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Non-Evidence based treatment and elimination methods in asthma. Dr.Fazilet Karakoç University of Marmara Division of Pediatric Pulmonology. Allergic diseases are becoming more common - PowerPoint PPT Presentation
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1
Non-Evidence based treatment and elimination
methods in asthma
Dr.Fazilet KarakoçUniversity of Marmara
Division of Pediatric Pulmonology
2
Allergic diseases are becoming more common
Predictions suggets that by the year 2020 more
than 50 % of the population will suffer from some
type of allergy
Respiratory allergies predominate and many of
them will be triggered by house dut mites.
3
Increased exposure to high concentration of
indor environmental allergens such as house
dust mite, cockroach may explain the increased
prevelance and severity of asthma in children
Children spend most of their time indoor and
exposure to indoor allergens seems to be more
significant
4
CatDog
Pollen
House dust miteSensitisation to Allergens
Pet OwnershipDog owner
Smoking StatusSmoker
SexFemale
*p = <0.0001 p=0.001 - 0.0001 p=0.05 - 0.001* *
1 1.2 1.4 1.6 1.8 2 2.2 2.42.6 3.0
**
**
*
*
*
Simpson.Custovic et alClin Exp Allergy 2001;31:391-399
Sensitisation – Risk Factor for Asthma
5
Environmental risk factors in asthma controlTreatment and elimination methods
Acupuncture
Diyet/Nutritional
treatment
Herbal medicine
Homeopathy
Breathing exercise
Others
House dust mite
Cockroach
Animal allergens
Molds
ETS
6
1925
Storm van Leeuwen
Living in allergen-free room
(in the hospital) or
Moving to high altitude
Decreased the exposure to
dust mite and had beneficial
clinical effects
Control Measurements in
order to decrease dust mite
exposure
7
Environmental measurements in Asthma
Physical Measures
Control environmental humidity and temperature
Mechanical measures ( collection/filtration)
Physical barriers (impermeable covers)
Chemical measures
Pesticides (to eliminate house dust mites and substances to denature the allergens)
8
Ev tozu akarı alerjisi
One of the most significant indoor allergens
A higher incidence of mite allergy has been reported in
asthmatic children of lower socioeconomic status
Most common allergen in Turkey ( %20-70)
House dust mites feed mainly flakes of human skin
A single adult person sheds between0.5-1 gr per day,
enough to feed 100 000 house dust mites a day
9
Particles carrying house dust mite allergen are relatively large (> 10µm) and settle quicky
Bedding, carpets,clothing and furnishings are the major sources of allergen.
During cleaning dust is disturbed and available for inhalation
10
• Can effective house dust mite allergen avoidance be achieved in homes?
• Does it make any clinical difference?
11
The relationship between allergen concentrations and
symptoms does not linear and predictable
Sensitivity and response vary greatly from individual
to individual.
Children are not raised in a single house
The concentration of house dust mites in each home vary
according to series of factors such as geographic location,
humidity, temperature, decoration and the number of the
people living in the home
12
Cochrane reviewsSheikh A,2003Gotzsche PC 2004
Cochrane reviewsSheikh A,2003Gotzsche PC 2004
29 studies
15 Physical
measurement
9 Chemical methods
5 CombinationOf methods
•Asthma symptoms
•Use of asthma medication
•Morning peak expiratory flow
NO statistically significant difference
13
Physcian should give advices about ideal
environmental control measurements to the
caregivers
14
Because of the high level of mite allergen exposure
during sleep, the bed is probably the most clinically
significant exposure site.
Encasement of the matress and pillows in allergen-
impermeable covers combined with frequent hot water
washing (>55 C) of bedding is the best method in order
to reduce dust mite exposure
Allergen-impermeable bed and pillow covers
15
BHR Asthma symptoms Bronchodilator use Inflammatory markers .
Halken, 2005EhnertB,2002Murray,1983Carswell F,1996Frederick,1997
Do allergen-impermeable bed and pillow covers effect the
control of asthma?
