Allergic rhinitis (“AR”) is an immune-mediated disease (immunoglobulin  E) that occurs after exposure to outdoor and/or indoor allergens (substances that produce an allergic reaction). Such allergens include dust mites, animal dander, insects, dust, molds, and pollens. When you breath in these allergens, they trigger an allergic response. The body releases certain chemicals, including histamine, which causes allergy symptoms such as itching, swelling, and mucus production.

Allergic rhinitis due to plant pollen is commonly referred to as “hay fever.” Depending upon the person and the region, the causes of hay fever varies. Common causes of hay fever include trees (especially in the spring), grasses (late spring and summer) and ragweed (late summer and early autumn). The likelihood of hay fever symptoms developing increases when there is more pollen in the air. On hot, dry, and windy days, there is more airborne pollen than on cool, rainy days.

 

What are the symptoms of allergic rhinitis?

Symptoms of AR can occur shortly after contact (acute symptoms) with the allergen or develop later on (chronic symptoms). Acute symptoms may include:

• Itching (“pruritis”), especially the nose, eyes, throat, mouth or skin
• Runny nose (“rhinorrhea”)
• Altered sense of smell
• Sneezing
• Tearing eyes

Symptoms that may develop later include:

• Chronic cough
• Nasal congestion and loss of sense of smell
• Sore throat
• Clogged ears and/or hearing loss
• Puffiness and/or dark circles under the eyes
• Fatigue and irritability
• Headache
• Memory problems and slowed thinking

How is allergic rhinitis diagnosed?

Your physician will take a complete history and then perform a physical examination. Your history of symptoms is important in diagnosing allergic rhinitis. In addition to symptoms, your doctor will elicit information about exposure to pets or other allergens, environmental exposures, the relationship of symptoms to time of day or season, and presence of other allergic conditions. Some diseases can be associated with AR, including asthma and eczema. Your family history of allergies and allergic disease is also important because these are commonly passed from parent (especially mother) to child.

Allergy testing may reveal the specific substances that trigger your symptoms. Skin testing is the most common method of allergy testing. Blood testing may includes Complete Blood Count (CBC), with eosinophil white blood cell count, and Immunoglobulin E level.

 

How is AR treated?

Optimal treatment includes allergen avoidance, control of symptoms, immune therapy, and asthma evaluation, when appropriate. The best treatment for AR is to avoid exposure to the allergens causing your symptoms. Although it might not be possible to completely avoid all of your triggers, you can take steps to reduce exposure.

• Intranasal corticosteroids: For mild to moderate AR, intranasal corticosteroid sprays are the most effective treatment available.  According to several studies, nasal corticosteroids are more effective than oral and intranasal antihistamines for allergic rhinitis. These sprays work best when used nonstop, but they can also be helpful when used for shorter periods of time. These sprays begin working in about 30 minutes but might require 2-4 weeks to reach maximal effect. There are many brands available in the US. They are considered safe for children and adults. There is no evidence that one corticosteroid is superior to another. Adverse side effects may include nosebleeds, stinging or burning of the throat, hoarseness, and dryness or sores of the mouth and nasal passages. The various intranasal corticosteroids appear to be comparably effective to one another, but only budesonide (Rhinocort Aqua) has a category B safety rating and has approval by the FDA for use during pregnancy.

For patients with moderate to severe allergic rhinitis, second-line treatments include antihistamines, decongestants, intranasal cromolyn, leukotriene receptor antagonists, intranasal anticholinergics, allergy shots, and non-pharmacological interventions such as nasal irrigation. Combination therapy has not been found to be superior to monotherapy with intranasal corticosteroids.

• Antihistamines:  Most antihistamines can be taken by mouth, and many preparations are available “over-the-counter.” You should check with your doctor before taking these on a long-term basis, especially for children. Although second-generation antihistamines are effective for relieving some nose and eye symptoms, they are mostly ineffective for nasal congestion. Except for cetirizine (Zyrtec), second-generation antihistamines are less likely to cause sedation or impair performance. Azelastine (Astelin)  and olopatadine (Patanase) are antihistamine nasal sprays approved by the FDA for treatment of allergic rhinitis but have limited use because of adverse effects (including bitter aftertaste, headache, nasal irritation, epistaxis, and sedation), higher cost, and decreased efficacy compared to intranasal corticosteroids. Antihistamines work well for treating many allergy symptoms, especially when they do not happen very often or last very long.

