals; those with allergies or asthma may experience discomfort in cold, dry air, often an asthma trigger. In addition, dust mites and molds thrive in humidity greater than 60 percent. The ideal humidity for persons with allergies is 25 to 40 percent; higher relative humidity may be irritating to the respiratory system. Humidification of the air from swimming pool water is excellent for moisturizing bronchial tubes, and the slow, deep breathing during swimming can be beneficial to asthmatics.

hunger, air dyspnea. See also

BREATHING; DYSPNEA.

hydroconion spray. See also

Shortness of breath, breathlessness,

An atomizer that produces a fine

AEROSOL.

hydrothorax An accumulation of fluid in the pleural cavity that is non-inflammatory. Patients with hydrothorax may exhibit symptoms including dyspnea, lack of vesicular breath sounds, and flatness over the buildup of fluid. hyperbaric oxygen therapy

A treatment using a hyperbaric chamber of oxygen to combat various problems such as bends (caisson disease), carbon monoxide poisoning, smoke inhalation, and acute ischemia of tissues. Hyperbarism involves exposure to greater than atmospheric pressure, often the case of deep-sea divers and miners. Hyperbaric oxygen is oxygen that is one-and-ahalf to three times absolute atmospheric pressure. The chamber itself is large enough to accommodate a patient and a team of medical professionals, and its pressure may be increased if more oxygen is necessary to treat the specific needs of the patient. See also BENDS.

hyperinflation

An excess amount of air in the

lungs.

hydrogen

A highly flammable, colorless, odorless, tasteless gas that occurs in water (hydrogen oxide, or H2O) and in nearly all organic compounds. Hydrogen is also present in all acids and as a component of all carbohydrates, proteins, and fats. The most abundant element in the universe, it occurs in a quantity of only 0.00005 percent of Earth’s atmosphere.

hydropneumatosis

Liquid and gasses found in body tissues that cause edema (swelling) and emphysema. See also EMPHYSEMA.

hydropneumothorax A collapse of a lung or lungs in which gas and fluids have accumulated in the space surrounding the lungs (pleural cavity). See also PNEUMOTHORAX. hydrorrhea

Excessive watery discharge from the nose, eyes, or other body parts. This symptom may be suggestive of allergic rhinitis (hay fever). See also RHINORRHEA.

hyperpnea

Rapid breathing or increased respiratory rate, such as that after exercise, or deeper than normal breathing during normal activity. Hyperpnea may be experienced at high altitudes or as a result of pain, drug reaction, hysteria, fever, heart disease, or respiratory disorder.

hypersensitivity pneumonitis (HSP) Also known as extrinsic allergic alveolitis, an allergic lung disease caused by repeated exposure to organic dusts or other offending agents. In an acute case, flu-like symptoms may include cough, shortness of breath, fever, chills, sweating, headaches or generalized pains, malaise, and nausea with onset from two to nine hours after exposure. Symptoms peak between six and 24 hours and last from several hours to several days. A subacute form that may gradually worsen over a period of days to several weeks may be much more severe, with shortness of breath progressing to the point of cyanosis and requiring hospitalization.

96 hypersensitivity pneumonitis CAUSES OF HYPERSENSITIVITY PNEUMONITIS Disorder

Source

Aspergillosis Bagassosis Bible printer’s lung Bird breeder’s lung Budgerigar fancier’s lung Chicken handler’s lung Pigeon breeder’s lung Turkey handler’s lung Cephalosporium hypersensitivity Cheese washer’s lung Coffee worker’s lung Corn farmer’s lung Detergent lung Drug-induced Duck fever Epoxy resin lung Familial hypersensitivity pneumonitis Farmer’s lung Furrier’s lung Humidifier air-conditioner lung Laboratory technician’s lung Malt worker’s lung Maple bark stripper’s lung Miller’s lung Mummy handler’s lung Mushroom worker’s lung Paint refinisher’s disease Paper mill worker’s lung Paprika slicer’s lung Pituitary snuff syndrome (snuff taker’s lung) Plastic worker’s lung Rat lung Sauna taker’s disease Sequoiosis Smallpox handler’s lung Streptomyces hypersensitivity pneumonia Suberosis Summer type Tea grower’s lung Thatched roof disease Wheat weevil’s disease Wood joiner’s lung Wood pulp worker’s lung Wood trimmer’s disease

