Originally published in the Ottawa Citizen, August 10, 2004

Shortness of breath (dyspnea) strikes deep at a person’s self-preservation instincts. The fear of suffocation commonly leads to a feeling of panic. The ability to diagnose and treat the condition depends upon past medical history, the ability to gather a good medical history of the acute condition and prompt evaluation of the patient’s physical findings.

We will run through a template for your use to help you gauge you first course of action. Acute shortness of breath is best assessed in an emergency department setting because it is equipped to manage, treat, and diagnose the problem.

It is a parent’s nightmare to see there newborn child or infant struggle to breathe. The ensuing panic understandably clouds the parent’s ability to assess the situation. Often, patients or family members will call their doctor’s office or help-line for advice.

An infant that is in respiratory distress will have these signs:

1)      The skin between their ribs tugs inward (indrawing)

2)      The abdomen pops outward while their ribcage pulls inward with each effort to breathe inward, then the reverse happens (paradoxical breathing).

3)      There is indrawing at the semi-circular notch at the top of the breastbone (sternum).

4)      The nostrils flare in order to maximize air intake.

5)      The head bobs forward with each inspiration

6)      Grunting noises

There are six criteria to consider in children when they are short of breath:

• Are they less than three months of age?
• Did the dyspnea start suddenly?
• Does the child have a sore throat?
• Do they have a croupy cough (sounds like a barking seal)?
• Are they lethargic?
• Do they have a temperature of 38.8 ºC of 102 ºF?

Answering “yes” to one or more of these questions requires prompt emergency department evaluation. If all the answers are “no”, the child needs a same-day office visit to his or her doctor.

The most common causes of shortness of breath in children are lung infections like pneumonia, croup and infection and swelling of the smaller airways (bronchiolitis).

Adults have a different set of criteria to assess whether urgent care is required:

• Do they have severe dyspnea?
• Are they experiencing dyspnea at rest?
• Is this the first time they have felt short of breath at rest?
• Do they have a sudden onset of chest pain?

An affirmative answer to any one of these criteria requires an emergency department assessment. If the patient has a history of congestive heart failure or chronic obstructive pulmonary disease but answers “no” to the above questions they must inform his or her doctor and pay them a same-day visit to adjust the treatment regimen.

The causes of dyspnea in adults are legion: congestive heart failure (CHF) asthma attacks, chronic obstructive pulmonary disease (COPD), heart attack, foreign-body obstruction of the airways and panic attacks among the many other causes.

Some of the other causes of dyspnea are revealed by a thorough patient history and physical exam. For example, a severe sore throat that is associated with shortness of breath may be due to a swollen epiglottis. The epiglottis is a flap of tissue that acts as a protective shield by covering the entrance into the lungs when you swallow food. If it swells too much it can lead to an airway obstruction.

Each symptom or sign may relate to a specific cause of dyspnea. Asthma and pneumonia are linked with cough. A painful chest wall can direct the physician to think about a collapsed lung (pneumothorax), pneumonia, a blood clot in the lung (pulmonary embolism) or inflammation of the outer skin covering the heart (pericarditis).

Someone who suddenly wakes up at night and bolts upright to catch their breath, requires pillows to prop up his or her head because they cannot breathe if they lie down or has markedly swollen feet may be suffering from a sudden exacerbation of congestive heart failure.

Tobacco users are at risk of developing chronic obstructive lung disease, congestive heart failure and pulmonary embolism.

Indeed there is an interrelationship between all these signs and symptoms. It is imperative to assess shortness of breath symptoms quickly because some of the causes cause greater harm in a shorter time frame than others.

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Originally published in The Ottawa Citizen July 2, 2004
Original Title: Asthma Perspectives
How many asthmatics think their asthma is under control? If you are like most Canadians, 91 per cent believe so. Indeed, perception is not a mirror of reality.

An Asthma in Canada survey done by the Division of Respiratory Medicine, University of Toronto, Division of Clinical Epidemiology, McGill University, the Angus Reid Group and Glaxo Wellcome indicates that 57 per cent of those who believe their asthma is well-controlled are wrong.
Ninety per cent of respirologists and 77 per cent of primary-care doctors believed their patients were managing their asthma well. In fact, only 43 per cent of these patients were controlling their asthma.

The impact of poorly managed asthma results in a poor quality of life, diminished physical functioning, absenteeism, increased emergency department and office visits, hospitalization and, for some, death.

Many will not notice their deteriorating condition because of the body’s ability to adapt to chronic disease; the gradual decline is insidious.

How can we reverse the trend that is seeing asthma control falling behind national standards set out in the Canadian Asthma Consensus Guidelines?

Knowledge is power. Many asthmatics mistakenly believe they will remain symptomatic from their asthma throughout their lives. They do not understand the role of various medications.