• Decongestants: These may be helpful in reducing symptoms such as nasal congestion but should not be used for more than 3-4 days. These can be taken orally or as a spray. Adverse effects include sleeplessness, anxiety, high blood pressure, and rebound nasal congestion (worsening of symptoms after withdrawal of medicine).

• Intranasal cromolyn: Intranasal cromolyn is safe for general use for allergic rhinitis, but it is not considered first-line treatment because of its lower efficacy for symptom relief and its inconvenient dosing schedule (3-4 times daily).

• Leukotriene receptor antagonists: Oral montelukast (Singulair) is FDA approved for allergic rhinitis but has been found to be less effective than intranasal corticosteroids and antihistamines and should not be used as first- or second-line therapy.

• Intranasal anticholinergics: Ipratropium (Atrovent) nasal spray is useful for excessive rhinorrhea (runny nose), but has to be administered 2 to 3 times daily.

• Allergy shots: Allergy shots (“immunotherapy”) are occasionally recommended for patients with unsatisfactory response to usual therapy and if the allergen cannot be avoided. Allergen-specific vaccines have been developed with use of recombinant DNA technology. This treatment consists of regular injections of the allergen, given in increasing doses. Anaphylaxis (a life-threatening allergic reaction) is the most severe adverse event potentially associated with immunotherapy.  Allergy shots may significantly relieve symptoms, while reducing skin sensitivity and use of other medications.

• Non-pharmacological: There is insufficient evidence for the efficacy of non-pharmacological therapies such as acupuncture, probiotics, and herbal supplements; therefore, such alternative treatments are not medically recommended at this time. Despite the high prevalence of dust mite allergies, mite-proof impermeable mattress and pillow covers have not been shown to be effective against allergic rhinitis in any studies. Be careful when using over-the-counter saline nasal sprays that contain benzalkonium chloride, as these may actually worsen symptoms and cause infection. For mild allergic rhinitis, a saline nasal wash can be helpful for removing mucus from the nose. The use of air filtration systems have no documented efficacy in preventing allergic rhinitis

What is the prognosis?

Generally the symptoms of AR can be treated successfully. More severe cases might require allergy shots. Some patients, especially children, may become less sensitive to the allergen. However, as a general rule, once a substance causes allergies for an individual, it can continue to affect the person over the long term.

 

Blood pressure relates to the interaction of the force of the blood produced by the heart and the size and condition of the blood vessels. Factors that can affect blood pressure include the amount of salt and fluid in your body, the functioning of your kidneys, heart, and nervous system, and levels of certain body hormones.

What is Hypertension? When the systolic blood pressure is consistently 140 mmHg or higher and/or the diastolic pressure is 90 mmHg or higher, you may have hypertension (or “high blood pressure”). Hypertension can affect anyone, including children and adolescents.Worldwide, there are an estimated one billion with hypertension. In the U.S., about one-quarter of the adult population has hypertension or takes blood pressure medicine.

What causes hypertension? Risk factors include smoking, diabetes mellitus, obesity, and close family members with hypertension. Too much salt in your diet can cause high blood pressure. Hypertension caused by a specific and identifiable condition or substance is called “secondary” hypertension. Such causes include: kidney disease, arteriosclerosis (hardening of the arteries), adrenal disease or tumor, sleep apnea, cocaine or amphetamine use, certain medications (including appetite suppressants, certain cold formulations, migraine treatments, birth control pills, and corticosteroids), pregnancy, alcohol abuse, thyroid disease, scleroderma, and others. Hypertension with no defined cause is called “primary” or “essential” hypertension, which is the most common (90% of cases or more).

What are the symptoms of high blood pressure? Unless the pressure gets very high, usually hypertension produces no symptoms (hence the monomer “silent killer”). Symptoms associated with high blood pressure include headache, nose bleed, chest pain, confusion, vision change, fatigue, buzzing in the ear, shortness of breath, and nausea.

