Asthma Treatment

1. Neutralization (described previously)
2. Fast relief (Beta Blocker)
3. Fast-acting steroid (oral or injectable)

If patients use their MDIs effectively, there is relief of symptoms in almost every instance. This is more the case with inhaled steroids than the Beta Agonists because even a small amount of albuterol inhaled into the lungs seems to have a dramatic effect in most cases. Once the patient can get a moderate amount of air into their lungs, I want them to begin LOADING UP with inhaled steroids.

1. Inhaled Steroids

Inhaled steroids are the mainstay of my prevention tactics during the first few weeks of treatment. These marvelous medications are almost always effective if we can get them into the lungs in high enough concentrations. Most patients simply cannot inhale enough steroid gas for effective treatment. One has to be an Olympic class-breathing expert to use one of these "MDIs". Most patients are given an MDI and told to use "use this four times a day" (or "two times," or "three," or whatever). But, few are instructed in how to use inhalers.

One patient I saw was a 70 year old lady on constant oxygen. She removed her nasal oxygen cannula to show me how she used her inhaler. She took a deep breath (as deep as she could), exhaled, squirted the gas into her mouth... and swallowed. In a few moments, she took the canister from her lips, inhaled softly and muttered...."The damn thing doesn't do a bit of good." Well, yes, I can see where it wouldn't!

Many of my patients come in with all the correct medicines. But, only rarely (and only recently) do they know how to use their medicines.

The quick relief of the Beta Agonists is a tender trap. Yes, they open the lungs, but it is like opening a stuck door with a hand-grenade. The door opens, but the method is pretty hard on the equipment. AND, when the door closes back (four or five hours later) you just have to do it all over again. This is like cutting off dandelion flowers in your yard with a machete... effective, but tedious and tomorrow the problem is right back.

Wouldn't it be better to "Oil The Hinges?" or "Dig out the dandelion roots?" Steroids oil the hinges. Even my friends the pulmonologists acknowledge that. We're in complete agreement about the effectiveness of steroids in controlling asthma and even preventing it. We simply disagree on How To Deliver The Steroids. They know about inhaled steroids, but they are frustrated with the huge number of patients who don't (or won't) use the inhaled steroids because..."The damn thing doesn't do a bit of good." So, they fall back on their mainstay... Prednisone.

At this point I am in complete and total disagreement with the treatment plan. I take almost every patient I see off PREDNISONE just as fast as possible. Why would I treat the person with a systemic steroid to address a problem that exists almost entirely in the lungs? I won't. I don't. I don't need to. Prednisone has horrendous side effects well known to the most naive patient and certainly well known to all physicians. Side effects include diabetes, liver and organ disease, and death. No one would use it if they had a reasonable alternative. Certainly one would NEVER use systemic steroids on children… If There Was An Alternative

Why don't the inhaled steroids work? Because no one stopped to examine how the patient uses them. I was so excited when the first nasal steroids came out. It was such a great breakthrough. But in no time at all, I began to hear patients complain that the nose sprays "Don't Work!" I couldn't imagine why they wouldn't, so I asked the patient to show me how he used it. The patient dutifully stuck the end of the nasal gas canister in his nostril, grimaced, triggered the gas discharge and at the same time, gave an enormous Snort and snuffed the gas vigorously up his nose. "Well, yes," I explained, "I can see where that gas isn't going to do much good." So we began to try to figure out some means of getting the gas where we wanted it (the nasal mucus membrane) and how we could keep it there long enough for the gas to be absorbed.

In retrospect I am amazed at how many patients reported good results. Even when Snuffing the Gas Vigorously! Apparently, the steroids are so effective that, in some mild cases, the miniscule amount absorbed en passant was enough to give some patients some relief of their symptoms. This is rarely the case.

What to do? When the patient snuffs vigorously (as we usually do when we're trying to clear something through the nose, a "sniffle in force," if you will), a wind is created, a 50 mile an hour wind which whips the gas, through the nose, down the throat and into the lungs. Into the lungs, where it does no harm but it certainly does no good for the nose.

I ask the patient, "Where do you think that gas goes when you snuff it up your nose?" Most reply..."into my head." So, I next explain how terribly effective this gas can be if it gets to the right place.

If we suppose a contest, where we each get one "spray" from a can of black spray paint in a white room, where the winner is the one who gets the most paint to stick on the walls, this becomes easier to understand.