Education is the means to reduce the suffering because it empowers patients to take control of their illness and make decisions on-the-fly instead of waiting to see their doctor for advice. Asthma medications will effectively control different mechanisms of the disease (for a full review of asthma, please go to http://members.rogers.com/barrydworkin/be_alert.html).

Inhaled corticosteroids, the mainstay of treatment, reduce and reverse the inflammation, mucous production and tissue destruction within the airways. Once started, they require about a week to reach their full therapeutic benefit.

Bronchodilators or beta-2 agonists (the blue puffers) relax the rings of muscle that encircle and squeeze the airways during an asthma attack. They are not to be used as the sole means of asthma control. Indeed, using them more than two or three times a week indicates uncontrolled asthma. Growing bodies of evidence indicates that combination therapy (a corticosteroid and long-acting bronchodilator like Advair and Symbicort) provides a better therapeutic effect.

Many people reduce inhaled corticosteroid use over the summer. Given that asthma is an inherently unstable disease, this action increases their risk of asthma exacerbations.

A study looking at childhood asthma attack frequency shows a spike at week 38 of the year (Sept. 10 to 18). Most children return to school at week 37. Viral infections spread quickly with the children at close quarters. This effect, in combination with a reduction of their medication use, accounts for this spike.

Parents should ensure that their children restart their inhaled steroids at least midway through August if they have reduced or discontinued them. This will help to ensure they are protected once they return to school.

A new asthma education program has started at the Ottawa Hospital. The program, PRIISME, is a co-operative effort between the hospital and GlaxoSmithKline. Glaxo is providing the funding and materials for the program.

PRIISME provides disease management tools for prevention, diagnosis, treatment, patient compliance and follow up. It offers patients a series of educational interventions centred on self-management. The goal is to improve detection of asthma sufferers with poor control, provide education about optimizing control and the role of their medications and provide medical services through the respirology clinic at the General campus of the Ottawa Hospital.

Dr. Bob Dales, chief of respirology, is providing his department’s services to support PRIISME. The program will offer family doctors the opportunity to educate their support staff so they can teach their patients about asthma. A certified asthma educator will book educational sessions at various clinics. Asthma education referrals can be directed to the Lung Association Education Center.

The goal is to reduce the workload of primary-care physicians yet improve patient education and asthma management. PRIISME will co-ordinate community services, provide continuing medical education and education for patients and their families. Emergency room visits, unscheduled doctors’ visits and hospitalizations in Quebec for asthma are down since PRIISME’s inception in 1999.

If you have daytime asthma symptoms four days a week or more, night-time symptoms more than once a week, diminished physical endurance, frequent asthma exacerbation, missing school or work and using you bronchodilator inhaler more than four times per week, you should consult your doctor; your asthma is not controlled.

There is no reason to suffer with this illness. Indeed, there is little reason to experience many of the symptoms associated with asthma if treated correctly. Your quality of life should be equal to someone who does not have asthma.

For more information about PRIISME, contact Kathleen Devecseri at the Ottawa Hospital, General campus.

Related articles:

1. Medication only part of asthma care
2. A reader asks about asthma
3. Be alert for early warning signs of asthma

Originally published in The Ottawa Citizen January 6, 2004
Original Title: A reader’s questions about asthma

From time to time I receive mail from readers asking about various medical conditions. One such letter contained numerous questions about asthma and lung disease that I wish to address in this column.

Can asthma lead to bronchitis or pneumonia?

Many people with a chronic cough are told they have chronic bronchitis. Often, what they probably have is asthma. If left untreated, asthma can cause the accumulation of mucus in the airways that can impair the lungs’ ability to clear out pneumonia-causing bacteria. Viral infections such as colds and flu can further impair this cleansing action. Well-controlled asthmatics have a minimal risk of developing pneumonia.

Can asthma leave for years and then return?

There can be periods of remission and relapse. Many children may experience severe asthmatic symptoms that gradually become less of a problem with age. Among the reasons for this are increases in lung size and airway diameter. This can reduce the risk of mucus plugging the airways. Allergies may become less severe or disappear. An environment that has fewer irritants and pollutants can reduce the frequency of asthma exacerbations. Relapses can occur without warning. Indeed, many people moving into Ottawa will report an increase in their asthma symptoms. The geographic characteristics of the Ottawa valley act as a reservoir for particulate matter and allergens.

Are there different kinds of asthma?

Yes. Each person may have specific asthma triggers. Some people will experience an attack when they exercise. Others may have completely normal lung function and require medications only when they develop a cold, flu or other infection. Allergies play a major role in asthma exacerbations for many others. Smoking can lead to the development of asthma and chronic lung disease. The treatment strategies may be different for each group.

Why are more people suffering from asthma?

This question perplexes many physicians. Various factors including maternal smoking, genetic factors, industrial pollutants and allergies contribute to the increased incidence of asthma. So far, there is no unified theory to explain the overall trend.