How is it diagnosed? Before deciding on treatment, your doctor will need to take your history and perform a physical examination, including checking your BP. Ideally, your doctor should obtain three separate readings about one week apart. If the readings are very high, or if there is evidence of organ damage, your doctor may start treatment on the first visit. Coming to your doctor with blood pressure readings from home can be helpful. Additional testing by the doctor might include blood and urine testing, EKG, chest x-ray, echocardiogram, or kidney ultrasound. Commonly obtained blood testing includes BUN, creatinine, hematocrit, sodium, potassium, calcium, thyroid function, cholesterol, triglycerides,and fasting glucose.

Treatment of hypertension: Lowering the salt in your diet, exercising more, consuming less alcohol, stopping smoking, and losing weight may be sufficient to correct your BP readings. If you have diabetes, work to keep your sugars controlled. Stress management may help for some.

If your doctor decides to give you medicine, there are many different types from which to select. Commonly prescribed general categories of medicines include beta blockers, diuretics, calcium channel blockers, alpha blockers, vasodilators, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and renin inhibitors. Quite often only one medicine is necessary, but some do require two drugs (often taken as a combination pill) or more. If you cannot tolerate a medicine, or develop an adverse side effect, there are plenty of others to try. It is important to keep taking your medicine even if the blood pressure is normalized by the medicine. Do not stop taking your medicine without your doctor’s approval and guidance.

What are the complications of hypertension? Poorly controlled or uncontrolled high blood pressure can cause damage to the body. It can cause lead to stroke, heart attack, kidney damage or failure, aortic dissection, loss of vision, heart disease or heart failure, blood vessel damage and brain damage. Chronic hypertension can cause the heart to enlarge.

When should I call the doctor? Patients with high blood pressure will usually see the doctor on regularly scheduled appointments. All adults should have their BP checked routinely, even if you have never been diagnosed with hypertension, especially if someone in your family has high blood pressure.

Call your doctor right away if self monitoring shows that your blood pressure remains or suddenly becomes high or you develop severe headache, chest pain, confusion, excessive tiredness, nausea and vomiting, shortness of breath, or vision changes.

Where can I learn more?

American Heart Association
National Heart, Lung and Blood Institute
American Journal of Hypertension
National Institutes of Health

What causes pleurisy? Pleurisy occurs when the lining of the lungs become inflamed and irritate the nearby nerve endings. Causes include:

1. Viruses (the most common cause), including CMV, EBV, influenza, RSV, coxsackie, and mumps
2. Bacterial infection, such as pneumonia or tuberculosis
3. Certain cancers, including lung cancer and mesothelioma
4. Chest injury
5. Pulmonary embolism (blood clot to the lungs)
6. Asbestos-related disease, such as pleural effusion or diffuse pleural thickening
7. Rheumatic disease, such as rheumatoid arthritis or systemic lupus erythematosus  (“lupus”)
8. Heart surgery
9. Other lung diseases, such as sarcoidosis
10. Sickle cell disease, certain genetic disorders
11. Chronic kidney failure

How will my doctor test me? The first step will be a medical history and physical examination. In addition to pleuritic chest pain, you might be having fever, night sweats, weight loss, shortness of breath, or sore throat. Your doctor will examine your chest with his/her hands and a stethoscope, listening for evidence of the inflamed pleural layers rubbing against each other (“pleural friction rub”) and for pleural effusion (fluid in the pleural space). Imaging of the lungs can be accomplished by chest X-ray or chest CT. Other testing can include blood tests (such as CBC, or complete blood count), lung scan, or blood oxygen measurement.

How is pleurisy treated? If there is fluid present in the pleural space, the doctor will remove it by a procedure called thoracentesis. The main treatment aims for pleurisy are to treat the underlying cause and to relieve the pain. Generally, the prognosis is good, but depends upon the cause.

Call your doctor if you have symptoms of pleurisy, especially if it is associated with shortness of breath, blue discoloration of skin or nail beds, unexplained fever, weight loss, or coughing up blood.

Where can I learn more?
Kass S, Williams P, Reamy B. Pleurisy. Am Fam Physician 2007;75:1357–64
Celli BR. Diseases of the diaphragm, chest wall, pleura, and mediastinum. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 100.