Asthma symptoms Pulmonary function tests İnhaled steroid dose
Rijssenbeek N,2002Woodcock A,2003Luczynska C, 2003Terreehorst I,2003
16
Dust mite control measurements in bedding
The use of acaracide or antimite shampoo in addition to encasement and hot washing doe not have any benefit
Ehnert B,1992, CarswellF,1996,Frederick JM,1997
17
Kill all live mites! BUT does not reduce allergen concentration!
DRY CLEANING
18
Carpets are amajor source for many indoor allergens
Houses with carpets have more allergens than those without
The use of Acaracides alone or in addition to other dust mite avoidance measures have not been demonstrated to be useful
Removalof carpets?
Rebmann H 1996, Woodfolk 1995, Ehnert B 1992, Carswell F 1996
CARPETS
19
Frequent vacuum cleaning effectively decrease dust mite in carpets
Even with improved filtration systems, vacuum cleaning may increase aeroallergen levels
It is advisable to wear a mask and open windows during and after cleaning
Adilah N,NZ Med J 1997
20
Control of house dust mite using extreme temperature,
either by freezing with liquid nitrogen or steam cleaning
has been shown to be effective
None of these methods is completely effective, the
amount of the allergen increase following intervention
21
Respiration-gas exchange in mites is cutaneous,
And they are particularly susceptible to loss of body
moisture
The placement of carpets in direct sunlight has been
shown to effectively decrease dust mite level, since mites
are susceptible to water loss (drying)
This is a simple , safe, and inexpensive way to reduce
house dust mites,especially if alternative methods are not
available
Tovey E JACI 1995
22
ASTHMA AND COCKROACH
23
Cocroach allergens are found
İn high concentrations in,
Blag 1,Blag 2 Cockroach feces
skin
Nest debris
Highest concentration of cockroach antigens are in dust
from kitchen floors and cupboards (50-fold more than
bedrooms)
Strongest relationship between exposure and sensitisation
has been found in the bedroom
Cockroach sensitisation is 10-40 % in Türkiye
COCKROACH
24
Increased level of cockroach allergen have been associated more frequent;
•Asthma related ER visit•Hospitalisation•Days of wheezing•Missed school days
Cockroach allergen levels has been found to be a risk factor for accelerated decline in FEV1 in adults with astma
Weiss ST J Allergy Clin Immunol 1998
ASTHMA AND COCKROACH
25
Reduction in cockroach allergen exposure may be
in important in asthma control
Gergen PJ, 1999,Carter MC,2001
Intervention studies showed no or modest reduction in cockroach allergen levels
Reduction in cockroach allergen levels were not associated with clinical benefits
26
Cockroach like to live in dark, humid and warm environment
Removal of cockroach alleregen from the house is not easy
Although the effectiveness of professional cockroach
extermination remains unproven, this is probably the only
method that will help control infestation in the long term
The goal is to eradicate not only the living cockroach
population but also the residue
Reinfestation from neighboring residences is also a
problem,especially for families living in the crowded apartment
buildings
•İn additon to extermination, elimination of cockroach food and
water sources through basic sanitation
measures , clearing harborages and
blocking entry point is important
•Grocery bags, empty bottles and newspapers make
wonderful habitats for cockroach and should not be stored in
the house
27
ASTHMA AND PETS
28
All warm-blooded pets, including small rodents and birds
Produce urine,dander,feces and saliva that may cause
allergic reaction
Animal allergen particles are small (1-20µm), sticky and
adhere surfaces
10% of children own pets in Türkiye
Transfer of animal allergens from homes to public places
(including schools) via clothing has been reported
PET ALLERGY
29
The most effective environmental
control measure for animal allergen is
removal of animals from the house
Once the animal removed, elimination of allergens
requires aggressive cleaning
Decreases in allergen levels can take months; removal
of carpeting and stuffed furniture can shorten this period
30
1000
100
10
1
0.1
0.01
Cat removed
0 5 10 15 20 25 30 35 40 45
Time (weeks)
Cat removed
Fel d 1 content(FDA units/gram
dust)
Wood et al, 1989
The Effect of Cat Removal on Fel d 1 Levels
31
•Different washing protocols for animals have been effective in the elimination of animal allergens
•However animals need to be washed twice a week to maintain decreased antigen levels
32
30
25
20
15
10
5
02 3 4 5 6 7 8
Baseline + h rs
Can f 1 (ng/m )3
dog+HEPA
dog-no HEPA
no dog+HEPA
no dog, no HEPA
35
Green et al, 1999
HEPA FILTER Air-Cleaners Reduce Airborne Dog Allergen
Baseline 2 3 4 5 6 7 Baseline+hrs
33
HAVA FİLTRELERİMcDonald E, Chest 2002Meta-Analiz
Alerjene maruziyeti azaltmak amacıile hava temizleyicileri ve diğerfiltrasyon cihazlarının kullanılmasınınetkinliği NET DEĞİLDİR!