Does obesity make asthma worse?

Abdominal obesity can restrict the chest’s ability to expand with breathing efforts. It does not necessarily cause asthma but can hinder lung function, reducing the volume of air that fills the lungs.

Are there any lung-strengthening exercises an asthmatic can do to strengthen the lungs and get rid of asthma once and for all?

No. Asthma is a chronic disease that causes swelling and mucous secretions within the airways (bronchi) leading into and throughout the lung. It is not caused by any structural weakness within the respiratory system. Appropriate medical treatment can completely control asthma for most people.

Why can’t I take a brisk walk some mornings without coughing and wheezing, but I can walk later in the same day without any problems?

In mid to late spring, summer and early autumn, mornings are usually cooler than in the afternoon. For some asthmatics, abrupt temperature changes and rapid respiratory rates during exercise can trigger wheezing and shortness of breath. Bronchi naturally constrict (bronchoconstriction) when exposed to cold air.

Why do my symptoms leave when I stop and rest?

With cessation of exercise, breathing rates slow, reducing the stress on the airways.

How many people in Canada die each year because of lung disease?
Is it because they did not take their medication or because their medication failed?

Most deaths and misery associated with lung disease are caused by chronic obstructive pulmonary disease (COPD) and primary lung cancer. Both these smoking-related illnesses are preventable. In 1997, Health Canada reported COPD to be the fourth leading cause of death in men and seventh for women, killing 9,618 Canadians, and overall the fifth leading cause of death in Canada. The past 30 years has seen a 400-per-cent increase in COPD deaths. By 2020, it will be one of the leading causes of death in Canada.

An estimated 21,000 Canadians (12,000 men; 9,000 women) will have been diagnosed with lung cancer in 2003, and 18,800 will die from it. One in 11 men and one in 18 women will develop lung cancer during their lifetimes. One in 12 men and one in 20 women have a lifetime risk of dying from lung cancer.

Despite newer medication formulations and treatment protocols, asthma rates continue to climb. All asthmatics who use their bronchodilators (Ventolin and Airomir, Apo-Salvent and Berotec) more than two to three times a week have, by definition, unstable asthma. Many do not use the proper technique to inhale their medication.

It is frustrating for family and friends to bear witness to needless suffering. COPD and primary lung cancer can be prevented. Asthma can be controlled. Your doctor is available to help you.

Related articles:

1. Be alert for early warning signs of asthma
2. Silent epidemic gains momentum
3. Medication only part of asthma care

Originally published in The Ottawa Citizen October 9, 2003
Original Title: Smoking out the silent killer

Take a regular diameter (pencil eraser) size straw and breathe through it while pinching your nose for five minutes. How many would be able to complete this task before gasping for air? Everyone understands the panic that envelops us when we cannot breathe. This universal response is one of our greatest fears. Despite this, an increasing number of people experience and live with the straw reality and are slowly suffocating to death.

Among the common fatal diseases, only one continues to buck the trend of diminishing incidence: chronic obstructive lung disease or COPD. Although air and industrial pollution and hereditary factors contribute to COPD, 90 percent is due to long-term cigarette smoking or passive exposure to second hand smoke.

COPD blocks the large and small airways of the lungs. A collection of diseases (emphysema, asthma and chronic bronchitis) contribute to chronic cough, difficulty breathing, increased mucous secretions within the lung’s airways (bronchi), impairment of the lungs ability to oxygenate the blood and airway obstruction.

Delicate air sacs at the end of the airways (alveoli) oxygenate the blood. Oxygen passes through the wall of the alveoli into the red blood cells in the bloodstream. Carbon dioxide follows the reverse path back into the lungs to be exhaled. The alveoli’s destruction forms cavities or holes within the lung tissue becoming “dead space” or emphysema. COPD is irreversible, destroys the lung’s natural ability to exhale and gets worse from year to year.

The normal elastic nature of the lung that is responsible for exhaling is destroyed. The lung remains permanently inflated with stale air with little means to forcefully breathe it out. Indeed, COPD sufferers breathe rapidly and shallowly to try to exchange what little oxygen they can with the bloodstream. They suffer tremendous debilitating effects of this disease: oxygen tanks in tow, minimal exercise capacity, social isolation and little to no energy to perform routine activities such as transferring from a sitting to standing position.

In 1997, Health Canada reported it to be the fourth leading cause of death in men and seventh for women killing 9618 Canadians and overall the fifth leading cause of death in Canada. The past 30 years has seen a 400 per cent increase in COPD deaths.

It is the fourth most common cause of hospitalization for men and sixth for women. It is truly a silent epidemic and is the only leading cause of death that increases every year. The majority of people affected are over the age of 60.