Like regular photos, motion can cause the image to be blurred. You will need to be still while taking X-rays. For chest X-rays, you will need to hold your breath.

 
What are X-rays used for? In general, there are three types of diagnostic uses for X-rays: (1) Normal X-ray tests; (2) Computed Tomography (CT) scanning; and (3) Fluoroscopy. In addition, X-rays may be used medically for therapeutic reasons, as a treatment for cancer.

• Normal X-ray tests: In this method, a single snapshot is taken. This is ideal for finding a major physical change like a broken bone, but is not good for examining many internal organs, such as the brain, heart, or liver.
• CT scanning: This method uses a computer to take more precise pictures, including 3-D imaging. Rather than one composite image, the CT comprises multiple “slices” to give more detail than normal X-ray tests.
• Fluoroscopy: Using X-rays, often with a contrast material to enhance the imaging, this test records the images like a movie on a TV screen. This technique is commonly used for examining for coronary artery (heart) disease, i.e. cardiac catheterization.

 
What are the risks of X-rays? Most of the radiation we encounter comes from elsewhere in the universe, such as the sun (so-called cosmic or background radiation). Published data reveal that the radiation from medical tests accounts for 14% of the yearly total radiation exposure. Although the amount of radiation absorbed is small, there is a slightly increased risk of cancer from medical X-rays. This risk is cumulative, however, so that the more X-rays one has, the higher the risk. The amount of radiation we absorb depends upon the type of X-ray test and the body part. Fluoroscopy and CT involve higher levels of radiation dose.

In the US, the radiation from medical X-rays has been estimated to increase a person’s lifetime risk of getting cancer by 0.9%. To put this in perspective, a 4-hour long airplane flight will expose a person to about the same amount of radiation as from a simple chest X-ray, or the same amount from “background” radiation that we are exposed to everyday over 10 days.

Getting a simple chest X-ray, X-ray of a broken arm, or dental X-ray adds less than 1 in a million to your lifetime risk of cancer (equal to a few days to a few weeks of background radiation). A mammogram adds between 1 in 100,000 and 1 in 10,000 (or a few months to a year of background radiation). A chest or abdominal CT, fluoroscopy, or barium enema X-ray adds between 1 in 10,000 and 1 in 1,000 to your lifetime risk (equivalent to a few years of background radiation). These risks are all very small additions to the 1 in 3 to 1 in 2 risk of developing cancer during our lifetime (National Cancer Institute. SEER Cancer Statistics Review 1975-2006).

 
How does an X-ray cause cancer? Simply put, when the X-ray energy is absorbed by the body, it causes electrons to leave the cell’s atoms, leaving behind “free radicals” that cause damage to DNA. Usually damaged cells repair themselves perfectly, or die, but in very rare occasions, the repair has mistakes, leading to cancerous growth.

 
What are the benefits of X-rays? All three forms of medical X-rays have benefit for diagnosis and treatment. For example, the benefit of diagnosing and mending a broken leg far outweigh the few extra days worth of radiation. Detecting and treating a cancer earlier hopefully provides for more cures than the radiation from the X-ray causes.

 
How do I minimize the risks?

• Avoid unnecessary X-ray procedures.
• If you are pregnant, or could be pregnant, tell your doctor because X-rays pose higher risks to unborn babies.
• If you need an X-ray, tell your doctor if you have had a recent similar X-ray.
• If you have had any of the higher dose X-rays (such as a CT scan or barium meal or enema), discuss this with your doctor.

 
Where can I learn more?

American College of Radiology
National Institutes of Health
X-ray risk calculator

What causes hemoptysis? There are many causes for hemoptysis, the most common being bronchitis, lung cancer, pneumonia, lung abscess, tuberculosis, bronchiectasis, and pulmonary thromboembolism (blood clot).  Conditions that cause massive hemoptysis (see discussion below) are diseases that erode into the bronchial circulation, which is under higher pressure than the pulmonary circulation. Common causes of massive hemoptysis are chronic infections or conditions complicated by infection (such as lung abscess, tuberculosis, bronchiectasis, or cystic fibrosis), as well as cancer. Many times the cause remains undetermined despite extensive work-up.