Aspergillus spores Moldy sugarcane Moldy typesetting water Avian droppings or serum Parakeets Chickens Pigeons Turkeys Contaminated sewage Cheese mold Coffee dust Corn dust Detergents (Bacillus subtilis enzyme) Amiodarone, gold, procarbazine Duck feathers and proteins Heated epoxy resin Contaminated wood dust in walls Moldy hay or grain Hair dust Thermophilic actinomycetes, amoebae Rat urinary proteins Moldy malt, malt dust Moldy maple bark Grain contaminated by wheat weevils Cloth wrappings of mummies Mushroom compost Automobile spray painting (diisocyanates) Moldy wood pulp Moldy paprika Bovine and porcine proteins Plastics, varnish (diisocyanates) Rat urinary proteins Pullularia in sauna water Moldy wood from maple logs, moldy redwood dust Smallpox scabs Contaminated fertilizer Moldy cork dust House dust contaminated with Trichosporon cutaneum Tea plants Dried grasses and leaves Infested wheat flour Sawdust Moldy logs Moldy wood trimmings

The chronic form has an even more gradual onset with increasing cough, shortness of breath, fatigue, and weight loss over several months. Diagnosis is based on a history of exposure to a recognized allergen and confirmed by positive skin tests, finding antibodies in the blood to that allergen, and biopsy. Chest X-ray findings range from normal to severely abnormal.

The diagnosis may be confused with immune deficiency diseases, pulmonary mycotoxicosis (atypical farmer’s lung), toxic organic dust syndrome (grain fever), idiopathic interstitial fibrosis (cryptogenic fibrosing alveolitis), cystic fibrosis, silofiller’s lung, psittacosis, eosinophilic pneumonias, allergic bronchopulmonary aspergillosis, collagen vascular diseases, granuloma-vasculitis syndromes, or sarcoidosis.

hypoxia 97 hyperventilation Rapid breathing resulting in diminished carbon dioxide levels in the bloodstream. Tingling or numbness in the extremities, muscle spasms, and a feeling of anxiety may simulate, or in some cases trigger, an asthma attack. hypnosis

Techniques including guided deep relaxation, trance or altered state of awareness, suggestions, ideas, and imagery performed by a hypnotherapist, psychologist, psychiatrist, or various certified health professionals with patients suffering from asthma, allergies, respiratory disorders, and other health-related ailments. According to Susan Bendersky Sacks, R.N., M.S.N., C.S., in an article in Nursing Spectrum, March 19, 2001, “Research studies have shown that hypnosis can significantly improve pulmonary function tests, increase compliance, decrease hospital admissions and medication requirements, and in some cases, result in discontinued medication altogether. Proposed explanations include: Hypnosis decreases bronchospasm and airway resistance by influencing cerebral metabolism and the vagal and sympathetic pathways; hypnosis decreases bronchoconstriction by activating the release of neurotransmitters that stabilize IgE-mediated mast cells; hypnosis creates the perception of reduced airway resistance; hypnosis reduces anxiety and increases coping and compliance with conventional treatment.” In addition to reporting that hypnosis as a technique is controversial, Sacks emphasizes that “hypnotic trance is attained solely by the control of the patient, while the hypnotherapist functions as a consultant, facilitator, and guide. . . . Myths and misconceptions about hypnosis are prevalent and often deter interested patients from seeking treatment. Patients commonly fear being controlled and manipulated into revealing secrets and engaging in embarrassing behaviors. . . . The truth is that patients can never be coerced into displaying unwanted or unnatural behaviors or disclosing personal information. During hypnosis, the patient is aware of everything that is said and is able to guard private issues.” More information is available at [emailprotected] or from the American Society of Clinical Hypnosis at www.asch.net.

hypocapnia

Abnormally low level of carbon dioxide in the blood.

hypoepinephria

A decrease in epinephrine secre-

tion in the body.