Other more noted diseases garner more attention but left to its druthers, COPD will supplant many of the diseases we diligently work to eradicate or control. Present trends indicate it will be one of the leading causes of death in Canada within the next ten to 20 years. The journal Lancet reports by 2020 it will be the third leading cause of death in the world.

The death rate for men should stabilize by 2016 because of their declining smoking rate. Women, who continue to provide the cigarette companies with increasing earnings and sales, will see their death rates triple by 2016 surpassing men. Indeed there is growing evidence women are more susceptible to the deleterious effects of smoking than men.

These numbers may indeed be an under-reflection of the problem because the Canadian National Mortality Disease Database does not record COPD as a cause of death and the public has difficulty recognizing the early stages of the disease.

The 1998/99 National Population Survey indicates 500,000 Canadians or 3.2 per cent of the adult population were diagnosed by a health professional with chronic bronchitis or emphysema. The burden upon hospital services will not wane. In 1995, 51,684 hospital discharges and 12,478 days were related to complications of COPD.

While COPD is a significant cause of death, the economic and social implications of the disease are a heavy burden. Health Canada estimates the treatment of respiratory illnesses like asthma and COPD cost $4.3 billion (1993 dollars) with COPD accounting for 75 per cent of the total.

This year 60,000 Canadians with COPD will end up in hospital increasing to 120,000 by 2016. It is an incurable illness and treatments to counter the disability are fair at best.

COPD sufferers lose contact with the outside world, lose their independence, control and confidence as they become reliant on others for their care. They lose hope because they discover they are not the person they used to be and witness the relentless deterioration of their condition.

The debilitating effects of chronic disease are legion. It is an imperative of modern medicine to alleviate suffering and reverse the effects of chronic disease upon the physical and spiritual well-being.

COPD is a preventable illness that frustrates the hell out of families and health-care professionals who witness the suffering and misery that it leaves in its wake. Please consult your doctor about quitting smoking and seek early treatment if you have concerns about COPD.

The Lung Association’s excellent web site: http://www.lung.ca/breathworks/D01.html and http://www.on.lung.ca/yourlungs/lungdisease.html or call The Lung Association’s Information Line at 1-866-717-2673.
© Dr. Barry Dworkin 2002

Related articles:

1. A reader asks about asthma
2. Understanding COPD
3. Doctors must factor in free will of the patient

Originally published in The Ottawa Citizen February 10, 2003
Original Title: No rest for the weary

Last week’s column reviewed how obstructive sleep apnea is more than just a problem of poor sleep. More than 90 per cent of obstructive sleep apnea sufferers remain undiagnosed and face real health risks.

Recent evidence implicates this condition with the development of high blood pressure (hypertension). Half of all people with high blood pressure have obstructive sleep apnea and half of all people with sleep apnea have hypertension. As the severity of obstructive sleep apnea worsens, so too does hypertension.

The effects of uncontrolled hypertension are well known. Recent studies indicate that successful treatment of sleep apnea significantly reduces blood pressure levels. Left untreated, obstructive sleep apnea can contribute to advanced heart disease, stroke, congestive heart failure, irregular heart rhythms, kidney damage, impaired concentration, divorce, headaches and impotence.

Indeed, the standard blood pressure medications do not work as well for some individuals with obstructive sleep apnea. When this occurs, it can confound both doctor and patient because the expectation is that medical therapy should work.

Blood pressure normally drops while you are asleep. Sleep apnea prevents this nighttime relaxation of the cardiovascular system. Breathing can stop (apnea) up to 600 times per night. The brief awakenings following each apneic spell cause a several second spike in blood pressure.

This spike stimulates hormonal changes that can affect kidney function, increase constriction of the arteries slowing blood flow and stimulate the nervous system increasing the heart rate. The sleep apnea sufferer has an increased risk of blood clots and stroke because of an increase in substances that promote clot formation.

Sleep apnea treatment encompasses lifestyle change, the use of special assist devices, and in some instances, surgery.

Lifestyle modifications include weight loss if obese, smoking cessation and avoiding alcohol and prescription sleeping pills. Sleeping on the back can cause loose throat structures to fall back into the airway blocking it. Lying on one’s side can alleviate this problem.

A low-tech solution for some people is using the “tennis ball technique”. Placing a tennis ball near the middle of your back (using a wide cloth belt to hold it in place) will prevent you from rolling onto your back. As you shift to your back the ball will press into the spine forcing you to return to your side.

Another option is to use an oral device such as a custom-made plastic mouthpiece. It can help keep the tongue and jaw remain in a forward position while sleeping.

The most effective means of controlling obstructive sleep apnea is by Continuous Positive Airway Pressure (CPAP). The device pumps air under low pressure through a nasal mask. This air pressure prevents the tissue structures within the throat from collapsing and blocking the airway.

Most patients with mild, moderate and severe obstructive sleep apnea can benefit from CPAP. It might take a few days to get used to wearing the mask but it can change your life for the better.

