For additional health news and information on allergies, sinusitis, asthma, COPD, lung fibrosis and other lung diseases like lung cancer, and nicotine dependence, please visit the following sites:
Allergy and Asthma Foundation of America
American Academy of Allergy Asthma and Immunology
American Cancer Society
American Lung Association
American Thoracic Society
National Heart Lung and Blood Institute
Surgeon Generals update on nicotine’s impact on the human body
For more information on Sleep Disorders and Sleep Medicine, please visit the following sites:
Allergic Rhinitis Sinusitis
Knoxville, TN was ranked as the second spring allergy capital of America and the seventh asthma capital of America by the Allergy Asthma Foundation of America.
Allergic rhinitis and sinusitis are very common medical problems. It is estimated that up to 40 million American adults and children have one or both of these conditions. Allergic rhinitis and sinusitis can make you miserable and rarely may lead to life-threatening complications.
The word rhinitis means inflammation of the nose that leads to increase in the production of the mucus that is produced by the lining of the nose.
Allergic rhinitis patient usually complains of sneezing, runny nose itching, watery eyes and postnasal drip. It is an allergic reaction to pollen from trees, grasses and ragweed. Other allergens include dust mites, mold, animal dander and cockroach debris.
Nonallergic rhinitis may be caused by overuse of topical nose sprays, hormonal changes, and occasionally by medications. Its symptoms are similar to those seen in allergic rhinitis.
Most cases of rhinitis go away once the source of irritation is gone. In the meantime, decongestants can help to relieve a stuffy nose. Overuse of over-the-counter decongestant nasal sprays can actually make your stuffy nose worse. Perhaps the most widely used type of medication used to control the symptoms of rhinitis is the antihistamines. The chief side effect of older antihistamines is drowsiness. A number of new antihistamines have been developed that do not cause drowsiness in most people. The most effective medications for allergic rhinitis are the corticosteroid antihistamine and anticholenergic nose sprays and a class of medications that is called anit-leukotrines like Singulair and Accolate.
Sinusitis is an infection or inflammation of the sinuses. The main types of sinusitis are allergic (similar to allergic rhinitis) and infectious sinusitis. Sinusitis can be acute or chronic. More than 50 percent of persons with moderate to severe asthma also have chronic sinusitis.
Alpha One Antitrypsin (A1AT) Deficiency
A1AT deficiency has been identified in virtually all populations and ethnic groups. An estimated 20 million people have one normal and one defective A1AT gene. Current evidence suggests that about 100,000 people with A1AT deficiency (ZZ) in the United States.
A1AT is a protein made in the liver. Normally, the A1AT goes into the bloodstream and helps protect the body’s organs from the harmful effects of other proteins. The low level of AAT in the blood occurs because the A1AT is abnormal and cannot be released from the liver at the normal rate. This leads to a build up of abnormal A1AT in the liver that can cause cirrhosis of the liver or other serious liver diseases and a decrease of A1AT in the blood that can lead to COPD and other lung diseases. A very small number of people who have A 1 AT deficiency have a rare type of skin disease called necrotizing panniculitis. This skin disease can cause painful lumps under or on the surface of the skin.
A1AT deficiency is a genetic disease that is passed from parents to their children through their genes. People with homogenous A1AT deficiency have received two defective A1AT genes. One defective gene came from their mother and one from their father. The most common abnormal genes are called S and Z. Normal genes are called M. A person who does not have A1AT deficiency will have two M genes (MM). People identified with A1AT deficiency most commonly have two Z genes (ZZ). People with one normal gene and one defective gene (for example MZ) are called “carriers”. Carriers may pass the defective gene on to their children.
Smoking is the leading risk factor for life-threatening lung disease if you have A1AT deficiency. If you have severe A1AT deficiency, smoking can shorten your life by as much as 20 years.
A1AT deficiency has no cure, but there are treatments. In most cases, treatment is based on the type of disease you develop. Intravenous replacement of A1AT is available for qualified patients.
Our practice is the only Clinical Research Center (CRC) in East Tennessee in the alpha one foundation https://www.alpha1.org
Asthma is a chronic disease that affects your airways. The airways are the tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways are inflamed (swollen). When the airways react, they get narrower, and less air flows through to and out of your lung tissue (air trapping). This causes symptoms like wheezing, coughing, chest tightness, and trouble breathing, especially at night and in the early morning.