hypostatic pneumonia

Pneumonia occurring in a patient, usually elderly or severely debilitated, who does not move enough to ward off alveolar fluid congestion, poor aeration or collapse of the lungs, and capillary pooling. The congestion creates an opportunity for infection to set in. Preventive measures should be taken for immobile patients.

hypoventilation syndrome Abnormally diminished respiration with reduced depth of inspiration and rate. It is characterized by cyanosis (skin or nail beds that appear blue), clubbing of the fingers, decreased oxygen content with a subsequent increase in red blood cells and blood hemoglobin (in the body’s attempt to improve the oxygen supply to the tissues), and an increase in carbon dioxide (level builds up because of the inability to exhale adequately). Hypoventilation occurs with the severe chronic obstructive lung diseases such as chronic bronchitis and emphysema, and from massive body obesity (also called pickwickian syndrome). Severe obstruction of the upper respiratory tract, which may occur in cases of extremely enlarged tonsils or adenoids, may result in diminished breathing during sleep; it usually improves with adenoidectomy. Less severe blockage may occur in cow’s milk allergy (also called Heiner’s syndrome), and this usually improves with elimination of cow’s milk protein from the diet. See also CHRONIC OBSTRUCTIVE PULMONARY DISEASE; HEINER’S SYNDROME. hypoxemia

Lack of sufficient oxygen in the

blood.

hypoxia

Lack of sufficient oxygen circulating to body tissues.

98 hysteria hysteria A state of severe anxiety that can involve emotional and physical symptoms, uncontrollable laughter, crying, or fear reactions. Individuals who experience severe shortness of breath may become so stressed as to be hysterical. The

term, derived from the Greek word hystera, or womb, was once applied to a woman’s disorder; contemporary terms for such anxiety include conversion, dissociative, or somatization disorders, and psychoneurosis.

I idiopathic pulmonary fibrosis

immediate hypersensitivity An alternate term for immediate allergic reactions. See also HYPERSENSITIVITY.

A lung disease secondary to interstitial pneumonitis or fibrosis characterized by dyspnea, weakness and fatigue, anoxia, rapid respirations, progressing to cyanosis, clubbed fingers, and heart failure. Corticosteroids, cyclophosphamide, other antibiotics, and oxygen therapy are among the treatments of this disease, which is usually fatal four to five years after its onset. See also HAMMAN-RICH SYNDROME.

immune complex A cluster of interlocking antigens and antibodies found in the bloodstream and usually cleared away by cells known as phagocytes, which “consume” and destroy other cells recognized as invaders. When this process fails, immune complexes may be deposited in, injure, and cause inflammation in tissues, such as kidney, lung, skin, joints, and walls of blood vessels. Diseases in which these complexes are involved include those in the category of type III hypersensitivity (antigen-antibody complement reactions): drug-induced systemic lupus erythematosus, serum sickness, nephritis, and bacterial endocarditis.

idiosyncrasy An individual’s unexpected abnormal response to a food, drug, or other usually nonallergenic substance. ID tags

See

MEDICAL ALERT BRACELETS AND NECK-

LACES.

immune complex assay

Methods of detection of circulating clusters of antigens and antibodies, or immune complexes, that are used to measure disease activity in patients with vasculitis, systemic lupus erythematosus, some malignancies, and other diseases. Immune complex assay is of doubtful importance in allergy diagnosis. See also IMMUNE COMPLEX DISORDERS.

IgE-mediated reactions

An alternate term for immediate allergic reactions. See also HYPERSENSITIVITY; IMMUNOGLOBULIN E.

illuminating gas

A combination of combustible gases such as hydrogen and carbon monoxide, which can be poisonous. Resuscitation may be necessary as treatment.

Ilosone

See

immune complex disorders A group of diseases associated with failure of the complement system and other components of the immune system. Immune complexes are aggregations or clusters of interlocking antigens and antibodies. Usually, these complexes are removed from the circulation by large phagocytic cells (macrophages) in the spleen and Kupffer cells in the liver. Research suggests that deficiencies of certain components of the complement system or complement receptors disrupt

ERYTHROMYCIN.

imagery A technique using mental pictures, sounds, odors, tastes, feelings, and other sensory experiences in order to understand and resolve psychological and physical problems. Imagery is also employed as a relaxation technique.

