What is asthma?
Asthma is a condition that causes swelling and inflammation inside the airways of the lungs. This inflammation and swelling is there to a greater or lesser degree all the time in people with asthma. The more inflammation there is the harder it becomes to breathe. People with asthma also have over-sensitive airways, so their airways react to triggers that do not affect other people. When sufferers come into contact with something that irritates their airways (a trigger), it can cause their airways to narrow. This happens in three ways:
1. The muscles that surround the airway tightens
2. The lining of the airway becomes inflamed and starts to swell.
3. Sticky mucus is produced which can narrow the airways further still.
How common is asthma?
Asthma is very common with over 5 million people in the UK receiving treatment
How do I recognise if I have asthma?
The most common symptoms of asthma are:
• Shortness of breath
• Chest tightness
• Activities are limited by coughing, wheezing, shortness of breath or cough.
As asthma is a variable condition, symptoms may vary depending on the time of day and from season to season. Not everyone with asthma will experience all of the symptoms described above. Everyone’s asthma is different and triggers for asthma vary between asthmatics. Apart from asthma, there are also other causes for persistent coughing, shortness of breath, chest tightness or wheeze. So if you experience these symptoms; it is important that you make an appointment to see your doctor for advice.
What will trigger my asthma?
It is important to identify what triggers your asthma. The first part of managing your asthma is avoiding triggers, so that you can reduce unnecessary symptoms. Triggers vary between individuals and individuals may have more than one trigger. The commonest triggers of asthma are:
Levels are likely to be higher during hot sunny days or in cities.
Allergy is one of the commonest triggers and one of the most important. Allergens (substances that cause an allergic reaction) that trigger asthma include: grass pollen, tree pollen, house dust mites, and pets. Food allergy can be responsible but is less common. It is essential to determine whether allergies trigger your asthma, as reducing the levels of allergen you are exposed to may improve your asthma.
Rhinitis-Colds, flu and chest infection
Most asthma patients also have rhinitis- ask your doctor to check you for this as treatment can improve asthma control. Colds are another common trigger of asthma. Annual flu vaccinations are recommended for all asthmatics. More severe asthmatics requiring regular steroid tablets should talk to their doctor about also receiving the pneumoccocal vaccination.
Laughter, excitement, fear or anger can bring on symptoms Exercise Some people with asthma may develop wheezing, shortness of breath or coughing during or after exercise. This is often a sign that asthma is poorly controlled. Therefore if you develop symptoms of asthma whilst exercising you should visit your doctor, so that your asthma control can be reviewed.
Some people with asthma are sensitive to aspirin, ibuprofen, diclofenac and other drugs in the NSAID family. Other medicines that can sometimes trigger asthma include beta-blockers used to treat heart conditions and glaucoma and certain cold and flu-remedies. When you are buying medicine at the chemists or when the doctor is prescribing a medicine for you always inform them that you have asthma.
Smoke contains thousands of chemicals which irritate the lungs. Most smokers find that their asthma will be worse in a smoky environment.
Changes in temperature or a cold spell can trigger asthma in susceptible individuals. Heavy thunderstorms have been shown to increase the risk of asthma attacks.
How does allergy play a role in asthma?
If you are allergic and are exposed to a particular allergen, (e.g. grass pollen, house dust mite, cat, moulds) it may trigger an asthma attack. There are two main ways in which allergy contributes to worsening asthma:
1. Allergy itself can produce allergic inflammation in the airways
2. Exposure to an allergen can trigger an asthma attack
It can be helpful to determine whether allergies do trigger your asthma, as if you can reduce exposure to triggering allergens your asthma may improve and your need for medication may decrease. Therefore after taking your history, your doctor may perform skin prick tests or blood tests (RAST) for allergen specific IgE to look for antibodies to allergens. Both skin prick tests and RAST tests have been medically proven to help diagnose allergy.
Can asthma be cured?
There is no cure for asthma but fortunately there are excellent treatments. With correct management most individuals can enjoy an active lifestyle and carry out day-to-day activities with no symptoms.
Which medicines are available to treat asthma?
Medications to treat asthma can be divided into three groups:
1. Relievers e.g. Ventolin, Bricanyl These provide relief from asthma symptoms within minutes by relaxing the muscles that surround the airways. This allows the airways to open up and it becomes easier to breathe. You should always carry your reliever with you, in case of emergency. If you require your reliever three or more times a week, it could be a sign that your asthma is not well controlled and you should check with your doctor.
2. Preventers e.g. Flixotide, Pulmicort, Qvar If you have asthma, you will probably find that your doctor prescribes you a preventer and a reliever inhaler. This is because preventers (unlike relievers) will directly reduce swelling and inflammation in the airways. They will also reduce over-sensitivity in the airways, so exposure to triggers (e.g. cigarette smoke, viral infections, allergens) will be less likely to cause symptoms. Preventers must be taken every day to be effective. They will not be effective if used on an ‘as and when’ basis. They do not give quick or immediate relief of symptoms and may take a couple of weeks to work, so do not stop using your preventer if you notice no improvement after the first week. Most patients find that they need their reliever inhaler less often once they are using a preventer regularly
3. Other treatments. If despite using a regular preventer, your asthma is not well controlled your doctor may suggest adding in other treatments. These include:
• Long-acting relievers which relax the airway muscles for up to 12 hours
• Combination inhalers which contain both a steroid preventer and a long-acting reliever
• Leukotriene receptor antagonists which block one of the inflammatory chemicals released in the airways of asthmatic patients
• Theophylline which relaxes the airway muscles
How can I tell if my asthma is well controlled?
Signs that your asthma is well controlled include:
• If you are able to sleep through the night and do not wake up wheezing or coughing or chest tightness or shortness of breath.
• If you are able to exercise and feel okay both during and afterwards
• If you are able to get through the day and your usual activities without developing wheezing or coughing or chest tightness or shortness of breath.
• You do not need your reliever inhaler more than three times a week.
How can I manage my asthma effectively?
There are lots of things you can do to improve the management of your asthma:
• Find a GP with an interest in asthma or a GP who runs an asthma clinic.
• Make sure you know what triggers your asthma and avoid these triggers if possible.
• Make sure that you own a peak flow meter and know what your peak flow should measure.
• Know how to use your asthma medications correctly, preferably via a spacer.
• Most people who experience an asthma attack give a history of gradual worsening of symptoms. So learn to recognise worsening symptoms of asthma. Ask your doctor for a written Asthma Action Plan so you are clear how to manage your asthma.
What should I do in an asthma attack?
• Sit upright and loosen any tight clothing
• Take your reliever inhaler (usually blue) immediately
• If there is no improvement take one puff of your reliever inhaler every minute for five minutes or until symptoms improve
• If there is no improvement call an ambulance
COPD describes a group of lung conditions that make it difficult to empty air out of the lungs because your airways have been narrowed. This information explains what it is, what the symptoms are, and how it’s diagnosed and treated.
Chronic obstructive pulmonary disease, or COPD, describes a group of lung conditions that make it difficult to empty air out of the lungs because your airways have been narrowed.
Two of these lung conditions are persistent bronchitis and emphysema, which can also occur together.
• Bronchitis means the airways are inflamed and narrowed. People with bronchitis often produce sputum, or phlegm.
• Emphysema affects the air sacs at the end of the airways in your lungs. They break down and the lungs become baggy and full of holes which trap air.
These processes narrow the airways. This makes it harder to move air in and out as you breathe, and your lungs are less able to take in oxygen and get rid of carbon dioxide.
The airways are lined by muscle and elastic tissue. In a healthy lung, the tissue between the airways acts as packing and pulls on the airways to keep them open. With COPD, the airways are narrowed because:
• the lung tissue is damaged so there is less pull on the airways
• the elastic lining of the airways flops
• the airway lining is inflamed
There are treatments to help you breathe more easily, but they can’t reverse the damage to your lungs – so it’s important to get an early diagnosis.