Asthma cannot be cured, but most people with asthma can control it so that they have few and infrequent symptoms and can live active lives.
When your asthma symptoms become worse than usual, it is called an asthma attack. During an asthma attack, muscles around the airways tighten up, inflammation increases, and the airways become more swollen and even narrower.
Asthma attacks are not all the same. In a severe asthma attack, the airways can close so much that not enough oxygen gets to vital organs. This condition is a medical emergency. People can die from severe asthma attacks.
So, if you have asthma, you should see your doctor regularly. You will need to learn what things cause your asthma symptoms and how to avoid them. Your doctor will also prescribe medicines to keep your asthma under control. The most effective treatment for asthma is inhaled steroids with or without long acting bronchodilators. The use of long acting bronchodilators alone can increase the chance of death in patients with asthma. Short acting bronchodilators “rescue inhalers” are helpful when asthma is not under control but you need to report to your doctor if you are using them very often. Anit-leukotrines (Zyflo, Singulair and Accolate) are also used in treatment of asthma. Xolair (Omalizumab) is preserved for patients who have moderate to severe persistent allergic asthma and whose symptoms are inadequately controlled with inhaled corticosteroids.
Chronic Obstructive Pulmonary Disease COPD (Chronic bronchitis and Emphysema)
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and throughout the world.
COPD is a lung disease in which the airways are partly or completely obstructed, making it difficult to get air in and out.
Cigarette smoking is the most common cause of COPD. Breathing in other kinds of lung irritants, like pollution, dust, or chemicals, over a long period of time may also cause or contribute to COPD.
The airways branch out like an upside-down tree, and at the end of each branch are many small, balloon-like air sacs (Alveoli). In COPD, the air sacs lose their elasticity and the walls between many of the air sacs are destroyed (Emphysema), or the walls of the airways become thick and inflamed (swollen) and the cells in the airways make more mucus (sputum) than usual, which tends to clog the airways (Chronic Bronchitis).
There is no cure for COPD. The damage to your airways and lungs cannot be reversed, but there are things you can do to feel better and slow the progression including:
- Smoking cessation.
- Visiting your doctor regularly.
- Using your oxygen if needed.
- Using your medications regularly.
- Receiving your influenza vaccination (flu-shot) yearly and pneumonia vaccine regularly (usually every five years).
- Joining pulmonary rehabilitation if recommended by your doctor.
- Asking your doctor if you qualify for lung volume reduction surgery LVRS (removing some part of the lungs) or even lung transplant.
Insomnia is the most common sleep disorder. Many people have trouble falling asleep, staying asleep or waking too early in the morning. Lack of sufficient sleep can lead to depression and may contribute to too many medical problems.
Here are some things you can do to help your insomnia:
- Good Sleep Hygiene:
- Go to bed at a regular time every night (including weekends) and keep a regular wake time.
- Do not eat, read or watch T.V. in bed.
- Keep your bedroom dark and quiet.
- Adjust your thermostat to keep your bedroom’s temperature comfortable to you.
- Exercise daily four hours before bedtime and take a warm shower two hours before bedtime
- No caffeine intake after 2 PM.
- No alcohol after 5 PM.
- Sleep Restriction
Limit the time you spend in bed. Do not enter your bed until you are sleepy (not tired). If you cannot fall asleep in 20 minutes or if you wake during the night and cannot fall asleep again within 20 minutes then rise from bed. Leave the bedroom until you are sleepy again.
- Relaxation exercises
Consider using a `sound generator` to provide a low level of relaxing music or background sound. Practice progressive muscle relaxation. Consider using yoga or getting training in biofeedback.
- Circadian Rhythm Issues
Your body clock regulates your bedtime and rise time. If you keep irregular sleep hours during the course of a week then the clock becomes confused. It is always easier to stay up later than it is to go to sleep earlier.
There is a long list of medications that can be used to treat insomnia but should be taken under the supervision of your sleep doctor.
Insomnia can be a very complex issue. Consult your physician or a sleep specialist for more detailed advice and treatment.
Interstitial Lung Diseases (lung fibrosis!)