100 immune system this process, allowing circulating immune complexes to accumulate inappropriately in certain organs such as the kidneys, lungs, skin, joints, or blood vessels and interfering with their function. An example is systemic lupus erythematosus (“lupus”). In this autoimmune disease, a continuous supply of autoantibodies overloads the immune system’s ability to remove the immune complexes. Immune complexes also play an important destructive role in many other diseases, including infections such as viral hepatitis, malaria, and allergic lung disorders such as farmer’s lung.

immune system A complex network of specialized cells and organs that protect the body against attacks by foreign invaders such as infections. When the immune system is intact, it fights off pathogenic, or disease-causing, bacteria, viruses, fungi, and parasites. When it is weakened or fails, the results can range from a minor allergy such as hay fever to the usually fatal acquired immunodeficiency syndrome, or AIDS. The immune system protects by barring the entry of, or destroying, dangerous foreign organisms while fostering peaceful coexistence of protective or beneficial organisms. The immune response requires a complex but cooperative interplay between the various cells of the system, including effector lymphocytes (killer T cells, antibody-producing B cells, mast cells), regulating lymphocytes (T-helper and T-suppressor cells), and phagocytes. Many other factors, some not yet understood by scientists, are involved in the control of and response to immune stimuli. The immune system is further influenced by genes that determine the body’s ability to respond to an antigen. Mutation, congenital or acquired, of certain genes may impair our response not only to allergens and infectious microorganisms but to cancerous cells as well. Tissues and Organs of the Immune System Immune system components are scattered throughout the body. Bone marrow, thymus, spleen, tonsils, adenoids, lymph nodes, the appendix, and Peyer’s patches in the small intestine are known as lymphoid organs, named for their ability to produce, develop, or control white blood cells, or lymphocytes.

There are two major types of lymphocyte: B cells and T cells. Bone marrow is soft tissue in the hollow shafts of long bones. The marrow produces all blood cells, including mature B cells. T cells migrate to the thymus, a gland located behind the breastbone, where they multiply and mature. In a process called “T-cell education,” these cells become immunocompetent—that is, they develop the ability to evoke an immune response and learn to distinguish self from nonself cells. B and T cells circulate throughout the blood vessels and lymphatics, a network similar to blood vessels. Clusters of lymph nodes, located in the neck, armpits, abdomen, and groin, contain collections of B and T lymphocytes and other cells capable of engaging antigens and causing an immune response. The spleen is a scavenger of the immune system. An encapsulated, highly vascular, fist-sized organ in the left upper portion of the abdomen, the spleen contains two distinct regions of tissues, the red and white pulp. Red pulp disposes of worn-out blood cells. Red pulp also contains immune cells called macrophages, which trap and destroy microorganisms in blood passing through the spleen during the circulatory process. White pulp contains lymphoid tissue similar to that of the lymph nodes and is similarly subdivided into compartments specializing in different types of immune cells. Patients with a nonfunctioning spleen or who have had the spleen surgically removed are highly susceptible to infections. The tonsils and adenoids in the respiratory tract and the appendix and Peyer’s patches in the digestive tract are nonencapsulated clusters of lymphoid tissue in the body’s main ports of entry—the mouth, nose, and anus. Lymph is a clear fluid that travels through the lymphatic vessels, bathing the body tissues. Lymph, along with lymphocytes, macrophages, other cells, and foreign antigens, drains out of tissues and seeps across the thin walls of lymphatic vessels to be transported to lymph nodes, where antigens can be filtered out and attacked by immune cells. Other lymphocytes enter and exit the nodes from the bloodstream. Tiny lymphatics feed into larger and larger channels, like small creeks joining larger streams and rivers. At the base of the neck, large