CAUSES of COPD
COPD usually develops because of long-term damage to your lungs from breathing in a harmful substance, usually cigarette smoke, as well as smoke from other sources and air pollution.
Jobs where people are exposed to dust, fumes and chemicals can also contribute to developing COPD.
You’re most likely to develop COPD if you’re over 35 and are, or have been, a smoker. Some people are more affected than others by breathing in noxious materials. COPD does seem to run in families, so if your parents had chest problems then your own risk is higher. A rare genetic condition called alpha-1-antitrypsin deficiency makes people very susceptible to develop COPD at a young age.
SYMPTOMS of COPD
The symptoms of COPD include:
• getting short of breath easily when you do everyday things such as going for a walk or doing housework
• having a cough that lasts a long time
• wheezing in cold weather
• producing more sputum or phlegm than usual
You might get these symptoms all the time, or they might appear or get worse when you have an infection or breathe in smoke or fumes.
If you have severe COPD, you can lose your appetite, lose weight and find that your ankles swell.
What’s the difference between COPD and asthma?
With COPD, your airways have become narrowed permanently – inhaled medication can help to open them up to some extent. With asthma, the narrowing of your airways comes and goes, often when you’re exposed to a trigger – something that irritates your airways – such as tobacco smoke, dust or pollen. Inhaled medication can open your airways fully, prevent symptoms and relieve symptoms by relaxing your airways. So, if your breathlessness and other symptoms are much better on some days than others, or if you often wake up in the night feeling wheezy, it’s more likely you have asthma.
Your doctor will ask if your breathlessness is brought on by anything, how your daily life is affected and other questions about your general health.
They’ll ask if you’ve smoked and if you’ve been exposed to dust, fumes or chemicals. Your doctor can check how well your lungs work by arranging a simple test called spirometry. This involves blowing hard into a machine which measures your lung capacity and how quickly you can empty your lungs. This is called the forced expiratory volume in one second, often shortened to FEV1.
Your doctor will use spirometry to measure how narrow your airways are. But this only covers one aspect. Someone with slightly narrowed airways can be more breathless than someone with very narrow airways depending on their level of fitness and the exact way COPD has damaged their lungs.
Other tests for COPD
Your doctor should arrange for you to have a blood test and a chest X-ray to rule out other causes of your symptoms. Your doctor will calculate your body mass index (BMI) to find out if you’re a healthy weight for your height. This is important because you can deal with your COPD better if you’re not underweight or overweight.
You may do more tests to give a better picture of your condition, covering:
• how well your lungs are functioning
• how often you have symptom flare-ups or chest infections
• how short of breath you feel during everyday activities
• whether your oxygen level is significantly lower
Treatments for COPD
Your health care professional can prescribe several types of medicine or combinations of medications to improve symptoms like breathlessness and to help prevent a flare-up. You can also do things to help manage your condition yourself. Keeping active and doing exercise can make a big difference – many people find this helps them more than inhaled drugs.
If you smoke, the most effective treatment for COPD is to stop. Your health care professional and pharmacist can help you find ways that make it easier for you. You’re four times as likely to quit with help from support services and medication. Have a look at the NHS Smokefree website to find out more.
Have a plan
It’s important you have a plan to help you manage your COPD that’s agreed with your doctor or nurse. You should also have regular check-ups with your health care professional – at least once a year.
Your doctor will decide with you which medications to use depending on how severe your COPD is, how it affects your everyday life, and any side effects that you may have experienced.
Your health care team may send you to a specialist to see if oxygen can help you. Oxygen is only useful as a treatment for people with a low oxygen level. It’s not a treatment for breathlessness, which in COPD is usually caused by difficulty moving air in and out as you breathe, rather than by a low oxygen level.
If you’re admitted to hospital with a severe flare-up of your condition, you may be offered non-invasive ventilation. This involves wearing a nasal cannula ( a soft tube inserted into your nose) or face mask connected to a machine that pushes air into your lungs. Non-invasive ventilation supports your breathing to give your muscles a rest and gently helps with each breathe you take. This increases your oxygen level and helps you breathe out more carbon dioxide. If you regularly wake up with a headache, tell your doctor. It can be a sign your breathing is shallow at night and you might benefit from non-invasive ventilation at home.
Lung volume reduction surgery
Some people with emphysema may benefit from surgery to remove the worst affected areas of the lung. This allows the remaining healthier parts of your lung to work better. If you’ve been through a pulmonary rehabilitation programme and are still limited by breathlessness, ask your doctor if you might be eligible for this sort of treatment. Bronchoscopic techniques for lung volume reduction are also becoming available. You may be considered for these instead of surgery as part of the assessment process for surgery.
If you have very severe COPD and have not got better with treatment, you might be a candidate for a lung transplant depending on your age, other illnesses and test findings. Lung transplant is a high-risk operation and is only suitable for a small number of people. There are also few suitable organ donors.
How can I manage my COPD better?
If you have a long-term condition like COPD, you’ll feel better if you self-manage your condition and take some control of your life. “If you have a lung condition, you can’t sit around and wait for other people to take care of you – you need to take care of yourself! I fully believe you get out of it what you put in” Knowing all you can about your condition, your symptoms, your medications and how to cope with flare-ups will make your day-to-day life easier.
Exercise and pulmonary rehabilitation
If you have COPD, being active and exercising can help you to improve your breathing, your fitness and your quality of life. Don’t avoid activities that make you breathless: you’ll get less fit and out of breath more easily. Regular exercise can help reverse this by strengthening your muscles. Exercise also benefits your heart and blood pressure, and makes you less likely to develop conditions such as diabetes and osteoporosis (fragile bone disease).
The best way to learn how to exercise at the right level for you is to take part in pulmonary rehabilitation. Ask your doctor to refer you. Pulmonary rehabilitation or PR is a programme of exercise and education designed for people living with COPD. It combines physical exercise sessions with advice and discussions about your lung health.
There is strong evidence that people with COPD benefit from PR and exercise more generally. Most people find PR improves their ability to exercise and their quality of life. The impact of PR is often bigger than the impact of taking inhaled medications. By combining the two approaches, you’re likely to get the most benefit.
Controlling your breathing
There are techniques to help you reduce breathlessness. Try to practise them every day. They can also help if you get out of breath suddenly. Being in control of your breathing means breathing gently, using the least effort, with your shoulders supported and relaxed.
Different things work best for different people. We've put together some techniques and positions to try.
Top tips for managing breathlessness
• Use a towelling robe after showering or bathing, as you’ll use less energy than drying off with a towel.
• Hold a handheld battery fan near your face if it helps you to feel less breathless.
• Plan your day in advance to make sure you have plenty of opportunities to rest.
• Find simple ways to cook, clean and do other chores. You could use a small table or cart with wheels to move things around your home, and a pole or tongs with long handles to reach things.
• Put items that you use frequently in easy-to-reach places.
• Keep your clothes loose, and wear clothes and shoes that are easy to put on and take off.
• Use a wheeled walking frame to help improve your breathlessness.
Eating well and keeping a healthy weight It’s important to eat a balanced diet and maintain a healthy weight. Your doctor or nurse can help you to work out what your healthy weight should be and can refer you to a dietician or local scheme to help you.
• If you’re overweight it will be harder for you to breathe and move around.
• If you’re losing too much weight because eating makes you feel breathless, or find it difficult to shop and prepare meals, try to eat little and often.
Make sure you get your flu jab every year to protect you against the flu viruses likely to be going round over the winter. The NHS offers it for free to people living with long-term conditions like COPD.
Your doctor should also offer you a vaccination against pneumococcal infection – a bacterial infection that can cause pneumonia and other illnesses. You only need to have this once.
You can also avoid infections by staying away from people – including babies – who have colds, flu, sinus infections or a sore throat. If you do get an infection, make sure you treat it quickly.
A flare-up – sometimes called an exacerbation – is when your symptoms become particularly severe.