Other causes  of hemoptysis include: trauma, vasculitis (inflammatory disease of the blood vessels), aspiration of foreign body (especially children), Systemic Lupus Erythematosis, Goodpasture’s Disease, Sarcoidosis, over-anticoagulation, congestive heart failure, mitral stenosis, aspergilloma (fungus ball), and severe coughing.

What happens if I have hemoptysis? In general, hemoptysis requires a systematic and thorough evaluation to discover its cause.  (Hemoptysis in a patient with chronic bronchitis during an acute exacerbation is a possible exception because it is usually mild and self-limited).  However, if the hemoptysis is massive, recurrent, or won’t go away, then further evaluation is indicated.

• Is it really hemoptysis? The history in most cases will suggest that blood is actually being coughed up from the lungs, but it may be difficult at times to distinguish hemoptysis from bleeding in the upper respiratory tract (such as the nasopharynx or sinuses), or blood from the gastrointestinal tract that was regurgitated or vomited.

• Is the bleeding massive (i.e. life-threatening)? This is important not only for necessitating a different approach to management, but will often alter the differential diagnosis, or list of possible causes.  Massive or life-threatening hemoptysis is more than 200 ml (or a little under a half pint) total in one day.  Any amount of bleeding at a high rate, even over a short period of time, should be managed as being potentially life-threatening because  blood will flood the airways and cause asphyxiation.

• What does the medical evaluation consist of? Generally, the initial evaluation will consist of a careful history and thorough physical examination. The doctor will ask about any acute or chronic pulmonary symptoms, including cough, shortness of breath, wheezing, or if you have had any previous lung disease. The history or physical may uncover findings suggesting a certain cause, such as underlying heart disease, vasculitis, or pulmonary thromboembolism. Systemic symptoms, such as fever, night sweats, weight loss, and malaise may be present in chronic infection, cancer, or inflammatory diseases.

• What tests might be done? Generally, the first test will be a two-view (front and side) chest x-ray. (The chest x-ray can be unrevealing despite the presence of an important disease as the cause for the hemoptysis.) The doctor will often obtain blood tests, including  complete blood count (CBC) and coagulation studies (PT/PTT). Depending on the patient age and clinical circumstances, sputum testing for infection and/or cancer may be obtained. Chest CT scanning (contrast, high-resolution, or spiral) is a non-invasive and sensitive x-ray technique that can help the doctor determine the cause of hemoptysis. Ventilation-Perfusion (V/Q) scan is useful in evaluating for thromboembolic disease. The decision whether to perform fiberoptic bronchoscopy should be made in consultation with a lung specialist (pulmonologist). An echocardiogram can help examine the functioning of the heart and heart valves. On rare occasions, more invasive testing is required, including surgery (such as thoracoscopy, mediastinoscopy, or thoracotomy).

What should you do if you have hemoptysis? If you have unexplained hemoptysis, especially if it is more than a few teaspoons total in a day, call 9-1-1 and go to the nearest Emergency Department. If you have other symptoms, including chest pain, severe shortness of breath, dizziness, or fainting, you should go to the ED. You should not ignore this symptom, as it can be life-threatening. If in doubt, call your doctor right away.

How is hemoptysis treated? The main treatment for hemoptysis targets the underlying disease process. For example, an infection will be treated with the appropriate antibiotic or antimicrobial agent. Otherwise, the treatment is nonspecific. If massive hemoptysis is present, the treatment might require surgery.

Where can I learn more?
National Institutes of Health
National Center for Biotechnology Information (pdf)
Rakel RE. Textbook of Family Practice. 6th ed. Philadelphia, Pa: WB Saunders; 2005:402-413.

What causes wheezing? The potential causes for wheezing are many. The most common cause is asthma, but “not all asthma patients wheeze and not everyone who wheezes has asthma.” Any condition that causes a narrowing of the airway caliber, including bronchospasm, edema, tumor, secretion, foreign body, external compression, or dynamic compression, can produce wheezing. Even healthy people can produce wheezing if exhaling hard enough.

