Essay: Treatment of Asthma

Section 1: Pathophysiology of Asthma

According to Austen (2013), asthma is best defined as ‘a disorder characterised by reversible bronchospasm with wheezing, the symptoms occurring in short-lived paroxysms’. Primarily, the lungs and airways are effected by asthma, particularly the bronchial smooth muscle, which undergoes contraction (ibid).

Asthma can further be described as a limitation in the airflow within the airways, hyper responsiveness of the airways to various stimuli, and of course overall bronchial inflammation (Kumar and Clark 2012).

Furthermore, it is broken down into both Extrinsic and Intrinsic asthma, essentially being allergic and non-allergic asthma respectively, although they do crossover (Austen et al 2013).

Extrinsic asthma is triggered by allergies, particularly to allergens which can be inhaled; for example fungi, pollens, dust mites, etc (Kumar and Clark 2012). Generally, Extrinsic asthma is a consequence of increased production of Immunoglobin, as well as hyper-responsiveness of airways, leading to destruction of mast cells and of course an overall inflammatory response (Crutchlow et al 2002).

Intrinsic asthma tends to start after the age of 35, and is generally caused by pollution, cold air, stress, etc, rather than specific allergens (Austen et al 2013). Importantly, people suffering from intrinsic asthma do sometimes have a history of childhood asthma or breathing difficulties, and also those suffering from adult onset asthma can test positive, via skin tests, for allergens (Kumar and Clark 2012). See below for a compare and contrast of the two:

Extrinsic

Intrinsic

Triggers

Dust mites, pollens, fungi, animal danders, environmental chemicals and pollutants

Emotional Stress, non-steroid anti-inflammatories (i.e. Aspirin), Beta Blockers, Environmental pollutants, dust, cold air, dry air, dust, tobacco smoke, Upper respiratory infection, exercise

Physiological Differences

Immune reaction

Non-Immune

(Kumar and Clark 2012)

So clearly there is some cross-over in what triggers asthma. In Pauls case, he has a childhood history of asthma, and until recently he had no symptoms or recurrence of the condition. However, since work began at his offices, lots of dust and mould has been released into the atmosphere and has begun to trigger a reaction. Also, since the beginning of the symptoms, cold air and pollutants have begun to trigger reactions too. Also, it is interesting to note that he also exhibiting anxiety.

In this instance, it is likely that Paul is allergic to dust mites and mould, and so is exhibiting some aspects of Extrinsic asthma, which would be unsurprising considering his childhood history of asthma. However, since the symptoms developed, he is now also clearly exhibiting signs of Intrinsic asthma, relating to pollutants, cold air, and possibly emotional stress. So Paul is currently exhibiting aspects of both versions of asthma, but is currently predominantly Intrinsic asthma. It would be useful for Paul to be allergy tested, particularly for mould, fungi and dust mites to confirm that there is an issue with these allergens.

In relation to the bodies responses to asthma, when a stimuli has been presented, the body will generally go through two stages, which are the same regardless of whether it is Extrinsic or Intrinsic asthma. During the first stage, coughing begins, with bronchospasm occurring in airways, generally peaking within 15-30 minutes (Crutchlow et al 2002). There are also inflammatory mediators causing this reaction, these being interleukin 4 & 5, leukotrienes and histamine (ibid).

In the second stage, within 2 to 6 hours of the start of the attack, mucous production and oedema has caused the airway to narrow further, as well as continued bronchospasm and inflammation (ibid). These reactions will lead to the symptoms of asthma, which is discussed further below.

Here is a diagram showing a summary of the bodies response:

(Adapted from Kumar and Clark 2012)

Section 2: Signs and Symptoms of asthma

Symptoms of asthma include chest tightening, coughing, wheezing, breathlessness and shortness of breath, which can worsen at night (Crutchlow 2002). These symptoms can be worse at night or in the morning as well. Interestingly, it is not known exactly why asthma can be worse at these times, but several hypotheses include the pattern of hormones released during sleep (therefore making the body more vulnerable to asthma symptoms), possible changes to bronchial airways during sleep, lying on ones back, and finally dry or cool air effecting the airways (Kaliner et al 2013).

Generally however, symptoms of asthma can be made worse by allergens or other factors stated earlier, so depending on Pauls exposure during the

In Pauls case, he is certainly displaying signs and symptoms of asthma, in respects of wheezing, shortness of breath, breathlessness, chest tightening and coughing. With regard to his symptoms at night, it would be worth investigating if Paul has the heating on very high (drying out the air) or if he is leaving the window open (making the air very cold) – either of these possible factors could be unknowingly exacerbating his symptoms at night.