immune system 101 lymphatic vessels merge into the thoracic duct, where its contents are emptied into the bloodstream to begin the cycle again. Self and Nonself The ability of the immune system to distinguish between self and nonself is vital to its function. All body cells have distinctive molecules that allow them to be recognized as “self.” When the immune system malfunctions, it may attack its own body. This occurs in diseases such as rheumatoid arthritis and systemic lupus erythematosus, which are referred to as autoimmune disorders. Antigens, Allergens, or Immunogens Any substance capable of triggering an immune response is called an antigen, allergen, or immunogen. An antigen can be a bacterium, fungus, parasite, virus, or a part of a substance produced by those organisms. However, not all antigens are capable of causing an antibody response, and some may provoke a cellular, or delayed hypersensitivity, response or even tolerance. Tissues or cells from another individual, except an identical twin, are also antigenic, that is, recognized as foreign. The structure of antigenic molecules varies from proteins, polysaccharides, lipids, or nucleic acids. The molecular weight of antigens ranges from less than a thousand to several million daltons (a unit of mass = approximately 1.65 × 10 –24) but must reach a threshold size in order to stimulate an immune response. Although the exact size required for allergenicity is unknown, the larger the size of a molecule, the better the chance that it will invoke a reaction. From the human organism to the smallest and simplest microbes, all cells have structures called epitopes on their surfaces that are characteristic and unique to that cell. Epitopes enable the immune system to recognize foreign cells and are the smallest antigenic structure capable of recognition by an antibody. Most cells carry different kinds of epitopes, which may number up to several hundred, on their surface. However, these epitopes differ in their immune-stimulating capabilities. Haptens are molecules too small to elicit an immune response in themselves. However, when haptens are coupled to a carrier immunogenic mol-

ecule, usually a protein or synthetic polypeptide, they can cause a very strong allergic response. Penicillin is one of many drugs that are haptens that bind with serum protein. This complex molecule then stimulates an allergic reaction to the penicillin or other drug. Other examples are the allergic responses to plant substances or metals that cause rashes upon contact with skin. The sensitizing allergens in poison ivy, oak, and sumac are haptens that combine with proteins in the skin. Upon subsequent exposure to these substances, antibodies in the skin react, causing the often debilitating contact dermatitis. Antigens such as pollen grains or cat dander are categorized as allergens because of their ability to provoke an allergic response in susceptible individuals. The first time an allergic individual is exposed to an allergen, the immune system responds by making a corresponding antibody. The antibody molecules are called immunoglobulin E (IgE). IgE molecules attach to the surfaces of mast cells in tissues or basophils in the circulatory system. Multiple factors determine the potential for an immune response. Among these are foreignness and chemical structure of the antigen. The genetic disposition of the exposed individual and the method of exposure—by injection, orally, skin or mucous membrane contact, or inhalation—affect the strength of immune response. Cells of the Immune System The immune system maintains a huge array of cells, some always present and others manufactured upon demand. Some cell types control general body defenses, while others target specific, highly selective targets. A competent immune system relies on the interactions of many of these cells by direct contact or by the release of chemical messengers by some. When mast cells or basophils with IgE antibodies on their surface encounter specific allergens, they release biochemical substances called mediators. Mediators include histamine, heparin, prostaglandins, and leukotrienes. These chemicals cause allergic symptoms—wheezing, sneezing, runny nose, watery eyes, and itching. The most serious response of the immune system is anaphylaxis, characterized by edema or swelling of body

102 immune system tissues and a sudden, dangerous decrease in blood pressure that can be life-threatening. Antibodies Immunoglobulins, commonly called antibodies, are protein molecules produced and secreted by B cells (lymphocytes manufactured in the bone marrow) designed to attack a specific foreign invader called an antigen. The resulting antibody is capable of binding, or attaching, to that specific antigen. For example, a cold virus stimulates a B cell to produce an antibody against that specific virus. When a B cell encounters its triggering antigen, T cells and other accessory cells collaborate with it to cause the production of large plasma cells. Each plasma cell becomes a factory for producing antibodies. Transported through the circulation to the site of inflammation or infection, antibodies neutralize or combine with and identify antigens for attack by other cells or chemical mediators. All antibodies have a common Y-shaped molecular structure consisting of two light (L) and two heavy (H) polypeptide chains bound together by two disulfide linkages or bridges. The resulting light and heavy chain section is called the fragment antigen binding, or Fab. A third portion of the immunoglobulin, Fc fragment, does not combine with antigen. The Fc portion of the antibody binds to cells, fixes complement, and allows for placental transfer. The five classes of immunoglobulins (Ig) identified in humans are IgA, IgM, IgD, IgE, and IgG. These immunoglobulins are distinguished by the structure of heavy chains called, respectively, t, a, m, z, and (. The two types of light chains are kappa (k) or lambda (L). IgG is the predominant human antibody and along with the other immunoglobulins has special roles in maintaining body defenses. Genes direct the manufacture of all body protein molecules including antibodies. (Insulin is another example.) Although there is a limited number of genes, the immune system apparently can produce an unlimited number of antibodies. The DNA segment of most genes is fixed; however, antibody genes are constructed from fragments of DNA scattered throughout the genetic material. A B cell sorts through the available material, arranging and rearranging these fragments and piecing them