You should have an action plan that you’ve agreed with your health care professional so you know what to do if you have a flare-up. Your plan may include a rescue pack of drugs (antibiotics and steroid tablets) that you keep at home.
What else can I do to manage my COPD better?
Remember, if you smoke, stopping smoking is the best thing you can do.
Make sure you sleep well and get enough rest every day. This will help with your energy levels. If you have trouble sleeping, try to exercise each day and don’t have tea, coffee or alcohol before bed time. Talk to your doctor if that doesn’t help.
Ask your doctor about ways you can adapt your home to help you move around more easily. An occupational therapist and your local council can help you with this. If your ankles swell, tell your doctor. Medicines can reduce this. But many people with COPD have other conditions, and leg swelling can be a sign of a heart condition. It’s important to talk to your doctor or nurse about longer-term treatments and advance care planning. This means thinking about what you would like to happen if your condition gets worse, or you experience more severe flare-ups, to help your family and your doctor to understand your wishes.
The sinuses are hollow air pockets in the bones of the face and head that probably exist to cushion the brain during trauma. The sinuses are lined with a thin layer of tissue that normally makes a small amount of mucus to keep the sinuses healthy and lubricated and flush away germs.
Rhinosinusitis occurs when the lining of the sinuses gets infected or irritated, become swollen, and create extra mucus. The swollen lining may also interfere with drainage of mucus.
Chronic rhinosinusitis refers to a condition that lasts at least 12 weeks, despite being treated, and causes at least TWO of the following symptoms:
● Nasal congestion
● Mucus discharge from the nose or mucus that drips down the back of the throat
● Facial pain, pressure, or "fullness"
● A decreased sense of smell
Chronic rhinosinusitis is different from the more common form of rhinosinusitis (called acute rhinosinusitis), which is a temporary infection of the sinuses that often occurs following colds. Chronic rhinosinusitis is a more persistent problem, which requires a specific treatment approach. It is sometimes overlooked by both patients and health care providers because the symptoms are more low-grade and chronic.
If you have been treated for rhinosinusitis with antibiotics multiple times within a single year or if you have two or more of the symptoms listed above much of the year, talk to your health care provider about whether you might have chronic rhinosinusitis. An article that discusses acute rhinosinusitis is available separately.
CHRONIC RHINOSINUSITIS CAUSES
Unlike acute rhinosinusitis, which is usually caused by infection, chronic rhinosinusitis often has more complicated and elusive causes. Infections can certainly contribute to or worsen chronic rhinosinusitis, but people with the chronic condition usually have long-standing inflammation that cannot be explained by infection alone. Health care providers divide chronic rhinosinusitis into three different categories, depending upon the features that are present.
● Chronic rhinosinusitis without nasal polyposis – Chronic rhinosinusitis without nasal polyposis is the most common type of rhinosinusitis. In this form of rhinosinusitis, the swelling and irritation of the sinus lining may be caused by different factors, such as allergies to things in the air, irritation from things in the air, and infections. The factors are different in different people.
● Chronic rhinosinusitis with nasal polyposis – Some people with chronic rhinosinusitis have abnormal growths inside their noses or sinuses called nasal polyps. The polyps can become large and numerous enough to clog the sinuses, causing symptoms. Scientists do not fully understand why some people form nasal polyps. Treatment involves medications to shrink the polyps or surgery to remove them. Some people need both.
● Chronic rhinosinusitis with fungal allergy ("allergic fungal rhinosinusitis") – Some people with chronic rhinosinusitis develop a strong allergic response to fungi (the plural of fungus) inside their sinuses. It is normal for air to contain small amounts of fungi (airborne spores), and most people can breathe in air containing fungal spores without problems. However, in some people, the allergy to fungi causes the sinus lining to make thick, dense mucus that fills the sinuses. To diagnose this type of chronic rhinosinusitis, a health care provider must find thick mucus in the sinuses, see fungi in the mucus under the microscope, and show (with allergy testing) that patients are allergic to fungi.
CHRONIC RHINOSINUSITIS RISK FACTORS
Several factors can increase your risk of chronic rhinosinusitis or worsen your symptoms once you have the disorder. These include:
● Allergies – Allergies are much more common among people with chronic rhinosinusitis than they are among people in the general population. This is especially true of allergies that are present year-round, such as dust mites, animal dander, molds, and cockroaches. Allergies that are poorly controlled can worsen the symptoms of chronic rhinosinusitis.
● Exposure to tobacco smoke or airborne irritants – Exposure to cigarette smoke or certain environmental toxins, such as formaldehyde, can increase the risk of chronic rhinosinusitis.
● Immune system disorders – Most people with chronic rhinosinusitis have normal immune systems. However, people with certain immune system problems are at an increased risk of chronic rhinosinusitis. They may also have recurrent problems with other infections, such as ear and chest infections. The most common immune problem associated with chronic rhinosinusitis is antibody deficiency (hypogammaglobulinemia). However, there can be more subtle problems with immune defense that mainly affect just the nose, sinuses, and lungs. The type of immunity involved in this is called innate immunity. Innate immunity functions as an alarm system to activate other components of the immune system, such as white blood cells (granulocytes and lymphocytes).
● Viral infections – Some people develop chronic rhinosinusitis after having repeated viral infections (such as the common cold), although it is not clear that the infections actually cause the chronic rhinosinusitis.
● Deviated septum – The piece of cartilage that runs down the midline of the nose and separates the nostrils, called the septum, is not entirely straight in many people. This is a condition called a deviated septum. This may be present from birth or develop later in life as the result of injury to the nose. A deviated septum is a common cause of nasal blockage. It may cause one nostril or sometimes both nostrils to be blocked, but it is not a common cause of chronic rhinosinusitis.
CHRONIC RHINOSINUSITIS SYMPTOMS
As noted above, the symptoms of chronic rhinosinusitis must include two or more of the following:
● Nasal congestion
● Mucus discharge from the nose or mucus that drips down the back of the throat
● Facial pain, pressure, or "fullness"
● A decreased sense of smell
Young children may have other symptoms, including chronic cough and halitosis (bad breath). Many people with chronic rhinosinusitis also experience fatigue, although this symptom is not used to diagnose chronic rhinosinusitis, because there are many other causes of fatigue unrelated to sinus conditions. Still, fatigue is a prominent feature of chronic rhinosinusitis, and it can be the most difficult symptom for some people to manage.
CHRONIC RHINOSINUSITIS DIAGNOSIS
Chronic rhinosinusitis is likely if a person has had two or more of the symptoms listed above for a period of at least three months. In addition, there should be evidence of sinus disease that can be seen on a sinus computed tomography (CT) scan or with a procedure called sinus endoscopy.
A sinus CT scan is a procedure that takes about 15 minutes and involves a series of radiographs of the head and face. The radiographs give a detailed picture of the sinus linings and any mucus or polyps within the sinus spaces.
Sinus endoscopy is an office procedure in which a clinician uses a thin tube attached to a camera to see inside the sinuses. Endoscopy also allows the clinician to take a sample of mucus from inside the sinuses to examine under the microscope. Samples of mucus from the nose (which are easier to obtain) are not representative of what is found in the sinuses.
CONDITIONS RELATED TO CHRONIC RHINOSINUSITIS
The linings of the nose and sinuses are similar to the linings of the lungs. About one in five people with chronic rhinosinusitis also has asthma. The people most likely to have asthma are those who have chronic rhinosinusitis and nasal polyps. Some patients with chronic rhinosinusitis, nasal polyps, and asthma also have a condition called aspirin intolerance. The symptoms of aspirin intolerance consist of a noticeable worsening in nasal or chest symptoms in the first few hours after taking aspirin, ibuprofen, naproxen sodium, or other nonsteroidal anti-inflammatory drugs (NSAIDs).
Worsening of symptoms may involve sudden nasal congestion, pain and pressure in the sinuses, wheezing, chest tightness, and cough. These reactions can be severe and even life-threatening. In contrast, acetaminophen (Tylenol) usually does not aggravate sinus and asthma symptoms. If you think you may have aspirin intolerance, you should avoid aspirin and other similar medications and talk to your health care provider.