HEPA filtrasyon astım semptomlarını ve astım ile ilişkili uyku bozukluklarını azaltır.HEPA filtrasyonu sigara dumanı gibi çeşitli inhale allerjenlere maruziyeti azaltabilirÇalışmalar hangi spesifil allerjene maruziyetin azalmasının klinik fayda sağladığını göstermemektedir
34
If removal of the animal is not acceptableExpert Panle Report2 : guidelines for the diagnosis and Management of Asthma suggest,
Keep the pet out of patients room
Keep the patients bedroom dor closed
Remove upholstred furniture and carpets from the home or isolate the pet from them as much as possible
35
Avoidance from CAT & DOG Allergens
Decrease inhaled allergen
Clinical Benefit
Removal of the pet YES ?
Washing pet LITTLE Probably NO
HEPA air filter LITTLE Probably NO
High filtration vacuum cleaner
NO NO
Removal of carpet ? ?
36
Although molds were commonly considered an outdoor allergen, spores can come indoors
Alterneria, aspergillus, penicillium etc are the most common molds in Türkiye.
Allergic sensitisation to molds has been reported 4-50 % in different regions of Türkiye
Damp homes and indoor molds have been associated with adverse respiratory symptoms and higher risk of asthma
•Maintaining adry environment with simple control measures
•Repair of water leaks and insulation defects
•İncreased bathroom ventilation
•No drying of cloths indoors
•Fewer indoor plants, has been shown to be effective in reducing exposure to mold spores
MOLDS AND ASTHMA
37
ASTHMA AND ENVİRONMENTAL
TOBACCOSMOKE
38
•ETS has been associated with increased risk of death and hospital admissions for respiratory disease as well as increased risk of asthma
Among children with established asthma ETS increase
•Asthma symtom scores•Attack frequency•Medication use
Di Franza 1996, Martinez 1992,Starchan DP 1998
•Advise caregivers and other smokers in the homes of patient with asthma to stop smking or to smoke outside the home
•The asthma care team should be knowledgeable about smoking cessation and should actively refer smokers to Programs
•Active smoking status of the patient?
•Discuss the ways to reduce exposure to reduce other sources of tobacco smoke such as from relatives, friends and day care providers
Environmental tobacco Smoke Exposure
39
CLINICAL TRIALS
OF MULTIFACETED
ENVIRONMENTAL
CONTROL
INTERVENTIONS
40
Hasta sayısı 444 425Days with asthma symptom
3.39 4.20 <0.001
Days of wheeze 2.65 3.43 <0.001Days of exercise limitation
2.34 2.84 <0.001
Night woke up 1.55 2.17 <0.001School days missed 0.65 0.82 0.003ER visit 0.93 1.08 0.17FEV1 87.0 87.4 0.56
Morgan JM,NEJM,2004
Results of a home-based intervention among urbanchildren with asthma
41
SONUÇ
•The asthma care team should evaluate environmental
conditions of the patients and discuss appropiate control
measuerments in order to decrease allergen exposure
•Physician should check the environmental control
measurement in F/U visits
•Reduction of ETS is an important target for
environmental control measurements
42
ALTERNATIVE
MEDICINE IN ASTHMA
That’s all the health insurance will pay for alternative medicine
43
THE USE OF ALTERNATIVE MEDICINE IN DIFFERENT COUNTRIES
0
10
2030
4050
6070
80
90100
ENGLAND USA GERMANY SINGAPORE
59 % 41% 26.5% 27.5%
44
ACUPUNCTURE
A large number of
small, uncontrolled
trials reported that
acupuncture
improved asthmatic
symptoms
45
Gruber et al
Thorax,2000
44 çocuk
Exercise induced asthma
Akupuncture NO protection against exercise induced
bronchospasm
Shapino et al
Chest,2002
23 patients with mild-persistent
asthma
Akupuncture NO change in
PFT ,PEF, BHR
Medici et al
J Altern Complement Med
66 patients Akupuncture NO change
PEF,FEV1,
BHR,Asthma symptoms
EFFICACY OF ACUPUNCTURE IN ASTHMA
TREATMENTS: RCT TRIALS
46
Linde K, Cochrane review,2000 7 trials with 174 pts
Martine J Eur Respir J,2002 200 publications
11 Randomised controlled trials
This is the last time I go to an acupuncturist for my asthma?!