together to form a new gene that with the antibody it encodes is unique. Each B cell proliferates, or clones, identical antibody-producing cells. As the cells continue to multiply, mutants arise that allow for the selection of antibodies that target specific antigens. This process enables antibodies to respond to an enormous range of antigens. T cells, or T lymphocytes, are processed by the thymus gland, act directly by attacking viruses and fungi, and are involved in transplantation rejection reactions. T cells react with specific antigens similar to antibodies. There are three types of T lymphocytes: “killer” T cells, which directly attack antigens; “helper” T cells, which help the killer cells; and “suppressor” T cells, which regulate the killer cells’ activity and stop their action when an infection has been controlled. Phagocytic white blood cells destroy invading foreign microbes by directly engulfing them. Most phagocytes are macrophages, large mononucleated cells derived from monocytes, which are produced and mature in the bone marrow. After a few days, they leave the general circulation and enter various tissues. Other phagocytic cells include Langerhans cells of the skin, dendritic cells, keratinocytes, and brain astrocytes. These cells affect chemotaxis (cell movement) by engulfing foreign antigens, ridding the body of dead tissues and cells. In the process of phagocytosis, these cells process the antigen and present an immunologically active antigen to the T lymphocytes. The macrophages are not antigenspecific like lymphocytes. Microphages consume bacteria. Complement is a complex series of blood proteins whose action “complements” the action of antibodies. The complement system comprises about 25 proteins that coat bacteria or immune complexes. This coating facilitates their ingestion and destruction by phagocytes. Complement also destroys bacteria by puncturing their cell membranes. When the complement system is activated by either the “classic” or an “alternative pathway” (also called the “proteolytic” or “properdin” pathway), an inflammatory response occurs. Immune complexes, consisting of IgG or IgM classes of immunoglobulin antibodies combined with antigen, activate a pathway targeting an invading sub-

immunodeficiency disease, severe combined 103 stance. During this process, the enzyme C1 esterase sets off a cascading-type reaction against the invader. The “proteolytic” alternative, or “properdin” pathway, can be activated without the presence of antibodies. The complement system not only aids in the body’s defense against infection but also helps protect against immune-complex diseases. However, if there is a deficiency of certain components of the system or cell receptors are deficient, the complement can actually induce immune-complex disorders such as serum lupus erythematosus. Serum complement levels are often measured to help diagnose hereditary angioedema, bacterial endocarditis, acute glomerulonephritis, serum sickness, systemic lupus erythematosus, and other autoimmune diseases. A deficiency in any component of the immune system may result in an immune deficiency disorder. In some cases there are no clinical manifestations, but in others recurrent, minor, or life-threatening infections may occur. See also IMMUNOGLOBULIN A; IMMUNOGLOBULIN D; IMMUNOGLOBULIN E; IMMUNOGLOBULIN G; IMMUNOGLOBULIN M.

immunity

The quality of being protected from, or resistant to, infection, disease, and any “invasion” imposed on the body. Being immune involves the ability of the immune system—consisting of white blood cells manufactured by the bone marrow, thymus, lymph, and other structures—to prevent or fight an infectious disease. Natural resistance or immunity refers to the human body’s rejection of certain cells, such as those causing Texas cattle fever, which cannot live in human tissues. Immunity is described in various ways: natural, passive, humoral, and cell-mediated (cellular). See also ACTIVE IMMUNITY; IMMUNITY, PASSIVE.