Surgical solutions are not always curative. An ear, nose and throat specialist (ENT) can determine if there indeed are anatomical causes of sleep apnea.

The ENT specialist will answer your questions about the various success rates and the risks and benefits of the various surgical procedures compared to non-surgical options. Further consultation with a sleep specialist adds another dimension to the decision-making process.

The most common surgical procedure is uvulopalatopharyngoplasty. A portion of the uvula (the tissue that hangs down in the back of the throat) and loose tissue is removed by laser. The success rate varies from 40 to 60 per cent and predicting which patients will respond well to treatment is problematic.

Other surgical procedures include unblocking the nasal cavity, removing the tonsils and adenoids, corrective surgery of the jaw and cheekbones and somnoplasty. The latter involves the use of a high-frequency energy beam to shrink part of the soft palate and tongue.

The treatment goals for obstructive sleep apnea are to prevent the complications of cardiovascular disease, excessive daytime sleepiness, motor vehicle accidents, accidental injury, poor work performance and for some, marital difficulties.

If you suspect you, a friend or family member has sleep apnea please consult your doctor. Some studies indicate that treatment reduces the rate of hospitalizations and death and improves the disease complications.

For more information, contact the National Center on Sleep Disorders Research at the National Heart, Lung, and Blood Institute Information Center, National Institutes of Health (http://www.nhlbi.nih.gov/health/prof/sleep/ index.htm) the American Academy of Sleep Medicine (http://www.aasmnet.org/) or the American Sleep Apnea Association (http://www.sleepapnea.org).
© Dr. Barry Dworkin 2003

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Originally published in The Ottawa Citizen February 3, 2003
Original Title: Snoring your life away

Aside from the jokes and a partner’s resignation to a lifetime of disrupted sleep, snoring is not an issue that gets much airplay. Snorers, including the “I-don’t-snore” crowd, may have more than just a problem of annoying those within their noise radius.

Snoring occurs when the muscles and structures lining the throat partially relax closing the airway. It is similar to forcing air through pursed lips. The lips vibrate and a raspberry is born. The rapid airflow through the narrowed airway causes the palate and tongue to vibrate creating the snoring sound or a raspberry in reverse.

Snoring can be a symptom of a serious health risk: obstructive sleep apnea. Obstructive sleep apnea is present in two per cent of women and four per cent of men between 30 and 60 years of age. Obstructive sleep apnea sufferers do not have restorative sleep and one-third have frequent urination during the night. They wake up tired, some with morning headaches, others with little drive or motivation akin to depression.

About ten times per hour, the snorer may stop breathing (apnea) between ten seconds to a minute at a time because the loose structures of the throat collapse blocking the airway.

Breathing restarts with gasping or “snarkling” noises before they resume their snoring rhythm. They may briefly wake up after each apneic spell but have no memory of doing so.

Anatomical changes, lifestyle habits and certain medications negatively affect obstructive sleep apnea:

* Chronic blockage of the nasal passages, a long and wide uvula (the structure that hangs down in the back of your throat), large tonsils and tongue and small lower jaw
* Smoking, lack of sleep, alcohol consumption and sleeping on your back instead of on your side
* Anti-anxiety medications and sleeping pills (valium, alprazolam, lorazepam, oxazepam among others), barbiturates and narcotics

Obesity accounts for 70 per cent of obstructive sleep apnea. Weight gain can increase the incidence of snoring and sleepiness. A large neck size and abdominal obesity are additional risk factors for obstructive sleep apnea.

Excessive daytime sleepiness is a red flag for possible obstructive sleep apnea. This classic sign includes falling asleep while sitting, reading, watching TV, or when at work. Obstructive sleep apnea sufferers tend to be forgetful, more irritable and state that their brain feels foggy. They have a sevenfold increase risk of motor vehicle crashes because of their tendency to fall asleep at the wheel.

They have a greater incidence of work-related accidents, poor job performance, depression, family conflicts and decreased quality of life than those without the sleep disorder. Family members notice these changes and are a great help in bringing this problem to the attention of their family physician.

If you suspect a loved-one or friend may have obstructive sleep apnea, your family doctor will take a detailed sleep history.

Is the snoring loud or quiet? Does it disappear when they lie on their side and return when they roll onto their back? Snoring that sounds like a variable speed buzz saw switching on and off is highly suggestive of obstructive sleep apnea as opposed to quiet steady snoring.

Does the person fall asleep when reading, watching TV, driving a car, sitting in a movie theatre or working at their desk? Are they sleepy, tired or fatigued throughout the day?

Do they stop breathing during the night? Most heavy snorers and patients with obstructive sleep apnea have a dry mouth because they usually breathe through their mouth while asleep.