Patients who "snuff" the nasal spray with vigor and force would be like contestants who open doors wide at either end of the room, spray the paint once and blow a 50 mile an hour wind through the room. Out of any 100 paint particles (bear with me) only 10 paint particles would "stick" to the walls. The rest would blow on out of the room.

I, on the other hand, (clever fellow that I am) would close the room up TIGHT and spray the paint once. I would move not a hair for ten seconds. By then, a great deal of the 100 paint particles would have stuck to the walls, probably 90 or so out of the 100!

We next stand in front of a mirror and I explain "gas law" to the patient. Gas will instantly expand to fill all of the space it occupies.

I then have the patient "squirt" a dose of the gas into one nostril, leaving his mouth open while watching himself in the mirror. He sees the gas come rushing out of his mouth and the other nostril. So, even without "snuffing," he will lose most of the gas.

Next, I have him close his mouth, hold his breath and raise the back of his tongue up to the roof of his mouth. This blocks the nasopharynx and keeps all the gas in his nose. Right?... Wrong!

He still has that other nostril open. It's better, but still no cigar! Next step. Repeat step one (mouth closed, nasopharynx blocked), now, hold the other nostril shut.

Perfect?? Not quite yet, almost... only one thing remains. Having done all this, I noticed that the moment he discharged the gas, he lowered the canister from his nose... and a lot still leaked out (50 paint particles).





So, here's PERFECT:

1. Hold your breath
2. Lift your tongue to block your nose in the back of your mouth
3. Hold one nostril shut
4. Firmly plug the other with the canister
5. Release gas and hold everything closed while you slowly count to ten.

If you do this absolutely perfectly, you are:

1. An alien being, or
2. Sure to discover the joy of a completely clear nose within 48 hours.

These gases cannot miss. They invariably work if the problem is allergy. If this doesn't work, you either have a virus (rhinovirus... count the days... nothing will open your nose until the virus does its thing... usually five days); or, you have some mechanical blockage (polyp, deviated septum, crayons stuck in your nose). Now it's just a matter of how much does it take to do the job?

I usually load up the patient with a large amount during the first two days. It often takes up to two days for the steroid to soak down through the tissue (like "oil into dry wood") to get to the bottom layer of cells that cause the problem. So, I start the patient with this highly effective method, using one "squirt" in each nostril (then "holding it in" for ten seconds) six times each day for the first two days. Since it isn't necessary to "space" the doses (as we might need to in order to achieve a fairly constant "blood level"), the patient can do one set after another and I usually suggest three "sets" in the morning and three in the evening.

Remember, these steroid gases and aqueous "mists" act like "oil into dry wood." As soon as one coat of oil soaks in, you can immediately add another, and another. We are trying to achieve complete control with a large loading dose of this very effective drug. Once the nose is comfortably clear, I have the patient reduce the dose by 50%, to, say, three "sets" of one "squirt" on each side (holding for ten seconds) for two more days. If they remain open and clear on this dosage, we reduce it once again, to one "set." If they continue "clear," I usually stop the gas entirely and try to maintain control with antihistamines as much as possible.

Now, what has all this nose spray stuff got to do with ASTHMA?

I'm glad you asked. I was just about to explain that. The problem in asthma is inflammation of the airways. The solution to asthma is the prevention of the inflammation of the airways. There are many medications that help prevent inflammation. For the short term, the best of these are steroids. Inhaled steroids. But like the nasal problem, I have to find a way to get enough steroids into the lungs.

Steroids are my first choice of initial anti-inflammatory medications. They work almost every time. The problem is getting them where you want them... and nowhere else. Why would anybody use a 50-year-old oral medication (prednisone) that invariably causes adverse side effects when used for any significant period? Why would one prescribe systemic steroids for a problem confined to the lungs? I understand the problem. Many physicians have not found inhaled steroids to be effective. Why not? The current corticosteroid gases are always superior to any amount of systemic steroids. The trick is to get an adequate amount of the gas in the patient.

Manufacturers, typically, do not offer much help. They suggest that the MDI canister be held near the open mouth, "squirt" the gas, inhale, and hold your breath.

Now let me ask you, have you ever seen anyone jogging down the trail sucking in a "gulp" of air and squirting the gas? The lungs do not absorb much gas when they are hyper-inflated. They work like "sponges," as they empty and fill. As we breathe air in and out, oxygen is extracted. If the lungs are hyper-inflated (as when one takes a deep breath and holds it) not much of the steroid is going to be absorbed and most of it will come right back out when the patient exhales. Furthermore, most asthmatics cannot get a deep enough breath to get much gas in to begin with. So, what is the solution?