immunity, passive

The protection from disease afforded by way of antibodies received by an infant from its mother through the placenta or breast milk, or antibodies conveyed by injecting immune serum globulin (gamma globulin) from an individual known to be immune to a certain disease into a susceptible individual. Passive

immunity is short-lived, but immediate protection against an infection. Serum from immune individuals or animals is pooled to achieve a highly concentrated suspension of antibodies against a specific infection such as hepatitis or tetanus. Immediate tetanus protection can be administered to a non-immunized person by injecting human tetanus immunoglobulin. Horse-derived equine tetanus antitoxin is rarely used because of the frequent occurrence of severe adverse reactions.

immunodeficiency disease

A defect or insufficiency of one or more components of the immune system resulting in an inability to fight off infections. A variety of immunodeficiency disorders can be inherited, acquired through infection or other illness, or caused by an adverse reaction to certain drugs. Some children are born with abnormal B-cell components and lack the ability to produce immunoglobulins or antibodies. These defects may be absolute, as in agammaglobulinemias, or partial, as in hypogammaglobulinemias. Injections of immunoglobulins can protect these children against infections. Children who lack T cells as a result of abnormal or missing thymus glands can be treated by thymus transplantation. Rarely, an infant lacks all immune defenses, which is referred to as severe combined immunodeficiency disease (SCID). These are the so-called bubble children who often live for years in germ-free rooms. Bone marrow transplants have cured a few of these children. Acquired immunodeficiency syndrome, or AIDS, is caused by the human immunodeficiency virus, or HIV. In AIDS, a virus destroys helper T cells, allowing microorganisms that are normally harmless to cause life-threatening infections. These are referred to as “opportunistic infections.” See also ACQUIRED IMMUNODEFICIENCY SYNDROME; IMMUNODEFICIENCY DISEASE, SEVERE COMBINED (SCID).

immunodeficiency disease, severe combined (SCID) A genetic disorder of the immune system giving rise to what has been called “bubble

104 immunofluorescence, direct babies”—children who are afflicted with SCID and require a highly protective environment to avoid contracting potentially fatal infectious diseases. Approximately one-third of SCID victims have shown a deficiency of the enzyme adenosine deaminase, which may be a cause of SCID. Enzyme replacement therapy treatments involve injections of the drug pegademase bovine. SCID is considered the most severe immunodeficiency disorder; victims lack adequate quantities of B lymphocytes and antibodies, and their T lymphocytes are either deficient or not functioning. SCID that afflicts infants usually begins with pneumonia and thrush (an oral fungal infection), and if untreated, an infant may not live into a second year. Diarrhea and other infections such as pneumocystitis pneumonia may also develop during infancy. Treatment options include antibiotics, immunoglobulin, and bone marrow or umbilical cord blood transplantation.

immunofluorescence, direct A test to detect antibodies in tissue specimens used to aid in the diagnosis of glomerulonephritis, systemic lupus erythematosus, Goodpasture’s syndrome, pemphigoid, pemphigus, and dermatitis herpetiformis, and herpes simplex infections. immunofluorescence, indirect A test to measure the presence and quantity of antibodies in body fluids. It is especially useful in detecting autoantibodies in diseases including diabetes mellitus, thyroiditis, myasthenia gravis, chronic active hepatitis, systemic lupus erythematosus, systemic sclerosis, pernicious anemia, pemphigus, and bullous pemphigoid. immunogen

Any substance capable of triggering an immune response. Immunogens may also be called antigens or allergens. An antigen can be a bacterium, fungus, parasite, virus, or a part of a substance produced by those organisms.