Your doctor will order a sleep study to confirm the diagnoses. It is the gold standard test for sleep apnea. The sleep lab uses electronic sensors to monitor the sleep cycle brain waves, breathing patterns and oxygen saturation of blood. The latter measurement decreases during apneic spells.

This condition is often neglected, unrecognized and undiagnosed in 80 to 90 per cent of people with obvious signs and symptoms. Studies from the United States report patients visit their family physician about 17 times and a specialist about nine times over an average of seven years before diagnoses of obstructed sleep apnea.

The simple reason for missed diagnosis is that physicians simply do not suspect sleep apnea. Physician awareness of the condition correlates with an eightfold increase in the number of patients diagnosed and treated.

Seven major studies over the past three years link obstructive sleep apnea as an independent risk factor for hypertension, stroke and heart disease. I cannot stress enough how potentially significant this evidence affects patient care.

With treatment, most if not all the signs and symptoms of obstructive sleep apnea resolves within days to weeks.

Why does sleep apnea causes cardiovascular disease? What are the treatment options? Get some sleep and be back here bright and early next week.
© Dr. Barry Dworkin 2003

Related articles:

1. Sleep apnea solutions range from tennis balls to surgery
2. Sleep apnea’s effects on memory storage
3. Gasping for Air

Originally published in The Ottawa Citizen November 19, 2002
Original Title: Quitters are Winners

Most people know the risks of cigarette smoking. They often employ many strategies to quit, often with lukewarm success. An understanding of the addictive nature and the associated habits and triggers of smoking is essential before attempting a smoking cessation program.

Nicotine is one of the most addictive substances known: worse than heroin. It is strongly psychoactive, incorporating itself in the chemical processes of brain function. The term “addiction” is commonly misused. An addiction is condition wherein a person needs a particular substance or activity in order to continue to function. He/she will go to any length to procure the substance should it become scarce. The effect it has on the brain dictates their behaviour. In short, these people lose the ability to function independently compared to a non-addicted person.

To wit, how many smokers do you know who would not hesitate to head out into a stormy winter night to buy a pack of cigarettes should their supply be depleted? One only needs to look at the short-term nicotine withdrawal effects to understand how powerful a hold this drug has on behaviour and brain chemistry. True, some people can go without cigarettes for extended periods of time but the vast majority cannot.

There are two sides to nicotine addiction; the chemical addiction and learned behaviours. Indeed, think of the myriad of associations with cigarettes; coffee, alcohol, social gatherings, sex, peer group status, anxiety, and pleasure among the many others. Over the years these factors incorporate themselves into the fabric of a person’s day-to-day life. They become commonplace and achieve a status of normalcy as the person adapts to and accommodates the “smoking lifestyle”.

These triggering events or activities become so strong that people forget how the cigarette ended up in their hands. The conditioning of their behaviour is so insidious that their actions seem to be automatic without any forethought.

Some patients, fed up with smoking, will come to the office seeking the nicotine patch or Zyban to implement a quick-fix solution. Indeed the desire and motivation to quit smoking requires support and encouragement. However, an ad hoc approach to smoking cessation can lead to frustration and a greater chance of relapse.

Some people can quit cold-turkey, most cannot. How do you reverse years of conditioning and dependency?

The first and most important step is the motivation to quit. The smoker must want to quit, not for others, but for themselves.

The second step is to keep a written smoking log. The log should be in a table format with four columns; time, location, activity and mood. Each time a person lights up they enter this data. The log should include three consecutive work days and one day off. I ask patients to bring this record back a week later for review. Many will say they know when and where they smoke but the written record is often more accurate. It reveals smoking patterns and common triggers. Completing this log indicates a true motivation to quit.

Step three asks the smoker to create a list of personalized enjoyable activities (PEAs) to substitute for their cigarette smoking time. The smoking log provides the template. What can the smoker do at this particular time of day in this location that will be close to or just as enjoyable as smoking a cigarette?

For example, an ashtray (clean and pristine) is set on the desk filled with a low fat salad dressing or dipping sauce. Next to it are baby carrot sticks, celery, or other low fat food. The act of dipping the celery stick in the ashtray, taking a bite and placing it back in the ashtray mimics the act of smoking.

Preparing for a stop-date is step four. The PEAs have to be as available to the smoker as their cigarettes. They should be put in the locations (identified in the log) ahead of time. This preparation gives the smoker a sense of control. They are aware that they will have an alternative when the craving hits them.

The final preparatory step is addressing the chemical addiction. Two products are available to help reduce or eliminate the nicotine craving. By virtually eliminating the burdensome effects of nicotine withdrawal, the smoker has a window of opportunity to incorporate new habits in response to their smoking triggers.

Your doctor can help set up a program for you. Based on your state of health, he/she will review whether the nicotine patch or Zyban is safe for you to use. Both can be a useful adjunct to smoking cessation. Using both concomitantly does not significantly increase the success rate. Indeed, using them as step one instead of step five will invariably lead to relapse.