CHRONIC RHINOSINUSITIS TREATMENT
The linings of the nose and sinuses are similar to the linings of the lungs. About one in five people with chronic rhinosinusitis also has asthma. The people most likely to have asthma are those who have chronic rhinosinusitis and nasal polyposis. Unfortunately, people with chronic rhinosinusitis usually need life-long treatment to keep the symptoms in check. Several treatment options are available for people with chronic rhinosinusitis, but not all treatments are appropriate for all people. Different combinations of these treatments will be recommended depending upon the type of chronic rhinosinusitis you have, the severity of your symptoms, and if other conditions are also at play (such as allergies or asthma).
Health care providers usually recommend starting with aggressive treatment to get symptoms and inflammation under control and then changing to a less aggressive approach over time.
Potential treatments for chronic rhinosinusitis include:
Lifestyle modifications — People with chronic rhinosinusitis who smoke cigarettes should stop.
People who have environmental allergies as a contributing factor to their sinus problems may be able to change things in their home or work conditions to reduce exposure to the specific allergens that bother them.
Daily nasal saline washing — Most people with chronic rhinosinusitis find that washing their nasal passages daily with saline (salt water) helps reduce symptoms. Washing the nose before applying medications also clears away mucus and reduces its interference with medications. The table provides instructions on how to make your own saline and perform nasal washes.
Glucocorticoid nasal sprays, washes, and drops — Because all forms of chronic rhinosinusitis involve some degree of inflammation (ie, irritation and swelling), most people with the condition need medications to reduce inflammation.
Glucocorticoids (commonly called "steroids") are very effective anti-inflammatory drugs. They also decrease mucus production and help shrink any polyps that may be present. Using glucocorticoids in the form of nasal sprays or drops has the advantage of putting the medicine right where it is needed and also of not treating the rest of the body where the drug is not needed.
Your health care provider will probably ask you to try a glucocorticoid spray initially, as sprays are easy to use. Sprays do not reach deep into the sinus cavities, but they reduce swelling in the nasal passages and open up the areas through which the sinuses drain. Some are available over-the-counter in the United States (sample brand names: Flonase Allergy Relief, Rhinocort Allergy), while others require a prescription.
If the sprays do not seem to be working well enough, your health care provider may suggest switching to nasal drops or adding a nasal glucocorticoid solution to the saline nasal wash. Nasal drops or washes help get the glucocorticoid solution higher up into the sinuses.
If drops are prescribed, you must put them into the nose while lying in specific positions. This allows the liquid to move into the different sinuses.
Glucocorticoid pills — In some cases, your health care provider will recommend taking glucocorticoids (steroids) by mouth (orally). The most commonly used oral glucocorticoid is prednisone.
Glucocorticoids taken orally get into the circulation and deliver higher doses of drug compared with nasal sprays, rinses, or drops. This can result in better treatment of the inflammation and more dramatic improvement in symptoms. However, glucocorticoids taken by mouth suppress normal immune responses throughout the body and can cause side effects, so health care providers use them only when necessary.
Antibiotics — Although chronic rhinosinusitis is often caused by inflammation rather than infection, sinus infections can develop and aggravate symptoms. As a result, some people need to take antibiotics. It is not unusual to need long courses of antibiotics, lasting several weeks, to fully treat a sinus infection in a person with chronic rhinosinusitis.
Leukotriene modifiers — Health care providers occasionally prescribe a group of medications called leukotriene modifiers to people with chronic rhinosinusitis. These medications include montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo). These treatments work by reducing inflammation in a different way than glucocorticoids. These medications are not used for all types of chronic rhinosinusitis, and they appear to be most helpful for people with chronic rhinosinusitis with nasal polyposis who also have asthma.
Surgery — Although health care providers usually attempt to get the symptoms of chronic rhinosinusitis under control with medication first, some people need surgery to reopen the sinus passages and remove trapped mucus or polyps.
Situations in which surgery is helpful include the following:
● When chronic rhinosinusitis symptoms do not improve enough with the medical treatments mentioned above and there is evidence of persistent sinus disease on sinus computed tomography (CT) scan, such as complete blockage of one or more sinuses.
● When nasal polyps are present that do not sufficiently shrink with steroid treatment.
● When "allergic fungal rhinosinusitis" is suspected. Patients with allergic fungal rhinosinusitis usually have one or more sinuses that are completely blocked on sinus CT scan. Often these sinuses appear on the CT to be filled with thick, dense mucus that is difficult to remove in any other way except surgery. The surgery also allows for collection of samples of mucus, which are needed to confirm the diagnosis of allergic fungal rhinosinusitis.
● When there is severe deviation of the septum causing nasal blockage or difficulty with sinus drainage.
As discussed above, surgery can be very useful in the treatment of chronic rhinosinusitis, although by itself, it is rarely enough to control symptoms long-term. The factors that caused the sinus linings to become irritated and swollen and produce extra mucus in the first place must be addressed. In addition, because it is often impossible to eliminate these factors completely, most people require medications to control inflammation over time.
Prescription drugs have been through a rigorous process of testing to ensure safety, despite this, a minority of individuals will develop side-effects. Side- effects are termed “adverse drug reactions” by doctors and although the majority of adverse drug reactions are relatively minor and may even allow continuation with the drug, in some cases more severe symptoms can occur.
The majority of adverse drug reactions are predictable and affect susceptible patients e.g. gastric irritation with aspirin, or occur due to an interaction between two drugs, e.g. bleeding with warfarin when taken with some antibiotics. Adverse drug reactions account for approximately 6.5% of hospital admissions and in up to 15% of patients prolong the hospital stay.
A smaller proportion of adverse drug reactions are due to drug allergy and in these cases the drug causes an unexpected reaction, which is not predictable in a particular individual. Typical symptoms include swelling of any part of the body, including the face, throat and tongue (angioedema), which may lead to difficulty in breathing, widespread itchy rash (urticaria), tight chest with wheeze and worsening of asthma or, in very severe cases, a drop in blood pressure leading to collapse or loss of consciousness. It is these cases of drug allergy that are investigated and managed in an NHS allergy department. Anyone who suffers such an allergic reaction should record details of the offending drug by keeping the original packaging, note down how much of the drug was taken, record as much detail about the reaction as possible, if appropriate, by taking photographs.
Typical cases of drug allergy presenting to an allergy department are as follows:
• Patients who have experienced a severe allergic reaction during general anaesthesia. All of these patients should be referred for further investigation.
• Patients allergic to multiple antibiotics where it becomes difficult to find a suitable antibiotic to treat infection.
• Allergy to a local anaesthetic, particularly at the dentist, where further dental work becomes difficult and sometimes leads to referral for general anaesthesia for relatively minor treatment.
• Patients who have experienced a severe allergic reaction, for example asthma or angioedema after taking an anti-inflammatory, e.g. aspirin, ibuprofen and diclofenac, and now require an anti-inflammatory for control of chronic arthritis.
• Patients on treatment for high blood pressure who develop recurrent episodes of swelling particularly of the tongue or inside the mouth.
• Patients who have experienced severe allergic reactions after vaccination. If the allergic reaction involves topically applied creams or ointments, or widespread peeling of the skin, it is more appropriate to be referred to a dermatology clinic.
Finally, it is important that all referrals for the investigation of drug allergy are made through the GP as he/she should have full details of previous allergic drug reactions. These details are essential before investigation can commence and the GP will also know of a suitable allergy clinic to which referral can be made.
If someone reacts to a food, they may have a Food Hypersensitivity (FHS). FHS reactions involving the immune system are known as food allergy (FA), all other reactions are classified as food intolerances (FI).
Between 6-8% of children and up to 4% of adults suffer from a FA. People with FA develop antibodies against certain proteins in foods known as allergens. When they eat that food their body reacts, usually immediately or less than an hour after eating, although some babies can have very delayed reactions to milk. Reactions usually involve itching or swelling of the mouth/throat and itchy rashes and/or hives like insect bites. Wheezing, hay fever, eczema and flushing can also occur.