immunoglobulin A (IgA) (secretory antibody) The primary immunoglobulin in body orifices, or entrances. IgAs are concentrated in body fluids such as the bronchial and intestinal secretions,

especially tears and saliva. IgA recognizes invading microorganisms in the mucous membranes as foreign protein. It combines with these invaders in antigen-antibody reactions to prevent viral and bacterial infections such as brucella, diphtheria, and poliomyelitis. IgA deficiency is the most common primary immunodeficiency, occurring in about one in 400 to 800 individuals, and more frequently in those with allergy. Most persons with low IgA levels produce sufficient IgM antibodies to provide an adequate defense against infections. However, IgA deficiencies are commonly associated with chronic lung infections, autoimmune diseases, especially rheumatoid arthritis and systemic lupus erythematosus, gastrointestinal disorders, hepatitis, and some malignant tumors. There are no known cures, and treatment is directed at the underlying disease or infection. Human immune globulin contains only minimal levels of IgA and is of no value in treating IgA deficiency disorders. In addition, IgA may cause anaphylaxis in persons with this deficiency. See also IMMUNOGLOBULIN G.

immunoglobulin D (IgD) A class of antibodies found in very small concentrations in human serum. IgD antibodies, first discovered in the 1960s, are found on the surface of lymphocytes. Although the IgD antibody’s exact role has yet to be defined, it seems to play a role as a specific surface receptor in the immune response. immunoglobulin E (IgE)

Antibodies manufactured by the immune system that play an important role in primary type I hypersensitivity, or immediate allergic, responses. Once called “reaginic antibodies,” these antibodies are normally present in very small quantities. Allergic individuals generally have higher total IgE levels in their blood. However, other diseases can also be associated with very high levels of IgE antibodies. Skin-sensitizing, anaphylactic antibodies are of this type. IgE antibodies’ unique biologic properties are based on their ability to bind with special receptors on mast cells and basophils in body tissues. People differ in their ability to develop an IgE response to common allergens in the environ-

immunoglobulin G 105 ment. The tendency to produce IgE antibodies is genetic. When IgE antibodies specific to a previously sensitized allergen are reexposed to that allergen, cells degranulate and chemical mediators of anaphylaxis and type I reactions are released. DISORDERS ASSOCIATED WITH ELEVATED SERUM IgE LEVELS Acral dermatitis Allergic diseases (severely elevated levels in allergic bronchopulmonary aspergillosis) Bone marrow transplantation (immediately post-transplantation) Bullous pemphigoid Celiac disease (gluten-sensitive enteropathy) Drug-induced interstitial nephritis IgE myeloma Infectious mononucleosis Job-Buckley syndrome Kawasaki disease Laënnec’s cirrhosis Minimal change nephritis Parasitic infections Polyarteritis nodosa Pulmonary hemosiderosis Selective IgA deficiency T-cell deficiency (DiGeorge syndrome, Wiskott-Aldrich syndrome, Nezelof syndrome) Wegener’s granulomatosus

Serum levels of IgE antibodies can be measured as “total IgE” or to identify specific allergens. This measurement is performed by a method called radioallergosorbent tests (RAST). Testing for allergen-specific IgE by RAST is useful when skin testing is unreliable because of generalized skin disease or dermatographia, or if the patient is unable to discontinue antihistamines.

immunoglobulin E (IgE) assay (total IgE, PRIST, RIST) A quantitative test measuring immunoglobulin E antibodies in the blood serum to assess an individual’s tendency to have allergies. An elevated level of IgE antibody in blood obtained from the umbilical cord at birth correlates with an increased risk of the development of allergy in later life. Persons with high total IgE levels are usually sensitive to many allergens, but an individual can be sensitive to specific IgE allergens and have a low total IgE level. Furthermore, allergic bronchopulmonary aspergillosis, parasitic infections, and other

rare diseases can cause extreme elevations in total IgE. There may be elevations of circulating IgE antibodies in some persons with food allergies, but the Allergy Council on Scientific Affairs of the American Medical Association considers this test investigational and experimental. The Paper Radioimmunosorbent Test and Radioimmunosorbent Test (both blood tests) are methods of measuring total IgE. In 1981, the Immunology Unit, a committee of the World Health Organization, recommended against the measurement of total IgE as a screening test for allergy. RELATIONSHIP OF IgE LEVELS TO DIAGNOSIS OF ALLERGY Total IgEU/ml

Predictability of Allergic Tendency

>100 25–100

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