This five-step approach is an open-source guideline. Tailor it to your own needs. When used within a comprehensive smoking cessation plan, about 50 to 60 percent of quitters remain so after a year. Most smokers with the motivation to quit will eventually succeed. With each effort they learn a little bit more about themselves and fine tune the strategy for next time. Take the time to learn to quit. You already know the advantages of doing so.
© Dr. Barry Dworkin 2002

Related articles:

1. Insights into nicotine addiction
2. Up in smoke
3. Discourage smoking by appealing to teens’ independent spirit

Originally published in The Ottawa Citizen November 12, 2002
Original Title: A Puff of Fresh Air

Part I – Be alert for early warning signs of asthma

Asthmatics can suddenly crash and burn. Last week’s column made note that asthma is an inherently unstable disease. Some patients unknowingly play with fire by ignoring the symptoms. A good web site to determine the risk of asthma in children and adults is found at http://allergy.mcg.edu/home.html.

Most physicians agree that aggressive treatment to stabilize and control asthma is a top priority. What approaches do physicians apply to prevent the serious consequences of asthma?

An initial patient history provides valuable information. Although medications are a mainstay of treatment, treating asthma is not just about prescribing them and wishing people well. The ultimate goal is a comprehensive approach that includes the minimum amount of medications to provide a maximum positive benefit.

An individualized approach includes determination of a history of allergies, sporting activities, smoking, medication use and work environment among other factors.

Removing asthma-triggering substances or optimizing protection from the elements or noxious substances is a helpful step. Indeed, piling on ever-increasing doses and types of medication to compensate for worsening asthma without determining its triggers misses an important aspect of care.

For arguments sake, assume that correcting for the above factors has not led to stable asthma control. The patient continues to suffer from his or her asthma. The choice of medication follows a rational stepwise approach.

The goal of asthma treatment is to reduce the inflammation and airflow resistance of the airways to improve lung function. The choice of medication depends on the severity of the illness.

Short-acting bronchodilators, usually packaged in blue-coloured inhaler delivery systems, include salbutamol, found in Ventolin, Apo-Salvent and Airomir, Bricanyl (turbutaline), Berotec (fenoterol) and Atrovent (ipatropium bromide). In very young children, liquid Alupent (orciprenaline) may be used to help diagnose Asthma prior to the use of inhalers. These fast-acting agents relax the smooth muscle bands around the airway. The diameter of the airway increases making it easier to breathe.

Bronchodilators can cause jitteriness and a temporary increase in heart rate. This usually subsides within ten to 20 minutes. Overuse of these medications can render them less effective.

Longer acting bronchodilators (turquoise packaging), Oxeze (formoterol) and Serevent (salmeterol), last up to eight to 12 hours between doses. They remain effective with long-term use.

The anti-inflammatory agents (inhaled steroids) are the key to treating asthma. They shrink the swollen inner walls of the airways curtailing mucous secretion and blockage. These medications (brown or orange packaging) include Flovent (fluticasone), Pulmicort (budesonide), Q-Var and Becloforte (Beclomethasone). A non-steroid formulation, Tilade, is available but is not commonly used for compliance and taste reasons.

Long-term studies indicate that there is little to no growth suppression in children who use them. They provide excellent asthma control. The most common side effects of inhaled steroids are a hoarse voice and oral thrush. Rinsing and gargling immediately after use reduces this risk.

Two combination inhalers, Advair (Serevent and Flovent) and Symbicort (Pulmicort and Oxeze) can improve overall asthma control.

Leukotriene inhibitors (Singulair and Accolate) block a specific biochemical pathway related to a delayed allergic response that stimulates inflammation. They are an adjunct to the standard asthma medications and tend to work better for people with exercise-induced asthma. A daily tablet for some people may reduce their daily dose of inhaled steroids.

For severe asthma exacerbations, oral or intravenous prednisone may be required. Prednisone, a steroid, rapidly reduces inflammation over 12 to 24 hours. It is used when asthma does not respond to the usual treatment regimen or the patient is temporarily unable to inhale their medication. The severity of the asthma exacerbation dictates whether the patient ends up at home or in hospital.

Asthmatics can have different symptoms. Those that wheeze and cough only while participating in aerobic activities have treatment that differs from someone who has symptoms at any time of the day or night. The bottom line is to prevent the progression of the disease. Some, as they age, will suffer fewer attacks while others have it for life.

Many people do not correctly use their inhalers. The proper technique is critical to successful therapy. These patients usually conclude that the medication did not work when in fact little medication reached the lungs. Your doctor, public health nurse or respiratory technician can show you how to use them.