Symptoms can be severe and include life-threatening anaphylaxis. FA in adults is often linked to hay fever in the spring and/or summertime, with reactions. This condition is known as Oral Allergy Syndrome (OAS) and involves immediate symptoms, typically itching of the lips, mouth and ears, triggered by a cross-reaction between the pollen antibodies and plant food proteins.
FI is commonly reported; about 20% of the population alter their diet because they believe they have a reaction to food. However the numbers who actually have FI are likely to be much lower. FI does not involve the immune system; symptoms are usually less severe than those in FA and may occur hours or days after the food was eaten. The commonest type of FI is lactose intolerance which affects people who cannot produce enough of the enzyme required to digest milk sugar. FI may be linked to other conditions; about 70% of people with irritable bowel syndrome report symptoms to specific foods.
The commonest foods causing FA are milk, egg, and peanuts, sesame seeds, kiwi fruit, fish, shellfish, tree nuts, wheat and soy. All of these foods (except for kiwi) have to be labelled if present or added to any food, however small the amount. A variety of fruits, vegetables or nuts can cause OAS, but the commonest triggers are apples, stone fruits (peaches, plums etc), hazelnuts and almonds. Milk and wheat are the foods most often reported to cause symptoms of FI.
FA and FI are best diagnosed by a specialist. For FA, tests measuring levels of food IgE antibodies may be useful, although a positive result may not mean the person is allergic to that food. There are currently no reliable tests to diagnose FI except when lactose intolerance is suspected. Once diagnosed, the only current treatment for FA or FI is avoidance of the known food trigger(s). Anyone with suspected or diagnosed FA or FI, who has cut out foods from their diet, needs to make sure their diet is not nutritionally unbalanced.
An expert assessment of the diet is essential for all children on food avoidance diets, and also for adults who are excluding milk or wheat. People with FA should also always carry their prescribed medication with them, and know when and how to take it. Some children will grow out of a FA, so teenage or young adults with an FA diagnosed in childhood should be reviewed.
Rhinitis means inflammation of the lining of the nose. Rhinitis is defined clinically as symptoms of runny nose itching, sneezing and nasal blockage (congestion). Common causes of rhinitis are allergies which may be seasonal (‘hayfever’) or occur all-year-round (examples include allergy to house dust mite, cats, dogs and moulds).Infections which may be acute or chronic represent another common cause. Rhinitis (whether due to allergic or other causes) is a risk factor for the development of asthma. Rhinitis is also implicated in otitis media with effusion and in sinusitis which should rightly be termed rhinosinusitis since sinus inflammation almost always involves the nasal passages as well.
Allergic rhinitis is very common, affecting one in four in the UK. As with other allergic disorders (asthma, atopic dermatitis) rhinitis is much more common in westernized societies; the prevalence of rhinitis continues to rise in many countries.
Allergic rhinitis is frequently ignored or regarded as trivial by family members, doctors and even sufferers themselves, probably because recurrent colds are common, particularly in small children. This is a big mistake since not only does rhinitis reduce quality of life, it can impair sleep and reduce school performance and attendance at work. Allergic children have been shown to have more infections and more problems with those infections.
Asthmatic children who get colds are 20 times more likely to be hospitalised due to their asthma if they are allergic and if they are exposed to high levels of their provoking allergens. Adequate treatment of underlying allergic disease helps to diminish these problems. Allergic rhinitis may itself be the first manifestation of allergic disease, e.g. as hay fever in teenagers or adults. Rhinitis may progress to persistent symptoms with resultant nasal congestion which impacts on adjacent structures such as the sinuses, throat, middle ear and bronchial tubes. This warrants proper investigation and treatment by a specialist in ENT or allergy.
Diagnosis rests on taking an adequate detailed history and supplementing this by examination and, if necessary, specific allergy tests. The timing of symptoms in relation to possible allergen exposure is of primary relevance.
Treatment of Allergic Rhinitis
This falls into 4 categories:
1. Allergen and irritant avoidance. Rhinitis is usually caused by inhalant allergens and very rarely by food. Some allergens such as pets can be avoided; others such as pollens are more difficult- although a holiday abroad or by the sea at the height of the relevant season can help. House dust mites are hard to avoid sufficiently reducing symptoms but some patients do find benefit from allergen proof bed covers particularly if such measures are combined with rigorous cleaning, avoidance where possible of soft furnishings and heavy curtains and use of hard flooring. However, in controlled clinical trials, such mite avoidance measures are not of proven value at the present time. Avoidance of irritants such as smoke also helps to reduce symptoms. Simply washing out the nose with a salt water solution can be very soothing. This can be achieved with half teaspoon of salt, half teaspoon of bicarbonate of soda (baking powder) added to a pint of lukewarm water, with gentle sniffing of the solution from the palm of the hand. Also salt sprays and custom-designed salt douches are inexpensive and available from high street chemists.
2. Drug therapy. Mild-moderate hay fever responds to antihistamines but it is very important to take advice from pharmacists and choose non-sedating antihistamines, otherwise driving, work and school performance is very likely to be impaired even in people who do not feel drowsy and who are not obviously sleepy. More problematic and persistent rhinitis is better treated with a topical nasal corticosteroid administered by spray or, in the case of associated sinusitis and/or nasal polyps by use of corticosteroid nasal drops. The new nasal corticosteroid sprays are not absorbed and can be very safely be used in adults and children.
Avoidance of directing the spray towards the nasal septum (the partition in the middle of the nose) and use of the nasal device without fiercely sniffing the spray into the back of the throat provides optimal benefit. Symptom relief is not immediate and treatment may take several days or a week or two to be fully effective. Combinations of treatments may be needed – other potentially useful treatments include anti-leukotriene tablets (Singulair), chromones (Intal, Nedocromil) and ipratropium (Rhinatec).
3. Immunotherapy (desensitization). Immunotherapy involves giving graded increases of allergens to which the sufferer is sensitive in order to induce allergen tolerance, which may last for years following discontinuation. Immunotherapy is reserved for patients with one or two major problematic allergens and without chronic asthma who are not controlled by the above measures. Injection (subcutaneous) or under the tongue (sublingual) immunotherapy is usually given regularly over 3 years. This form of treatment must only be prescribed initially by specialists in allergy.
Sublingual immunotherapy once the first dose has been given under expert supervision can be administered each day in the home. Sublingual reactions are very mild- mostly involving local itching and swelling in the mouth and throat- and short term lasting 1-2 weeks or less. Local side effects are to be expected and usually apparent at the first dose which should be given under supervision Side effects from injection immunotherapy may occasionally be more severe so injections must take place in the presence of a trained physician in a setting where immediate resuscitation facilities are available. Pre-seasonal treatment is effective for seasonal allergies, but it is not yet clear whether preseasonal use confers long term benefit, as observed for the injection route when used regularly all year round for 3 years.
4. Surgery. Surgery is only very rarely needed for rhinitis. Occasionally surgery with/without turbinate reduction is needed to allow access to the nose for more effective use of sprays or to open the sinuses in patients insufficiently responsive to medical treatment because of structural problems.
The allergic process can affect the skin producing 2 main types of rashes namely urticaria (hives, nettle rash, welts) or eczema.
Urticaria is a red itchy bumpy rash that is often short-lived and can appear in various shapes and sizes anywhere on the body. It is very common affecting 1 in 5 of the population at sometime in their lives. In some people urticaria is accompanied by large dramatic swellings commonly affecting lips, eyelids, tongue and hand called angioedema. In many individuals no cause can be found for the urticaria and angioedema but it can occur as part of an allergic reaction such as to foods, drugs, insect stings. Sometimes external/physical stimuli can provoke the condition such as sunshine, water, pressure on the skin, exercise and stress.