Interstitial lung diseases include numerous conditions that have different causes, treatment and prognosis.
Some of the many possible precipitating factors include silica dust (silicosis), asbestos fibers (asbestosis) or grain dust, sugar cane, dust from bird and animal droppings and moldy hay can cause hypersensitivity pneumonitis. A long list of drugs can also cause ILD. ILDs are seen sometimes in patients who have lupus, scleroderma, rheumatoid arthritis, dermatomyositis, polymyositis, Sjogren’s syndrome and sarcoidosis.
When the cause is not known exactly the ILDs are called idiopathic ILDs. The Usual interstitial pneumonitis/Idiopathic Pulmonary Fibrosis (UIP/IPF) is the most prevalent type. Other, less common types of idiopathic pulmonary fibrosis include nonspecific interstitial pneumonitis (NSIP), cryptogenic organizing pneumonia (COP), respiratory bronchiolitis-associated interstitial lung disease (RBILD), desquamative interstitial pneumonitis (DIP), lymphocytic interstitial pneumonitis (LIP) and acute interstitial pneumonitis (AIP). Some of the risk factors for idiopathic interstitial lung diseases include smoking, Gastroesophageal reflux disease (GERD) and rarely genetic factors like in familial pulmonary fibrosis. The history is a key component in identifying any cause that can be avoided to reverse or prevent further damage.
The following tests are very important to know the exact cause and decide the treatment plan:
- High-resolution computerized tomography (HRCT) of the chest.
- Pulmonary function tests (PFTs).
- Six minute walk test.
- Bronchoscopy (transbronchial biopsy, and Bronchoalveolar lavage)
- Video-assisted thoracoscopic surgery (VATS).
The drug therapies that are currently available to treat IPF can have serious side effects and often aren’t effective and they include corticosteroid drugs, cytotoxic drugs like Azathioprine (Imuran), anti-fibrotics such as bosentan, colchicine, interferon gamma-1b, penicillamine and pirfenidone, and antioxidants such as acetylcysteine. Oxygen therapy and pulmonary rehabilitation are also important in the treatment plan. Lung transplantation may be the only option for people with severe interstitial lung disease who aren’t likely to benefit from other treatment options. Pulmonary Hypertension (PH) has been found to increase mortality in patients with IPF and few trials are underway to find out if treatment of PH will decrease mortality.
Lung cancer is the leading cause of cancer deaths in the United States, among both men and women. It claims more lives each year than colon, prostate, lymph and breast cancers combined. Smoking accounts for nearly 90 percent of lung cancer cases.
The signs and symptoms of lung cancer typically occur only when the disease is advanced and may include a new cough that doesn’t go away, coughing up blood (even a small amount), shortness of breath, chest pain, wheezing, hoarseness and weight loss.
Types of lung cancer include small cell lung cancer and non-small cell lung cancer. The most common types of Non-small cell lung cancers include squamous cell carcinoma, Adenocarcinoma and large cell carcinoma. Unfortunately it has not been proven till now that a Computed tomography of the chest is beneficial for screening of lung cancer. Until further studies are available CT of the chest for screening of lung cancer should not be used. In the mean time, talk with your doctor if you’re concerned about your risk of lung cancer. Together you and your doctor can determine the best strategies to reduce your risk and decide whether screening tests are appropriate for you.
In order to diagnose lung cancer, your doctor may recommend imaging tests like an X-ray or CT tissue samples (biopsy) via bronchoscopy, mediastinoscopy, or CT guided needle biopsy keeping in mind that a biopsy sample may also be taken from lymph nodes or other areas where cancer has spread, such as your liver. Non-small cell lung cancer has four stages based on the size, lymph nodes involvement and distant spread of the cancer whereas small cell lung cancer can be either limited when it is confined to one lung and to its neighboring lymph nodes or extensive. Cancer has spread beyond one lung and nearby lymph nodes
Treatment options typically include one or more treatments, including surgery (wedge resection, lobectomy, or pneumonectomy), chemotherapy (mainly Carboplatin, Cisplatin, Taxotere, Taxol and Gemzar), radiation therapy or targeted drug therapy (Avastin and Tarceva). In some cases comfort (palliative) care to treat only the symptoms the cancer is causing, such as pain might be the best option.