Now you see the connection with the long discourse on nasal steroids. Like the nasal steroid, the inhaled steroid can't miss, if we get an adequate amount in the lungs and keep it there.

HOW? By getting enough steroid gas in the lungs to do the job.

One might ask if I am not worried about side effects from excessive steroid levels. I have never seen any systemic side effects from these large doses of inhaled steroids. Using the methods described here, I find most of my patients are off all inhaled steroids within a few days or weeks. None are kept on "loading" doses over one or two weeks. There are usually no side effects probably because I use a large enough loading dose in the first 48 to 72 hours to completely prevent reoccurrence of the asthma attack. And how can I get enough gas in to do the job? By using a RE-BREATHER.


2. Anti-Leukotriennes

A new tool in the asthma prevention category is the anti-leukotrienne class of drugs. Three new drugs of this type have been introduced. They are Accolate, Zyflow and Singulaire. They block an enzyme reaction that stimulates smooth muscle spasms leading to constriction of airways.

In some of my patients, these drugs have been completely successful in preventing asthma symptoms. In a few patients, they have been the only medication necessary to do this. It is typical of humans to react differently to medications and these medications are no exception to the rule. Some do better on Zyflow than Accolate, some on Singulaire and so forth. If one of these doesn't help, be sure you try the other two before you give up this marvelous possibility.

It is interesting to note that the handful of patients who responded best to these drugs were my worst cases. In two cases in particular, I had been treating men who had continuous problems with asthma for over 20 years. We could maintain control but only by using every modality we had available. They needed constant environmental control, allergy neutralization and desensitization, food restriction and all the medication I could get in them. They used large amounts of inhaled steroid and frequent "blockers" like albuterol.

In recent months, I noticed I hadn't heard from them so I called to see how they were doing. J.F. said he was having, "No trouble with asthma at all, so long as I take my Accolate twice a day." The second patient, R.P., has had a history of crisis after crisis but now has been almost completely symptom-free for the several months he has been on Singulaire once a day.

These were the two most difficult patients I have had and both have had surprising relief using this new class of drugs. Interestingly, each was begun on a different drug than the one they ended up on. When they saw no improvement after a four week trial, I switched them to a different drug in the same group and then they experienced this outstanding result.

Both are still very allergic and we still deal with their airborne and food reactions in the usual fashion, but the only asthma drug they are using is an anti-leukotrienne.

Section 4. Food Avoidance The "quickest" measure one can take to prevent problems is to drastically limit food choices and neutralize any metabolic acidosis (over production of acid in the stomach) which also affects breathing. It is difficult for anyone to extract oxygen from the air in the face of respiratory or metabolic acidosis (Oxygen Dissociation Curve which explains the negative effects of acidosis on our ability to extract oxygen from inspired air). I test my patients for reactions to a few foods initially, in an effort to find a "safe" diet to use for the critical few days. It is important to find foods the patient does not react to, lest they deteriorate, meal-by-meal, from the outset. Usually chicken (organically grown), brown rice, water and salt comprise the entire diet of an adult (breakfast, lunch, supper, and snacks) for the first three to four days. Modifications to this strict diet have to be made for kids. For one thing, they simply won't do it. At least, not willingly. Little ones (under four) are pretty much limited to what Mom gives them, so we have less trouble here. I suggest at the very least, eliminating several food groups (just for a few days, NOT forever): AVOID:

1. All diary: NO cows milk, cheese, yogurt, ice cream. Rice or soy milk is usually OK for this short period.
2. Tomatoes and tomato products: NO tomatoes, ketchup, pizza, lasagna, spaghetti, hot sauce, etc.
3. Pineapple and citrus fruits and juices: These are already very acidic and will usually aggravate the condition by causing or contributing to acidosis.
4. Chocolate: Remember, this isn't forever, just a few days.
5. Sugar: Candy, corn syrup, etc. This is why kids "crash" in the ER when an IV is begun. It is usually "D5W" which is Dextrose 5% in water, i.e., corn sugar.
6. All grains except brown rice: NO Bread, cereal, cookies, chips, cake, pasta, etc.
7. Brown things to drink: NO chocolate drinks or colas, diet or otherwise, and only minimal amounts of coffee or tea.
8. Anything the patient eats "addictively," or "craves" or eats on a daily basis: Especially if it is something the patient wants or "needs" when they do not feel good.

There is more information on asthma under hormones.