More common causes for wheezing include:

1. Asthma
2. Emphysema/COPD
3. Pneumonia/pneumonitis
4. Tracheobronchitis
5. Bronchiolitis
6. Foreign body in the lungs (aspiration)
7. Smoking
8. Heart failure/pulmonary edema (“cardiac asthma”)
9. Severe allergic reaction (anaphylaxis)
10. Medication-induced bronchospasm
11. Vocal Cord Dysfunction
12. GERD
13. Certain viral infections

Less common causes of wheezing include:

1. Tracheo-bronchial tumor
2. Aortic aneurysm
3. Carcinoid
4. Tracheal stenosis
5. Post-radiation stenosis
6. Tracheomalacia
7. Amyloid deposition
8. Sarcoidosis
9. Post-lobectomy

What are the characteristics of wheezing? Wheezing is usually most noticeable during exhalation. This usually results from significant reduction of expiratory flow rates (how well you can quickly exhale). On the other hand, inspiratory wheezing often signifies permanent airway stiffness (such as from stenosis, scar tissue, or tumor) or foreign bodies. The location of wheezing may also aid in the diagnosis. For example, wheezing heard all over the chest is more likely due to underlying diffuse lung condition, whereas localized wheezing suggests a more localized process, such as tumor or foreign body obstructing an airway. Wheezing is usually louder than the underlying breath sounds and can sometimes be heard without a stethoscope.

When do I call the doctor? You should call your doctor right away if you have:

• Wheezing for the first time
• Wheezing accompanied by shortness of breath, chest pain, bluish discoloration of the lips or nails, altered mental status or confusion
• Wheezing caused by allergic reaction, including insect bite or sting, food, or medication
• Wheezing that keeps occurring without explanation
• Wheezing associated with swelling of the face, tongue or lips

If wheezing is severe or occurs with severe shortness of breath, you should go directly to the nearest emergency room.

What will happen at the doctor’s office? Your doctor should take a detailed history and then perform a physical examination, particularly of the head & neck, lungs, and heart.  Additional testing might include chest x-ray, breathing tests, and blood work (including arterial blood gases). Your doctor may prescribe drugs to relieve narrowing of the airways. You might require hospitalization.

Where can I learn more?

National Institutes of Health
European Respiratory Journal reprint on wheezing
WebMD

How does the predictive value the blood test compare to TST? Although there have been studies confirming the increased future risk of active TB in individuals with positive TST, the same was not true for those with a positive Interferon Gamma Release Assay (IGRA) result. In 2008, a study from Germany demonstrated that a positive IGRA result is predictive of future active TB risk (Diel R, Loddenkemper R, Meywald-Walter K, Niemann S, Nienhaus A. Predictive value of a whole-blood IFN- assay for the development of active tuberculosis disease after recent infection with Mycobacterium tuberculosis. Am J Respir Crit Care Med 2008;177:1164–1170). Moreover, IGRA was at least as sensitive and was more specific compared to traditional TST. Negative IGRA results do not require confirmation, but results can be confirmed with either a repeat IGRA or TST if the accuracy of the initial test is in question.With any of the testing methods, persons who have a negative test result can still have LTBI.  Individuals with a negative IGRA result but who are likely to have LTBI and who are at greater risk for severe illness or poor outcomes if TB disease occurs might need treatment or closer monitoring for disease.

What are the currently approved IGRA tests? Currently approved (by the FDA) IGRA tests in the US are QuantiFERON TB Gold, QuantiFERON TB Gold In-Tube, and T-Spot.TB. The current CDC guidelines allow for the use of IGRA in all circumstances in place of PPD skin testing.

What are the advantages of IGRA testing?

• Single patient visit (no need to return in 48-72 hours)
• No anamnestic (“boosting“) response
• More specific (better able to separate those who might have had a false-positive PPD from prior BCG vaccination or many non-tuberculous mycobacterial infections)
• Results available in 24 hours
• No reader bias or error

What are the disadvantages of IGRA testing?

• More costly
• May be less available in certain locales
• False positive can occur in individuals with certain non-tuberculous mycobacterial infections
• Collection/Transporting/Laboratory errors
• Performance in immunocompromised individuals and children not completely determined
• Blood must be tested within 8-12 hours

Additional Information: Due to insufficient available information, IGRA is not recommended for screening of children under 17 years, pregnant women, or for those with diseases that increase the risk for progression of LTBI to active TB (e.g., HIV/AIDS). There is no reason to follow a positive IGRA with PPD testing. It is important to note that active TB cases can have a negative IGRA and a positive IGRA cannot differentiate between LTBI and active disease.