Narcolepsy is a chronic disorder caused by the brain’s inability to regulate sleep-wake cycles normally. At different times during the day, people with narcolepsy experience sudden urges to sleep. If the urge becomes overwhelming, individuals will fall asleep for periods lasting from a few seconds to several minutes. In severe cases, this could happen even in the middle of a sentence, while standing up or while driving. In rare cases, some people may remain asleep for an hour or longer. In addition to excessive daytime sleepiness (EDS), three other major symptoms frequently characterize narcolepsy including cataplexy or the sudden loss of muscle tone when excited; hallucinations during sleep onset or upon awakening; and brief episodes of paralysis at the beginning or end of sleep. Narcolepsy is sometimes not diagnosed until 10 to 15 years after the first symptoms appear. The cause of narcolepsy remains unknown.
There is no cure for narcolepsy. Drug therapy with medications like Nuvigil ® (Armodafinil), Provigil ® (Modafinil) or other medications like Ritalin ® (methylphenidate hydrochloride) or Adderall ® (amphetamine and dextroamphetamine) should be supplemented by behavioral strategies. In severe cases another medicine can be used and it is called Xyrem ® (Sodium Oxybate). Many people with narcolepsy take short, regularly scheduled naps at times when they tend to feel sleepiest. Improving the quality of nighttime sleep can combat daytime sleepiness and help relieve feelings of fatigue. Among the most important measures people with narcolepsy can take to enhance sleep quality are actions such as maintaining a regular sleep schedule, and avoiding alcohol and caffeine-containing beverages before bedtime.
Parasomnias (Abnormal Sleep Behaviors)
Parasomnias (abnormal sleep behaviors) are so many disorders including REM Behavior Disorder (RBD) where patients move vigorously or violently during sleep REM sleep. These episodes of abnormal movements may result in injury to the patient or a bed partner. Parasomnias also include but are not limited to sleep terrors, nightmares, sleep walking, sleep talking and various repetitive movements during sleep.
The diagnosis of RBD is sometimes very apparent based on the patient’s history. Other cases, it is difficult to distinguish the symptoms from those of sleepwalking, sleep talking, seizures or sleep terrors. It is helpful to do a sleep study known as a polysomnography (PSG).
The dream-enacting behaviors are usually non-directed and may include punching, kicking, leaping, or jumping from bed while still asleep. The person may be awakened or may wake spontaneously during the attack and vividly recall the dream that corresponds to the physical activity.
Pulmonary hypertension affects only the arteries in the lungs and the right side of your heart.
Pulmonary hypertension is a serious illness that becomes progressively worse and is sometimes fatal. Although it isn’t curable, treatments are available that can help lessen symptoms and improve your quality of life. The most important signs and symptoms of PAH are: Shortness of breath (dyspnea), fatigue, dizziness, fainting spells, chest pressure or pain, swelling (edema) in your ankles, legs and eventually in your abdomen (ascites), bluish color to your lips and skin (cyanosis), and palpitations.
The PAH is usually divided into two main categories:
- Idiopathic pulmonary hypertension:
When an underlying cause for high blood pressure in the lungs can’t be found, the condition is called idiopathic pulmonary hypertension (IPH) or primary pulmonary hypertension (PPH) and when it happens in families it is called “inheritable” PH.
- Secondary pulmonary hypertension:
Pulmonary hypertension resulting directly from another medical problem is called secondary pulmonary hypertension. Medical conditions that may lead to secondary pulmonary hypertension include:
- Blood clots in the lungs (pulmonary emboli)
- Left-sided heart failure
- Sleep apnea
- Congenital heart disease
- Pulmonary fibrosis.
Pulmonary hypertension is hard to diagnose early because it’s not often detected in a routine physical exam and the patient does not have symptoms until it is advanced. The tests that are used to diagnose pulmonary hypertension and the possible cause include:
- Pulmonary function test.
- Perfusion lung scan.
- Right heart catheterization. This test is the most reliable way of diagnosing pulmonary hypertension.
- Computerized tomography (CT).
- Open-lung biopsy (to diagnose ILD).