Angioedema without urticaria can occur and may be related to blood pressure lowering drugs called ACE inhibitors and examples of this group are lisinopril, enalapril and ramipril. Interestingly these reactions often start after several months/years of regular treatment and hence this important association must not be overlooked. Release of histamine in the skin produces urticaria and therefore antihistamines are the mainstay of treatment. The non sedating ones are most suitable such as cetirizine, fexofenadine and loratadine. In some individuals the rash persists over weeks and months and this chronic form may require specialist intervention to allow the condition to be appropriately treated.
Bronchiectasis is a long-term condition where the airways of the lungs become abnormally widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection.
The most common symptoms of bronchiectasis include:
a persistent cough that usually brings up phlegm (sputum)
The severity of symptoms can vary widely. Some people have only a few symptoms that don't appear often, while others have wide-ranging daily symptoms.
The symptoms tend to get worse if you develop an infection in your lungs.
How the lungs are affected The lungs are full of tiny branching airways, known as bronchi. Oxygen travels through these airways, ends up in tiny sacs called alveoli, and from there is absorbed into the bloodstream.
The inside walls of the bronchi are coated with sticky mucus, which protects against damage from particles moving down into the lungs.
In bronchiectasis, one or more of the bronchi are abnormally widened. This means more mucus than usual gathers there, which makes the bronchi more vulnerable to infection. If an infection does develop, the bronchi may be damaged again, so even more mucus gathers in them, and the risk of infection increases further.
Over time, this cycle can cause gradually worsening damage to the lungs.
Why it happens
Bronchiectasis can develop if the tissue and muscles that surround the bronchi are damaged or destroyed.
There are many reasons why this may happen. The three most common causes in the UK are:
- a lung infection during childhood, such as pneumonia or whooping cough, that damages the bronchi - underlying problems with the immune system (the body’s defence against infection) that make the bronchi more vulnerable to damage from an infection - allergic bronchopulmonary aspergillosis (ABPA) – an allergy to a certain type of fungi that can cause the bronchi to become inflamed if spores from the fungi are inhaled.
However, in many cases of bronchiectasis, no obvious cause for the condition can be found (known as idiopathic bronchiectasis).
Who is affected
Bronchiectasis is thought to be uncommon. It's estimated that around 1 in every 1,000 adults in the UK have the condition. It can affect anyone at any age, but symptoms don't usually develop until middle age.
Over 12,000 people were admitted to hospital in England during 2013-14 with bronchiectasis. The majority of these people were over 60 years old.
How bronchiectasis is treated
The damage caused to the lungs by bronchiectasis is permanent, but treatment can help relieve your symptoms and stop the damage getting worse.
The main treatments include:
Exercises and special devices to help you clear mucus out of your lungs
Medication to help improve airflow within the lungs
Antibiotics to treat any lung infections that develop
Surgery is usually only considered for bronchiectasis in rare cases where other treatments haven't been effective, the damage to your bronchi is confined to a small area and you're in good general health.
Complications of bronchiectasis are rare, but they can be serious. One of the most serious complications is coughing up large amounts of blood, caused by one of the blood vessels in the lungs splitting. This problem can be life-threatening and may require emergency surgery to treat it.
Idiopathic pulmonary fibrosis (IPF) scars your lungs and so reduces the efficiency of your breathing.
The build-up of scar tissue is called fibrosis. Fibrosis causes the lungs to become stiffer and lose their elasticity so they’re less able to inflate and take oxygen from the air you breathe.
IPF is a progressive condition and usually gets worse over time. In some people the symptoms gradually get worse over several years. For others, the symptoms get worse more quickly.
It’s difficult to predict how IPF will progress. Sometimes when the condition has been stable, people can get sudden flare-ups of symptoms, called acute exacerbations. Everyone is different - talk to your specialist doctor about your individual situation.
How does IPF affect breathing?
Each time you breathe in, you draw air in, down through your throat and into your windpipe. Your windpipe splits into two smaller tubes, called bronchi, which go to your lungs. The air passes down the bronchi, which divide into thousands of smaller airways called bronchioles.
The bronchioles have many small air sacs. Inside the air sacs, oxygen moves across paper-thin walls to tiny blood vessels and into your blood. The air sacs also pick up the waste gas, carbon dioxide, from your blood ready for you to breathe it out.
If you have IPF, scarring affects the air sacs, limiting the amount of oxygen that gets into the blood. With less oxygen in the blood, you can get breathlessness from everyday activities like walking.
Causes of IPF
Researchers now believe that the body creates fibrosis in response to damage in the lung. The initial damage might be from:
acid reflux from the stomach
viruses – in some studies, IPF has been linked to certain viruses, including the Epstein Barr virus, which causes glandular fever. The herpes virus and hepatitis C have also been suggested as possible causes
environmental factors such as breathing in kinds of dusts - It’s more common if you’ve been exposed at work to dust from wood, metal, textiles or stone, or from cattle or farming
Some people may be genetically predisposed to develop IPF when their lung is damaged.
The scar tissue cannot currently be changed back to healthy tissue, so there is no cure yet for IPF. Current treatments aim to slow the rate of scarring, but they do not stop it.
Before the availability of specific treatments, studies showed that almost half of people with IPF in the UK died within three years of their diagnosis. However, about one in five people lived for more than five years after they were diagnosed. Clinicians believe the treatments now available will mean that people diagnosed today will survive longer.
Treatment for IPF
Your specialist will try to slow the scarring and treat your symptoms so you feel better and your quality of life improves.
You should have hospital appointments every three to six months and your care might include:
pulmonary rehabilitation - a tailored exercise programme, which will help you cope with feeling short of breath
oxygen therapy – if the level of oxygen in your blood falls, you can have a portable oxygen cylinder or an oxygen concentrator at home, to make the air you breathe richer in oxygen
medication to help with symptoms
medication to slow the scarring in your lungs help to stop smoking, if you smoke
For a very few people, having a lung transplant might be an option if the IPF progresses and isn’t controlled by treatment. Transplants are rare. Dr O'Hickey will discuss lung transplantation with you within six months of being diagnosed, if it’s suitable for you. And, if you wish to explore the possibility, your doctor will contact the transplant centre.
For coughing, your doctor might treat problems that are making it worse, such as heartburn (acid reflux) or a stuffy nose. Make sure you tell your doctor if you have heartburn – there’s some evidence this may make your fibrosis worse as well as your cough.
To help you cope when you get out of breath, pulmonary rehabilitation is an important treatment and you’ll learn breathing techniques so that you feel more in control.
N-acetyl-cysteine or NAC helps break up mucus in the lungs, so your doctor may recommend it if you find it difficult to cough up phlegm or mucus. There’s anecdotal evidence that some people find it helps their cough, but others experience stomach discomfort, trapped wind or nausea.
Medication to slow scarring in your lung
There are currently two drugs which are licensed for use in IPF: pirfenidone and nintedanib. They both slow down the development of scar tissue in the lungs of people with IPF.
Several clinical trials are currently looking at possible new treatments, including combinations of existing treatments, so other options may be available in the coming years.
The National Institute for Health and Care Excellence (NICE), which advises the NHS on using new drug treatments, has only recommended the use of pirfenidone and nintedanib for people whose lung function is within a certain range. This means there’s a chance that your doctor may not be able to prescribe you either drug - they will explain why.
NICE has also recommended that if your IPF continues to get worse, these drug treatments should be stopped. Again, your consultant will discuss this with you.
Pirfenidone and nintedanib have not been directly compared in clinical trials. Your lung specialist will be able to discuss the pros and cons with you to help you decide which drug is best for you.
Pirfenidone - brand name Esbriet
This treatment comes in the form of capsules: the usual dosage is nine capsules each day (three taken with each meal).
Scientists don’t know exactly how pirfenidone works yet, but they think it slows down inflammation and the build-up of scar tissue in the lungs. In medical studies, it slowed down the loss of lung function in most people with IPF, decreased the rate at which their symptoms got worse and also improved life expectancy.