Where can I learn more?

Centers for Disease Control (CDC)
National Center for HIV, STD, and TB Prevention

Dr. Steven Dubinett, Professor of Medicine and Pathology and Director of the Lung Cancer Research Program at the David Geffen School of Medicine, University of California, presented research on the use of a blood test to detect lung cancer. Using a panel of 40 biomarkers, protein substances measurable in the blood and thought related to lung cancer development or progression, the testing was accurate in detecting the presence of lung cancer (scientifically termed sensitivity) 88% of the time. The testing had a 79% specificity, or ability to correctly identify those without lung cancer. The testing was also sensitive enough to be able to detect lung cancer at early stages.

Reducing the requirement for invasive testing, such as lung biopsy, is very useful, especially if the blood testing permits diagnosis at an earlier stage, when biopsying is more difficult and treatment is potentially more beneficial.

Further testing and clinical trials will be necessary, but the current research results are promising. If this methodology holds up, look for clinical availability in 3-5 years.

What are the types of pneumonia? Doctors classify pneumonia by the (1) cause, (2) location in the lung, or (3) clinical setting.

• Causes: Pneumonia can be caused by bacteria, viruses, fungi, parasites, chemicals, and other agents. 
• Location: Lobar (confined to a specific location, or lobe) versus interstitial (more widely spread throughout the lungs).
• Clinical Setting: Includes Community-acquired Pneumonia (CAP), Hospital-acquired Pneumonia (also called nosocomial pneumonia), Ventilator-associated Pneumonia (VAP), Aspiration Pneumonia (from gastric content entering the lungs), Opportunistic Pneumonia (in people with defective immune systems), Atypical Pneumonia (based on symptoms and infectious cause), and Occupational/Regional (some jobs or places may predispose you to a certain type of pneumonia).

What are the symptoms of pneumonia? For some pneumonias, such as Pneumococcal Pneumonia (from Streptococcus pneumoniae, the most common cause of CAP), the symptoms develop very rapidly- hours rather than days. Common symptoms of pneumonia include:

1. Fever (often after a shaking chill)
2. Chest pain (on the side of the pneumonia), particularly when coughing or breathing deeply
3. Shortness of breath
4. Cough (often with darkened mucus)
5. Nausea, vomiting, and muscle aches

Elderly patients with pneumonia may have fewer symptoms or less rapid onset, and experience confusion or lethargy. Atypical Pneumonia characteristically has more slowly progressive symptoms (often with flu-like symptoms first), dry hacking cough, and less severe chest pain.

How is pneumonia diagnosed? Your doctor will take a thorough history from you, and perform a physical examination. Listening to the lungs with a stethoscope, palpating your chest, and percussing your lungs (tapping with fingers) help your doctor determine if you have pneumonia. The chest x-ray (or maybe chest CT) will give your doctor a visual image of the location and type of pneumonia. A sputum test might be ordered to help identify the cause. Blood tests, such as CBC (to look for abnormal White Blood Cell count) or blood cultures (to look for infection spread to the bloodstream) might be taken. Sometimes, your doctor might need to do invasive testing, such as bronchoscopy, thoracentesis, or lung biopsy.

How is pneumonia treated? The treatment approach in patients with pneumonia involves several decisions by your doctor:

1. Do you need to be in the hospital, or can you be treated at home?
2. What type of pneumonia is it or is the most likely?
3. Do you have any underlying health issues?
4. What is the best choice of antibiotic (or antimicrobial), if any?

What are the complications of pneumonia? Although the vast majority of pneumonias respond well to treatment, some cases develop complications. These include:

1. Lung abscess (a thick-walled, pus-filled cavity in the lung)
2. Atelectasis (deflated lung)
3. Respiratory failure (inability to keep up the demands of breathing)
4. Bacteremia (bacteria spread to the blood)
5. Pleural effusion (fluid in the space between the lungs and chest wall)
6. Empyema (pus in the pleural space)
7. Pneumothorax (collapsed lung)
8. Dehydration
9. Hypoxia (low oxygen)
10. Kidney complications and electrolyte imbalances
11. Heart problems, including arrhythmia (abnormal heart rhythm) and heart attack

Is there prevention? Yes, there are things you can do to help decrease your chance of getting pneumonia.