Treatments for pulmonary hypertension include the following:
- Blood vessel dilators: The most commonly prescribed vasodilators for pulmonary hypertension are epoprostenol (Flolan), Treprostinil (Remodulin intravenous or subcutaneous or Tyvaso inhalation) and Iloprost (Ventavis)
- Endothelin receptor antagonists. These medications include Bosentan (Tracleer) and Ambrisentan (Letairis).
- Phosphodiesterase- 5 (PDE-5) inhibitors including: Revatio (Sildenafil) and Adcirca (Tadalafil).
- High-dose calcium channel blockers (for qualified patients).
- Warfarin (Coumadin).
Restless Legs Syndrome (RLS)
Restless legs syndrome (RLS) is a common sleep disorder affecting between 10-24 % of adults. The clinical definition of RLS includes the presence of at least four features:
- Strange feeling in the legs like insects crawling under the skin, tightness or pain with an intense urge to move the legs (or rarely other body parts).
- The strange feeling is triggered by rest or inactivity.
- Temporary or complete relief by movement.
- Worsening during the evening and night.
Some but not all patients with RLS have periodic limb movements during sleep (PLMD). A recent poll conducted by the National Sleep Foundation found that 50 percent of sufferers experience delayed sleep. The frequency of symptoms can vary from nightly (about 8 percent of sufferers) to only a few nights a month (in 25 percent of patients).The problem is more frequent in women (about twice as many as men) and often begins early in life (about 40 percent of adults report symptom onset prior to age21). Secondary causes of RLS include iron deficiency anemia, pregnancy, renal failure, and certain neurological disorders.
Periodic limb movement disorder (PLMD) is a related entity that involves repetitive limb movements during sleep. PLMD may not have clinical relevance, unless the patient suffers from hypersomnia or insomnia as a result of it.
The evaluation of RLS includes taking a compatible history, performing a physical exam to exclude possible neuropathy, and obtaining lab studies (iron and ferritin levels). Therapy should include interventions such as increased physical exercise, hot baths, and the avoidance of alcohol, nicotine, and caffeine. The two most commonly used medications for RLS/PLMD are Requip ® (Ropinirole) and Mirapex ® (Pramipexole) which are also used for treatment of Parkinson’s disease.
Sleep apnea is a common disorder that can be very serious. Most people don’t know they have sleep apnea. In sleep apnea, your breathing stops or gets very shallow while you are sleeping.
Sleep apnea occurs in two main types: obstructive sleep apnea that occurs when throat muscles relax, and central sleep apnea, which occurs when your brain doesn’t send proper signals to the muscles that control breathing. Additionally, some people have a combination of both.
The most common signs and symptoms of obstructive and central sleep apneas include:
- Excessive daytime sleepiness (hypersomnia)
- Loud snoring, which is usually more prominent in obstructive sleep apnea
- Abrupt awakenings accompanied by shortness of breath.
- Awakening with a dry mouth or sore throat
- Morning headache
- Difficulty staying asleep (insomnia)
When you have sleep apnea you can be very sleepy during the day keeping in mind the most common symptom in patients who have sleep apnea is fatigue.
Sleep apnea happens more often in people who are overweight, but even thin people can have it. Other risk factors include neck circumference more than 17.5, large tonsils or adenoids, use of alcohol, sedatives or tranquilizers, smoking, male gender, black or Hispanic races, age above 50, and some diseases like high blood pressure (HTN) and congestive heart failure (CHF).
Untreated sleep apnea can increase the chance of death, HTN, heart attack or stroke. Untreated sleep apnea can also increase the risk of diabetes and the risk for work-related accidents and driving accidents.
Treatments for OSA may include lifestyle changes such as losing weight or quitting smoking, Positive airway pressure like Continuous Positive airway pressure CPAP or Bi-level Positive airway pressure (BiPAP), oral appliances (CPAP is much more effective than oral appliances) or surgery (Uvulopalatopharyngoplasty (UPPP), maxillomandibular advancement, Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated nasal septum), surgery to remove enlarged tonsils or adenoids or tracheostomy). Laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) are procedures that doctors sometimes use to treat snoring.
Treatments for central and complex sleep apnea may include treatment for associated medical problems (optimizing therapy for heart failure may eliminate central sleep apnea, supplemental oxygen, PAP (CPAP, BiPAP, BiPAP ASV, VPAP ASV).