There are some common side effects. These are skin reactions to sunlight, feeling sick or nauseous, tiredness and indigestion. Talk to your doctor about possible side effects if you’re considering taking pirfenidone.
Nintedanib – brand name Ofev
Nintedanib is a new treatment which has also been shown in trials to slow the rate at which lungs become scarred in IPF. This drug is taken in the form of capsules, usually two a day.
Trials indicated nintedanib slows down the loss of lung function in people with IPF and may also reduce the rate of sudden flare-up of the symptoms.
Common side effects include diarrhoea and nausea. If you’re taking certain medications such as blood thinners, you may be advised not to take nintedanib.
Immunotherapy, often referred to as desensitisation, is the closest thing to a cure for allergy, particularly for allergies to some stinging insects and for allergic rhinitis. Immunotherapy is a well-established treatment for certain severe allergies, and involves the administration of gradually increasing doses of allergen extracts over a period of years, given to patients by injection or drops/tablets under the tongue (sublingual).
What is immunotherapy?
Allergy develops when the immune system makes IgE antibodies to 'fight off' a substance (allergen) that wouldn't normally bother us, such as pollen, animal dander, house dust mites, mould spores, foods or the venom of bees or wasps. Immunotherapy is an attempt to modify the immune system so that it no longer reacts to allergens as a threat. By giving the patient increasing doses of the allergen at regular intervals (starting with a very small dose) in a carefully controlled way, it is possible to teach the immune system to tolerate the allergen and not ‘fight’ it. If successful, immunotherapy causes the production of 'regulatory' immune cells, which stop the production of IgE and result in tolerance to the allergen.
All immunotherapy carries a degree of risk, is time-consuming and expensive. In the UK, it is generally reserved for patients with specific, severe allergies, particularly:
• treatment of potentially life-threatening allergic reactions to bee and wasp stings
• allergic rhinitis (hay fever) where symptoms are severe
The evidence for immunotherapy in atopic eczema and asthma is limited. A number of research studies are currently looking at oral immunotherapy for food allergies.
Will I benefit from immunotherapy?
Patients with certain allergies may be considered for Immunotherapy (IT):
1. Life-threatening reactions to wasp or bee stings
Severe reactions include sudden collapse (anaphylactic shock) or other life-threatening reactions such as swelling of the airways. Venom immunotherapy is highly effective, giving 98% protection against serious wasp venom reactions and about 90% protection against serious reactions to a bee sting. Patients with severe allergy to wasp and bee stings should always carry injectable adrenaline (epinephrine), but sometimes further medical aid may be necessary after a sting. It is for this reason that patients may be offered immunotherapy, which is usually given over a three to five year period. Around 10% of patients have reactions to the immunotherapy injections during the course, which is why therapy should always be undertaken and supervised by a trained specialist such as an allergist or immunologist.
Minor reactions, such as swelling at the site of the sting, or nettle rash (urticaria), are common and can be treated simply. Such patients do not need immunotherapy.
If you have had allergic reactions to wasp or bee stings, an allergy specialist's advice may be helpful in deciding whether immunotherapy is necessary, as the classification of reactions is complex.
There is no vaccine available for mosquito bites which rarely, if ever, cause generalised allergic reactions.
2. Severe hay fever
Most hay fever symptoms are well controlled with medicines such as nasal sprays, anti-histamines and eye drops. If these measures are effective then there is no need for immunotherapy. Most allergy clinics will not accept patients for immunotherapy unless they have tried all the usual treatments first and have taken them properly and in the right combination.
Patients often need a combination of medicines to control symptoms:
• regular steroid nasal spray, started at least 3 weeks prior to the hay fever season (once symptoms have started, it is much harder to control nasal inflammation)
• regular sodium cromoglycate eye drops
• regular steroid inhaler, if you have asthma
regular anti-histamine tablets
Where these medicines are used appropriately and yet fail to control symptoms, your doctor may recommend other medicines, such as a leukotriene-receptor antagonist, intranasal anti-histamine spray or occasionally, a short course of oral steroids. However, if you have tried the preventive approach outlined above and still need steroid tablets or have very severe symptoms, then you may be a candidate for pollen immunotherapy.
3. Animal allergies
Avoidance of the allergen is the most important step in preventing allergic symptoms due to an animal. If you keep pets to which you are allergic at home, you will not be considered for immunotherapy as it is unlikely to succeed when there is a background of continuous allergen exposure causing symptoms.
Most people who occasionally come into contact with animal allergens can treat themselves successfully by taking anti-histamines and inhalers prior to contact with the pet. For instance, if going to a friend's house where pets are kept, treatment should be started 30-60 minutes beforehand.
Immunotherapy may be indicated when a highly allergic individual is unable to control symptoms by this strategy and for those who react to the tiny quantities of allergen found on other people's clothes or in public buildings. An allergy specialist's advice is essential in this circumstance, to determine the contribution of the allergen exposure to allergic symptoms. Occupational exposure, such as in veterinary surgeons or nurses, or in patients whose job involves visiting people’s homes, may also be considered for treatment.
Conditions for which immunotherapy is unhelpful
• Multiple allergies. It is unusual for patients to receive immunotherapy for more than two allergies. Where a patient has severe symptoms caused by a number of different allergens (for example nasal symptoms caused by grass pollen, house dust mites, cats and moulds) they may be given immunotherapy for one or two of these so that symptoms are reduced to the level where they can be managed by the usual drug treatments.
• Food allergies There are currently no preparations available for immunotherapy treatment of food allergy. Research is ongoing to 'desensitise' people with allergy to particular foods such as egg and peanut by giving them a tiny dose of the food and gradually increasing the amount over time. Early results are promising but this research is still in its infancy and the technique is not widely available. It must be carried out on carefully screened individuals and in controlled conditions, and is not suitable for use at home as allergic reactions are frequent.
• Allergic rashes Rashes such as eczema and nettle rash cannot be treated with immunotherapy. Research is ongoing into whether certain forms of immunotherapy might be helpful in severe atopic eczema.
What does immunotherapy treatment involve?
Screening at an allergic clinic
If you and your doctor think that you may need immunotherapy, you will need to be referred to an allergy specialist. In some areas, this may mean travelling some distance, perhaps to a teaching hospital.
You will be asked to have some allergy tests: a skin prick test and sometimes a blood test for allergic antibodies.
You will also need a physical examination to assess your general fitness. It is important that conditions such as uncontrolled high blood pressure and asthma are stabilised prior to commencing treatment. It is sensible to get such problems sorted out before attending the allergy clinic, if possible.
If you are taking a beta blocker (a heart medicine) for any reason, you will need to discuss changing this for an alternative treatment.
If you have asthma…
Few asthmatics will be considered for immunotherapy. In general, the more severe your asthma, the less likely it is that you will be considered. This may seem unfair, but the reason is that severe allergic reactions to immunotherapy, although rare, are most dangerous in asthma patients. However, there are exceptions; for example, patients who develop asthma which occurs only in the pollen season can undergo immunotherapy to pollen when it is started well before the pollen season. Patients with asthma and severe allergy to bee or wasp stings can also undergo immunotherapy, as the risk of a life-threatening reaction to a sting outweighs the risk of any reactions during immunotherapy. However, it is important that asthma control is carefully maintained to reduce risks.
If the specialist thinks that you need treatment…
You may have to join a waiting list.
Pollen immunotherapy cannot be started during a pollen season. If your hay fever is uncontrolled by standard treatment during the current season, you may need a course of steroids from your doctor to tide you over. It is best to ask for a referral as soon as possible, in order to try and get on to the waiting list sooner. Treatment will need to be started several months in advance of the next pollen season.
Improvement with immunotherapy does not occur immediately. It usually takes at least 6 months before symptoms improve, often longer. It is recommended that immunotherapy is continued for about 3–5 years, to decrease the chance that the allergies will return. Patients undergoing immunotherapy need to continue to use their usual medications until the effects of the immunotherapy are well-established.