Pauls symptoms in the daytime however are clearly been triggered by cold air, fumes and also possible animal dander from his cat. It would also be important for Paul to examine these causes. Finally, his anxiety which is mentioned may also be worth exploring, as potentially high levels of anxiety could also be causing him problems also.

With regards to signs and symptoms causing clinical concern, the waking at night coughing, wheezing or having difficulty breathing is an indication of potentially quite severe asthma (Crutchlow 2002), so it would be important had this investigated.

Also, the way Paul has come in is actually a concern. The fact he is having difficultly speaking, and that his breathing rate is now 36 breaths a minute is potentially worrying. According to Stephenson (2016), when the breath is 30 or more per minute, and has difficulty speaking, it is a sign of a severe asthma attack, and that there is a lack of oxygen getting into the body due to severe restriction in the airways. Another severe sign would also be the heart rate, which if is between 100-130 beats per minute, is also an indicator (ibid). It would be important to measure this. This collection of signs and symptoms; the difficulty speaking, high breathing and heart rate, strongly indicates a condition called status asthmaticus, which requires immediate medical intervention due to the potential for suffocation (ibid). So these signs and symptoms are what would be also termed red flags.

Furthermore, it is also worth noting that there are variations in Adults and Children with regard to these red flags – the below rates would be a cause for concern:

Newborn

60 breaths a minute or more

Infant

50 breaths a minute or more

Young Child

40 breaths a minute or more

Older child / Adult

30 breaths a minute or more

(Adapted from Stephenson 2013)

Finally, an additional red flag, as well as the above symptoms for status asthmaticus is cynasosis, where the lips turn blue due to a lack of oxygen (Stephenson 2013). When this occurs this is obviously quite a concern and would also be an indication of immediate medical intervention been required.

Section C: The Management of Pauls Asthma

Due to Pauls condition, in respects of more than 36 breaths per minute, difficulty speaking, and anxiety are three significant red flags. This potentially suggests status asthmaticus, and so I would immediately look at getting Paul to hospital. Having contacted emergency services, I would then engage in several actions.

Firstly I would try to keep Paul calm and as comfortable as possible – I would make it clear that we are getting Paul to hospital as a precautionary measure – it is vital in these situation’s to keep the patient as calm as possible without further triggering anxiety, especially when asthma is involved (Duff and Gormly 2012).

Secondly, if I hadn’t already, I would take Pauls pulse to see what was happening. If the pulse was between 100-130 beats a minute, this would further confirm the potential danger of the situation. I would also monitor Pauls heartbeat every 5 minutes to see how he was (ibid).

Lastly I would begin to engage in general first aid procedures, following the actions particularly prescribed in Stephensons (2013) manual. These actions would be:

• Keeping the patient upright, looking to increase oxygen supply in the room and / or exposing the patient to steam to attempt to help open airways (ibid). So I would probably have Paul sit comfortably on my acupuncture bed, and if a supply of steam is available, begin to administer

• If a blue inhaler is at all available, I would ask Paul to take a puff every 5 minutes, which may help pacify the suspected asthma attack (ibid).

• If Paul loses consciousness, I would attempt to keep airway open and also begin CPR until help arrives (ibid).

Although Paul may not be having status asthmaticus, the three significant red flags do indicate that this is very likely, and so engaging in the above actions I believe would be very important to ensuring a favourable outcome for Paul.

With regard to how allopathic medicine would treat Paul’s condition overall, in the short-term Paul would certainly receive hospital treatment. If by the time Paul had arrived at hospital, and the attack had not abated, the emergency services would likely engage in the following actions:

• Providing additional Oxygen (Kaliner 2013)

• Administration of reliever medication (ibid)

• Usage of steroids (ibid)

• Other drugs to help relieve the attack (ibid)

Once the hospital had successfully dealt with the attack, it would be important to in fact officially diagnose the asthma. This would be done by testing the lungs peak flow rate, which shows how much air the lungs are able to take in and expunge (Stephenson 2016). This helps indicate quite successfully whether the person has asthma. The hospital will also conduct an X-ray too, which will help prove if asthma is present (ibid).