1. Good hygiene. Wash your hands and don’t touch infected surfaces. Using ordinary soap is sufficient. Alcohol-based gels are also effective for everyday use.
2. Avoid transmission. Stay away from sick people (if possible).
3. Vaccination. A single dose of the Pneumococcal Polysaccharide vaccine works for most adults in protecting against Pneumococcal Pneumonia. A revaccination after 6 years may be needed. Yearly Influenza vaccination (“flu shot”) may reduce your risk of pneumonia.
4. Healthy lifestyle. Eat a well-balanced diet, and don’t smoke, use illicit drugs or drink alcohol excessively.

Where can I learn more?

National Institutes of Health/National Institute of Allergy and Infectious Diseases

Centers for Disease Control and Prevention (CDC)

American Lung Association

National Heart Lung and Blood Institute

 

What are the different ways inhalers deliver medicine? The two main systems are Metered-Dose inhaler (MDI) and Dry Powder inhaler (DPI). The MDI has a pressurized canister with medicine inside, fitted to a boot-shaped plastic holder. Typically, the medicine is released when you actuate the canister by pushing down on it. Some actuate automatically when you inhale. Dry Powder inhalers release the medicine when you take a deep, fast breath, rather than using a gas propellant like the MDI.

What are the commonly prescribed medicines used in inhalers? Inhalers usually contain bronchodilators (medicines that relax and open the airways), corticosteroids (medicines that reduce the airway inflammation), or some combination.

Bronchodilators: “airway openers”

• Short-Acting Beta Agonist (SABA)- These work rapidly (seconds) to open the airways, but typically only last 4-6 hours. Commonly prescribed SABAs include albuterol (Proair, Proventil, Ventolin), levalbuterol (Xopenex), and pirbuterol (Maxair).
• Long-Acting Beta Agonist (LABA)- These keep the airway relaxed and open for about 12 hours, but do not begin rapidly like SABAs. LABAs are better for maintenance therapy and should not be used for “rescue” or acute asthma symptoms. In the US, commonly prescribed LABAs include salmeterol (Serevent), formoterol (Foradil) and aformoterol (Brovana).
• Anticholinergic- These also open the airways, but by a different mechanism than the beta agonists. The main short-acting drug is ipratropium bromide (Atrovent) and long-acting drug is tiotropium bromide (Spiriva).

Inhaled Corticosteroid (ICS): These medicines have no significant effect on relaxing smooth muscle like bronchodilators, but instead work to reduce airway swelling and mucus production. Commonly prescribed ICS inhalers include beclamethasone (Qvar), fluticasone (Flovent), budesonide (Pulmicort), mometasone (Asmanex), flunisolide (Aerobid), and triamcinolone (Azmacort).

Combination inhalers: In the US, the most commonly prescribed combination of bronchodilator (LABA) and corticosteroid are Advair (fluticasone and salmeterol) and Symbicort (budesonide and formoterol). The combination of beta agonist (albuterol) and anticholinergic (ipratropium bromide) is called Combivent.

How can I be sure there is medicine remaining in my inhaler? Many newer inhaler brands include a counter but for others the best way is to keep track of the number of inhalations used and discard when you have reached the total number indicated on the box and/or inhaler. People using MDIs may mistakenly keep using an inhaler with only propellant inside (no drug). In other words, inhalers can still generate a “puff” sound or “feel” like there is something inside, but the drug has been completely used up. This is a serious problem if you depend upon the inhaled medication. Be sure to get a new inhaler before you used all the doses of the old inhaler.

How do I properly use my Metered-Dose inhaler?

• Closed Mouth Technique:

• Open Mouth Technique:

How do I use my Dry Powder inhaler?

• Aerolizer

• Diskus:

• Flexihaler

• HandiHaler

• Twisthaler

Where can I learn more?

American College of Chest Physicians (pdf instructions in English and Spanish)

National Institutes of Health (closed mouth technique)

National Institutes of Health (with a spacer)