Immunotherapy injections (subcutaneous immunotherapy)
Subcutaneous immunotherapy is the most common type of immunotherapy treatment, and involves giving an injection to the patient containing the allergen to which they are sensitised. The injections are usually given as a course of injections of purified allergen extracts, under the skin of the upper arm. The schedule may vary at different hospitals.
In the beginning (induction phase), injections will be given at intervals of a week or less, while allergen doses are gradually increased. Once on the maintenance dose, you will be asked to continue attending for injections every few weeks for at least 2 years. You will be asked to wait in the clinic for one hour after each injection so that if serious side effects occur they can be rapidly treated.
"Rush" immunotherapy is a rapid method of reaching the maintenance dose. Several injections may be given each day, and sometimes this will require admission to hospital. This method is often used in patients with bee and sting anaphylaxis, as speeding up the protocol means the patient will be safer quicker should they be stung again. “Rush” protocols are only used in exceptional circumstances with other allergens, as allergic reactions to this type of treatment are more common.
Individual responses to immunotherapy vary and the duration of your treatment will be tailored to your needs. Skin tests and blood tests may be used to help determine how effective your treatment is.
Itching and swelling are common reactions at the injection site, although many patients experience no reaction at all. For some patients swelling can increase over hours to days after the injection. Anti-histamine tablets and an ice pack will help ease the swelling in this situation. Some patients feel tiredness or flu-like symptoms over the hours following an injection. Avoiding alcohol or strenuous activities on the day of the injection reduces the risk of side effects such as these.
There were some serious reactions to immunotherapy in the past but modern immunotherapy vaccines have a good safety record. The allergen extracts are more highly purified and are administered only by highly experienced specialists in a safe environment.
Some new injection vaccines are becoming available which produce their desensitising effect much more rapidly and can be given as one short course of four injections over 3–4 weeks before the pollen season, with few side-effects and good results. The same technique may also be used for immunotherapy to house dust mites and animals, which would greatly reduce the expense and time-consuming commitment required to undergo current immunotherapy regimes.
Alternatives to injections – sublingual immunotherapy
Sublingual immunotherapy (SLIT) is being used at some specialist centres in children and adults who have airborne allergies. A standard course of this treatment involves a dose of the allergen given as a daily tablet or spray under the tongue, which is increased over time. There is a risk of some mild allergic reactions, but these generally disappear over time, and overall the treatment has shown to be successful in reducing the severity of symptoms and allowing patients to take less medication to control their allergy.
Sublingual drops are becoming more commonly used in specialist allergy clinics but are still not widely available. A tablet version for grass-pollen desensitisation is licensed for use in the UK, and a similar product for house dust mite may be introduced in the near future. Treatment is started in a specialist allergy clinic where the necessary diagnostic tests are carried out and suitable patients can be identified. Once it is established that the treatment is safe for that patient, it can be continued at home by taking one tablet daily. This type of treatment works well and generally has few side effects. The current recommendation is for a 3-year course of treatment but it may be that a shorter course will be shown to be almost as effective. At the moment this treatment is expensive and is not widely used, but availability should improve over time.
SLIT has been shown in large studies to be an effective treatment for allergic rhinitis, but good comparison studies have not yet been done to compare SLIT with injectable immunotherapy. It is very important to take the SLIT medicine regularly (usually daily), and missing out doses will cause it to fail. Therefore, many patients prefer injections as compliance is less of an issue. On the other hand, SLIT is more acceptable to children and adults who dislike needles. Your allergy specialist will be able to discuss your treatment options, as not all forms of immunotherapy are available as SLIT.
At present, sublingual immunotherapy is not available as a treatment for food allergies. It is also only available in a small number of specialist centres.
Pulmonary rehabilitation (PR) is a programme of exercise and education for people with long-term lung conditions provided by the NHS and, in some areas, privately.
It combines physical exercise sessions with discussion and advice on lung health and is designed to help you to manage the symptoms of your condition, including getting out of breath.
A course of PR lasts about six to eight weeks, with two sessions a week. Each session usually lasts between one-and-a-half and two hours. You will be part of a group, commonly between eight and 16 people.
• help to improve your muscle strength, so you can use the oxygen you breathe more efficiently.
• improve your general fitness and help you to cope better with feeling out of breath.
• help you to feel to stronger and fitter, and able to do more.
Please bear in mind, however, your lung function is not likely to change, so you might not see a difference when you take the simple ‘blowing test’. This is also called a spirometry test.
Who should go to pulmonary rehabilitation?
PR is aimed at people who have breathing difficulties caused by a lung condition that affects their ability to do normal activities. A lot of these people have chronic obstructive pulmonary disease (COPD). Some studies have shown that people with asthma and other long-term lung diseases such as bronchiectasis or idiopathic pulmonary fibrosis (IPF) also benefit.
Your age and the severity of your condition will not stop you from taking part in PR, or from seeing an improvement. Completing a course of PR is a good way to learn how to exercise at the right level for you.
Research tells us that PR leads to improvements in your ability to walk further and in your quality of life. PR should help you to feel less breathless doing day-to-day activities, such as walking up stairs, shopping and dressing. You should feel less tired too. Taking part will help you learn how to exercise in a safe and sociable environment. Most people enjoy the programme, gain confidence and benefit from meeting others in a similar situation and sharing their experiences. Some PR courses are held in a hospital, but often they take place in community halls, leisure centres or health centres.
How do I get pulmonary rehabilitation?
The first step is to ask your GP to be referred to your local programme. You can also ask your practice nurse, your respiratory team or chest clinic. Pulmonary rehabilitation should be available across the UK, but some programmes will have waiting lists, so the sooner you act, the sooner you start.
While you are waiting you can get in touch with your local respiratory team or PR team for advice. They should be able to give you some general information over the telephone or as part of your care. You can also ask your GP for an assessment of your fitness to exercise and for a referral to an activity you want to take part in.
What happens in a pulmonary rehabilitation course?
During your course, your PR team will teach you how to increase your activity safely and effectively, and manage breathlessness and feelings of anxiety or panic. Your team will be made up of trained health care professionals such as physiotherapists, nurses and occupational therapists. A typical PR course will always start with an assessment of your health and abilities. Ideally, this assessment will take place a week or two before you start your course.
The health care professionals taking you through the course will ask questions to understand you and your body, and help you get the best out of the course.
They will want to find out:
• what you can and cannot do;
• how activity affects you; and
• how you are feeling and coping with your condition.
At each session, you will spend about half the time on physical exercise. This will be carefully designed according to your needs, so that it provides just the right level of activity for you. The rest of the time will be spent providing information and tips about living with a lung condition and getting the best out of life. These discussions will take place in a friendly, supportive atmosphere. Topics might include:
• breathing techniques to use when recovering your breath, or during physical activity or if you feel anxious
• why exercise is so important for people with lung conditions
• how to manage stress
• healthy eating
• how to use your inhalers and other medicines
• what to do when you are unwell
Being with other people who have similar problems to you can also be very helpful, as well as making sessions enjoyable and fun. Group members often share useful tips with one another.
You will get out of breath when you take part in a PR course, but this is part of the therapy. You will always be monitored and you will never be asked to do more than you can do safely.
PR is about helping you manage your condition better. It is not a cure, but you will feel better and more confident and in control. PR requires your commitment to really work. You need to attend sessions regularly and follow the advice given by your team. After you have completed your course, it is important to carry on exercising regularly, stay active and use the techniques you have learned.
Important points to remember:
• PR is designed for people who have breathing difficulties caused by a lung condition and should be available across the UK. Ask for a referral from your doctor, nurse, respiratory team or chest clinic.
• PR combines a physical exercise programme with advice on lung health to enable you to find the right level of exercise for you and help you understand and better manage your condition.
• You will get out of breath during the course; this is part of the therapy.
• PR is not a cure, but you will feel better and more in control.
• After you have completed your course, it is important to carry on exercising regularly, stay active and use the techniques you have learned.