Following a presumed diagnosis of asthma, the hospital would then begin looking at giving Paul a prescription of different nebulisers and also lifestyle advice to help best manage the asthma. We shall now examine the drugs involved and the lifestyle tips as well.

If we examine the British National Formulary (2016), there are some general long term prescriptions and steps which may apply in Pauls case. In step 1, an occasional relief bronchodilator (short acting agonist) is given and used by the patient, up to once daily. Salbutamol would be an example of this. If this is needed more than twice a week, it is advised to move to step 2 (ibid). In step 2, a corticosteroid based inhaler is also issued, or a non-corticosteroid is issued instead depending on the patients needs, although these are considered not as effective (ibid). The remaining two steps are in effect more of the same, but more frequent and stronger in general. Treatment is reviewed every 3 months, and once a regime (or indeed step) has been found to work, rolling back the steps will be attempted to reduce the overall prescribed dosage (ibid). For children, there are similar steps and measures taken as well.

In respects of lifestyle management, the NHS has several points of advice. These are taking medicine as prescribed, stopping smoking, regular exercise, good diet, been aware of your asthma triggers, vaccinations, and improving sleep hygiene (NHS 2017).

Section D: The Energetic Interpretation of Salbutamol

Question

Answer

Into which one or more of the 15 Chapters of the British National Formulary (BNF) does Salbutamol® fit ?

Respiratory System (Chapter 3)

Thinking only about Paul’s use of Salbutamol ® into which main section would this drug fit ? (Ch. number plus one decimal place)

3.1

In what way do drugs in this main section relieve the symptoms of asthma physiologically ?

They open the airways, reducing inflammation and reversing obstruction.

Drugs in this main section may be categorized further into sub-sections. Into which sub-section of the main section would Salbutamol ® fit ? (3 decimal places after the chapter number )

3.224

In what way do drugs in this sub- section relieve the symptoms of asthma physiologically ?

Remember to explain any medical / technical terms which you use)

As a selective beta short acting agonist, it acts on the beta adrenoreceptors, mimicking the function of adrenal hormones, causing the smooth muscle tissue within the airways to relax (Kaliner 2013)

What is a simple Chinese Medicine interpretation of the disease being treated. (You do not have to answer this question as you have not yet had the corresponding asthma lecture in Chinese Medicine)

One theory would be:-

Kidney and Lung Qi deficiency.

External Wind trapped in the bronchi and reactivated during an asthma attack causing bronchospasm.

How does Salbutamol® alleviate an acute asthma attack in Chinese Medicine terms ?

Moving and descending of lung qi (Stephenson 2016)

What are the common side effects of Salbutamol ® listed in the BNF ?

Tremor, nervous tension, headaches, muscle cramps and palpitations (BNF 2016)

What would be a simple TCM interpretation of 3 common side effects of the drug?

Muscle Cramps – depletion of Kidney Yin causing Blood deficiency

Palpitation – Kidney Yin deficiency causing Heart Yin Def

Nervous Tension – Kidney Yin deficiency

Into which of the 9 categories of Mode of Action does Salbutamol® fall ?. (Please refer to the 9 modes of action in Clare Stephenson’s book)

7. Other drugs that artificially stimulate natural bodily functions

How would you summarise the energetic interpretation of the drug?

(in terms of placebo, cure, suppression, drug induced disease, no effect)

Actions boosts Lung and Kidney Qi, but overtime is likely to deplete these two organs

References

1. Austen et al. 2013. Asthma: Physiology, Immunopharmacology, and Treatment. Academic Press: Michigan

2. British Medical Association. (2016) British National Formulary. BMJ Group: London

3. Crutchlow et al. (2002) Pathophysiology. SLACK: New Jersey

4. Duff, J., Gormley, P. (2012) First Aid and Wilderness Medicine. Cicerone Press: Singapore

5. Kaliner, M. (2013) Current Review of Asthma. Current Medicine Group: New York

6. Kumar, P. Clark, M. (2012) Kumar and Clark’s Clinical Medicine: Eighth Edition. Elsevier: London

7. NHS. (2016) Living with Asthma [Online]. Available from: http://www.nhs.uk/Conditions/Asthma/Pages/living-with.aspx [Accessed 19th June 2017]

8. Stephenson, C. (2016) The Complementary Therapists Guide to Conventional Medicine. London: Singing Dragon

9. Stephenson, C. (2013) The Complementary Therapists Guide to Red Flags and Referrals Elsevier: London

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