Bronchodilator use more than two to three times per week indicates poor asthma control. Asthmatics experience more bouts of pneumonia, colds and flu. Some cannot keep up with the physical demands of their job or sport. There are Olympic athletes that depend on their asthma medications in order to compete.

Some asthmatics continue to smoke. Their asthma attacks become progressively more severe and frequent. In my practice, several wonderful patients continue to deteriorate. Each asthma attack is worse than the last. I fear they will soon succumb to their asthma if they do not quit smoking.

There is a tendency to experience our illnesses from an individual perspective. In fact, most illnesses affect the entire family. As difficult as it is to quit smoking, the challenge is to stay alive to see your children grow up. Consult with your doctor and do what you must to succeed, for everyone’s sake.

Related articles:

1. How to control asthma
2. Be alert for early warning signs of asthma
3. A reader asks about asthma

Originally published in The Ottawa Citizen November 5, 2002
Original Title: Every Breath You Take
Part II: Medication only part of asthma care

Asthma management continues to be a problem for some patients. This is borne out by the telephone call from a patient who frequently runs out of their Ventolin puffer. A review of their chart shows repeat monthly or bimonthly renewal requests; a red flag denoting poor asthma control.

Despite newer medication formulations and treatment protocols, asthma rates continue to climb. The Centers for Disease Control review of rates during 1982 to 1992 showed an increase of 52 percent (34.6 to 52.6 per 1000) for people between the ages of five to 34 years. The greatest increase occurs in people under 18 years of age.

The next two columns will review what causes asthma, its diagnosis and treatment in children and adults. It will provide the tools to improve your ability to take charge of this condition.

Asthma is an inflammatory disease that plugs up the lungs and obstructs the ability to breathe. Its principal causes include genetic factors, allergies, chronic exposure to cigarette smoke and other chemical airborne irritants.

The bronchi are the tubes that carry air into the lungs. Lining their inside walls are cells that produce mucous. Other cells have sweeping and cleaning functions that clear the airway of contaminants, viruses and bacteria.

Elastic bands of muscle wrap around the bronchi’s outer walls. Their function is to dilate and constrict the bronchi in response to environmental or physiological factors. The terms for these actions are bronchodilation and bronchoconstriction. This action is important for proper lung function.

For example, inhaling cold winter air can cause the airways to produce mucous and bronchoconstrict. This increases the time to fill the lungs with air. The net result is more time to warm the air to prevent a reduction in core body temperature.

A combination of factors in asthma impairs normal breathing function. The bronchi become irritated and swollen under different conditions thereby causing bronchoconstriction and abnormal amounts of mucous secretions. The swelling of inner bronchial wall decreases its diameter. The net result is airflow obstruction.

Asthma triggers include exposure to allergic substances (allergens), colds and flu, pneumonia, aerobic exercise, cold air and smoking.

It is easy to overlook or ignore the initial physical symptoms associated with asthma. Many people do not seek medical attention for that intermittent nagging cough. They adapt to their symptoms and assume it is their normal state.

Most people associate wheezing with asthma. Although a common adult symptom, it can be absent in some young children. Children may have a deep hacking non-wheezy nighttime cough. The coughing fits can be so strong that the child vomits thereafter. Many parents will bring their child to the office not for the cough but rather because of the vomiting.

The spirometer is a tool used to diagnose asthma. It measures a wide variety of lung functions. These measurements determine if there is any airway obstruction during rapid exhaling and inhaling through the device.

If there is obstruction Ventolin, a bronchodilator medication, may be administered to the patient prior to repeating spirometry. A measurable improvement in lung function may indicate asthma.

Young children are unable to perform spirometry. Careful observation, physical examination and a detailed medical history can help establish the diagnoses.

To wit, some factors are particularly useful in establishing a diagnosis in young children. Does the child cough at night, during physical activity, playing outside in the cold winter air or when they catch a cold virus? Do they wheeze more than three times a year? Do they have eczema? Do the parents smoke in the house or car? Is there a family history of asthma or eczema?

Often, physicians will initiate a trial of a Ventolin inhaler or liquid Alupent to see if it relieves the cough and wheezing. If successful it may indicate asthma.

There is a straightforward way to determine whether asthma treatment needs adjustment. All asthmatics that use their bronchodilators (Ventolin and Airomir (salbutamol), Apo-Salvent and Berotec) more than two to three times a week have by definition unstable asthma. This instability increases the risk of a more severe asthma attack. More definitive approaches are in order.

Next week we will look at the five principles of effective asthma treatment;

• individualized continuing care,
• the ways the medications work in preventing and relieving symptoms,
• medication side effects and how to manage them,
• preventive treatment to reduce inflammation when symptoms are absent,
• early treatment to reduce inflammation when symptoms are present.

Get a head start and consult your doctor should you be using your bronchodilator medication more often than usual.

Related articles:

1. A reader asks about asthma
2. Medication only part of asthma care
3. How to control asthma