The authors did not find evidence
of an effect of acupuncture
in reducing asthma,
whatever outcome was used
47
HOW ABOUT SAFETY
125 papers reporting side
effcets of acupuncture in
the period 1981 to 1994
Norheim AJ, J Altern
Complement Med 1996
‘You gotto be kidding! His asthma is still not undercontrol?!’
‘You gotto be kidding! His asthma is still not undercontrol?!’
Pneumothorax Hepatitis Death
48
DIYET/NUTRTIONAL THERAPY
Kaur et al.
Cochrane Database,2001
Vit C supp. 6
RCT Not Beneficial
Gilliland et al.
Am J Epidemiol 2003
Antioxidant vitamin intake
2566 children PFT small but significant
improvement?
Aroraet al.
Pediatr Allergy Immunol 2002
Vit A
levels
35 Asthma
29 control
Vit A levels were lower in children
with asthma
Woods et al
Cochrane Database,2001
Fish Oil 9
RCT Not Beneficial
49
HERBAL MEDİCİNE/ TRADITIONAL CHINESE MEDICINE
50
INCIDENCE OF HERBAL MEDICINE
USAGE IN TURKEY
31% of children with asthma use herbal medicine
Orhan F, Ann Allergy Asthma Immunol 2003
51
HERBAL MEDICINE
Until now , there has been no evidence of efficacy of herbal medicine
Studies are very heterogeneous, low quality studies with small patients numbers
Only a few RCT
There is insufficient evidence to recommend herbal medicine use as first-line or even adjunctive therapy for asthma
52
HERBALMEDICINE /SIDE EFFECT?
Although widespread use
and advertising of herbal
medicine there is
insufficient data about the
safety
‘It appears to be a side effect from the herbal medicine you’re drinking!?’
Mizushima and Kobayashi
published a series of 24
cases of interstitial
pneumonitis induced by
herbal medicine
53
Cooper et al
Thorax ,2003
Buteyko
Pranayama
Placebo
No difference FEV1,BHR,ICS
Manocha et al.
Thorax ,2002
Shaja yoga Limited but significant benefit in asthma symptoms and BHR
Huntley et al,
Thorax, 2002
Kas gevşetici teknikler
Improvement in PFT
Weiser Chest,2002
Solunum kasları
Çalıştırma teknikleri
Significant reduction of perceived dyspnea and bronchodiator use
BREATHING EXERCISES AND ASTHMA
54
OTHER ALTERNATIVE TREATMENTS IN ASTHMA
REFLOXOLOGY
55
Hondras et al
Cochraine Database,2002
Manual therapy
5
RCT
NOT BENEFICIAL
Blackhall et al
Cochraine Database,2002
Air ionizers 6
RCT
NOT BENEFICIAL
Hackman et al. Hypnosis No RCT NOT BENEFICIAL
Brygge T Refloksoloji No RCT NOT BENEFICIAL
OTHER ALTERNATIVE TREATMENTS
56
‘That’s right , Kenji.Everything happens for a reason, but no one has a clue what it is!’